Enhancing Veteran Care Through the Chicago Collaborative

The Challenge?

VA Chicago Healthcare System faces significant challenges in coordinating care for dual-eligible and tri-eligible veterans who use both VA and non-VA clinical services. The system serves over 60-100k veterans and their families, providing a wide range of services. However, knowledge gaps about available services at different locations and effective care coordination methods create potential issues in veteran care.?

Veterans face difficulties in accessing care despite the support provided for managing their health through prescription refills, secure messaging, scheduling, and accessing medical records. These services need augmentation to optimize efficiency and outcomes while maintaining affordability. Social determinants of health (SDoH) such as socioeconomic status, education, social support networks, food insecurity, housing instability, transportation challenges, and employment opportunities significantly influence health outcomes and contribute to health disparities among veterans.?

Goals & Key Objectives

Goals:?

• Design and launch a collaborative initiative involving key stakeholders, organized by ReefPoint Group and partnering with Impact Advisors and TransUnion.?

• Improve services to VA members by identifying opportunities to enhance and coordinate transitions.?

Key Objectives:?

1. Improve Care Coordination: Enhance communication and information sharing between discharge planners, coordination specialists, and VA and non-VA providers to create seamless, continuous care.?

1. Address Social Determinants of Health: Analyze factors such as housing, economic status, food security, social health, and access to care.?

1. Leverage Technology and Data Analytics: Identify areas for improvement and facilitate better care coordination and access to medical services.?

Our Process and Approach?

1. Capabilities Assessment: Identify VA capabilities, key points of contact, gaps, and needs for community care.?

1. Population Analytics: Analyze the veteran population to discover underlying trends and community care needs.?

1. Financial Forecasting: Price out solutions by leveraging analysis of gaps in coverage.?

Our Approach: The collaboration includes RPG, TU, and IA, leveraging their expertise in technology adoption, data analytics, information technology, and thought leadership. As healthcare organizations adapt to using both VA and non-VA services, the collaborative supports VA in moving towards a more efficient value-based care model with an emphasis on population health.?

The process begins with identifying healthcare executives' pain points, examining where VA members receive care, and understanding care transition strategies. Initial planning sessions with healthcare executives will outline challenges and primary analysis of the veteran population, considering SDoH such as housing instability, economic inequality, access to healthcare, food insecurity, social isolation, and transportation barriers.?

Parallel interviews with veterans and the community will help develop a holistic view of current needs. Insights into the specific needs, preferences, and challenges of isolated groups will inform subsequent meetings with healthcare providers to present findings and outline solutions.?

?

The Solutions?

The Chicago Collaborative, through the combined efforts of ReefPoint Group, Impact Advisors, and TransUnion, aims to enhance healthcare coordination and access for veterans in the Chicago area. By addressing care coordination, leveraging technology and data analytics, and tackling social determinants of health, this initiative strives to improve health outcomes and quality of life for veterans with respect, compassion, integrity, and inclusion at its core.?

Integrated Care Networks:?

• Establish networks combining VA facilities, community healthcare providers, social services, and veteran support organizations.?

• Use data analytics to identify trends, gaps, and areas for improvement, such as mental health services utilization.?

Telehealth Expansion:?

• Expand telehealth services to reach underserved veterans or those with mobility issues, facilitating easier access to medical and mental health care.?

• Develop targeted outreach programs to connect veterans with services, including mobile health clinics and veteran resource fairs.?

Transportation Services:?

• Implement transportation assistance programs to help veterans access healthcare facilities, addressing barriers like travel distance and traffic in a large city like Chicago.?

Community Care Coordination:?

• Ensure non-VA providers have access to veteran health records and clear communication channels with VA providers to improve care quality and continuity.?

Community Partnerships:?

• Form partnerships with local organizations to address food insecurity, provide job training, economic support, and offer social engagement opportunities to reduce isolation among veterans.?

Housing Initiatives:?

• Collaborate with local housing authorities and organizations to develop programs providing stable and affordable housing for homeless veterans or those at risk of homelessness.?

Implementation and Metrics:?

• Number of integrated care programs implemented, percentage of veterans enrolled, and reduction in hospital readmission rates.?

• Number of telehealth consultations, percentage of veterans with access, and satisfaction rates.?

• Number of veterans utilizing transportation programs and improved access to healthcare services.?

• Number of community partnerships, veterans served, and impact on food insecurity, unemployment, and social isolation.?

• Number of homeless veterans housed, reduction in homeless veterans, and stability of housing after assistance.?

The commitment to leveraging partnerships and focusing on social determinants of health underscores the initiative's holistic vision for supporting veterans in navigating their healthcare journeys. As the collaborative moves forward, its impact will be measured not only by the improved access and coordination of services but also by the positive changes in the lives of the veterans it serves, reinforcing a commitment to compassion, integrity, and inclusion in healthcare.