Pilot Study to Improve Care Coordination

Patient Perceived Continuity of Care was assessed using Haggerty's measure of the same title. Informational Continuity refers to whether patients experienced communication failures between providers. The possible range on this measure was between 12 and 36. The analysis was conducted on the pre-post difference on Informational Continuity, subtracting the baseline score from the post-intervention score. For this measure a lower score and a decline between post intervention and baseline scores (or a negative value) indicates more positive outcomes.

Time frame: Baseline to 12-month follow-up

Population: All study participants with a baseline and 12-month follow-up assessment completed of Haggerty's Patient Perceived Continuity of Care from Multiple Clinicians.

Patient Perceived Continuity of Care was assessed using Haggerty's measure of the same title. Role Continuity refers to the role of all clinicians being clear to the patient and to the providers on the treatment team. The possible range on this measure was between 6 and 30, and the analysis was conducted on the pre-post difference on this measure. More positive score indicated greater perceived role clarity and, when comparing pre and post score, a more positive score indicated greater improvement in perceived role clarity.

Time frame: Baseline to 12-month follow-up

Population: All participants who had a baseline and 12- month follow-up assessment of the Patient Perceived Continuity of Care from Multiple Clinicians.

Patient Perceived Continuity of Care was assessed using Haggerty's measure of the same title. Management continuity refers to the patient being able to identify one provider who is the main coordinator and assures all the links within the health care team. The possible range on this measure was between 5 and 40 and the analysis was conducted on the pre-post difference on Management Continuity, subtracting the baseline score from the post-intervention score. More positive score indicated greater perceived management continuity and greater improvement in perceived management continuity.

Time frame: The time frame is from baseline assessment to 12 months post baseline during which at least one VA and one Community medical visit occurred.

Population: All participants who completed the study and had both a baseline and 12-month follow-up assessment of Patient Perceived Continuity of Care from Multiple Providers. A positive score indicates improvement on this measure over the study period.

Participants had at least one VA medical visit and one community medical visit. Medical records were obtained from both visits and compared. Patients were considered to have a laboratory duplication if the same labs were drawn at both visits and the two visits occurred within three months of each other.

Time frame: Baseline assessment to 12 months post-baseline, where a laboratory duplication is only counted if the medical visits occurred within three months of each other.

All participants had at least one VA medical visit and one community medical visit. Medical records were obtained from both visits. Medication lists were obtained from both visits. A medication concordance metric (proportion) was calculated where the denominator was the total number of unique medications identified on both the VA medication list and the community provider medication list. The numerator was the total number of medications (including dose and frequency) that were concordant between the medication lists. This comparison did not include over the counter medications.

Time frame: Time frame between two medical visits occuring within the one year study period

Population: This sample is based on all participants for whom we had both the VA medication list and the community provider list. We obtained the VA medication list for all, but did not receive all medical records from community providers even after repeated requests.

Relational Coordination was assessed using Gittell's 7-item measure as described iRelational coordination amongst health professionals involved in insulin initiation for people with type 2 diabetes in general practice: an exploratory survey. The scale total score could range from 7 to 35 with higher scores indicating greater relational coordination.

Time frame: Providers completed the coordination measure at the time of the medical visit which could occur at any point in the 12 month follow-up period.

Population: This analysis population is based on community providers who actually returned the assessment provided by the patient.

Relational Coordination was assessed using Gittell's 7-item measure as described Relational coordination amongst health professionals involved in insulin initiation for people with type 2 diabetes in general practice: an exploratory survey. This was assessed by providers seeing patients enrolled in this study, and this outcome is based on VA providers assessment of Relational Coordination. The scale total score could range from 7 to 35 with higher scores indicating greater relational coordination.

Time frame: Providers completed the coordination measure at the time of the medical visit which could occur at any point in the 12 month follow-up period.

Population: Veterans gave providers this measure at the medical visit and asked them to complete it and mail it to the study team.