Improving Team-Based Care Coordination Delivery and Documentation in the Health Record
Chronic diseases affect a substantial proportion of the US population, with 25% of adults diagnosed with 2 or more chronic health conditions.1 In 2010, 2 chronic diseases, heart disease and cancer, accounted for nearly 48% of deaths.2 Due to the significant public heath burden, strategies to improve chronic disease management have attracted a great deal of focus.3,4 Within increasingly complex health care delivery systems, policy makers are promoting care coordination (CC) as a tool to reduce fragmented care for patients with multiple comorbidities, improve patient experience and quality of care, and decrease costs and risks for error.3-8
Background
The Agency for Healthcare Research and Quality (AHRQ) defines care coordination as “deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care.”5 Nationally, large scale investments have expanded health care models that provide team-based CC, such as patient-centered medical homes, known as patient-aligned care teams (PACTs) within the Department of Veterans Affairs (VA), accountable care organizations, and other complex care management programs.9-12 Additionally, incentives that reimburse for CC, such as Medicare’s chronic care management and transition care management billing codes, also are emerging.13,14
While there is significant interest and investment in promoting CC, little data about the specific activities and time required to provide necessary CC exist, which limits the ability of health care teams to optimize CC delivery.6 Understanding the components of CC has implications for human resource allocation, labor mapping, reimbursement, staff training, and optimizing collaborative networks for health care systems, which may improve the quality of CC and health outcomes for patients. To date, few tools exist that can be used to identify and track the CC services delivered by interdisciplinary teams within and outside of the health care setting. 
This article describes the development and preliminary results of the implementation of a CC Template that was created in the VA Computerized Patient Record System (CPRS) to identify and track the components of CC services, delivered by a multidisciplinary team, as part of a quality improvement (QI) pilot project. Through use of the template, the team sought a formative understanding of the following questions: (1) Is it feasible to use the CC Template during routine workflow? (2) What specific types of CC services are provided by the team? (3) How much time does it take to perform these activities? (4) Who is the team collaborating with inside and outside of the health care setting and how are they communicating? (5) Given new reimbursement incentives, can the provision of CC be standardized and documented for broad applicability?
In complex systems, where coordination is needed among primary, specialty, hospital, emergency, and nonclinical care settings, a tool such as the CC Template offers a sustainable and replicable way to standardize documentation and knowledge about CC components. This foundational information can be used to optimize team structure, training, and resource allocation, to improve the quality of CC and to link elements of CC with clinical and operational outcomes.
