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2019 HSR&D/QUERI National Conference Abstract

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1024 — Advancing VA-Community Healthcare System Partnership under the Veterans Choice and VA MISSION Acts: A Model of Interorganizational Care Coordination

Lead/Presenter: Lynn Garvin,  COIN - Bedford/Boston
All Authors: Garvin LA (VA Boston Healthcare System, Boston University School of Public Health), Miller CJ (VA Boston Healthcare System, Harvard Medical School Department of Psychiatry), Vincenti MP (VA Rural Health Resource Center-White River Junction/VHA Office of Rural Health, White River Junction VA Medical Center) Lee PW (VA Rural Health Resource Center-White River Junction, VHA Office of Rural Health) Lee RE (VA Rural Health Resource Center-White River Junction, VHA Office of Rural Health) Gurewich D (VA Boston Healthcare System, Boston University School of Medicine Department of General Internal Medicine) Pugatch M (VA Boston Healthcare System, Brandeis University) Koppelman EA (Boston University School of Public Health) Pendergast JN (VA Boston Healthcare System) Clark JA (Boston University School of Public Health)

Objectives:
The US Department of Veterans Affairs (VA) is undergoing major transformation to provide Veterans with timely access to efficient, high quality care. Under the Veterans Choice and VA MISSION Acts, more than 2.2 million "dual eligible" rural Veterans receive care from both VA and community providers. VA's repositioning as a responsive partner offers implementation opportunities, such as in interorganizational care coordination (ICC): the shared care of patients by independent healthcare systems. Developing a clinician-driven ICC model could guide collaboration between many independent systems for more effective care.

Methods:
We conducted 22 semi-structured interviews and 2 focus groups (N = 39 respondents overall) with care coordinators, physicians and leaders of rural New England hospitals and VA medical centers regarding interactions with Veterans and each other. Findings guided a literature review of 83 peer-reviewed articles on care coordination focused on rural and multi-system settings. Based on interview themes and literature review findings, we developed a conceptual model of ICC.

Results:
Findings revealed the complexities of interorganizational care coordination. The resulting model addresses factors such as health system size, complexity and culture; and contrasts routine communication among frontline providers for normal patient cases vs. data-driven, shared decision making for acute and chronic cases.

Implications:
This model suggests that quality of multi-system care coordination relies on how clinicians balance functional and relational coordination mechanisms. ICC is positively impacted when: (1) patient population complexity determines clinicians' choice of (2a) provider social networks (for joint task definition and accomplishment); (2b) mechanisms (tasks, accountability, communications and information systems); and (3) care transition settings (e.g. hospital-to-home, chronic care by multiple medical homes). Model elements are consistent with themes voiced by VA and community providers and literature review.

Impacts:
This presentation offers a novel, clinician-driven model of interorganizational care coordination. As VA expands its learning healthcare system to community partners, it can leverage current innovations in in-person communication (e.g. Office of Care Coordination) and electronic communication and data-sharing (e.g. Office of Connected Care's Mobile and Telehealth Services) into multi-system pilots. Such ICC advances may accelerate Veterans' access to high quality care and promote VA-community engagement to forge change.