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Health Services Research & Development

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HSR&D In Progress

June 2018

In This Issue: Care Coordination
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Identifying and Delivering Point-of-Care Information to Improve Care Coordination

Feature Article

Veterans are in particular need of optimal care coordination given that many suffer from multi-morbid conditions, mental health problems, and a challenging socioeconomic environment. Multidisciplinary care teams, such as VA’s Patient Aligned Care Teams (PACTs), have been proposed as one of several strategies to improve care coordination in the primary care setting. For such a strategy to succeed, PACT members must excel at the act of coordinating, such as working collectively on interdependent tasks to deliver evidence-based care that could not be accomplished as effectively by a single provider. However, the ability to monitor team coordination is still in its infancy, and a clear understanding of the objectives and standards of coordination, as well as the information needs at the point-of-care, are essential to successfully coordinating care.

This ongoing HSR&D study seeks to determine the point-of-care information PACT members need to successfully coordinate care, with a special emphasis on three high-risk patient care scenarios: patients with uncontrolled diabetes mellitus, patients at risk for delayed cancer diagnosis, and patients with congestive heart failure and sub-optimal medication dosage after a recent hospital discharge. Point-of-care information needs center on two main areas: Patient information (i.e., current contact information, current health summary, and assessment of patient computer literacy), and a need for common understanding between both patients and PACTs (i.e., knowing what options are available, and why certain procedures/process matter), as well as within the PACT (i.e., feedback to PACTS regarding patient satisfaction).

Thirty-four PACTs representing four facilities from VISNs 12 and 16 participated in a controlled trial testing the effectiveness of a team-based audit-and-feedback intervention at improving performance on the coordination indicators developed in the initial part of this study (i.e., percentage of patient appointment started on time, patient satisfaction, clinical reminder completion). An additional 34 matched control teams from five VA facilities were followed passively. The research team will monitor coordination for up to one year after the end of baseline. Differences in coordination across sites then will be assessed.


Recommendations from focus group participants (11 clinical personnel) for improving coordination at the point-of-care included adjustments to the workflow, direct feedback to all PACT members (not just the provider), training and education for both patient and staff regarding available services and options – and "the whys and wherefores" of processes, dedicated resources (staff, equipment), and improvements to patient-related communications. Findings identified numerous process changes needed to improve care coordination, including:

  1. Improvements to information technology and changes to CPRS (computerized patient record system) programming to facilitate information;
  2. Training/education for patients and for PACT members on selected aspects of coordination; and
  3. Management buy-in to facilitate suggested changes.

This project has identified a set of practical, feasible, and prioritized behavioral measures of care coordination in PACT settings, which in conjunction with regular feedback, can help PACTs pinpoint areas for improvement. These measures have the added benefit of already existing or being readily calculated from VA data sources. Importantly, the identified measures and the recommendations for point-of-care tools and improvements relate to processes and improvements in communication and team functioning generally, rather than any condition-specific initiative. These tools may be of even greater importance in the era of Choice. Finally, the project also helps advance the science of implementation of team-based coordination tools, by identifying elements of coordination that are important regardless of clinical condition or disease – and by highlighting the importance of dose consistency in team-based feedback interventions for coordination.

The implementation evaluation will help identify the requirements for successful implementation of this and similar interventions in primary care team settings.

Principal Investigator:  Sylvia Hysong, PhD, is part of HSR&D’s Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Houston, TX.


Weaver S, Che X, Petersen L, and Hysong S. Unpacking care coordination through a multi-team system lens: A conceptual framework and systematic review. Medical Care. March 1, 2018; 56(3):247-259.

Identifying and Delivering Point-of-Care Information to Improve Care Coordination project abstract

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