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 fragmentatin 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 departmental boundaries and geographic locations. In the 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. Thus the overall goal of the proposed study is 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. Working with operational partners, this knowledge can then be used to develop interventions that enhance patient- experienced integration (PEI). We propose to target patients with diabetes and co-morbid conditions that differ on two dimensions: co-morbidity domain (physical;mental health-related) and severity (low;high). As the number of providers and locations multiply, so do the integration challenges. The most complex co-morbidities, presenting the greatest threat to integration, are those that cross physical and mental domains and require both primary and specialty care services. Studying these four groups will expose challenges in integration and identify actionable levers for organizational change. We propose to achieve the overall study goal by addressing four specific research questions: We propose to achieve the overall study goal by addressing four specific research questions: (RQ1) How integrated is the care experienced by Veterans with diabetes, and does experienced integration vary among patient groups 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 are associated with higher and lower levels of PEI in the four patient groups? (RQ3) What is the relationship between the various dimensions of PEI and clinical processes and outcomes for diabetes in the four patient groups? (RQ4) What specific inter- and intra-departmental relationships, managerial practices and staff behaviors constitute the structures and processes that produce higher levels of PEI? We propose a four-year mixed-methods study. The quantitative phase will address RQs 1, 2 and 3 using multiple existing secondary databases and new survey-based variables obtained from both Veterans and VHA staff. For RQ4, we propose to qualitatively compare sites selected from the upper and lower extremes of the patient-experienced integration continuum. Working with our operational partners, relevant results from our study will be incorporated into specific national training and quality improvement programs.
The overall goal of the proposed study is to assess the extent to which Veterans experience their care as integrated and to identify organizational characteristics and specific care processes associated with higher levels of patient-experienced integrated care. We will focus on patients with diabetes and co-morbid conditions that differ with regard to domain (physical;mental health) and severity (low, high). The most complex cases, presenting the greatest threat to integration, are those with co-morbidities that cross domains and require both primary and specialty care. We propose a mixed-methods study involving primary quantitative survey data collection and available quality of care measures. We will also interview staff at eight medical centers to identify specific staff behaviors and clinical or administrative processes that underlie an organization's capacity to provide high levels of patient-experienced integration.