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2023 HSR&D/QUERI National Conference Abstract

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1069 — Comparison of VA PCPs’ Experience of Care Coordination with VA Specialists vs. Community Care Specialists under the MISSION Act

Lead/Presenter: Varsha Vimalananda,  COIN - Bedford/Boston
All Authors: Vimalananda VG (Center for Healthcare Organization and Implementation Research, Bedford), Zocchi M (Center for Healthcare Organization and Implementation Research, Bedford) Wormwood JB (Department of Psychology, University of New Hampshire, Durham, NH) Meterko M [VHA Office of Reporting, Analytics, Performance, Improvement and Deployment (RAPID – 10EA)] Sitter KE (Center for Healthcare Organization and Implementation Research, Bedford) Benzer J (Center of Excellence for Research on Returning War Veterans, Waco) Berlowitz DR (Department of Public Health, University of Massachusetts, Lowell) Fincke GF (Center for Healthcare Organization and Implementation Research, Bedford)

Objectives:
Poor care coordination is associated with medical mistakes, wasted resources, patient dissatisfaction, and clinician burnout. The MISSION Act of 2018 presented VA with an unprecedented challenge to coordinating care with non-VA specialists. In response, VA launched several initiatives to strengthen coordination between VA and Community Care (CC) providers. We compared VA primary care provider (PCP) experiences of specialty care coordination within VA vs. for CC.

Methods:
The PCP Coordination of Specialty Care (CSC) Survey was administered online from April-December 2021 to two VA PCP cohorts: one to respond about VA specialty care (VA-VA, N = 1560), and one about CC specialty care (VA-CC, N = 1773). PCPs were assigned to answer about one of 8 medical specialties. Overall experience of coordination was assessed using a 0-10 scale. Five multi-item scales assessed dimensions of coordination from 1(never) to 7(always). Mechanisms for coordinating care were rated for both ease of use and helpfulness from 1(not at all) to 4(very).

Results:
Response rates were VA-VA 23% (N = 351); VA-CC 15% (N = 266). More VA-CC respondents were at CBOCs (66.8% vs. 38.5%); other characteristics were similar. The mean rating for overall coordination was higher for VA-VA vs. VA-CC [7.0(2.3) vs. 6.2(2.6), p = 0.002, Cohen’s d = 0.2 (small effect size)]. Three scale scores were higher for VA-VA vs. VA-CC - Data Transfer: 5.9 vs. 4.2, p < 0.001, Cohen’s d = 1.5 (large effect); Relationships and Collaboration: 5.1 vs. 4.6, p < 0.001, Cohen’s d = 0.4 (moderate effect); Role Clarity: 4.9 vs. 4.5, p = 0.02, Cohen’s d = 0.2 (small effect). Although there were no differences in Making Referrals or Communication scale scores, there was evidence of systemic differences in communication: 39% of VA PCPs indicated they never communicated directly with CC specialists, compared to only 9% for VA specialists. The most helpful mechanism for facilitating coordination among both cohorts was phone, but the ease of reaching specialists by phone was low [VA-VA 2.3(1.2); VA-CC 2.4(1.1), p = 0.60]. VA-VA respondents rated ease of using encrypted email more highly than VA-CC respondents (3.2 vs. 2.0, p < 0.001) and rated it more helpful (3.1 vs. 2.3, p = .03). The Joint Legacy Viewer read-only EHR was rated low for ease and helpfulness in both cohorts.

Implications:
VA PCPs rated specialty care coordination higher within VA than CC. Ratings were also higher for Data Transfer, Relationships and Collaboration, and Role Clarity. The frequency of communication with CC specialists was fourfold lower. Differences reveal targets for improvement, especially in communication. Notably, the EHR alone is not sufficient; PCPs find mechanisms that leverage direct interaction (email and telephone) more helpful. This is congruent with the substantial literature highlighting the importance of direct personal interaction to coordination.

Impacts:
VA-specialist coordination for Community Care occurs mostly through local Offices of Community Care (OCC), which provide invaluable support and standardization for the referral process. But VA PCPs, who are held responsible for coordinating cross-system care for their patients, are unable to access some of the most powerful mechanisms for ensuring successful coordination. Initiatives to improve cross-system coordination should balance the role of local OCCs with an expansion of VA PCPs’ direct access to CC specialists.