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Spotlight on Care Coordination

July 2019

With the passing of the Veterans Access, Choice and Accountability Act of 2014 (Choice Act)1, and more recently the VA MISSION Act of 2018 (MISSION Act)2, Veterans have more options for healthcare providers and systems. With these increased options comes the potential for fragmentation of treatment, information loss, pharmacological duplication or drug interaction, and deterioration of patient experiences.

Within VA’s healthcare system, coordination of care between providers is a high priority, as many Veterans suffer from multiple comorbid conditions and seek treatment from multiple providers, including primary care, internal medicine specialists, and mental health specialists. Patient Aligned Care Teams (PACTs) are one way in which care coordination is supported within VA, including the PACT Intensive Management (PIM) model for highly complex care needs3.

In 2018, VA held a State of the Art (SOTA) conference with the goal of increasing knowledge and use of evidence-based approaches for coordinating care both within VA and between VA and community-based care. Other efforts include the application of quality improvement and implementation science methods to improve care coordination4. Following are examples of continued efforts to improve care coordination within the VA system, and between VA and non-VA providers.

Care Coordination for High-Risk Patients with Multiple Chronic Conditions

Care Coordination for High-Risk Patients with Multiple Chronic Conditions

(Photo © iStock/asiseeit)

Care fragmentation is a challenge for Veterans, many of whom face multiple chronic conditions requiring care from different providers and clinics. This issue is likely to intensify in the current policy environment that increasingly encourages Veterans' dual use of VA and community care. When patient care is dispersed across providers, clinics, and health systems, it increases risks of information loss, medication interactions, and unwieldy treatment regimens, leading to health deterioration. Veterans in poor health and those with functional limitations or resource constraints may be especially vulnerable, yet little is known about fragmentation patterns and care coordination needs in these high-risk patients.

This ongoing study seeks to advance the understanding of the impact of care fragmentation, and care coordination's potential among Veterans who are at high risk for hospitalization. Among a high-risk Veteran cohort, investigators are measuring fragmentation and examining its variation by several patient characteristics such as demographics, rurality, chronic conditions, housing status, and enrollment in care coordination programs. Additionally, this study is examining findings from a PACT Intensive Management (PIM) Demonstration Program to study whether intensive care coordination influences the relationship between fragmentation and patient outcomes. Using VA records and Medicare administrative data for FY14, this study will compare properties and predictive validity of the following fragmentation measures:

  • Count of unique providers
  • Concentration of care with an empirically defined “usual provider”
  • Two measures of dispersion of care across providers
  • Health system fragmentation for those with dual use of VA and Medicare

Preliminary Findings:

  • In FY14, Veterans who were at high risk for hospitalization (≥90th percentile) had a mean of 6.5 VA providers.
  • Not understandable
  • For multiple measures of fragmentation, patients with mental health conditions have more fragmented care.
  • Increased fragmentation is associated with a greater likelihood of hospitalization in the following year.

Impact: Veterans are increasingly facing care fragmentation, a challenge that will likely intensify in a policy environment that encourages Veterans to use both VA and community care. Veterans who are at high risk for hospitalization and individuals with functional limitations or resource constraints may be especially vulnerable to negative consequences from fragmented care. This study’s findings will inform both current and future efforts to improve and streamline care for high-risk Veterans with multiple chronic conditions.

Principal Investigator: Donna M. Zulman, MD, MS, is with HSR&D’s Center for Innovation to Implementation (Ci2i) at the VA Palo Alto Health Care System, Palo Alto CA.

Identifying and Delivering Point-of-care Information to Improve Care Coordination

Cancer Care Coordination

(Photo © iStock/asiseeit)

Poor care coordination is a principal cause of avoidable morbidity, mortality, resource use, and dissatisfaction for both patients and clinicians. Veterans are in particular need of optimal care coordination, given that many suffer from multimorbid conditions, mental health problems, and a challenging socioeconomic environment. Furthermore, in the era of the Choice and MISSION Acts, coordination of VA and non-VA care is increasingly challenging and important. Multidisciplinary care teams, such as VA’s Patient Aligned Care Teams (PACTs), have been proposed as one of multiple strategies to improve care coordination in the primary care setting. For such a strategy to succeed, PACT members must excel at working collectively on interdependent tasks to deliver evidence-based care that could not be accomplished as effectively by a single provider. In other words, teams must excel at team coordination in order to excel at care coordination. However, the ability to monitor team coordination is still in its infancy. Thus, a clear understanding of the objectives and standards of coordination, as well as the information needs at the point of care, is essential to successfully coordinating care.

This ongoing study seeks to determine the point-of-care information that PACT members need for successful coordination. Clinicians at a VA primary care clinic participated in a series of structured, facilitated focus groups to identify coordination objectives and indicators of effective coordination. Following this phase, three traditional focus groups were conducted to identify needed information at point-of-care to improve performance for each indicator. Next, 34 PACTS participated in a controlled trial testing the effectiveness of a team-based audit-and-feedback intervention aimed at improving performance on the coordination indicators developed earlier, and 34 PACT control teams were monitored passively. The intervention consisted of monthly team-level feedback reports of the coordination indicators followed by monthly structured team debriefings.


  • Seven measures indicative of performance, on objectives of creating Veteran engagement through patient-centered care, and ensuring quality and efficiency were developed:
    • Percentage of patient appointments that start on time
    • Score on patient satisfaction survey (intervention arm only)
    • Clinical reminder completion (intervention arm only)
    • Timely recall scheduling
    • Reliance on ER Care by current PACT patients
    • My Health-E Vet secure messaging enrollment
    • Education offerings utilization
  • Common areas where change needs were identified included technology systems improvements, training/education for patients and PACT members, and management buy-in to facilitate suggested changes.
  • Controlled trial results showed improvement over time in selected team and care coordination indicators; this effect was only present, however, in teams that consistently attended debriefings and in teams whose members were assigned to fewer PACTs.

Impact: This project has identified a set of practical, feasible, and prioritized behavioral measures of care coordination in PACT settings, which in conjunction with regular feedback, can help PACTs pinpoint areas for improvement. These measures have the added benefit of already existing or being readily calculated from existing VA data sources. The project also helps advance the science of implementation of team-based coordination tools, by identifying elements of coordination that are important regardless of clinical condition or disease and highlighting the importance of dose consistency in team-based feedback interventions for coordination.

Principal Investigator: Sylvia J. Hysong, PhD, is with HSR&D’s Center for Innovations in Quality, Effectiveness and Safety (IQuESt) at the Michael E. DeBakey VA Medical Center, Houston, Texas.


Weaver SJ, Che XX, Petersen LA, Hysong SJ. Unpacking Care Coordination Through a Multiteam System Lens: A Conceptual Framework and Systematic Review. Medical care. 2018 Mar 1; 56(3):247-259.

Hysong SJ, Che X, Weaver SJ, Petersen LA. Study protocol: identifying and delivering point-of-care information to improve care coordination. Implementation science: IS. 2015 Oct 19; 10:145.

Hysong SJ, Woodard L, Garvin JH, Murawsky J, Petersen LA. Publishing protocols for partnered research. Journal of general internal medicine. 2014 Dec 1; 29 Suppl 4:820-4.

Hysong SJ, Francis J, Petersen LA. Motivating and engaging frontline providers in measuring and improving team clinical performance. BMJ quality & safety. 2019 May 1;28(5):405-11.

Cancer Care Coordination

Cancer Care Coordination

(Photo © iStock/asiseeit)

Understanding cancer care coordination from the patient perspective is critical. The few instruments that exist to measure coordination do not measure key domains such as the facilitation of transfers and health information technology-enabled coordination. Before now, no instruments have been developed specifically for cancer care coordination within VA. It will be of value to Veterans, clinicians, and researchers to have accurate and reliable measures that capture the experience of coordination from the patient perspective.

This study used interviews with Veteran cancer patients and input from an expert advisory council to assess cancer care coordination and identify items missing in prior measures. Investigators then developed and piloted a new quantitative instrument to assess patient perspectives on cancer care coordination and evaluated its reliability and validity.


  • At the outset of treatment, Veterans expressed the need for active mechanisms to meet care coordination needs, but as they adjusted to the care system they perceived more coordination.
  • Nurse navigators and pre-treatment tours of facilities were suggested by Veterans to increase coordination.
  • Convenient scheduling, emotional support, financial needs, and MyHealtheVet use, and items related to informed decision-making emerged as care coordination needs.

Impact: Among Veterans with cancer, providing clear and explicit information at the outset of treatment about what to expect may reduce patient barriers to navigating a complex care system. With this new set of tools to assess the coordination needs of the Veteran cancer population, clinicians and researchers can better monitor and improve VA cancer care.

Principal Investigator: David Haggstrom, MD, is with HSR&D’s Center for Health Information and Communication (CHIC) at the Richard L. Roudebush VA Medical Center, Indianapolis, IN.

Improving PACT Coordination across Settings and Services: Coordination Toolkit and Coaching (CTAC) Project

Improving PACT Coordination across Settings and Services

(Photo © iStock/seb_ra)

Inefficiencies in care coordination for chronic conditions are a significant source of waste in the US, and VA legislation allowing patients to seek care from community providers has further complicated care coordination in VA primary care practices, in which patients already have higher rates of comorbidity than their private-sector counterparts. The Coordination Toolkit and Coaching (CTAC) project, part of the Care Coordination QUERI program, aims to improve patients’ experience of care coordination, while also developing better methods for bringing research evidence on care coordination into routine care. CTAC is a multi-site project that uses an evidence-based quality improvement (EBQI) strategy to support participating sites in undertaking care coordination improvement projects for vulnerable patients visiting PACT, and compares the effectiveness of two different implementation strategies: a passive strategy (access to online resources for care coordination compiled into a toolkit) and an active strategy (access to the online toolkit plus weekly support from a distance-based coach). Twelve clinics (six matched pairs of “toolkit only” clinics and “toolkit plus coaching” clinics) are participating in the project; one clinic from each matched pair has been randomly assigned to each strategy. The primary outcome of interest is Veteran experience of care; secondary outcomes include implementation outcomes (including adoption and sustainment of care coordination tools) as measured through semi-structured stakeholder interviews.

Results: The Care Coordination Toolkit, available on the https:/ (available on the VA intranet only), provides access to 18 tools covering the topics of managing referrals to specialty care, medication management, patient after-visit summary, patient activation materials, and provider contact information. It also includes access to the coaching manual that CTAC coaches use to provide distance-based coaching. Full results from CTAC are expected in 2020.

Impact: The CTAC project is expected to improve care coordination in VA primary care clinics and provide readily-applicable methods for spreading improvements throughout VA. The project will inform VA policymakers regarding what other implementation strategies, including the use of distance coaching, might influence the use of toolkits within healthcare delivery systems.

Principal Investigator: David Ganz, MD, PhD, is with HSR&D’s Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), at the VA Greater Los Angeles Healthcare System, Los Angeles, CA.

This study has resulted in the following publications:

Ganz D, Barnard J, Smith N, et al. Development of a Web-based Toolkit to Support Improvement of Care Coordination in Primary Care. Translational Behavioral Medicine. June 2018;8(3):492-502.

Olmos-Ochoa TT, Bharath P, Ganz D, Noel PH, Chawla N, Barnard J, Rose DE, Stockdale SE, Simon A, Finley EP. Staff Perspectives on Primary Care Teams as De Facto “Hubs” for Care Coordination in VA: a Qualitative Study. J Gen Intern Med 2019;34(Suppl 1):S82-S89


  • Fact Sheet. Veterans Access, Choice and Accountability Act of 2014(“Choice Act”). [Internet]. Washington (DC): US Department of Veterans Affairs; 2014 [cited 2019 June 19]. Available from:
  • Vantage Point. MISSION ACT 101: How the law will improve VA’s ability to deliver health care to Veterans [Internet]. Washington (DC): US Department of Veterans Affairs; 2019 [cited 2019 June 19]. Available from:
  • An operations-partnered evaluation of care redesign for high-risk patients in the Veterans Health Administration (VHA): Study protocol for the PACT Intensive Management (PIM) randomized quality improvement evaluation. Chang et al. Contemp Clin Trials. 2018 Jun;69:65-75. Epub 2018 Apr 23
  • Improving Care Coordination for Veterans Within VA and Across Healthcare Systems. Cordasco KM, Hynes DM, Mattocks KM, Bastian LA, Bosworth HB, Atkins D. J Gen Intern Med. 2019 May;34(Suppl 1):1-3.

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