Background: Epilepsy (a neurological disorder characterized by recurrent seizures) is a growing concern for the VA as it serves two growing populations at high risk for the disorder: individuals with traumatic brain injury (TBI) and the elderly. The growing number of Veterans with epilepsy and the resultant need to improve access while more effectively managing care led to the creation of four geographic Epilepsy Centers of Excellence (ECOEs) in FY09. The COE approach arose out of the need to improve delivery care but has yet to be studied for its effectiveness as a model of care. We seek to examine the impact of the ECOE model using the relational coordination (RC) framework as way to understand the impact of the ECOE structure on the interdependencies between VA providers. Research using the RC framework has demonstrated that in situations where patients and providers deal with an unpredictable chronic illness and have to coordinate care across multiple facilities and providers under time-constrained conditions such as in epilepsy, the quality of communication and relationships among participants affects both the timeliness and quality of care. This study seeks to examine how changes in the structure of epilepsy care are associated with RC and with quality of and access to epilepsy care. Objective 1: Describe changes in quality of and access to epilepsy care before and after ECOE initiative implementation. Objective 2: Describe the associations between changes in the structure/ processes of care implemented by the four geographic ECOEs and RC among epilepsy care team members in each ECOE. Objective 3: Determine whether variations in access to and quality of VA epilepsy care among geographic ECOEs are associated with RC. Methods: This four-year comparative case study will use VA inpatient, outpatient, and pharmacy data to identify Veterans with epilepsy, and medical chart abstraction data from a random sample stratified within ECOE by epilepsy chronicity and seizure control to identify changes in quality of and access to care in the VA throughout ECOE implementation (FY08-FY14). In order to examine the associations between RC and structural change we will first administer RC surveys to staff from each hub, and from 4 spokes who refer to each hub;the spokes will be selected based on high and low referrals within each hub. We will then use survey results to select individuals from each location surveyed for semi-structured interviews to obtain richer details regarding the organization of care and specific innovative approaches used by epilepsy care teams in each ECOE to improve the quality of and access to care. Finally, we will link RC among providers, and epilepsy clinical outcomes to determine the extent to which RC is associated with improvements in quality of and access to epilepsy care using multivariable models. Impact: This study will provide valuable information for VA stakeholders through demonstrating the impact of the ECOE model of care on clinical outcomes. Our findings will lay the foundation for assessing the value of the COE model for care of other diseases and hub-and-spoke models of subspecialty care. Identification of quality gaps provides specific targets for interventions that will have the greatest impact on patient outcomes and system utilization. While this study focuses on VA epilepsy care, no similar studies of a COE model exist outside the VA. Thus findings from this study may provide insights regarding care models for both VA care of other diseases for which a COE model may be considered, and for non-VA epilepsy care. Finally, our inclusion of the RC framework contributes to implementation science by providing an understanding of the impact of the COE structure on interdependencies among VA providers, and suggesting specific types of interventions that may be used to improve RC and specific aspects of epilepsy care simultaneously.
A number of Centers of Excellence (COEs) have arisen in response to the necessity to provide care but have yet to be studied for their effectiveness as a model of care. The funding of Epilepsy Centers of Excellence (ECOEs) provides a unique opportunity to examine the impact of ECOEs on clinical outcomes. This study will identify specific gaps in the quality of and access to VA epilepsy care that may be targets for intervention. The application of the relational coordination framework provides insight into mechanisms through which quality of care may be improved above and beyond traditional interventions, such as protocols and clinical reminders. Because this study is novel both within and outside the VA, information gleaned from this project may be useful in a variety of epilepsy care settings, thus improving the quality of epilepsy care more globally. Moreover, this study provides a foundation for evaluation of other COE models and insight into quality of care issues in other settings where hub-and-spoke models of sub-specialty care are used in and outside the VA.