Purpose: Often, rural veterans with cancer must transition across multiple settings to be diagnosed and receive treatment. To meet its strategic goal of delivering coordinated, patient-centered care for these veterans, the VHA must monitor and evaluate care with appropriate measures. A literature review revealed confusion about the distinct differences between coordination, patient-centered care, outcomes, and the care environment. As a result, coordination cannot be measured precisely. The purpose of this study was to synthesize a coherent, comprehensive theoretical framework and to identify measures appropriate to the framework to be used in performance improvement and research to improve coordination.
Methods: We comprehensively reviewed the theoretical and empirical literature to identify key concepts and measures relevant to the care of rural veterans with cancer who transition across care settings. The Agency for Health Care Quality framework that identified clinician activities and continuity as coordination components framed our review, as did the Institute of Medicine’s definition of patient-centered care. We focused our review on the following 3 key measurement gaps identified by policy and federal stakeholders: (1) attending to perspectives from nonphysician clinicians; (2) evaluating coordination for transitions across outpatient and other nonhospital settings; and (3) using data from electronic records. The empiric literature, including qualitative and quantitative studies, provided patient outcomes that are affected by patient-centered care. Peer-reviewed literature describing challenges for rural veterans and for patients with cancer who were treated in multiple settings provided key considerations for the framework’s concepts. Verification methods included iterative consideration of the framework among study team members. We also consulted clinical and methodologic experts from the VHA Office of Rural Health, the VACO Office of Nursing Services Oncology Field Advisory Committee, VHA survey experts, and experts in VA performance measurement. Finally, we relied on federal stewards in our identification of valid and reliable subjective and objective measures.
Results: Our review revealed considerable conceptual overlap for the constructs of coordination, patient-centered care, and patient outcomes. We determined that measurement error is inevitable unless these constructs are distinguished from one another. For example, without precise conceptualization and measurement, there is an increased possibility of erroneous estimates of variance explained in patient outcomes by care coordination. Our resultant framework distinguishes between and defines key concepts. As asserted in the AHRQ conceptualization, we found that the literature-supported coordination construct is composed of 3 types of care continuity (informational, relational, and management) and 4 types of clinician activities (designating accountability, communicating, facilitating transitions, and linking to resources). However, our findings are different in identifying patient-centered care to be a distinctive construct that comprises care individualization, proficiency, and responsiveness. Moreover, our framework incorporates patient outcomes important for rural veterans with cancer: health care utilization and health-related quality of life. The framework also conceptualizes the environment of care as health care system characteristics. Relationships delineated in the framework concluded that continuity and clinician activities directly affect patient-centered care and indirectly affect patient outcomes after a transition in care settings. Our findings also include subjective (questionnaires) and objective (CPRS) candidate measures to operationalize the concepts.
Conclusions: This study represents progress toward unifying divergent conceptualizations of coordination. One next step is to identify and psychometrically assess how measures of the framework’s concepts work when used together. This framework can guide the operation of key coordination concepts in both research and improvement activities. A variety of data sources are suggested. Also, by conceptualizing clinician–not just physician–activities, the framework includes professionals such as nurses who play critical roles in care coordination. Last, the framework identifies relationships between coordination, patient-centered care, outcomes, and the care environment that can be empirically tested.
