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The Care Coordination QUERI program focuses on improving the experience of care for Veterans who are heavy users of VA services and have complex physical or mental health problems that require care from multiple health professionals and settings. These Veterans are at risk of "falling through the cracks" if care is not well-coordinated. Directly engaging these Veterans and their caregivers – and improving handoffs between health care providers across settings – can help create a better experience of care and better health outcomes. Although the Veteran is the primary "customer" in the Care Coordination QUERI program, VA employees who directly or indirectly provide care to patients also are key stakeholders. Past work in implementation science and quality improvement has shown that desired changes are only sustainable if they are integrated into employees' work routines and tailored to local needs. When it comes to knowing "how things work around here," frontline employees know best.
For this reason, the projects in the Care Coordination QUERI program each feature employee engagement at various phases of the project, as well as at multiple levels of the organization. The program's local quality improvement (QI) project has already begun, and is engaging the VA Greater Los Angeles (GLA) Healthcare System leadership and frontline providers across disciplines to improve communication between the GLA Emergency Department (ED) and Patient-Aligned Care Teams (PACT) for Veterans with urgent or specific post-ED care needs. This QI project utilizes a CPRS (computerized patient record system) order-based tool to send a message from ED providers to PACT RN Care Managers describing the post-ED care need(s). The PACT RN Care Managers then work with their PACT team to address the patient's need(s).
"A big selling point of the ED-PACT Tool is that it brings the RN Care Manager into the communication loop and improves the PACT RN's workflow," noted Dr. Kristina Cordasco, one of the principal investigators of the Care Coordination QUERI program and the lead for the ED-PACT Tool QI Project. "Instead of having the patient walk into the PACT clinic unexpectedly after an Emergency Room visit, the PACT RN can proactively work with the team to ensure the patient gets the needed care in a way that is efficient and patient-centered."
Care Coordination QUERI investigators also are developing a toolkit and coaching strategy to improve patients' experience of outpatient care, particularly in PACT. VISN, medical center, and front-line providers will be involved in the vetting and decision-making process for selecting and adapting toolkits and tools. Another Care Coordination QUERI project is testing a community engagement approach to enhancing the transition of patients from the hospital into the community setting, particularly by improving the linkage between VA and non-VA community organizations. Employee engagement is embedded in this approach, which seeks to involve all relevant stakeholders in a dialogue about the best strategies to improve care.
Lisa Rubenstein, MD, MSPH
Principal Investigator: Care Coordination QUERI