Health Services Research & Development

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Response to Commentary

Care coordination is nearly always listed as a key feature in descriptions of new patient-centered primary care models, such as VA's Patient Aligned Care Teams (PACT). Truly coordinated care holds promise for improving patient care and reducing costs by preventing negative outcomes, increasing efficiency, and avoiding unnecessary or duplicative services. Coordinated care, and the level to which it is achieved, has rarely been defined or measured in evaluations of these new models. In bringing together the definitions, measures, and actions related to care coordination in PACT, Shear and Corrigan have provided the beginnings of a map between theory and implementation for care coordination within new models of primary care.

Care coordination is necessary whenever two or more parties need to perform distinct tasks related to a patient's care. 1 Those involved may include primary or specialty care providers, other members of the health care team (e.g., nurses, pharmacists, social workers), informal caregivers, or the patient. Using this broad conceptualization, it is difficult to think of scenarios in modern medicine that do not require at least some care coordination, especially with the rising prevalence of chronic disease. Yet, or perhaps because of this, care coordination is a longstanding, tenacious, and pervasive challenge in health care. As noted by Shear and Corrigan, coordination is particularly challenging across transitions in settings and care providers, such as between inpatient and outpatient care, primary and specialty care, and care that crosses health care systems, such as VA and non-VA care.

As described by Shear and Corrigan, since 2010 VA has invested heavily in establishing structures and processes to facilitate care coordination within implementation of PACT. PACT notification of admissions, PACT involvement in discharge planning, and post-hospitalization phone calls aim to coordinate care across inpatient and outpatient transitions. Consult monitoring, electronic consultations (e-consults), and videoconferencing between primary care and specialist providers are tools to coordinate care between primary and specialty care. Providers facilitate care coordination between VA and non-VA providers by explicitly asking Veterans about their use of non-VA care and providing Veterans with electronic access to portions of their VA medical record. This represents considerable progress. However, more is needed for VA to fully realize its aim of providing highly-coordinated, seamless transitions in care.

Compared to prior primary care models, PACT provides substantially more support for care coordination and communication. Yet, gaps remain in promoting bidirectional provider communication, which is foundational for care coordination. For example, while VA's electronic medical record (EMR) allows all VA providers to view a complete record of care that has been delivered by other VA providers and in distant VA settings, and selected information can be "pushed" to providers by using an "additional signer" mechanism, these communication mechanisms are either passive or, at best, unidirectional. The recent innovation of e-consults appears to improve communication, but again, in its current implementation is unidirectional—i.e., in most cases, the primary care provider asks a specialist a question and receives an answer without discussion. More difficult still is achieving bidirectional communication with non-VA providers; as highlighted by Shear and Corrigan, achieving even consistent unidirectional communication in this area would be a major advance.

New communication tools show great promise for improving coordination, but further research is needed to fully understand their most appropriate, effective, and efficient uses. Videoconferencing, for example, can build communication and collaboration across distances, yet is only beginning to be understood in terms of its optimal use for care coordination.

Studies have also shown that more intensive care coordination interventions may be needed for certain patient populations. 2 Research is needed to identify the patients who may need more (or less) coordination assistance when transitioning across health care settings, providers, or systems. Akin to clinical trials assessing the appropriate dose, and differences across patients, there are likely different "dosages," of care coordination needed for different patients, depending on their medical, social, or personal characteristics.

In addition, given VA's core educational mission, interdisciplinary training for achieving coordination needs development. Optimal care coordination requires special skills in collaboration, communication, and teamwork. 3 In all of the above actions, and those mentioned by Shear and Corrigan, assessment and improvement of training is needed to achieve optimal care coordination in PACT.

In conclusion, successful VA development, implementation, and research on care coordination will have a positive impact on all VA patients. Further, as the issue of care coordination gains increasing attention nationally, VA, as a large, fully-integrated health care system with a comprehensive EMR, and having already made significant strides in this area, is primed to be a leader in both innovation and research in this important topic.

  1. McDonald, K.M. et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination). Rockville (MD): Agency for Healthcare Research and Quality (US) 2007.
  2. Scott, I.A. "Preventing the Rebound: Improving Care Transition in Hospital Discharge Processes," Australian Health Review 2010; 34(4):445-51.
  3. Press, M.J. et al. "Care Coordination in Accountable Care Organizations: Moving Beyond Structure and Incentives," American Journal of Managed Care 2012; 18(12):778-80.