Improving Team-Based Care Coordination Delivery and Documentation in the Health Record

Discussion

Though all components of CC encounters could not be assessed during the pilot phase due to continuous improvement of the CC Template, the authors showed that it is feasible to use this tool to document and describe granular details about team-based CC. Pilot data from AVAMC show that the use of the CC Template standardized team CC documentation in a busy clinic setting provided data about the complexity of coordination activities and duration of CC activities. It also informed future CC QI projects, such as improving communication with primary care during the hospital discharge process.

Future evaluation of CC Template data can be used to (1) describe types of CC activities for high-risk PIM patients; (2) quantify the time required to complete CC activities to assist with staff labor mapping; (3) describe staff roles and referrals needed to complete specific CC activities inside and outside VA; (4) describe modes of communication between PIM and collaborators; (5) relate patient demographics and associated diagnoses with quantity of CC encounters; and (6) quantify frequency and time frame of CC after hospitalizations and ED care and subsequent impact on repeat hospitalizations and ED visits. Future research also can explore the link between CC activities and effort with clinical and patient-reported outcomes.

Social network analysis could be used with CC Template data to understand the network of referrals and collaborators involved in the care of a CC team’s patients. This type of analysis would assist teams to strengthen and formalize ties with collaborators as appropriate. For example, if data show that the team frequently collaborates with the cardiology clinic for a large subset of its patients, they may consider creating a CC agreement with formalized modes of communication that would streamline collaboration.

In order to improve the quality of the CC Template and to assess factors that may lead to sustainable use in clinical practice, qualitative assessment through survey, interview, or usability testing with staff would be beneficial to identify strategies to increase its adoption among clinical providers. This type of assessment will add knowledge about the CC Template implementation process, including contextual barriers or facilitators, feasibility of use during day-to-day operations, versatility of template use within construct of team-based care, and overall satisfaction with the template.

Limitations

Though the CC Template offers a large amount of data about the components of CC delivery, the information is based on self-report by staff. Training to ensure that all team members are documenting in the same manner is crucial to maintain the internal validity of the data. The template is limited to the fields currently developed, and future research could explore additional data elements that are critical to include based on feedback from VA staff.

Conclusion

To our knowledge, this VA medical center CC Template is the first tool described in the literature that standardizes and captures data about CC components in the EHR. This pilot data show that the template is feasible for use in a busy clinic setting and can streamline the process for capturing CC data that may otherwise not be documented.