3001 — Primary Care Directors' Report of Coordination of Care Problems with Medical Specialty Outpatient Care
Rose DE, Farmer MM, Taylor SL, and Canelo IA, Greater Los Angeles VA; Schectman G, Acting Chief Consultant for Primary Care; Stark RC, Chief, Primary Care Operations; Rubenstein L, and Yano EM, Greater Los Angeles VA;
VA patients commonly have one or more chronic conditions, requiring many patients to obtain medical subspecialty care outside their VA patient-centered medical home in primary care (PC) in the “medical home neighborhood.” Given that VA’s medical home model—patient aligned care teams (or PACTs)—is responsible for coordinating care outside of PC, we evaluated PC reports of care coordination problems and identified their organizational determinants.
Using the national PC survey (2008) (n = 229, 92% response rate), we surveyed the census of VA Medical Centers (VAMC) and larger Community Based Outpatient Clinics (CBOCs) about the degree to which coordinating medical specialty outpatient care represented a management challenge to their primary care practice. Responses regarding care coordination were dichotomized (e.g., extremely/moderately challenging vs. somewhat/slightly/not at all challenging). Using resource dependence theory to guide variable selection, we performed bivariate and multivariate logistic regressions and identified organizational determinants of coordination problems.
Nationally, 28% of directors reported moderately to extremely challenging care coordination problems with medical specialty care. Sites reporting sufficient supply of specialty care providers, sufficient informatics/computer support, and greater authority over specialty referrals were less likely to report challenges with care coordination (OR for specialist supply: 0.85, 95%CI:0.8-0.9, p <0.001; OR for sufficient informatics: 0.5, 95%CI:0.3-0.9, p <0.05; OR for specialty referral authority: 0.6, 0.4-0.9, p <0.05), after controlling for facility type (VAMC vs. CBOC) or size (e.g., number of PC patients). There were no significant area-level variations.
A substantial number of PC programs experience significant challenges in coordinating care with outpatient medical specialists. Organization-level determinants included problems with specialist supply, insufficient informatics resources, and poor PC-specialty referral relationships where PC lacks authority to obtain timely referral results. Interestingly, these challenges uniformly affected PC practices at VAMCs and CBOCs.
VA PACTs are expected to coordinate patients’ care beyond PC to streamline Veterans’ care experiences. Not all challenges are within their influence (e.g., specialist shortages), however some challenges may be amenable to policy and resource attention (e.g., infusion of informatics resources and improved service agreements regarding specialty referrals).