Project Background: Care coordination is a fundamental component of PACTs and lies at the heart of their ability to deliver higher quality care than what is possible with traditional clinic models. However, best practices on how to coordinate successfully in health care environments are scarce. Okhusen &Beckhy's integrative model of coordination identifies the mechanisms that make it possible for teams to work collectively (e.g., defining responsibilities for tasks, resource allocation, hand-off work), and is an excellent framework for developing best practices for coordination. Pilot research by the PI indicates that clinical performance measures requiring more complex interaction amongst clinical personnel (e.g., depression screening) take longer to reach target performance levels than those requiring simpler interactions (e.g., cervical cancer screening), regardless of clinical condition, and that considerable variation exists among VAMCs in their performance of measures at a given level of clinician interaction. It is therefore imperative to identify and understand the elements of coordination most accountable for performance variability, and thus most ripe for intervention. To help identify said practices, we will use Okhuysen &Bechky's framework as our criterion standard for measuring and characterizing coordination. Project Objectives: The goal of the proposed research is to test the proposition that elements of coordination (as defined by Okhuysen and Bekchy) will interact with clinician interaction to predict incremental variance in clinical performance. We intend to accomplish our research goals via the following objectives: 1. Determine the complexity of clinician interaction required for each outpatient clinical performance measure 2. Identify the specific practices employed by VA PACTs indicative of effective coordination as defined by Okhuysen and Bechky's model 3. Assess the extent to which the PACTs employing practices indicative of improved coordination exhibit improved clinical performance for outpatient measures of varying levels of clinician interaction. Project Methods:
Aim 1 Participants: 6-8 geographically dispersed primary care physicians experienced in outpatient clinical quality performance measures (e.g., External Peer Review Program (EPRP), PACT Compass) will serve as subject matter experts (SMEs) to support assessment of clinician interaction.
Aim 1 Procedure: Consistent with our previous pilot work (PPO 09-274), we will use functional job analysis (FJA) to assess each outpatient clinical performance measure on clinician interaction. We will conduct structured FJA focus groups with the SMEs to identify the tasks required to satisfy the performance criteria for each EPRP measure. We will rate each task using the worker interaction scale from FJA;finally, for each EPRP measure, we will calculate a composite rating of worker interaction from the individual tasks.
Aim 2 Participants: Members of currently existing PACT teamlets (provider, nurse, clerk) at VAMCs nationwide.
Aim 2 Procedure: We will develop and deploy an online survey of coordination practices as defined by Okhuysen &Bechky's model, to be completed by primary care PACT teamlet members at VAMCs nationwide.
Aim 3 Data Source: We will obtain PACT-level outpatient clinical quality performance measure data from VA's Office of Quality and Performance (EPRP, PACT Compass), as well as Medical Home Builder Survey and related organizational characteristics to use as covariates in our models.
Aim 3 Procedure: We will combine our clinician interaction ratings from Aim 1 with our survey responses from Aim 2 to predict improvements in clinical performance over a period of 1 year. Clinical performance measures will be stratified by level of clinician interaction. DATA ANALYSIS. We will employ growth curve models to test the proposition that elements of coordination will interact with clinician interaction to predict incremental variance in clinical performance.

Public Health Relevance

Anticipated Impacts on Veteran's Healthcare: VA has invested significantly to transition primary care into Patient Aligned Care Teams (PACT), which represents a paradigmatic shift in the way VA delivers primary care. Coordination, that is, working collectively on interdependent tasks to deliver evidence-based care that could not otherwise be accomplished as effectively by a single provider, is among the most critical principles of PACT, and requires a more complex level of interaction amongst primary care team members (clinician interaction) than the traditional model of care;without a good understanding of best practices in coordination, PACTs will not be successful. By using a theoretical framework to identify the optimal coordination practices in situations requiring high clinician interaction, we can develop best practices for coordination in PACT settings, identify facilities most in need of help with these practices, and help ensure the smooth, high quality care delivery our veterans deserve.

National Institute of Health (NIH)
Veterans Affairs (VA)
Non-HHS Research Projects (I01)
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HSR-5 Health Care System Organization and Delivery (HSR5)
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Michael E Debakey VA Medical Center
United States
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