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Director's Letter

In today's VA, where the average patient has long medication lists, sees multiple providers in multiple clinics, and receives inpatient care from hospitalists, active coordination is needed to ensure treatments are aligned and handoffs are not missed. Coordinating care will be challenged even further if the current crisis over wait times pushes VA to outsource more care to community providers.

An integrated system like VA has many advantages in coordinating care: our well-functioning electronic health record, advanced primary care - mental health integration, and growing electronic communication with patients and among clinicians. Information exchange alone doesn't ensure coordinated care, however. That only happens when everyone caring for an individual patient is working toward common, patient-identified goals.

Coordination challenges are evident in VA; research has documented that an increasing number of prescribers correlates with worse outcomes. Risk of opiate overdose rises as patients are prescribed pain medication from both VA and non-VA providers. Efforts to improve coordination in VA face two fundamental challenges: (1) how to improve coordination without simply adding another layer of personnel, decisions, and communications to an already complex system (with many mandatory VA "coordinator" positions, e.g., OEF/OIF, suicide, homelessness, etc., some Veterans need a coordinator for all their coordinators); and (2) to establish a business case for better care coordination by focusing on the subset of patients for whom uncoordinated care is most likely to lead to waste and poor outcomes. As the articles in this issue document, better coordination is possible and necessary—but it needs to be built into the system of care and not added on as an afterthought.

David Atkins, M.D., M.P.H., Director, HSR&D