Evaluation of Care Coordination Review Teams

Purpose: Care coordination and integrated case management (CCICM) is a Veterans Health Administration (VHA) practice framework that addresses the fragmentation, variation, and gaps in care by introducing a system-wide, integrated care coordination framework. An integral element of this framework is the deployment of the care coordination review team (CCRT), which is made up of interprofessional team members who review veterans with complex care needs. The CCRT members determine and assign a lead coordinator (LC) who is a readily accessible and clearly identifiable point of contact for a veteran, their caregiver, and care team members. Evaluation of the CCRT review process was created to provide feedback to facilities regarding CCRT implementation to ensure integration of communication, collaboration, and coordination for LC assignment for veterans with complex care coordination needs.

Description: The CCICM framework was deployed in October 2021 through a phased approach among 139 facilities across VHA. Care coordination is an essential component for effective holistic care within the largest integrated healthcare system in the United States. The framework includes five (5) milestones and 24 critical actions that need to be addressed for implementation. One of the critical actions of this framework includes the deployment of the CCRT which identifies and assigns a LC to veterans with complex care needs. The LC helps ensure the veteran’s care is coordinated across services and episodes of care. Having a LC who oversees care coordination and facilitates communication, reduces intervention duplication, and improves delivery of care. Evaluation of the CCRT implementation and LC assignment process was created using the plan-do-study-act (PDSA) model. In addition, Prosci change management tools were reviewed for the development of the evaluation process. In alignment with the high-reliability organization (HRO) pillar of continuous process improvement, the review process supported stakeholders with CCRT processes by providing feedback to ensure the integrity of the purpose and intent of this multifaceted critical action.

Evaluation/outcome: A standardized CCRT evaluation process was created to support stakeholders with implementation. The evaluation process was conducted among 11 sites that had CCRTs implemented. A total of 90 cases (146 observations) were reviewed by the evaluation team comprised of CCICM field consultants since the initiation of the process in June 2022 through June 2023. Trends regarding CCRT processes were identified, shared with end-users, and utilized to augment the implementation process. Feedback from stakeholders regarding the process indicated the following: the review was helpful in improving the CCRT process, review elements addressed pertinent CCRT critical actions, and changes to CCRT processes were implemented because of the reviews. Additionally, because of the evaluation process, the need to develop a CCRT toolkit was identified. In July 2023, another workgroup was established to develop a CCRT toolkit that included training and resources to further support CCRT implementation.