Improving Transitions of Care for Veterans Transferred to Tertiary VA Medical Centers.

Veterans are often transferred from "spoke" Veterans Administration (VA) clinics or hospitals to "hub" tertiary VA hospitals for advanced inpatient care, but they face significant barriers to safe transitions home. The Transitions Nurse Program was developed as an intervention to address the unique needs of this population. A difference-in-differences (DiD) analysis was used to compare outcomes between 303 veterans enrolled in this program and veterans transferred from the same spoke sites to a second, similar tertiary VA hub. Veterans enrolled in the program had significantly increased rates of follow-up with their primary care clinic within 14 days of discharge (DiD estimate: 10.43%, 95% confidence interval = 1.20 to 19.66), and a trend toward fewer unplanned 30-day readmissions (DiD estimate: -6.9%, 95% confidence interval = -14.2 to 0.31%, P = .06). There were no significant differences in 30-day emergency department visits or costs. Lessons learned from this preliminary intervention can inform implementation at other VA and non-VA sites.