Perspectives of Nurses in the VA Coordinated Transitional Care (CTraC) Program: A Qualitative Study

The Coordinated Transitional Care (CTraC) program is an evidence-based, nurse-driven, low-cost intervention that improves transitional care for geriatric patients following hospital admission. CTraC reduces readmissions and enhances outcomes for older Veterans with chronic conditions or minimal caregiver support.

This program evaluation was a component of the US Department of Veterans Affairs (VA) Geriatric Learning Health System initiative, which seeks to support community-dwelling older Veterans as they transition from hospital to home. We examined CTraC's operation across diverse hospital settings and identified critical transitional processes and contextual factors supporting patients transitioning from hospital to home. Our goal was to identify lessons to support the widespread deployment of CTraC systemwide.

Semi-structured interviews were conducted with CTraC nurses at 11 VA hospitals. Qualitative data explored program set-up, protocol use, data tracking, program challenges and successes, and readmission reduction strategies. Comparison matrices were developed within a rapid qualitative analysis approach.

CTraC nurses act as the point person for Veterans, address concerns, provide guidance, and resolve potential issues before escalation. Five themes emerged on CTraC alleviating gaps in transitional care and the program's organizational factors impacting implementation and sustainment. Nurses identified and addressed problems, including medication issues, follow-up appointment scheduling, in-home safety issues, and handling tasks overlooked by other clinicians. Interviews indicated variation in CTraC nurses' ability to track data, integrate CTraC into existing systems, and communicate program effectiveness with leadership. Sustainability challenges (e.g., facility decommissioning CTraC due to limited leadership awareness of program effectiveness) highlighted the need for enhanced data infrastructure and analytic support to report program efficacy.

Adaptation and feedback-driven refinement are critical to expanding CTraC's impact and promoting sustainment. Strengthening data feedback support and workforce resources may enable CTraC to sustain its adaptive, patient-centered approach to transitional care for Veterans.