Schedule a Video at Every Discharge (SaVED)

Purpose: The Veteran Health Administration established the two-day post-discharge contact ratio in 2010, with a national goal of 75% to improve care transitions, facilitate optimal health outcomes, and reduce readmission rates. In March 2022, less than 50% of patients assigned to a VA San Diego Healthcare System primary care team being discharged from a VA medical center were being contacted within two days of discharge. The purpose of this project was to use an evidence-based approach in improving post-discharge contact and care coordination among veterans assigned to a patient-aligned care team (PACT) in the VA San Diego Healthcare System.
Description: Using the San Diego 8As evidence-based practice model, a PICOT question was developed: In patients discharged from an inpatient hospital stay in VA San Diego, do scheduled nursing video visits compared to usual care (unscheduled telephone follow-up visit) increase two-day post discharge contact in six months? A search strategy was developed using the search terms hospital readmission, “readmi*” (readmitted, readmission), follow-up, telephone, “nurse*” (nurse, nursing), telehealth, video, and discharge. 25 articles were reviewed across multiple databases including CINHAL, PubMed, and Google Scholar.
Some of the key findings indicated that process standardization and staff education can improve the rate of scheduling outpatient follow-up visits at the time of discharge and patient may prefer technology to communicate with their health care team post-discharge and their preference should be considered in post-discharge planning. A five-phase implementation design included EBP design and stakeholder engagement; establishment of infrastructure; training; execution, monitoring, and plan/do/study/act cycles; and sustainment. The phased implementation includes establishing infrastructure to generate an automatic nurse video appointment order at discharge, reconciling nurse scheduling infrastructure to support bookable appointments, and providing individualized technological support to the veteran prior to discharge. Launching in June 2020, PACT registered nurse video visits were scheduled prior to the veteran being discharged from their inpatient hospital stay. Project leads were identified to serve as the primary point of contact at each community-based outpatient clinic (CBOC) to help guide and support staff at their site. Other virtual tools such as Microsoft Teams were used to facilitate prompt communication and troubleshooting as part of the plan, do, study, act cycle.
Evaluation/outcome: In 6 months, VA San Diego Healthcare System improved the 2-day post-discharge contact ratio by 28.66%, from 49.50% to 63.68%. Patient-aligned care team registered nurses increased RN VA video connect (VVC) volume by 300%, from 66 VVCs per month to 264 VVCs per month. This evidence-based approach has demonstrated success, and facility leadership is currently in the process of updating standard operating procedures and staff competencies to support the continuation of this practice as standard work.