1136 — An early evaluation of the implementation of the Referral Coordination Initiative

Lead/Presenter: Anna Zogas,  COIN - Bedford/Boston
All Authors: Zogas A (Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System; Boston University School of Medicine), Vimalananda V (Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System; Boston University School of Medicine) Linsky A (Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System; Boston University School of Medicine) Chatelain L (Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System) McCullough M (Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System; University of Massachusetts, Lowell, Department of Public Health) Mattocks K (VA Central Western Massachusetts Healthcare System; University of Massachusetts Chan Medical School)

Objectives:
In response to the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018, VA implemented the Referral Coordination Initiative (RCI) to improve specialty care and Community Care (CC) coordination via three main mechanisms: create dedicated local referral coordination teams, improve scheduling timeliness, and empower Veterans to choose the care that is right for them. It is unclear how the RCI has been implemented at each VA Medical Center (VAMC), making it a challenge to determine which specific structures and processes are associated with desired outcomes. To address this knowledge gap, we studied post-RCI referral coordination workflow to identify structures and processes used in implementing RCI and factors that influence fidelity to the program outlined in the RCI Guidebook.

Methods:
Semi-structured interviews with 19 VA employees engaged in RCI tasks at 5 VAMCs in Veterans Integrated Service Network (VISN) 1, sampled based on each facility’s type of implementation (centralized, decentralized, hybrid) and employees’ RCI-related role (clinical, administrative).

Results:
Of the facilities in the sample, 2 sites had centralized or hybrid implementation, meaning a team of clinical and/or administrative employees triaged and scheduled consults for multiple specialties. The other 3 sites had decentralized implementation, meaning that employees triaged and scheduled consults for their own specialty. Per the RCI Guidebook, either structure may be implemented, however, we noted key differences between them. At sites with centralized/hybrid implementation, Registered Nurses performed clinical review of consults and contacted Veterans. This was the ideal staffing specified in the RCI Guidebook. By contrast, at sites with decentralized implementation, some Nurse Practitioners and physicians triaged consults and contacted Veterans. We found additional variation between centralized/hybrid and decentralized implementations in how information about specialty services and wait times was shared among employees. For instance, centralized teams were co-located and held routine meetings (e.g., schedulers and specialty directors discussed scheduling needs). By contrast, employees with RCI-related responsibilities at sites with decentralized implementation communicated ad hoc with other VA clinics and local Offices of Community Care.

Implications:
This qualitative evaluation demonstrates variability in structures and processes associated with RCI implementation, and subsequent evaluations of RCI’s effectiveness must account for these differences. These preliminary findings suggest that implementation model and referral coordination team structure may lead to differences in the desired outcomes of the RCI, dynamics which we will explore in subsequent work.

Impacts:
Since the MISSION Act, 31% of VA-enrolled Veterans have been referred to CC, at a cost of $17.6 billion in 2020. A priority for VA is delivering coordinated, quality care in the best setting for each Veteran while balancing spending on CC. The RCI has great promise for achieving these goals. Whether and how it is effective is unknown. This is among the first studies to look at the implementation of RCI. Its findings are the beginning of a taxonomy of RCI core elements, which will be a tool used in future efforts to standardize implementation and evaluate RCI’s effects at the patient and enterprise level.