Care Coordination Models and Tools: A ... - Veterans Affairs



Evidence Synthesis Program

Care Coordination Models and Tools: A Systematic Review and Key Informant Interviews

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

June 2020

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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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:

? Develop clinical policies informed by evidence;

? Implement effective services to improve patient outcomes and to support VA clinical practice guidelines and performance measures; and

? 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: .

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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ACKNOWLEDGMENTS

Evidence Synthesis Program

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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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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TABLE OF CONTENTS

Evidence Synthesis Program

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--What are the key characteristics of care coordination models? .................................... 18 KQ2--What is the effect of implementing care coordination models?.................................... 19 KQ3--What are the characteristics of settings in which effective models have been implemented? ............................................................................................................................ 20 KQ4--What 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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