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Amy Kilbourne, PhD, MPH, Director of QUERI

Director's Letter

Optimizing Care Coordination for Veterans

Healthcare is undergoing a rapid transformation, challenging current thinking on how medical services can reach those who need them the most, at the right time, right place, and with patient preferences in mind. Enhancing information technology, while crucial to the functions of care coordination, is insufficient without the human factors that ensure a shared vision for who provides what care and under what circumstance. QUERI investigators have been at the forefront of implementing and evaluating innovative models of care coordination that take into account the complexities of provider and system factors that influence optimal care coordination. This issues describes key examples of implementation of care coordination for specific populations (e.g., geriatrics), treatment settings (e.g., emergency department), and level of intervention (e.g., individual providers, clinics).

Several themes emerge from this body of work. First, VA investigators need to move quickly from describing models of care coordination to actively working with VA operations to implement and evaluate the most promising models. For example, the VA healthcare system will need best practices to care for its aging Veteran population, especially with the advent of the Choose Home caregiver initiative (designed to allow Veterans to remain in their homes rather than using institutional care) to better coordinate non-institutional services for Veterans experiencing a wide range of needs (i.e., polytrauma, dementia). Second, these models of care will need to be tested in community care settings, where over one-third of VA enrollees receive services. Finally, implementation science expertise will be needed to help break down silos to empower frontline providers to support VA adopting core competencies of care coordination that cut across provider type and information technology infrastructures, notably by navigating each other’s different professional background and job function statements in order to identify roles and accountability, and ultimately buy into a common mission to optimize care for all Veterans.

Amy Kilbourne, PhD, MPH
Director, Quality Enhancement Research Initiative