Combined Assessment Program - Evaluation of Coordination of Care in Veterans Health Administration Facilities

The purpose of the review was to evaluate discharge planning for Veterans Health Administration inpatients with the following selected post-discharge needs: (1) special diet, (2) weight monitoring, (3) wound care, and (4) prosthetics (supplies and/or equipment). We conducted this review at 50 Veterans Health Administration medical facilities during Combined Assessment Program reviews performed across the country from October 1, 2013, through September 30, 2014. Although we observed many positive practices, we identified four opportunities for Veterans Health Administration facilities to improve. We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that: Clinicians provide and document discharge instructions for all identified needs. Clinicians reassess patients’ learning needs prior to providing important instructions, including discharge instructions. Clinicians reconcile conflicting needs and instructions before discharging patients. Patients receive ordered post-discharge referrals.