The VA faces a plethora of care coordination challenges. Many Veterans have multiple conditions and providers, and many get a portion of their care in the community, a number that will only grow as recent legislation expands options for private care. These challenges have spawned new VA initiatives for redesigning care to meet them, described in this supplement in an editorial by Hosenfeld and colleagues. The VA Health Services Research and Development (HSR&D) service, in partnership with VA’s Office of Primary Care, and Office of Community Care, sponsored a State of the Art (SOTA) conference with the goals of (a) summarizing what is known about care coordination relevant to Veterans’ care; (b) identifying care coordination approaches ready for wider dissemination and implementation within VA; and (c) identifying a research agenda and recommendations, as appropriate, for increasing VA’s knowledge and use of evidence-based approaches for coordinating care. Held in March 2018, the SOTA was jointly planned by VA HSR&D and Offices of Primary Care, Community Care, Nursing Services, and Care Management and Social Work, and convened VA and non-VA health services researchers, clinicians, and policy makers. This supplement presents recommendations from the SOTA as well as original research papers on care coordination strategies within VA and between VA and non-VA providers

Atkins, David

Bastian, Lori A.

Bosworth, Hayden B.

Cordasco, Kristina M.

Hynes, Denise M.

Mattocks, Kristin M.

English

eScholarship@UMMS

University of Massachusetts Medical School eScholarship@UMMS Population and Quantitative Health Sciences Publications Population and Quantitative Health Sciences 2019-05-01 Improving Care Coordination for Veterans Within VA and Across Healthcare Systems Kristina M. Cordasco University of California, Los Angeles Et al. Let us know how access to this document benefits you. Follow this and additional works at: https://escholarship.umassmed.edu/qhs_pp  Part of the Epidemiology Commons, Health Services Administration Commons, Health Services Research Commons, and the Military and Veterans Studies Commons Repository Citation Cordasco KM, Hynes DM, Mattocks KM, Bastian LA, Bosworth HB, Atkins D. (2019). Improving Care Coordination for Veterans Within VA and Across Healthcare Systems. Population and Quantitative Health Sciences Publications. https://doi.org/10.1007/s11606-019-04999-4. Retrieved from https://escholarship.umassmed.edu/qhs_pp/1268 This material is brought to you by eScholarship@UMMS. It has been accepted for inclusion in Population and Quantitative Health Sciences Publications by an authorized administrator of eScholarship@UMMS. For more information, please contact Lisa.Palmer@umassmed.edu. EDITORIAL AND COMMENTImproving Care Coordination for Veterans Within VAand Across Healthcare SystemsKristina M. Cordasco, MD, MPH, MSHS1,2,3, Denise M. Hynes, PhD, MPH, RN4,5,Kristin M. Mattocks, PhD, MPH6,7, Lori A. Bastian, MD, MPH8,9, Hayden B. Bosworth, PhD10,11, andDavid Atkins, MD, MPH121VAHealth Services Research andDevelopmentCenter for the Study of Healthcare Innovation, Implementation and Policy, Los Angeles, CA, USA;2Division of General Internal Medicine, Department of Medicine, VAGreater Los Angeles Healthcare System, Los Angeles, CA, USA; 3Departmentof Medicine, University of California Los Angeles (UCLA) Geffen School of Medicine, Los Angeles, CA, USA; 4Center to Improve VeteranInvolvement in Care, Portland VAHealthCare System, Portland, OR, USA; 5College of Public Health and Human Sciences, Oregon State University,Corvallis, OR, USA; 6VA Central Western Massachusetts, Leeds, MA, USA; 7University of Massachusetts Medical School, Worcester, MA, USA; 8PainResearch, Informatics, Multimorbidities and Education Center, VA Connecticut, West Haven, CT, USA; 9Division of General Internal Medicine, YaleSchool ofMedicine, NewHaven,CT, USA; 10Center of Innovation toAccelerate Discovery and Practice Transformation (ADAPT), DurhamVeteransAffairs Medical Center, Durham, NC, USA; 11Departments of Population Health Sciences, Medicine, Psychiatry, and School of Nursing, DukeUniversity, Durham, NC, USA; 12VA Health Services Research and Development Services, Office of Research and Development, Washington, DC,USA.J Gen Intern Med 34(Suppl 1):S1–S3DOI: 10.1007/s11606-019-04999-4© Society of General InternalMedicine (This is a U.S. government work andnot under copyright protection in the U.S.; foreign copyright protectionmay apply) 2019I n the Veterans’ Health Administration (VA), care coordi-nation is described as facilitating integration of, and navi-gation through, healthcare services, within and across caresettings, to help patients receive the care they need and wantwithout unnecessary duplication of services or avoidable in-convenience.1 VA coordinates care within VA and with non-VA providers across a continuum of service intensity—frombasic care coordination (for all Veterans), to care management(for Veterans with chronic medical illnesses), to highlyresource-intensive case management (for Veterans withbiopsychosocially complex conditions).2 Coordinating careis essential for improving patients’ clinical outcomes, enhanc-ing patients’ experiences of care, increasing provider satisfac-tion, and decreasing costs.3The VA faces a plethora of care coordination challenges.Many Veterans have multiple conditions and providers, andmany get a portion of their care in the community, a numberthat will only grow as recent legislation expands options forprivate care. These challenges have spawned new VA initia-tives for redesigning care to meet them, described in thissupplement in an editorial by Hosenfeld and colleagues.4The VA Health Services Research and Development(HSR&D) service, in partnership with VA’s Office of Prima-ry Care, and Office of Community Care, sponsored a Stateof the Art (SOTA) conference with the goals of (a) summa-rizing what is known about care coordination relevant toVeterans’ care; (b) identifying care coordination approachesready for wider dissemination and implementation withinVA; and (c) identifying a research agenda and recommenda-tions, as appropriate, for increasing VA’s knowledge and useof evidence-based approaches for coordinating care. Held inMarch 2018, the SOTA was jointly planned by VA HSR&Dand Offices of Primary Care, Community Care, NursingServices, and Care Management and Social Work, and con-vened VA and non-VA health services researchers, clinicians,and policy makers. This supplement presents recommenda-tions from the SOTA as well as original research papers oncare coordination strategies within VA and between VA andnon-VA providers.VA STATE OF THE ART CONFERENCE ON CARECOORDINATIONThe SOTAwas organized into three workgroups: (a) measuresand models of care coordination; (b) care coordination withinthe VA system; and (c) care coordination between VA andnon-VA providers for care paid for by VA.The SOTA measures and models of care workgroup fo-cused on research theory and frameworks relating to carecoordination. Prior to the SOTA, Peterson and colleagues5systematically reviewed healthcare coordination theoreticalframeworks, with findings forming the foundation for theworkgroup’s discussions during the SOTA. Building on thiswork, McDonald and colleagues6 provide a perspective ontranslating theory to practice for coordinating VA care. Sepa-rately, Gittell and Hajjar7 describe howVA could use relationalcoordination theory for VA human resources practices to fosteran organizational structure that would facilitate care coordina-tion. Together, these three manuscripts address how VA canuse existing theory and frameworks to improve care coordi-nation for Veterans.Published online May 16, 2019S1JGIMA second SOTAworkgroup focused on coordination withinthe VA system for Veterans with greater needs for care coor-dination. This workgroup, whose recommendations are de-scribed by Cordasco and colleagues,8 used key articles andexpert opinion to formulate recommendations for VA policies,organizational initiatives, and future research topics. The thirdSOTAworkgroup, described in a separate manuscript by Mat-tocks and colleagues,9 focused on care coordination betweenVA and non-VA providers for care paid for by VA. Thismanuscript synthesizes relevant literature and provides recom-mendations on approaches for future evaluations of cross-system care coordination.CARE COORDINATION AND VA’S PATIENT-ALIGNEDCARE TEAMSIn the patient-centered medical home (PCMH)model, primarycare is the locus for coordinating care. Four papers examinehow VA’s implementation of PCMH, patient-aligned careteams (PACT), has supported care coordination and wherethose functions can be strengthened.In this supplement, Olmos-Ochoa and colleagues10 describeinterviews with PACTclinical staff in five VAmedical centers.Interviews revealed coordination-related resource barriers andchallenges in aligning priorities across patients, staff, andleaders. These stakeholders recommended VA pay attentionto staffing, training, clarifying roles and responsibilities, andlaunching care coordination initiatives.For patients with chronic illnesses, co-management andtransitions in care between PACT, specialists, and hospitalistsare common. Mohr and colleagues11 found that VA primarycare providers’ assessments of relational coordination withspecialists were correlated with patients’ perceptions of howwell their care was coordinated. This finding suggests thatefforts to improve relational coordination between VA primarycare providers (PCPs) and specialists would improve Vet-erans’ experiences of care. Rinne and colleagues12 examinedVA provider perspectives on the current state of coordinationacross care transitions for Veterans with chronic obstructivepulmonary disease (COPD) hospitalized in non-VA settings.Providers described experiencing major challenges, with de-layed, missed, or duplicative care, jeopardizing the overallquality, safety, and efficiency of Veteran care. Findings fromboth these studies underscore the need for systems-level solu-tions to support care coordination for Veterans with complexchronic conditions.For Veterans with the highest and most complex care needs,intensive primary care programs have been proposed as a modelfor providing and coordinating care. Zulman and colleagues13conducted a survey of VA patients who took part in a five-sitedemonstration of PACT Intensive Management (PIM). Veteransrandomized to PIM were more likely to report having a VAhealthcare provider who helps coordinate their care; that theywere asked about their health goals; that they have aVA providerwhom they trust and who respects them; and that their primarycare satisfaction level was 10 on a 10-point scale. Other mea-sures of satisfaction and access were similar between PIM andnon-PIM patients. These findings suggest that the PIM modelmay hold promise for coordinating care for medically andsocially complex Veterans, although further investigations areneeded to assess its impact on clinical outcomes.COORDINATING CARE FOR VETERANS’ MENTALHEALTH NEEDSThe VA system cares for many Veterans with mental healthneeds, many of whom have concurrent physical illnesses. In thissupplement, Benzer and colleagues14 examined how Veteranswith mental health issues may have care coordination needs thatdiffer fromVeterans without mental health issues. Among nearly6000 Veterans with diabetes completing an online survey, Vet-erans with mental health conditions reported significantly lowerexperiences with coordinated care compared to Veterans withoutmental health conditions. Correlated with these findings, Mat-tocks and colleagues15 surveyed 276 post-partum Veterans, andfound that women Veterans who received mental healthcarefollowing pregnancy had lower ratings of care coordination thanVeterans who did not use post-partum mental healthcare. Takentogether, thesemanuscripts bolster previous evidence supportingVA initiatives integrating primary care and mental health teamsand suggest that further attention may be needed in coordinatingcare between mental health providers and VA and non-VAspecialists.APPLYING QUALITY IMPROVEMENT ANDIMPLEMENTATION SCIENCE METHODSTwomanuscripts in this supplement describe recent successfulapplications of quality improvement and implementation sci-ence methods for improving VA care coordination. McCreightand colleagues16 describe how they used Lean Six Sigmaprocess-mapping to assess context at five VA sites prior toimplementing a care coordination program. Leonard and col-leagues17 describe how they used the BPractical, Robust Im-plementation and Sustainability Model (PRISM)^, an imple-mentation science framework, to implement a nurse-led na-tional care coordination program targeting rural Veterans.These manuscripts are examples and timely reminders of theimportance of VA continuing to prioritize developing thescience of translating research on successful care coordinationmodels into widespread practice.CONCLUSIONThis supplement presents recommendations from VA’s CareCoordination SOTA, as well as original research papers on carecoordination strategies within VA, and between VA and non-S2 Cordasco et al.: Improving Care Coordination for Veterans JGIMVA providers. Research utilizing existing care coordinationtheory and frameworks is needed to better understand andevaluate cross-system care delivery. To maximize quality, safe-ty, efficiency, and Veterans’ care experiences, we will need tounderstand more about Veterans’ and VA providers’ coordina-tion challenges, and resulting delayed, missed, or duplicativecare. We should also focus on developing, testing, andimplementing innovative system-level solutions, such as PIM,those described by Hosenfeld and colleagues, and others. Thiswill require new and innovative partnerships between re-searchers and Veterans, VA administrative and policy leaders,and clinicians, both VA and non-VA.With the concerted effortsof all stakeholders, VA can lead the way in building the evi-dence base for twenty-first-century care coordination practices,enhancing patient experiences, and maximizing care quality,safety, and efficiency, for Veterans and non-Veterans alike.Acknowledgments: We would like to acknowledge the invaluableassistance and administrative support of Geraldine McGlynn in thepreparation of this special issue.Corresponding Author: Kristina M. Cordasco, MD, MPH, MSHS; VAHealth Services Research and Development Center for the Study ofHealthcare Innovation, Implementation and Policy, Los Angeles, CA,USA (e-mail: kristina.cordasco@va.gov).Funding This work was funded by the VA Office of Research andDevelopment, Health Services Research and Development.Compliance with Ethical Standards:Conflict of Interest: All authors are employees of the Department ofVeterans Affairs. No authors reported any additional conflicts of inter-est with this work.Disclaimer: The views expressed within are solely those of the au-thors and do not necessarily represent the views of the Department ofVeterans Affairs or the US Government.REFERENCES1. Veterans’ Health Administration Handbook 1101.10, https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2977, accessed Jan-uary 23rd, 2019.2. Veterans’ Health Administration Handbook 1110.04, https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2884, accessed Jan-uary 23rd, 2019.3. Bodenheimer T. Coordinating Care — A Perilous Journey through theHealth Care System. N Engl J Med. 2008; 358(10):1064–1071.4. Greenstone CL, Peppiatt J, Cunningham K, et al. Standardizing CareCoordination with the Department of Veterans Affairs J Gen Intern Med.2019; https://doi.org/10.1007/s11606-019-04997-6.5. Peterson K, Anderson J, Bourne D, et al. Health care coordinationtheoretical frameworks: A systematic scoping review to increase theirunderstanding and use in practice. J Gen Intern Med. 2019; https://doi.org/10.1007/s11606-019-04966-z6. McDonald K, Singer S, Gorin SS, et al. Incorporating theory intopractice: Reconceptualizing exemplary care coordination initiatives fromthe US Veterans health delivery system. J Gen Intern Med. 2019;https://doi.org/10.1007/s11606-019-04969-w7. Gittell J, Hajjar L. Implementing patient-centered care reliably in the VHA:How relational coordination and human resource management can help. JGen Intern Med. 2019; https://doi.org/10.1007/s11606-019-04996-7.8. Cordasco K, Frayne S, Kansagara D, et al. Coordinating care across VAproviders and settings: Policy and research recommendations from VA’sstate-of-the-art conference. J Gen Intern Med. 2019; https://doi.org/10.1007/s11606-019-04970-39. Mattocks K, Cunningham K, Elwy AR, et al. Recommendations for theevaluation of cross-system care coordination from the VA state-of-the-artworking group on VA/non-VA care. J Gen Intern Med. 2019; https://doi.org/10.1007/s11606-019-04972-110. Olmos-Ochoa T, Bharath P, Ganz D, et al. Staff perspectives on primarycare teams ad de facto BHubs^ for care coordination in VA: A qualitativestudy. J Gen Intern Med. 2019; https://doi.org/10.1007/s11606-019-04967-y11. Mohr D, Benzer J, Vimalananda V, et al. Organizational coordinationand patient experiences of specialty care integration. J Gen Intern Med.2019; https://doi.org/10.1007/s11606-019-04973-012. Rinne S, Resnick K, Weiner RS, et al. VA provider perspectives oncoordinating COPD care across health systems. J Gen Intern Med. 2019;https://doi.org/10.1007/s11606-019-04971-213. Zulman D, Chang E, Wong A, et al. Effects of intensive primary care onhigh-need patient experiences: Survey findings from a Veterans Affairsrandomized quality improvement trial. J Gen Intern Med. 2019; https://doi.org/10.1007/s11606-019-04965-014. Benzer J, Singer S, Mohr D, et al. Patient-experienced integrated carefor diabetes with cardiovascular and mental health comorbidities in theDepartment of Veterans Affairs. J Gen Intern Med. 2019;15. Mattocks K, Cunningham K, Kroll-Desrosiers A, Baldor R, Singer S.Understanding Maternity Care for Women Veterans Using an IntegratedCare Model Approach. J Gen Intern Med. 2019; https://doi.org/10.1007/s11606-019-04974-z16. McCreight MS, Gilmartin HM, Leonard CA, et al. Practical use ofprocess mapping to guide implementation of a care coordination programfor rural Veterans. J Gen Intern Med. 2019; https://doi.org/10.1007/s11606-019-04968-x17. Leonard C, Gilmartin H, McCreight M, et al. Operationalizing animplementation framework to disseminate a care coordination programfor rural Veterans. J Gen Intern Med. 2019; https://doi.org/10.1007/s11606-019-04964-1Publisher’s Note Springer Nature remains neutral with regard tojurisdictional claims in published maps and institutional affiliations.S3Cordasco et al.: Improving Care Coordination for VeteransJGIM

Improving Care Coordination for Veterans Within VA and Across Healthcare Systems

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Improving Care Coordination for Veterans Within VA and Across Healthcare Systems

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