Featured Fellow Neha Pathak: What does Team-based Care Coordination Look Like? Implementation of a Care Coordination Template Pilot

IMG954302As healthcare delivery systems become more complex, policy makers are promoting care coordination (CC) as a tool to improve patient experience, quality of care and to decrease costs and risks for error. Nationally, investments have expanded healthcare models that provide team-based CC, such as Patient Centered Medical Homes and complex care management programs. But, little data about the specific activities and time required to provide necessary CC exists, limiting the ability for healthcare teams to optimize CC delivery.

Our work focusses on the development and preliminary results of the implementation of a Care Coordination Template, created in the VA’s Computerized Patient Care System (CPRS) to identify and track the components of CC services delivered by a multidisciplinary team, as part of a quality improvement (QI) pilot project. Using the template, our team sought a formative understanding of the following questions: Is it feasible to use the CC Template to standardize and document CC during routine workflow? What specific types of CC services are provided by the team? How much time does it take to perform these activities? Who is the team collaborating with inside and outside of the healthcare setting? How are they communicating?

Pilot data show that use of the CC Template helped to standardize team CC documentation in a busy clinic setting, provide data about the complexity and duration of coordination activities, and inform future CC QI projects. For example, over the course of 35 weeks of use, CC Template documentation showed that 79.4% of CC encounters were < 20 minutes and 9.9% of encounters were > 61 minutes. CC during hospitalization and discharge accounted for 5.9% of template use. Of the CC encounters documenting hospital transitions, 94.4% documented communication with the inpatient team, 58.3% documented coordination with social support, and only 11.1% documented communication with primary care teams. Improving communication with PACT teams after hospital discharge was identified as a future QI project based on this data.

In complex systems, where coordination is needed between primary, specialty, hospital, emergency, non-clinical care settings and patients, a tool such as the CC Template offers a sustainable and replicable way to standardize documentation and knowledge about CC components. This foundational information can be used to optimize team structure, training, and resource allocation, to improve the quality of CC, and to link elements of CC with clinical and operational outcomes.