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Investigator: Neha Pathak
Phone: (404) 321-6111 ext. 1972
Primary Research Interest: Internal Medicine
Description of Research: We propose to conduct a mixed methods evaluation of care coordination services provided by PIM teams at two VA PIM sites using the a CC Template. Documentation with the CC Template will serve as an electronic data source to describe the breadth of CC services provided to high-risk veterans. After the PIM teams utilize the CC Template during day-to-day operations for 6 months, we will qualitatively assess the feasibility of the CC Template to document care activities and work flow through semi-structured interviews. These foundational findings will inform future efforts to: 1) improve the level of CC provided to high-risk patients, 2) plan staffing or team composition, 3) determine the cost of CC activities with the goal of reimbursement, and 4) assess outcomes of CC.
Relevance to VA: Despite the implementation of Patient Aligned Care Teams (PACT) within VA, high-risk patients frequently do not receive necessary care in a timely manner, potentially due to difficulty with access, lack of knowledge about the resources available to them, and other unmet needs that are beyond what outpatient PACTs are able to deliver, leading to overuse of emergency department (ED) care and preventable hospitalizations. An emerging body of evidence suggests that complex care management programs may improve high-risk patients’ experience of care and decrease ED visits and hospitalizations. PACT INTENSIVE MANAGMENT (PIM) pilot study funded at 5 sites by VHA. A common component of these programs is the provision of care coordination (CC) as there is evidence that CC benefits patients with multiple comorbidities. Despite interest in promoting CC,there is little data about the specific activities and time required to provide necessary CC for high-risk patients. It is difficult to optimize the structure CC teams and improve the quality of CC.Many questions remain about the 1) types of CC services provided by care coordinators, 2) time it takes to perform these activities, 3) collaborators within and outside of the healthcare setting, and 4) modes of communication for CC. Standardizing documentation of CC with the EHR may allow for precise description of these activities and may have implications for training care coordinators with the optimal skill set.

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