Tools Used to Improve Care Coordination for High-Risk Veterans across Multiple Settings

January 28, 2021

Takeaway: The Improving PACT Coordination across Settings and Services: Coordination Toolkit and Coaching (CTAC) project clarifies the most effective strategies for improving care coordination between PACT, specialty care, and community care, while the Improving Emergency Department (ED) Coordination with PACT tool (ED-PACT Tool) improves coordination between ED and PACT for Veterans with urgent or specific ED follow-up care needs. The ED-PACT tool has been used more than 24,000 times across three VA sites (Los Angeles, New Jersey and West Palm Beach), and has been further adapted to support COVID care in Los Angeles, CA and inpatient and Clinical Contact Center communications in West Palm Beach, FL.

Led by David Ganz, MD, PhD, the Care Coordination QUERI program aims to improve care coordination and experience of care for high-risk Veterans in PACT (Patient-Aligned Care Teams), and develop novel approaches to coordinating care between the Veteran, his or her primary care team, and other settings, including specialty care, the emergency department, and home and community resources. Specifically, the Improving PACT Coordination across Settings and Services: Coordination Toolkit and Coaching (CTAC) project provides access to 18 tools covering the topics of managing referrals to specialty care, medication management, patient after-visit summaries, patient activation materials, and provider contact information. It also includes access to the coaching manual that CTAC coaches use to provide distance-based coaching. The Care Coordination Toolkit is currently available on the VA Intranet only at https:/vaww.visn10.portal.va.gov/sites/Toolkits/toolkit/Pages/Home.aspx. The Improving Emergency Department (ED) Coordination with PACT (ED-PACT Tool), whose development and implementation was led by Kristina Cordasco, MD, MPH, MSHS, improves coordination between ED and PACT for Veterans with urgent or specific ED follow-up care needs by facilitating messages from ED providers to PACT nurse care managers. Further information about the ED-PACT Tool, and implementation materials, are available on the VA Intranet at: https://dvagov.sharepoint.com/sites/vhathe-ed-pact-tool/SitePages/ED-PACT.aspx (VA network access only).

Impacts

• The CTAC project has been implemented in 12 clinics. One clinic spread its quality improvement intervention to 23 primary care teams.
• The ED-PACT Tool  has been used to coordinate care following more than 24,000 ED visits across three VA sites (Los Angeles, New Jersey and West Palm Beach), and has been further adapted to support COVID care in Los Angeles, CA and inpatient and Clinical Contact Center communications in West Palm Beach, FL.