Traumatic brain injury (TBI) is the signature wound of Operation Enduring Freedom/Operation Iraqi Freedom Veterans. Reflecting the priority placed on caring for their needs, VA established 22 Polytrauma Network Sites (PNS) for post-acute rehabilitation. TBI can occur in combination with other disabling conditions that require ongoing interdisciplinary care. Coordination of care remains challenging, and further study is needed to understand variation across PNSs on two known factors related to outcomes: level of structural integration and coordination (SI/C) mechanisms. SI includes organizational features like formal reporting relationships, decision-making processes, team composition, and physical space. Regarding coordination, key distinctions have been made between relational coordination, programming, and feedback as mechanisms for achieving communication among providers needed for effective patient care.
To apply previously developed interview and survey measures of SI/C to PNS clinic providers involved in TBI care, and to adapt those measures to suit this population while maintaining their reliability.
In Phase 1 we modified an existing SI measure for use in the PNS clinic context, which was reviewed by a PNS clinic director to ensure adequacy. The refined measure was then administered to the other 21 PNS clinic directors. Information obtained from Phase 1 informed the Phase 2 coordination measures. These instruments were administered to two focus groups comprised of PNS clinic core providers and staff to which the PNS clinics make referrals. Staff provided feedback on how to improve the surveys. Based on these results, in Phase 3 we created a web-based coordination survey and administered it to providers at 10 randomly selected PNSs. The psychometric properties of the coordination scales were then assessed.
In Phase 1, the number of providers per team varied significantly between sites, ranging from 3 to 14 (based on 18/22 PNS clinic director responses). The final coordination measure developed in Phase 2 and tested in Phase 3 had good internal consistency and test-retest reliability. Based on 76/294 responses, the Cronbach's alphas for the programming and feedback scales were .84 and .95, respectively. The test-retest reliabilities were computed at two points in time, approximately 3 weeks apart. For the adapted coordination approach measures (based on 31/76 responses), r = .76 and .80 for the programming and feedback scales, respectively. The correlations between the relational coordination indices were .90 for core staff rating of referral services, and .92 for referral staff ratings of core services.
Findings from future research based on this pilot study may ultimately identify organizational structures and coordination processes that represent best practices for fostering effective rehabilitation programs for those with multiple, chronic conditions in current and future systems of care.
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Grant Number: I01HX000281-01
None at this time.