Measuring and improving specialty care coordination in VA

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BACKGROUND Fragmented health care – the splitting of a patient's care across multiple providers – increases risks of patient and provider dissatisfaction, resource waste, and potentially devastating health outcomes. Coordinating care to prevent these outcomes is a VA priority, and an increasing challenge as Veterans receive more care from non- VA providers. Coordination is the organization of patient care between two or more participants to ensure appropriate delivery of healthcare services. For specialty care referrals, which number >25 million yearly in VA, the most direct participants are patient, specialist and PCP, the “specialty care triad”. To improve specialty care coordination, a measure and interventions are needed that account for the experience of each triad member. OBJECTIVES Aim 1. 1.1. Adapt a trio of surveys designed to a) measure the experience of specialty care coordination, and b) measure the frequency and effectiveness of specific coordination mechanisms among patients, medical specialists, and primary care providers 1.2. Determine the psychometric properties of the survey questions on coordination (from 1.1a) Aim 2. 2.1. Use qualitative methods to identify barriers and facilitators to effective use of 4 specialty care coordination mechanisms that are found in Aim 1 to be both widely used and variably successful Aim 3. 3.1. Use data from Aim 2 to develop and pilot-test an intervention to implement one or more mechanisms to improve specialty care coordination, and evaluate it on the basis of feasibility, acceptability, and changes in scores of survey questions about mechanisms (from 1.1b) 3.2. Examine concurrent validity of the survey questions about coordination (from 1.1a) by comparing changes in them pre- and post-intervention to changes in existing validated scales METHODS In Aim 1, existing instruments will be adapted into 3 surveys to measure the experience of specialty care coordination and the helpfulness of specific mechanisms to coordinate. Psychometric properties of the surveys will be assessed through a national VA pilot administration. In Aim 2, semi-structured interviews will be conducted with triad members at 8 VA medical centers, to understand the key factors to success of 4 selected mechanisms. Data analysis will use a mixed deductive-inductive approach and be guided by the Consolidated Framework for Implementation Research. Aim 3 will build on Aims 1 and 2 to develop and evaluate a multi- faceted intervention that uses one or more mechanisms to improve specialty care coordination for the triad. ANTICIPATED IMPACT This CDA will provide a metric of success that accounts for the experience of the most direct participants in specialty care coordination, including the patient. It will provide information about the barriers and facilitators to success of commonly used mechanisms to coordinate specialty care. It will also result in an intervention to improve specialty care coordination for the triad members. In future work, the survey measure 1) can be used to evaluate and compare interventions to improve coordination, both within and outside of VA; 2) can be used to identify which organizational features and mechanisms to coordinate care correlate with high and low success in specialty care coordination, for each triad member; and 3) will allow examination of which aspects of coordination, from which triad members' perspectives, are associated with which clinical and cost outcomes.