Multidisciplinary care teams, such as the Veterans Administration's (VA) Patient Aligned Care Teams (PACTs), have been proposed as one of multiple strategies to improve care coordination. For such a strategy to succeed, PACT members must excel at the act of coordinating, i.e., working collectively on interdependent tasks to deliver evidence-based care that could not be accomplished as effectively by a single provider. However, the ability to monitor team coordination is still in its infancy; current measures of care coordination focus primarily on utilization outcomes such as hospitalization or Emergency Department utilization. Previous research by one of the PIs identified timely, individualized, and customizable feedback and tracking tools as essential facilitators of successful referral team coordination and improved quality of care. Additionally, in a planning meeting for this application our VISN 12 partners identified a need for aids to help better coordinate patient care, noting that current PACT Compass coordination measures arrive 2-3 months after an encounter. Thus, point-of-care coordination aids are a critical need for patient tracking, feedback, and follow-up. PROJECT OBJECTIVES Our objective is to determine the point-of-care information needs of PACT members to successfully coordinate care and to identify the optimal mechanisms of delivering that information at the point of care. Using as test cases care coordination in PACT settings for three high-risk patient care scenarios: patients with uncontrolled diabetes mellitus, patients at risk for delayed cancer diagnosis, and CHF patients with sub-optimal medication dosage after a recent hospital discharge, we will accomplish the following objectives: 1. Develop measurable criteria for effective coordination in PACTs, prioritized and weighted by contribution to overall quality of care. 2. Using the measurable criteria developed in Aim 1, determine the specific information needed at the point of care to improve coordination and develop point-of-care aids for delivering the needed information. 3. Assess the effect of adopting the aforementioned coordination criteria and point-of-care aids on PACT clinicians' coordination behaviors. PROJECT METHODS This implementation planning pre-trial employs a mixed methods design; we will adapt the Productivity Measurement and Enhancement System (ProMES, a structured methodology for developing performance measures and assessing productivity) to develop measures of effective coordination (Aim 1), identify PACT practice-based coordination information needs and develop point-of-care aids for improving coordination (Aim 2), and assess the effectiveness of their coordination in pre- and post-adoption/implementation periods (Aim 3) in primary care clinics. The study will comprise 3 arms: (1) a concurrent control arm (2 VISN 16 sites), which will only be monitored passively; (2) a measurement and feedback arm (2 VISN 12 sites), which will be involved in designing the coordination measures and receive periodic feedback on their coordination performance; and (3) a full intervention arm (2 VISN 12 sites) which, in addition to everything included in the measurement and feedback arm, will design and use point-of-care aids aimed at improving coordination. We will monitor coordination for up to one year after end of baseline (i.e., the period between the completion of care coordination measure development and the first deployment of point-of-care aids). Differences in coordination both across sites and pre- vs. post- deployment of point-of-care aids will be assessed using descriptive statistics and longitudinal analyses such as multilevel modeling.
ANTICIPATED IMPACTS ON VETERAN'S HEALTHCARE Poor care coordination is pervasive and a principal cause of avoidable morbidity, mortality, and wasteful resource use as well as patient and health care team dissatisfaction. Veterans are in particular need of optimal care coordination, given that many suffer from multimorbid conditions, mental health problems, and a challenging socioeconomic environment. The proposed research will address this complex problem by employing a structured methodology for systematically thinking about care coordination in PACT settings, and identifying the information needs that will maximally facilitate successful coordination of care. Should we observe the results we have anticipated, this will significantly impact care coordination as well as deliver a valid set of coordination measures that could potentially be adopted VA-wide.
