The Veterans Affairs office of inspector general has revealed a fundamental way to improve care. It has to do with how medical staff assess patients about to be discharged. The OIG has recommended a national policy to use social determinants of health, and health-related social needs, when evaluating patients. The Federal Drive with Tom Temin spoke to the VA deputy assistant IG Julie Kroviak about why that’s important.

Interview Transcript: 

Tom Temin And this is an interesting study because it’s not really an operational problem or a financial problem, but really a Care Corps related issue. Tell us about these two factors and what they mean in general for assessment of how it works.

Julie Kroviak Yeah. So, these are really just formal terms for risk factors that an individual patient faces when they leave a clinical setting. So, there’s a citation in the report where 20% of a patient’s outcome is due to actually what happens clinically. And it’s this other 80% that influence the true outcomes and their true recovery outside of the clinical space. So, this is a way to address and measure, potentially measure those issues. So, I can give the patients the right medication, the right equipment that they might need to go home and even arrange follow up appointments. But once they get home, there may very well be barriers to them complying with what I’ve prescribed for them and getting access to the follow up care and conditions they need to properly heal.

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Tom Temin So, for example, if someone had knee replacement and there’s a lot of follow up PT that has to happen. But if the social determinants say, well, they live alone or they live in a rural or difficult area or some way, they’re not inclined to do the follow up work, they still won’t be able to walk very well.

Julie Kroviak Yeah, absolutely. I might have said they need 30 minutes of exercise as well, but what if they can’t afford a, you know, to go to a gym or have equipment to exercise? Or what if the neighborhood isn’t even safe for them to walk in? What if I prescribe fresh fruit, vegetables, and fish, but there’s not a grocery store in their neighborhood, or they can’t afford that type of food? There’s a disconnect there, and it will absolutely influence their outcome.

Tom Temin Right. So, what could the clinicians then do? Knowing what someone’s circumstances are? They can’t change the circumstances, right?

Julie Kroviak But they can target them with support services. You just have to dig deep and doing what is a psychosocial analysis, particularly at these points where we’re sending a patient to a different level of care. So, transitions of care are high risk for patients. So, when I put someone from an ICU into a regular medicine floor there’s a risk. The biggest risk is when I have them in the hospital. And then I’m preparing them to go home. We need to make sure that we understand where exactly we’re sending that patient to. And you’re right. We can’t buy the patients a new house. We can’t go pick them up every time and take them to their appointments or take them grocery shopping. But we have to look at services to coordinate overcoming these barriers. And some of them are unique to the VA. So, VA can supply some of these services, but also coordinating with community services, you know, state, local, you know, counties, city support systems that veterans will be eligible for as well. But if we don’t know the barriers, we can’t target them.

Tom Temin And who in VA in the whole chain of events, from admitting someone to discharging them, is the best, most qualified to conduct that evaluation and to start arranging what services might be needed?

Julie Kroviak Yeah. So, there’s lots of players on this stage. So certainly, the clinical staff, like the attending physician, is ultimately liable for making sure the patient is going home with the appropriate care they need as well as the education. But it is a social worker position that sort of assumes a starring role at this transaction. So the information can be provided, the prescriptions can be written, the follow up visits coordinated, pharmacy is on board physical therapy if need be, but it is the social worker who ensures that the patient understands and caregivers understand what they need to comply with, and then have an in-depth discussion to talk about barriers and then coordinate services that can support overcoming those barriers once that patient’s home so they can stay home, that they’re not readmitted for the same exact reason that they were admitted previously for.

Tom Temin And VA has this type of staff on board.

Julie Kroviak So they certainly have social workers. And, you know, we surveyed and interviewed across the system at 120 facilities. So social workers for the most part played the dominant role in discharge planning. And that’s appropriate. But what we saw is they’re all sort of doing things differently. And that is the problem when there’s not a national guidance. Out there that locally, these teams are following to ensure this discharge process is completed across the board and that it can be measured. So, you can say, okay, look, they’re struggling in this part of the country with discharge at these V.A. hospitals. What’s going on? Is there an education problem? Is there a staffing shortage? Did they lose access to some community resources? How can we target our resources differently to correct this in real time?

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Tom Temin We are speaking with Julie Kroviak, deputy assistant inspector general for health care inspections at the Veterans Affairs Department. And getting to your actual study here. Your look at this. Did you find that this never happens, the use of these social determinants, or is it that VA doesn’t have a national policy for how it should happen?

Julie Kroviak Yeah. So, we found locally people are the social workers and the discharge teams are examining them but not identically across the system. So, they are missing opportunities to track and trend where they need to target resources. And when we interviewed local staff, they want guidance. They want a national standard that they can follow. The other thing that we really pushed for with our recommendation is to make it look the same in the electronic medical record. So have a template that is really a critical checklist to make sure all the players are on board, that all these functions have, you know, been completed prior to sending that patient home again. That way you can track and trend and target support when you need to.

Tom Temin It sounds like you’ve set the electronic health record project back another two years.

Julie Kroviak Well, so we have to be thoughtful as we recommend, you know, templates and things that are specific to the HR because we recognize they’re going under a massive transition. But there are, we think, interim solutions. And we asked them to consider those potential solutions and roll those out so that before we’ve put Cerner across the board, we don’t need to wait for that to address these critical issues.

Tom Temin And it sounds then as if there are two levels at which this needs to operate. One, the care center directors need to make sure it happens in their care staff throughout the country at the different medical facilities, but also the national policy and the approach. That would be like at the Dr. Elnahal level.

Julie Kroviak Sure. So, you know, we appropriately send all these recommendations to Doctor Elnahal, the undersecretary for health, but we are asking for Central Office VA to put forward the guidance and make sure that at the local level, there is compliance at that front line exchange. When you’re sending a patient home, make it look the same in terms of the processes that have to be run through or at least considered, and make it relevant to the local conditions that a patient is facing. We get it. Topeka looks different than Boston, but if you have a structure through which you’re going through to assess the patient’s needs and risk at discharge, you can capture all these risks effectively.

Tom Temin Are there any private sector models of this that the VA could look at?

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Julie Kroviak So I have to say we didn’t look at industry standards for this, but no one does. Social services and support like VHA. There are so many programs in place to support veterans because veterans have incredibly unique needs. No one knows veterans like VA, but that doesn’t mean they can do everything. So, one of our recommendations really enforces the need to make sure, at the local level, these discharge teams know what community resources are in place, and veterans are eligible for supplementing and enhancing what VA can do to support these veterans when they’re discharged home.

Tom Temin And with respect to the recommendations to have this policy and to make sure it happens; did VA generally agree with you?

Julie Kroviak Yeah, they were actually, I think, very appreciative of this unique look into their discharge process and bringing forward this topic that isn’t really new to medicine at all. It’s just starting to get some important attention to say, hey, this is really interfering with our patients getting well and then being readmitted for the same conditions over and over again. So, the clinical experts and leaders at VHA certainly recognize the need for this and appreciated our luck and concurred with our recommendations.

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