Coordination Toolkit and Coaching Project

Background: High-risk Veterans are defined as individuals who are at increased risk for poor
clinical outcomes and higher use of unplanned health services relative to their non-high-risk
counterparts. These Veterans typically have multiple chronic health problems and are
vulnerable to gaps in care due to impaired physical, psychological, and/or social
functioning. Despite efforts to integrate care through VA's Patient Aligned Care Teams (PACT)
in primary care, deficits in care coordination persist. In VA, most high-risk Veterans are
managed in primary care rather than a specialty service. PACT was expected to improve care
coordination by creating the care manager role for the PACT teamlet nurse. However, there
have been significant challenges in implementing the care manager role as intended. Many of
the care coordination challenges involve the "medical neighborhood" outside of PACT.

To improve the quality of care coordination in outpatient care and also develop better
methods for spreading innovations, the Coordination Toolkit and Coaching project was funded
by VA's Quality Enhancement Research Initiative (QUERI) to develop and pilot an online
toolkit and distance-based coaching process, and then compare the effectiveness of the
toolkit alone to the combination of the toolkit plus distance coaching for improving VA
patients' experience of care, communication and coordination between primary care providers
and specialists, and utilization of acute care services. Both toolkit and combined
toolkit/coaching strategies have been used individually in VA quality improvement
initiatives, and each strategy has been compared individually to other alternatives, however,
to the investigators' knowledge, these strategies have not formally been compared
head-to-head.

Additional Outcome Information: The project's primary outcome is a measure of patient
experience, the Health System Hassles Scale. This 16-item scale asks patients questions such
as whether their medications are being refilled on time, whether they were given information
about why they were referred to a specialist, whether there has been poor communication
between different doctors or clinics, or whether there have been disagreements between
doctors about the patient's diagnosis or the best treatment for the patient.

Sample Size Calculations: The sample size calculation for this study is based on a simple
presumption of a difference-in-differences analysis (across the two time points) for the
comparison of the two implementation strategies. The primary outcome is the Health System
Hassles Scale. The investigators assume 12 clinics in the study (6 per study group), which
will be viewed as clusters in order to evaluate the sample size. Since the number of patients
per cluster may vary, the investigators assume a coefficient of variation of cluster sizes of
about 0.9. With an effect size of 0.3 standard deviations (which is considered to be a small
to medium effect size in Cohen's terminology) for the difference-in-difference analysis and
an intra-cluster correlation of 0.023 (based on preliminary evaluation of prior data), then
with 80% power and two-sided 5% significance level, 149 patients per clinic are needed for a
total of 1788 patients (evenly divided between the two groups).

Statistical Analysis Plan: The primary endpoint of the Health System Hassles Scale will be
compared between the two implementation groups (toolkit and combined toolkit/coaching) using
a difference-in-differences (between the two time points: baseline and 12 months) analysis
adjusted for the clustering by clinic. This analysis will be performed initially with a
general linear model using the between time point difference as the dependent variable and
study group as the independent variable, with clinic as the clustering variable (and, thus,
using an appropriately chosen variance-covariance matrix). A further adjustment model may
incorporate appropriate covariates including patient-level factors, such as gender, age, and
use of non-VA care.

Inclusion Criteria:

- VA primary care clinic

- Clinic's facility director must sign a letter of endorsement in support of patients
being surveyed about their experience of care

- Identify a clinic champion to serve as point of contact

- Clinic champion has adequate release time to take on a new quality improvement project

Exclusion Criteria:

- Insufficient number of patients to obtain adequate sample size for primary outcome
measure.