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HSR&D Researchers Develop Online Toolkit to Improve Primary Care Coordination within VA and with Community Providers

Inefficiencies in care coordination for chronic conditions are a significant source of waste in the US (e.g., $25-$45 billion in 2011). Recent VA legislation allowing more patients to seek care from community providers has further complicated care coordination in VA primary care practices, in which patients already have higher rates of comorbidity than their private-sector counterparts. The Coordination Toolkit and Coaching (CTAC) project aims to improve patients' experience of care coordination, while also developing better methods for bringing research evidence on care coordination into routine care. In this article, investigators describe CTAC's first phase, which involved selecting tools for an online care coordination toolkit and developing a VA Intranet site to support the tools. Candidate tools (n=300) were identified and underwent a three-step process to determine if they should be included in the final toolkit: 1) initial screening to identify tools relevant to care coordination in VA primary care; 2) a two-clinician expert review process assessing tool characteristics and assigning each tool a summary rating; and 3) semi-structured interviews with Veterans, frontline clinicians, and staff.


  • The final Care Coordination Toolkit, available on the **VA Intranet** (you must access within VA firewall), provides access to 18 tools that remained after the selection process noted above, as well as detailed information about tools' expected benefits, and the resources required for tool implementation.
  • The 18 tools cover 5 topics: 1) managing referrals to specialty care, 2) medication management, 3) patient after-visit summary, 4) patient activation materials, and 5) provider contact information for patients.


  • The CTAC project is expected to improve care coordination in VA primary care clinics and provide readily-applicable methods for spreading improvements throughout VA. In addition, the project will inform VA policymakers regarding what other implementation strategies, including the use of distance coaching, might influence the use of toolkits within healthcare delivery systems.


  • Investigators had limited resources to find tools and to interview prospective users about their appropriateness. Therefore, they identified candidate tools using a snowball approach, beginning with known existing online resources. A more systematic tool identification strategy and a broader set of user interviews may have resulted in a different set of tools being selected.

This study was funded through VA HSR&D's Quality Enhancement Research Initiative (QUERI). Dr. Ganz leads the Care Coordination QUERI program and is Associate Director of HSR&D's Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA.

PubMed Logo Ganz D, Barnard J, Smith N, et al. Development of a Web-based Toolkit to Support Improvement of Care Coordination in Primary Care. Translational Behavioral Medicine. June 2018;8(3):492-502.

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HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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