Care Coordination Models and Tools: A Systematic Review ...

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Evidence Synthesis Program

Care Coordination Models and Tools:

A Systematic Review and Key

Informant Interviews

June 2020

Prepared for:

Department of Veterans Affairs

Veterans Health Administration

Health Services Research & Development Service

Washington, DC 20420

Prepared by:

Evidence Synthesis Program (ESP) Center

Minneapolis VA Health Care System

Minneapolis, MN

Timothy J. Wilt, MD, MPH, Director

Wei Duan-Porter, MD, PhD, Associate Director

Authors:

Principal Investigator:

Wei Duan-Porter, MD, PhD

Co-Investigators:

Isomi Miake-Lye, PhD

Susan Diem, MD

Timothy J. Wilt, MD, MPH

Research Associates:

Kristen Ullman, MPH

Brittany Majeski, BA

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Care Coordination Implementation

Evidence Synthesis Program

PREFACE

The VA Evidence Synthesis Program (ESP) was established in 2007 to provide timely and accurate

syntheses of targeted health care topics of importance to clinicians, managers, and policymakers as they

work to improve the health and health care of Veterans. These reports help:

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Develop clinical policies informed by evidence;

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Implement effective services to improve patient outcomes and to support VA clinical practice

guidelines and performance measures; and

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Set the direction for future research to address gaps in clinical knowledge.

The program is comprised of 4 ESP Centers across the US and a Coordinating Center located in

Portland, Oregon. Center Directors are VA clinicians and recognized leaders in the field of evidence

synthesis with close ties to the AHRQ Evidence-based Practice Center Program and Cochrane

Collaboration. The Coordinating Center was created to manage program operations, ensure

methodological consistency and quality of products, and interface with stakeholders. To ensure

responsiveness to the needs of decision-makers, the program is governed by a Steering Committee

comprised of health system leadership and researchers. The program solicits nominations for review

topics several times a year via the program website.

Comments on this evidence report are welcome and can be sent to Nicole Floyd, Deputy Director, ESP

Coordinating Center at Nicole.Floyd@.

Recommended citation: Duan-Porter W, Ullman K, Majeski B, Miake-Lye I, Diem S, and Wilt TJ.

Evidence review: care coordination models and tools. Washington, DC: Evidence Synthesis Program,

Health Services Research and Development Service, Office of Research and Development,

Department of Veterans Affairs. VA ESP Project #09-009; 2020. Available at:

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This report is based on research conducted by the Evidence Synthesis Program (ESP) Center located at the

Minneapolis VA Medical Center, Minneapolis, MN, funded by the Department of Veterans Affairs, Veterans

Health Administration, Health Services Research and Development. The findings and conclusions in this document

are those of the author(s) who are responsible for its contents; the findings and conclusions do not necessarily

represent the views of the Department of Veterans Affairs or the United States government. Therefore, no statement

in this article should be construed as an official position of the Department of Veterans Affairs. No investigators

have any affiliations or financial involvement (eg, employment, consultancies, honoraria, stock ownership or

options, expert testimony, grants or patents received or pending, or royalties) that conflict with material presented

in the report.

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Care Coordination Implementation

Evidence Synthesis Program

ACKNOWLEDGMENTS

This topic was developed in response to a nomination from the Office of Nursing Services and

the Office of Care Management and Social Work Services to support the Coordinated Care and

Integrated Case Management (CC&ICM) Initiative. The scope was further developed with input

from the topic nominators (ie, Operational Partners), the ESP Coordinating Center, the review

team, and the technical expert panel (TEP).

In designing the study questions and methodology at the outset of this report, the ESP consulted

several technical and content experts. Broad expertise and perspectives were sought. Divergent

and conflicting opinions are common and perceived as healthy scientific discourse that results in

a thoughtful, relevant systematic review. Therefore, in the end, study questions, design,

methodologic approaches, and/or conclusions do not necessarily represent the views of

individual technical and content experts.

The authors gratefully acknowledge the following individuals for their contributions to this

project:

Operational Partners

Operational partners are system-level stakeholders who have requested the report to inform

decision-making. They recommend Technical Expert Panel (TEP) participants; assure VA

relevance; help develop and approve final project scope and timeframe for completion; provide

feedback on draft report; and provide consultation on strategies for dissemination of the report to

field and relevant groups.

Lisa Perla, MSN, FNP, CNRN, CRRN

Co-lead, Data Management and Research Workgroup

Coordinated Care and Integrated Case Management Initiative

Janet Belisle, MHA, RHIA, FACHE

Co-lead, Data Management and Research Workgroup

Care Management and Social Work Services

Jimmy Boerschmann, RN, BSN, MSHC

Co-lead, Data Management and Research Workgroup

Office of Nursing Services

Elizabeth Sprinkle, LCSW, C-ASWCM, MVF-ASW

Field Advisor

Coordinated Care and Integrated Case Management Initiative

Technical Expert Panel (TEP)

To ensure robust, scientifically relevant work, the TEP guides topic refinement; provides input

on key questions and eligibility criteria, advising on substantive issues or possibly overlooked

areas of research; assures VA relevance; and provides feedback on work in progress. TEP

members are listed below:

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Care Coordination Implementation

Evidence Synthesis Program

Erica Abel, PhD

Psychologist and Associate Investigator, Pain Research, Informatics, Multi-morbidities, and

Education (PRIME) Center, VA Connecticut Healthcare System

Assistant Clinical Professor, Yale School of Medicine

Kristina Cordasco, MD, MPH, MSHS

Core Investigator, Center for the Study of Healthcare Innovation, Implementation and Policy

(CSHIP), VA Greater Los Angeles Healthcare System

Associate Clinical Professor of Medicine, University of California, Los Angeles

Denise Hynes, BSN, MPH, PhD, RN

Research Health Scientist, Investigator, Center to Improve Veteran Involvement in Care

(CIVIC), VA Portland Health Care System

Professor, School of Social and Behavioral Health Sciences, College of Public Health and

Human Sciences, Oregon State University

Kristin Mattocks, PhD, MPH

Associate Chief of Staff/Research & Education, VA Central Western Massachusetts

Associate Professor, University of Massachusetts Medical School

Peer Reviewers

The Coordinating Center sought input from external peer reviewers to review the draft report and

provide feedback on the objectives, scope, methods used, perception of bias, and omitted

evidence. Peer reviewers must disclose any relevant financial or non-financial conflicts of

interest. Because of their unique clinical or content expertise, individuals with potential conflicts

may be retained. The Coordinating Center and the ESP Center work to balance, manage, or

mitigate any potential nonfinancial conflicts of interest identified.

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Care Coordination Implementation

Evidence Synthesis Program

TABLE OF CONTENTS

Acknowledgments ......................................................................................................................... ii

EXECUTIVE SUMMARY .......................................................................................................... 1

Introduction ................................................................................................................................. 1

Methods....................................................................................................................................... 1

Results ......................................................................................................................................... 4

Discussion ................................................................................................................................... 7

Abbreviations Table.................................................................................................................... 11

EVIDENCE REPORT ................................................................................................................ 12

INTRODUCTION....................................................................................................................... 12

METHODS .................................................................................................................................. 13

Topic Development................................................................................................................... 13

Conceptual Framework of Care Coordination Models ......................................................... 13

Key Questions (KQ) ............................................................................................................. 14

Search Strategy ......................................................................................................................... 15

Study Selection ......................................................................................................................... 15

Quality Rating & Data Abstraction........................................................................................... 15

Data Synthesis for Systematic Reviews & Relevant Primary Studies...................................... 16

Interviews with Key Informants who Implemented Care Coordination Models ...................... 16

Peer Review .............................................................................................................................. 17

RESULTS .................................................................................................................................... 17

Overview of Eligible Systematic Reviews ............................................................................... 17

KQ1¡ªWhat are the key characteristics of care coordination models? .................................... 18

KQ2¡ªWhat is the effect of implementing care coordination models? .................................... 19

KQ3¡ªWhat are the characteristics of settings in which effective models have been

implemented? ............................................................................................................................ 20

KQ4¡ªWhat are the tools and approaches used by effective models? ..................................... 20

Key Informant Interviews ......................................................................................................... 20

SUMMARY AND DISCUSSION .............................................................................................. 27

Summary of Key Findings ........................................................................................................ 27

Implications for Policy.............................................................................................................. 28

Evidence Gaps and Future Research Needs.............................................................................. 29

Limitations ................................................................................................................................ 29

Conclusions ............................................................................................................................... 30

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