Optimizing care coordination to address social determinants of health needs for dual-use veterans.

ABSTRACT:

Background

Veterans increasingly utilize both the Veteran's Health Administration (VA) and non-VA hospitals (dual-users). Dual-users are at increased risk of fragmented care and adverse outcomes and often do not receive necessary follow-up care addressing social determinants of health (SDOH). We developed a Veteran-informed social worker-led Advanced Care Coordination (ACC) program to decrease fragmented care and provide longitudinal care coordination addressing SDOH for dual-users accessing non-VA emergency departments (EDs) in two communities.

Methods

ACC had four core components: 1. Notification from non-VA ED providers of Veterans' ED visit; 2. ACC social worker completed a comprehensive assessment with the Veteran to identify SDOH needs; 3. Clinical intervention address

SUBMITTER: Sjoberg H 

PROVIDER: S-EPMC8754195 | biostudies-literature | 2022 Jan

REPOSITORIES: biostudies-literature