The Coordination Toolkit and Coaching Project: Cluster-Randomized Quality Improvement Initiative to Improve Patient Experience of Care Coordination

Abstract

BACKGROUND: Given persistent gaps in coordination of care for medically complex primary care patients, efficient strategies are needed to promote better care coordination. OBJECTIVE: The Coordination Toolkit and Coaching project compared two toolkit-based strategies of differing intensity to improve care coordination at VA primary care clinics. DESIGN: Multi-site, cluster-randomized QI initiative. PARTICIPANTS: Twelve VA primary care clinics matched in 6 pairs. INTERVENTIONS: We used a computer-generated allocation sequence to randomize clinics within each pair to two implementation strategies. Active control clinics received an online toolkit with evidence-based tools and QI coaching manual. Intervention clinics received the online toolkit plus weekly assistance from a distance coach for 12 months. MAIN MEASURES: We quantified patient experience of general care coordination using the Health Care System Hassles Scale (primary outcome) mailed at baseline and 12-month follow-up to serial cross-sectional patient samples. We measured the difference-in-difference (DiD) in clinic-level-predicted mean counts of hassles between coached and non-coached clinics, adjusting for clustering and patient characteristics using zero-inflated negative binomial regression and bootstrapping to obtain 95% confidence intervals. Other measures included care coordination QI projects attempted, tools adopted, and patient-reported exposure to projects.KEY RESULTS: N = 2,484 (49%) patients completed baseline surveys and 2,481 (48%) completed follow-ups. Six coached clinics versus five non-coached clinics attempted QI projects. All coached clinics versus two non-coached clinics attempted more than one project or projects that were multifaceted (i.e., involving multiple components addressing a common goal). Five coached versus three non-coached clinics used 1-2 toolkit tools. Both the coached and non-coached clinics experienced pre-post reductions in hassle counts over the study period (− 0.42 (− 0.76, − 0.08) non-coached; − 0.40 (− 0.75, − 0.06) coached). However, the DiD (0.02 (− 0.47, 0.50)) was not statistically significant; coaching did not improve patient experience of care coordination relative to the toolkit alone. CONCLUSION: Although coached clinics attempted more or more complex QI projects and used more tools than non-coached clinics, coaching provided no additional benefit versus the online toolkit alone in patientreported outcomes. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03063294

Systematic review of contemporary improvement interventions on care coordination, discharge support and transitional care from the patient experience perspective

“…Context-wise, all studies were multi-site PCMHs or other primary care practices, all from a network or integrated health system in the US: Veterans’ Health Administration (VHA), 32–34 a statewide PCMH network, 35 Federally Qualified Health Centers, 36 a Safety Net Medical Homes’ Initiative, 38 or academically-affiliated primary care practices. 37…”

“…A recent RCT at the VHA, with the fewest appraised risks of bias (Table 1), used QI facilitation (e.g., coaching) on the site’s use of a care-coordination improvement toolkit – beyond its internal dissemination (control); both groups improved, with no significant benefit for the more resource-intensive arm. 34…”

“…Overall, the inclusion of varied study designs, interventions, and patient experience measures and metrics may inform further improvement activities and its study, at varying levels of available resources. Across study designs, some common intervention approaches were found, such as enhanced supports for QI facilitation on care coordination 34 35 or tailored approaches for at-risk populations (e.g., socially vulnerable, homeless), 32 33 36 38 often showing mixed patient experience results relative to standard supports. In turn, discharge support approaches that used a reengineered discharge or teach back strategies were also common but with less favorable results when compared to studies and reviews on other outcomes, such as reducing readmissions.…”

“…52 Fourth, the VHA in the US has its own patient experience measurement system, which was used a standardized assessment measure in studies externally reported and included here. 33 34 Fifth, improvement activities otherwise fitting the study eligibility criteria from other countries may have been conducted but not reported in English or through peer-reviewed journals.…”

Patient experience surveys for vulnerable families

“…• Focus groups on patient experience of the Behavioral Health Integration and Complex Care Initiative (BHICCI) 24 • Health Care System Hassles Scale 10,23 Sax Institute | Patient experience surveys for vulnerable families 18…”