Integration remains a signature challenge for healthcare. Fragmentation limits healthcare systems' ability to provide the right care, at the right time, at reasonable cost. This fragmentation is driven by several factors including the rapid expansion of medical knowledge and technology, and the related specialization among clinical professionals. These factors increase the number of hand-offs across organizational boundaries and geographic locations. In VA, major national redesign innovations such as Primary Care-Mental Health Integration (PC-MHI) and Patient-Aligned Care Teams (PACTs) have been initiated to promote integration across the boundaries of specialty, role, and physical location where information and patient hand-offs occur. The ultimate goal of these efforts is to enhance patient-centered care. However, the degree to which these integrating innovations at the structural and process level enhance the patient's experience of integrated care remains unknown.
The objectives of this study are to assess the extent to which Veterans experience their care as integrated, and to identify the alterable organizational characteristics and specific care processes that promote patient-experienced integrated care.
This is a mixed-methods study completed in two phases. In phase 1, we measured the extent of integrated care through patient and provider surveys, and administrative data from existing secondary databases. We then used patient, provider, PACT, and PC-MHI survey data to categorize sites by their level of patient-experienced integration (PEI) and provider perceptions of integration (based on PACT/PC-MHI implementation). Using these categorizations we chose 8 sites to be included in phase 2: 2 high, 2 low, and 4 mixed based on patient and provider data. In phase 2, leadership, managers and front line staff at the eight selected sites were interviewed using semi-structured interview guides to identify organizational characteristics and care processes that influence care integration.
In phase 1 we sent surveys to patients with diabetes and co-morbid conditions that differ on two dimensions -- domain (physical/mental health-related) and severity (low/high) -- and their providers. From these data we addressed the following questions: RQ1: how integrated is the care experienced by Veterans with diabetes, and does experienced integration vary among patients given differences in co-morbidity domain and extent of specialty care involvement, as well as differences in other patient-level characteristics? RQ2: in addition to patient-level characteristics, what provider and organizational characteristics relate to higher and lower levels of PEI among patients with different co-morbidity domains and severity? Using phase 2 interviews and phase 1 survey data, we also addressed RQ3: what specific policies, relationships within and between departments/services, managerial practices, and/or staff behaviors constitute the structures and processes that produce higher levels of PEI? For quantitative data analysis we used multiple linear regression with hierarchical modeling (RQ1-2). For qualitative data analysis, we used iterative qualitative methods, including the constant comparative method (RQ3).
Response rates for the provider and patient surveys were 30% and 49%, respectively. A total of 89 semi-structured interviews with providers across all eight sites were completed. Several themes emerged from ongoing coding of successes and challenges to integrated care. We found that patient-experienced integration is associated with strong PACT huddle practices, same-day access to mental health services, and strong medical center leadership (i.e., service chiefs and quadrad). Integration is generally strengthened by mental health providers, clinical pharmacists and dieticians embedded in primacy care. Provider-experienced integration is associated with innovative PACT programs, and working to the top of license. Turnover, hiring, service agreements, and difficulties in the referral process were challenges in our previous primary care study in 2009 and remain serious challenges across sites.
By identifying alterable organizational characteristics and specific care processes that promote patient-experienced integrated care, as well as by better understanding the extent to which Veterans experience their care as integrated, VA may change policies and procedures to improve integrated, patient-centered care. This study has identified factors directly affecting integration, as well as nuances in their use that determine whether the practice is a facilitator or barrier to integration. For example, having service agreements between primary care and specialties can facilitate integration in the presence of trusting working relationships and good communication but can be a barrier when such relationships and communication are not present. Such additional information not only increases our understanding of the organizational practices but also provides a needed perspective to effectively implement improvements.
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Treatment - Observational