Improving Team-Based Care Coordination Delivery and Documentation in the Health Record

During the pilot phase, the CC template allowed the PIM team to identify a small subset of patients within the PIM complex management who have a high level of CC needs. By identifying these patients, further work can be done to understand the specific needs of these higher utilizers and the types of CC activities required to assist them so that resources can be directed appropriately to that smaller subset. Telephone CC accounted for a large proportion of delivery, which has implications for ensuring that staff have access to mobile phones and EHR capability to document this additional workload. The PIM staff maintained use of the template throughout the pilot period and increased documentation when the CC Template was easily accessible and already linked to their CPRS notes, suggesting that in future implementation, ensuring that the template is linked to notes in use by the care team will be important for successful spread.

Additionally, CC Template data identified gaps in high-quality, evidence-based CC that can be addressed in real time, for example during the discharge process. Data from the CC Template showed that only 11.1% of CC encounters had documentation of communication between the PIM and primary care teams during transitions from hospital to home. Improving communication with PACT teams after hospital discharge was identified as a future PIM QI project based on these data. By improving documentation of CC in the EHR, the resulting information is foundational for future work that can improve the quality of team-based CC; plan staffing, team composition, and labor mapping; determine the cost of CC activities and improve reimbursement in certain settings; and assess outcomes of CC.

This tool has potential for application beyond the PIM team in the VA. The CC Template and training manual is scalable to any setting with team-based CC, including PACT, homeless programs, palliative care, Mental Health Intensive Case Management (MHICM) programs, nurse navigator programs, and other complex care delivery models involving care coordinators. Future study of its implementation and data may inform initiatives to develop ongoing team-based care coordination programs.

Acknowledgments
The authors thank the following colleagues for their input and support: Florence Longchamp, RN, Clinical Applications Coordinator at the Atlanta VA Medical Center without whom the CC Template would not have been created; the Atlanta and San Francisco VA PIM teams for their thoughtful comments and enthusiastic embrace of the CC Template; and the PIM National Evaluation Center for their support of this QI project. PACT Intensive Management demonstration sites are funded by the VA Office of Patient Care Services. During the implementation of the CC Template pilot and the preparation of this paper, the primary author was supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Academic Affiliations, Advanced Fellowships, VA Quality Scholars Program.