The study had three parts:

Part 1: Patients (or their home caretakers) who live outside of Denver and receive their primary care at a location other than the Denver VAMC were interviewed after their discharge. The interview covered the patient's perspective about the transition of their medical care from the Denver VA to their primary care facility.

Part 2: Primary care providers from the VA facilities that refer patients to the Denver VA were interviewed regarding their opinions of transition process from the Denver VA back to the primary care VA facilities.

Part 3: The data from the above interviews were used to develop an intervention to improve the transition process from the Denver VA back to the primary care VA facilities.

Aim 1 was to describe barriers and facilitators of the transition process from hospital to home through qualitative interviews among patients discharged from Denver VA Medical Center (tertiary facility) after being transferred from a primary care VA.

Aim 2 was to describe barriers and facilitators of the transition process through qualitative interviews among providers at primary care VA facilities who take care of patients discharged from the Denver VA Medical Center for a cardiac condition.

Aim 3 was to pilot test the transitions of care intervention that targets patients and providers to evaluate the feasibility of the intervention to improve process of care measures, including: 1) PCP follow-up within 2-4 weeks of hospital discharge; 2) medications reconciled between pre and post-hospital discharge; 3) discharge summary available to PCP at time of visit; and 4) patient awareness of symptoms that require medical attention. This pilot was informed by the interviews from Aims 1 and 2 and best practices from the literature. Finally, as part of Aim 3, the primary care providers who saw the patients who completed the pilot were contacted to ask for their input and feedback regarding the pilot project.

Description of Enrolled Population: Study Design and Research Methods This was a mixed methods study where both qualitative and quantitative methods were employed. Through a series of qualitative interviews (n=26), potential barriers and facilitators of the current discharge process were assessed in this hub and spoke model of cardiac care. Informed by these interviews, the transitions of care intervention refined elements from prior studies that have improved this transition process. Finally, a pilot test of this intervention was implemented to assess the effectiveness of the intervention to improve important processes of care during this transition period among patients (n=8) discharged from Denver VAMC after transfer from a primary care VA facility.

Inclusion Criteria:

Aims 1 and 3:

• Patients transferred from primary care VA facilities (i.e., Cheyenne, Grand Junction, Sheridan, Ft. Harrison) for cardiac care (e.g., heart failure, acute myocardial infarction) or procedures (coronary angiography, pacemaker implantation) to the Denver VAMC and discharged home to follow-up with their primary care provider, were eligible.

Aim 2:

• Providers from VA primary care facilities, (i.e., Cheyenne, Grand Junction, Sheridan, and Ft. Harrison) who took care of patients discharged from the Denver VAMC for cardiology care, were eligible for the qualitative interviews.

Exclusion Criteria:

Aims 1 and 3:

• Exclusion criteria included:

  • Planned discharge to nursing home or skilled nursing facility;
  • Irreversible, non-cardiac medical condition (e.g. metastatic cancer) likely to affect 6-month survival or ability to execute study protocol;
  • Lack of telephone/ cell phone; and
  • VA is not their primary source of care or their PCP is not in the VA system.

Aim 2: There were exclusion criteria.