Understanding care coordination for Veterans with complex care needs: protocol of a multiple-methods study to build evidence for an effectiveness and implementation study

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  • Hynes, Denise M.
    • Other Affiliation: Oregon Health & Science University
  • Govier, Diana J.
    • Other Affiliation: Oregon Health & Science University
  • Niederhausen, Meike
    • Other Affiliation: Oregon Health & Science University
  • Tuepker, Anaïs
    • Other Affiliation: Oregon Health & Science University
  • Laliberte, Avery Z.
    • Other Affiliation: Oregon Health & Science University
  • McCready, Holly
    • Other Affiliation: Oregon Health & Science University
  • Hickok, Alex
    • Other Affiliation: Oregon Health & Science University
  • Rowneki, Mazhgan
    • Other Affiliation: Oregon Health & Science University
  • Waller, Dylan
    • Other Affiliation: Oregon Health & Science University
  • Cordasco, Kristina M.
    • Other Affiliation: University of California, Los Angeles
  • Singer, Sara J.
    • Other Affiliation: Stanford University School of Medicine
  • McDonald, Kathryn M.
    • Other Affiliation: Stanford University School of Medicine
  • Slatore, Christopher G.
    • Other Affiliation: Oregon Health & Science University
  • Thomas, Kathleen C.
    • Affiliation: Eshelman School of Pharmacy, Division of Pharmaceutical Outcomes and Policy
  • Maciejewski, Matthew
    • Other Affiliation: Durham Veterans Affairs Health Care System
  • Battaglia, Catherine
    • Other Affiliation: Eastern Colorado Health Care System
  • Perla, Lisa
    • Other Affiliation: Veterans Affairs Central Office
Abstract
  • Background For patients with complex health and social needs, care coordination is crucial for improving their access to care, clinical outcomes, care experiences, and controlling their healthcare costs. However, evidence is inconsistent regarding the core elements of care coordination interventions, and lack of standardized processes for assessing patients’ needs has made it challenging for providers to optimize care coordination based on patient needs and preferences. Further, ensuring providers have reliable and timely means of communicating about care plans, patients’ full spectrum of needs, and transitions in care is important for overcoming potential care fragmentation. In the Veterans Health Administration (VA), several initiatives are underway to implement care coordination processes and services. In this paper, we describe our study underway in the VA aimed at building evidence for designing and implementing care coordination practices that enhance care integration and improve health and care outcomes for Veterans with complex care needs. Methods In a prospective observational multiple methods study, for Aim 1 we will use existing data to identify Veterans with complex care needs who have and have not received care coordination services. We will examine the relationship between receipt of care coordination services and their health outcomes. In Aim 2, we will adapt the Patient Perceptions of Integrated Veteran Care questionnaire to survey a sample of Veterans about their experiences regarding coordination, integration, and the extent to which their care needs are being met. For Aim 3, we will interview providers and care teams about their perceptions of the innovation attributes of current care coordination needs assessment tools and processes, including their improvement over other approaches (relative advantage), fit with current practices (compatibility and innovation fit), complexity, and ability to visualize how the steps proceed to impact the right care at the right time (observability). The provider interviews will inform design and deployment of a widescale provider survey. Discussion Taken together, our study will inform development of an enhanced care coordination intervention that seeks to improve care and outcomes for Veterans with complex care needs.
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  • Article
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  • Attribution 4.0 International
Journal title
  • Frontiers in Health Services
Journal volume
  • 14
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  • English
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  • 2813-0146
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  • Frontiers Media SA

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