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Since undergoing a transformation of primary care into patient-centered medical homes (PCMH) via Patient Aligned Care Teams (PACT), VA has been increasing
efforts to address care coordination challenges. Veterans with complex health needs require additional care outside of PACT in the larger "medical
neighborhood," including care from specialists, emergency department, and inpatient, as well as care from non-VA or community providers. Guided by the
logic model outlined by Taylor et al, 1 we examined the prevalence of care coordination problems experienced in VA primary care before PACT implementation, and identified barriers and
facilitators to care coordination. While facilitators serve as examples of best practices, barriers indicate potential pathways to improved care
Our studies used data from two national surveys of VA primary care directors, both funded through research-policy partnerships. The VHA Clinical Practice
Organizational Survey (2007) asked primary care directors to report how frequently their providers encountered challenges in coordinating care with each of
25 different medical specialty clinics (e.g., neurology, cardiology) or allied health programs (e.g., pharmacy, physical therapy, social work). The VHA
Primary Care Survey (2008) asked primary care directors to assess the degree to which care coordination with other VA settings (e.g., medical, surgical,
and mental health specialties; inpatient and emergency care; and VA to non-VA settings) posed significant management challenges. We found widespread
reports of care coordination challenges. More than 80 percent of VA primary care directors reported frequent care coordination problems with at least one
medical specialty clinic. The most frequently cited clinics for care coordination challenges included neurology, cardiology, and gastroenterology. Across
different medical neighborhood settings, the most often-cited challenge was coordinating care between VA providers and non-VA or community providers.
Primary care directors cited sufficient primary care staff (e.g., doctors, nurses, physician assistants, administrators, clerks, and receptionists) as
facilitating care coordination. This finding highlights the time commitment required for effective care coordination, which can include requesting
consultations, setting up appointments for labs or diagnostic tests, explaining care plans to patients, making follow-up calls or sending e-mails if
consultation requests were declined, then reviewing specialty consultation letters sent back to primary care. PACT has designated RN care managers whose
roles explicitly focus on these care coordination tasks, however, early findings from the PACT Demonstration Laboratories suggests that care managers may
already be overwhelmed and that lack of role clarity and gaps in support staffing levels pose ongoing challenges.
We found that VA primary care practices with more fully implemented service agreements reported fewer care coordination problems. Serving as "contracts"
between primary care and specialty care clinics, service agreements can specify the types of patients that should be referred to specialty care, the kinds
of information required by specialists to act efficiently on consult requests (e.g., labs, diagnostic tests, some initial trials prior to consultation),
and timelines for consultations and communication—all of which help to prioritize referrals, clarify roles and responsibilities for clinicians, and enhance care coordination. The communication between
primary care and specialists required for developing service agreements may offer important opportunities to facilitate care coordination.
In another study, we described the prevalence of management challenges faced by primary care directors before PACT implementation. 3 While electronic medical records (EMRs) like VA's Computerized Patient Record System (CPRS) are widely cited as promoting effective coordination of care,
VA primary care directors' foremost challenges were actually related to information technology (IT): the burden of excessive CPRS alerts; the volume of
clinical reminders; the time and effort to input notes; as well as gaps in the adequacy of clinical informatics support. In additional analyses, we found
that the number of IT challenges were associated with care coordination challenges in the medical neighborhood. Addressing clinician challenges with EMRs
may be an opportunity for quality improvement interventions among clinicians and IT staff, to improve "end user" efficiencies and enhance clinicians' best
efforts to coordinate care.
Earlier studies found that patients with multi-morbidity face significant care coordination challenges. In our work, we identified a number of care
coordination challenges at the primary care clinic level, as well as barriers and facilitators to care coordination that are mutable, and amenable to
quality improvement interventions. Further study is needed to understand challenges to implementing best practices, and identifying additional strategies
to improve care coordination and optimize Veterans' care experiences.
The authors would like to acknowledge the contributions of Ismelda Canelo, M.P.A.; Michael L. Parchman, M.D., M.P.H. with the MacColl Center for Health
Care Innovation, Group Health Research Institute, Seattle, Washington; and Lisa V. Rubenstein, M.D., MS.P.H.
Taylor, E. et al. "Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms,"
White paper. AHRQ publication.
Rodriguez, H.P. et al. "Teamlet Structure and Early Experiences of Medical Home Implementation for Veterans,"
Journal of General Internal Medicine
2014; 29 Suppl 2:623-31.
Farmer, M.M. et al. "Challenges Facing Primary Care Practices Aiming to Implement Patient-Centered Medical Homes,"
Journal of General Internal Medicine
2014; 29 Suppl 2:555-62.