QUERI – Quality Enhancement Research Initiative

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The Care Coordination QUERI: Improving Patient-Centered Care Coordination for High-Risk Veterans in PACT

Los Angeles, CA

Principal Investigators: David Ganz, MD, PhD (Corresponding PI, VA Los Angeles), Kristina Cordasco, MD, MPH, MSHS (VA Los Angeles), Michael Ong, MD, PhD (VA Los Angeles)

Principal Operational Partners: Primary Care Services, Office of Quality, Safety and Value (Patient Safety and Veterans Engineering Research Centers), Geriatrics and Extended Care (GEC), Access and Clinic Administration Program (ACAP), Office of the Assistant Deputy Under Secretary for Health (ADUSH) for Clinical Operations

View program fact sheet

Executive Summary:

Veterans cared for by primary care as part of VA's Patient Aligned Care Teams (PACT) can be identified as at high risk of deteriorations in health (resulting in a need for emergency department or hospital care), using the Care Assessment Need (CAN) score. Often, one of the major challenges to preventing worsened health is coordinating care effectively across the different providers and care settings required to address these Veterans' needs. The Care Coordination QUERI, through three different focused efforts, aims to learn how to improve coordination between the Veteran, his or her primary care team, and the specialty care, emergency department, hospital, and home community resources the Veteran may need. In carrying out its projects, this QUERI program will assess the effectiveness of care coordination tools, facilitation, and organizational readiness assessment as improvement approaches.

Program MyVA Goals: The MyVA initiative will reorient VA around Veterans' needs and empower employees to assist them in delivering excellent customer service to improve experience with VA healthcare. The Care Coordination QUERI is aligned with this goal and will assess the experiences of Veterans and staff in relationship to each project's improvements.

Program Objectives:

The program's overall objective is to improve care coordination and experience of care across settings for high-risk Veterans in PACT. Implementation Project 1 (Improving PACT Coordination across Settings and Services) will clarify the most effective strategies for improving care coordination between PACT, specialty care, and non-VA care. The Quality Improvement Project (Improving Emergency Department (ED) Coordination with PACT) aims to improve ED-PACT handoffs. Implementation Project 2 (Improving Hospital to Community Coordination with PACT) will improve coordination of services for chronically ill Veterans between the VA and non-VA community agencies at hospital discharge. The implementation core focuses on assessing and improving organizational readiness for care coordination between PACT and other care settings, and reviews prior evidence and tools related to care coordination.

Program Methods:

The program is a collaboration between investigators in the VA Greater Los Angeles Healthcare System, the VA Palo Alto Health Care System, the South Texas Veterans Health Care System (San Antonio, TX), and the VA Center for Applied Systems Engineering in the Richard L. Roudebush VA Medical Center (Indianapolis, IN). Implementation Project 1 will determine whether a distance coach and an online toolkit together can help PACT teams improve care coordination compared with PACT teams that use just the online toolkit. The Quality Improvement Project will adapt and spread a pilot-tested Computerized Patient Record System (CPRS)-based electronic communication tool for ED-PACT handoffs across late-adopter primary care clinics. Implementation Project 2 will improve post-discharge care for high-risk Veterans. The project focuses on linking a Veteran's inpatient social worker to community health workers in the Veteran's home community, and fostering coordination between needed community resources and the Veteran's PACT care team. Finally, the program's implementation core supports all three projects by:

  • Assessing and improving organizational readiness for care coordination between PACT and other care settings;
  • Creating core evaluation metrics reflecting patient care coordination and patient-reported care experiences; and
  • Reviewing existing tools and literature on care coordination, and developing a comprehensive Care Coordination Toolkit based on prior tools in combination with the findings of the three projects.

The proposed program will thus result in better understanding of the process of implementing improved coordination - and of methods for spreading it.

Project Summaries:

Implementation Project 1: Develop an online toolkit for care coordination in PACT, pilot a distance coaching intervention at PACT sites, and compare the effectiveness of an online toolkit alone with the combination of the toolkit plus coaching.

Quality Improvement Project: Improve communication between the VA GLA Healthcare System's Emergency Department and the PACT teams through a CPRS-based structured message sent from ED providers to PACT nurse care managers who then take the lead in triaging and arranging for appropriate care for the discharged Veterans.

Implementation Project 2: Improve care coordination for high-risk Veterans who are discharged from VA hospitals by linking the patient's PACT care team, VA social workers, and non-VA community organizations. Community health workers will monitor Veterans in their own communities and facilitate Veterans' access to community-based services, with support from the patient's PACT team.