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Management Brief No. 175

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Management eBriefs
Issue 175 September 2020

The report is a product of the VA/HSR Evidence Synthesis Program.

Care Coordination Models and Tools: A Systematic Review and Key Informant Interviews

Over the past 20 years, there has been substantial interest in care coordination interventions, particularly to reduce the use of acute care services. In 2016, the VA Care Coordination and Integrated Case Management (CC&ICM) initiative was launched as a collaboration between VA Care Management and Social Work, part of Patient Care Services, and VA’s Office of Nursing Services. The main goals of this initiative are to standardize and integrate care coordination services across all VA facilities and points of care for Veterans. To assist the CC&ICM initiative, HSR&D’s Evidence Synthesis Program (ESP) was asked to review evidence on implementation and outcomes of various care coordination models.

Care coordination models usually involve systematic strategies developed to improve continuity and bridge transitions of care, but it remains unclear whether care coordination interventions can sufficiently address gaps in care and improve patient outcomes.

Investigators with VA’s Evidence Synthesis Program (ESP)ESP Center in Minneapolis, MN searched the literature including MEDLINE, CINAHL, Embase, Cochrane Database of Systematic Reviews, Agency for Healthcare Research and Quality Evidence-based Practice Center reports, and VA ESP reports from inception until September 2019. Investigators also identified relevant primary research studies included by reviews and conducted a search for randomized controlled trials (RCT) in MEDLINE and Embase from 2018 until February 2020. They screened and reviewed results from this additional search for RCT. Of 2,324 unique citations for systematic reviews, 72 underwent full-text review. From these, investigators identified 16 eligible systematic reviews, 14 of which examined case management or transitional care interventions, and 2 others evaluated intensive primary care models (i.e., home-based primary care). In addition, they conducted interviews with research investigators and members of teams (n=11) that implemented care coordination models.

Summary of Findings

Existing evidence on care coordination models indicates inconsistent effects on reducing hospitalizations and/or emergency department visits for high-risk community-dwelling adults. It remains unclear whether such interventions should be implemented – and how they may be adapted to different healthcare settings. Implementation of new care coordination services should be carefully evaluated, preferably using randomized designs. Policymakers also should consider whether, for certain patient populations, a larger-scale redesign of care models may be necessary to improve continuity and collaboration.

Additional findings include:

  • Two systematic reviews reported that a key component of effective care coordination models were patient selection criteria focused on specific risk factors and/or needs.
  • One systemic review reported that high-intensity models and/or multidisciplinary plans were required for effectiveness (in combination with selection criteria noted above).
  • Interventions used a variety of approaches to improve communication between patients and providers, including coaching and role-playing. In some interventions, care coordinators also directly communicated with providers on patients’ behalf, including participation at outpatient appointments.
  • Primary studies reporting effective interventions were conducted in a variety of settings (i.e., rural community hospitals, academic medical centers in urban settings, and public hospitals).
  • Systematic reviews, primary studies, and interviews provided little information on specific tools or approaches used to assess patient trust or healthcare team integration.
  • Key informant interviews suggested variation in sustainability of care coordination interventions, with substantial adaptation occurring among many of those that have continued.

Some key informants also suggested that care coordination interventions may work better for those with modifiable factors and/or less severe conditions. With such an approach, an important challenge is that the intervention may need to serve a large number of patients before demonstrating appreciable differences in acute care utilization. One key informant described it as: “You can allocate a lot of resources to extremely high need patients…or you can allocate resources to a larger population and… have a smaller impact on individual level, but on population level have greater impact…


  • Care coordination models were complex and differed along multiple dimensions, thus presenting substantial challenges for summarizing and comparing results across studies.
  • Several systematic reviews that sought to examine key characteristics and/or organizational settings of care coordination models reported difficulty finding adequate published evidence to address questions.
  • Among 11 primary studies demonstrating effective care coordination models, none reported specific tools or approaches for measuring patient trust or healthcare team integration.
    • Key informant interviews did not provide additional information on these areas.

Research Gaps/Future Research

ESP investigators recommend the following:

  • Evaluate future care coordination interventions using randomized designs;
  • Consider application of standardized tools to assess patient trust or working alliance, healthcare team integration, and communication between patients and providers;
  • Consider study designs that explicitly consider implementation outcomes in future studies of care coordination models; and
  • Define “core” intervention components and describe local adaptations, particularly in multi-site studies.

Implications for VA Policy/Practice

The VA Care Coordination and Integrated Case Management (CC&ICM) initiative has implemented several tools for evaluating Veteran needs and matching the level of care coordination services to those needs. It will be important to evaluate feasibility and effects of widely implementing such tools on delivery of services and patient outcomes. Additionally, it will be important to understand differences in utility of these tools across large and small VA sites, and those serving urban and more rural communities. A potential avenue to achieving more consistency of services, while allowing flexibility, may be to align services and programs based on program goals and Veterans’ needs; this information may be collected in a central hub for easier referrals. It also may be valuable for the CC&ICM initiative to provide educational materials to guide local adaptations.

From the CC&ICM initiative workgroup: This ESP review highlighted an absence of patient-provider assessment tools and revealed inconsistency in the evaluation of care coordination interventions and applications. Research is needed to describe and evaluate the strategies and tools which determine patient needs, support care coordination services, and fortify patient-provider communication and trust. An unprecedented need also exists to coordinate services for Veterans utilizing federal and private sector healthcare settings. This requirement and a lack of validated care coordination tools are aligned with the need to use an overarching research framework to prioritize care coordination research questions. Researchers and care coordination stakeholders should consider the application of implementation science to evaluate the effectiveness of newer programs such as those being piloted under the CC&ICM initiative. Strategically, subject matter experts from VA HSR&D and care coordination should partner in the development of a research framework to prioritize research questions, evaluate outcomes, and optimize care coordination for Veterans.

Duan-Porter W, Ullman K, Majeski B, Miake-Lye I, Diem S, and Wilt TJ. Evidence review: Care coordination models and tools. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #09-009; 2020.

To view the full report, go to (If you have intranet access, copy and paste link into your browser.).

ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of VA/HSR&D's Evidence Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers –; and to disseminate these reports throughout VA.

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