Given persistent gaps in coordination of care for medically complex primary care patients, efficient strategies are needed to promote better care coordination.
The Coordination Toolkit and Coaching project compared two toolkit-based strategies of differing intensity to improve care coordination at VA primary care clinics.
Multi-site, cluster-randomized QI initiative.
Twelve VA primary care clinics matched in 6 pairs.
We used a computer-generated allocation sequence to randomize clinics within each pair to two implementation strategies. Active control clinics received an online toolkit with evidence-based tools and QI coaching manual. Intervention clinics received the online toolkit plus weekly assistance from a distance coach for 12 months.
We quantified patient experience of general care coordination using the Health Care System Hassles Scale (primary outcome) mailed at baseline and 12-month follow-up to serial cross-sectional patient samples. We measured the difference-in-difference (DiD) in clinic-level-predicted mean counts of hassles between coached and non-coached clinics, adjusting for clustering and patient characteristics using zero-inflated negative binomial regression and bootstrapping to obtain 95% confidence intervals. Other measures included care coordination QI projects attempted, tools adopted, and patient-reported exposure to projects.
N = 2,484 (49%) patients completed baseline surveys and 2,481 (48%) completed follow-ups. Six coached clinics versus five non-coached clinics attempted QI projects. All coached clinics versus two non-coached clinics attempted more than one project or projects that were multifaceted (i.e., involving multiple components addressing a common goal). Five coached versus three non-coached clinics used 1–2 toolkit tools. Both the coached and non-coached clinics experienced pre-post reductions in hassle counts over the study period (− 0.42 (− 0.76, − 0.08) non-coached; − 0.40 (− 0.75, − 0.06) coached). However, the DiD (0.02 (− 0.47, 0.50)) was not statistically significant; coaching did not improve patient experience of care coordination relative to the toolkit alone.
Although coached clinics attempted more or more complex QI projects and used more tools than non-coached clinics, coaching provided no additional benefit versus the online toolkit alone in patient-reported outcomes.
ClinicalTrials.gov identifier: NCT03063294
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The authors would like to acknowledge technical assistance from Nicholas Jackson, PhD, and Frances Barry, MA.
This material is based on work supported by the Department of Veterans Affairs, Quality Enhancement Research Initiative through a grant to the Care Coordination QUERI Program (QUE 15-276). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. Additional support was provided by NIH National Center for Advancing Translational Science (NCATS) UCLA CTSI Grant Number UL1TR001881.
Conflict of Interest
All authors report support from one or more of the following during the conduct of the study: VA QUERI, VA HSR&D, National Institutes of Health, Patient-Centered Outcomes Research Institute, VA Office of Primary Care, Enhancing Tools and Resources to Improve Coordination of VA Primary Care: A Research to Impact for Veterans (RIVR) Project, Agency for Healthcare Research and Quality (AHRQ), Department of Defense, Administration on Community Living, and WellMed Charitable Foundation.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Ganz D, Penney L, Noël PH, Olmos-Ochoa T, Chawla N. The influence of facilitation on care coordination in VA primary care: Evaluation of the CTAC quality improvement project. VA Health Services Research & Development Cyberseminar. 4/15/2020. https://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archives/video_archive.cfm?SessionID=3792.
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Noël, P.H., Barnard, J.M., Leng, M. et al. The Coordination Toolkit and Coaching Project: Cluster-Randomized Quality Improvement Initiative to Improve Patient Experience of Care Coordination. J GEN INTERN MED (2021). https://doi.org/10.1007/s11606-021-06926-y
- primary care
- care coordination
- patient experience
- cluster-randomized controlled trial