Lead/Presenter: Ekaterina Anderson,
COIN - Bedford/Boston
All Authors: Anderson E (Center for Healthcare Organization and Implementation Research, VA, Bedford, MA), Soylemez-Wiener R (VA Center for Healthcare Organization and Implementation Research, Bedford, MA; The Pulmonary Center, Boston University School of Medicine), Resnick K (Boston University) Hoffer-Gittell J (Heller School for Social Policy and Management, Brandeis University) Elwy AR (VA Center for Healthcare Organization and Implementation Research, Bedford, MA; Department of Psychiatry and Human Behavior, Brown University, Providence, RI) Rinne ST (VA Center for Healthcare Organization and Implementation Research, Bedford, MA; The Pulmonary Center, Boston University School of Medicine, Boston, MA)
As a learning healthcare system, the VA's approach to reducing high hospital readmission rates for chronic obstructive pulmonary disease (COPD) exacerbations must be evidence-based. However, evidence is lacking on the organizational factors underlying inter-site variation in COPD readmission rates, including differences in care coordination. To address this gap in knowledge, our primary objective was to describe differences in COPD care coordination at VA sites with high vs. low readmission rates through the perspectives of local providers.
We used positive-deviance methods, which first involved selecting six sites based on COPD readmission rates, including three VA sites in the lowest readmission quartile and three in the highest quartile. We then conducted semi-structured interviews with primary care and specialist providers involved in inpatient and/or outpatient COPD care at the selected sites. Using Relational Coordination Theory to guide qualitative analysis, we identified contrasts and similarities between accounts from interviewees at sites with low (n = 14) vs. high (n = 11) readmission rates.
All sites had ongoing initiatives to improve care, but only providers at low readmission sites described practice environments with robust care coordination for patients with COPD. Specifically, they referenced strong work relationships and high-quality communication between outpatient and inpatient providers and between primary and specialty care providers. By contrast, providers at high readmission sites described relationship and communication challenges. In addition, low readmission site providers reported fewer structural barriers in such areas as availability of outpatient care, patient volume, and co-location between pulmonologists and other specialists.
The most notable difference between VA sites with low vs. high readmission rates for COPD had to do not with specific readmission-reduction initiatives, but with the quality of inter-provider relationships and communication, as reported by providers themselves. Low readmission site providers described environments with more robust care coordination and fewer structural barriers.
Our results can inform future organizational reforms aimed at reducing readmission rates for COPD. Furthermore, since organizational factors underlying successful care coordination are not COPD-specific, this study has implications for improving quality of care and reducing readmissions for other chronic conditions, thus contributing to the VA's ongoing transformation into a learning healthcare system.