The authors share a model that facilitates patient-centered care and can be adopted by other health systems to promote a successful transition of care for the traveling patient.
Am J Manag Care. 2021; 27 (11): In the press
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Points to take away
- We provide a framework for how high quality, consistent, and timely care for the traveling chronic illness patient can be delivered nationwide.
- The Veterans Health Administration’s Traveling Veterans Program facilitates patient-centered care and can be adopted by other integrated health systems.
- Future research should focus on implementing existing models of travel coordination programs and integrating electronic health records while maintaining high quality care.
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As the rollout of the COVID-19 vaccine continues, people are starting to travel again. Before the pandemic, travel was an integral part of everyday life. Many baby boomers traveled to hang out with loved ones, change their residence seasonally, or just enjoy retirement.1 Nearly 80% of older adults have at least 2 chronic illnesses that require regular health care.2 A survey conducted by AARP In 2019, 32% of baby boomers felt their health was a major barrier to travel.1 The Veterans Health Administration’s (VHA) Traveling Veterans Program (TVP) provides a framework for care transitions for patients with chronic conditions, across the nationwide healthcare system through the use of integrated electronic health records (EHRs) and a structured care transition program.
Established in 2015, TVP ensures veterans receive uninterrupted patient-centered care regardless of their location. A coordinator who is a nurse or advanced physician in a Veterans Affairs (VA) facility uses the EHR and communicates with the target facility to transfer care by registering the patient, appointments based on those recommended by the referring provider Scheduling appointments and bridging communication between patients and facilities.
Supply Transitions: Implementation in Non-VA Networks
The term nursing transitions refers to the movement of a patient between 2 healthcare facilities; Successful transitions require effective provider communication and patient engagement.3 In the private sector, specialized services such as home hospice and dialysis, which have access to a national network of facilities, have successfully carried out care transitions for traveling patients. These services use a coordinator to identify the appropriate destination facility, check insurance, schedule an appointment, and contact the patient.4,5 If a network does not have facilities at the patient’s destination, coordinators help find an alternative Establishment in the region.4, 5 Although large health systems such as Kaiser Permanente provide the ability to create medical records and accounts elsewhere within their system, it is the patient’s responsibility to obtain a local medical record number, identify the appropriate target facility, and schedule appointments 6 Structured transition of care programs can further improve the continuity of care for the traveling patient belonging to a large health care network.
Integrated EHR: Key to Mobility
Transferring medical records between different healthcare systems can be inefficient and time consuming. Large healthcare systems such as VHA and Kaiser Permanente benefit from an integrated EHR that facilitates continuity of care for a traveling or moving patient. Advances in EHR integration through programs such as Epic’s Care Everywhere and the CommonWell Health Alliance are enabling providers not affiliated with the same healthcare systems to electronically exchange records. Seamlessly transferring medical records for patients with complex chronic conditions is an important step in addressing health concerns as a barrier to travel.
Telemedicine: An Incomplete Solution
Telemedicine has grown in importance during the pandemic, and many providers and patients have adopted telemedicine as an alternative to face-to-face visits. Various state medical associations have changed restrictions on providers providing telemedicine follow-up care or prescribing non-narcotic medication for patients in another state.7 If these changes continue after the pandemic, it could extend continuity of care with a traveling patient’s primary provider . However, patients who do not live in a state with these changes or who require personal services such as procedures, laboratory tests, imaging, or intravenous medication, still need a way to avoid interruptions in care and avoid unnecessary emergency rooms or urgent care visits.
Patient satisfaction: case study
In the age of personalized care, patient satisfaction is recognized as a performance indicator for service providers and hospitals. We present the case of a patient aged 68 who receives all health care within the VHA. He was planning a trip to the United States but was diagnosed with metastatic cancer in January 2020. He was willing to cancel the trip as he needed intravenous immunotherapy, laboratory tests, and clinic visits, but his doctor recommended the TVP. Given his limited prognosis, the patient and his wife decided to drive across the country, following strict quarantine protocols while living in their RV and avoiding COVID-19 surge areas. He received timely cancer treatment through successful care transfers in 5 VA facilities.
The veteran said he had a fantastic experience and expressed his great appreciation for TVP, as otherwise he would not have been traveling for long periods of time and treating cancer. He was satisfied with the high quality and consistent support in all facilities, even though he met a new team every time. He recognized the complex logistics of the coordinator, such as patient registration, communication with patients and service providers as well as timely appointments based on his treatment plan. However, obstacles to patient navigation included providers unfamiliar with TVP when a referral was required for the next destination, the inability to independently schedule appointments without a coordinator, and the inability to understand the coordinator’s role in the process.
Communication: Successful handovers
Clear communication between facilities, service providers and the patient is crucial for successful handovers during care transitions. Similar to a hospital discharge summary, TVP requires the referring physician to provide the date that follow-up care is required, the specialty or primary care services that need to be scheduled, and a brief summary of the recommended treatment or monitoring at the next visit. Rather than requiring the patient to navigate the new patient process, TVP uses coordinators to act as bridges between facilities to convey critical information and confirm timely continuity of care. These coordinators ensure that the necessary information and documentation is available to facilitate patient handover. The improved communication enables patients to continue treatment as an established patient in the system. This shortens waiting times and improves timely access to health services.
Conclusions
Continuity of care for the traveling chronic illness patient is feasible and offers the opportunity to improve timely access to health care, patient satisfaction and quality of life. The VHA TVP facilitates patient-centered care and can be adopted by other healthcare systems to promote a successful transition of care for the traveling patient. In order to expand programs for traveling patients on a larger scale, future research should focus on implementing existing models of travel coordination programs and integrating EHR while maintaining high quality care.
Author connections: Center for Innovation in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center (DTC, JAD, YHS), Houston, TX; Department of Health Research (DTC, JAD, YHS) and Department of Hematology and Oncology (YHS), Faculty of Medicine, Baylor College of Medicine, Houston, TX.
Funding source: This project was supported by the Veterans Affairs Health Services Research & Development Service (IIR-14-101, PI: J. Davila) and the facilities and resources of the Center for Innovation in Quality, Effectiveness and Safety (CIN 13-413) and the Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX. The views expressed in this article are those of the authors and do not necessarily reflect the views of the funding institutions.
Information about the author: Dr. Sada reports that he has received a Veterans Affairs Seed Grant on an unrelated subject. The remaining authors report no relationships or financial interests with companies that would constitute a conflict of interest with the subject matter of this article.
Information on authorship: Concept and design (DTC, JAD, YHS); Acquisition of data (DTC, YHS); Analysis and interpretation of data (DTC, JAD, YHS); Preparation of the manuscript (DTC, JAD, YHS); critical revision of the manuscript to include important intellectual content (DTC, JAD, YHS); administrative, technical or logistic support (DTC); and supervision (YHS).
Address correspondence to: Debra T. Choi, PhD, MPH, Center for Innovation in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, 2450 Holcombe Blvd, Ste 01Y, Houston, TX 77021. Email: debra.choi@bcm. edu.
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https://healthy.kaiserpermanente.org/northern-california/get-care/traveling
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