Complexity of health care services and care fragmentation contribute to adverse health outcomes and poor patient experiences of care. Over the past 20 years, there has been substantial interest in care coordination interventions, particularly to reduce utilization of acute care services. Care coordination models usually involve systematic strategies that aim to improve continuity and bridge transitions of care. Often, this takes the form of care or case management, in which a designated person or team helps patients manage their medical care and navigate interactions with the health care system(s). It remains unclear whether care coordination interventions can sufficiently address gaps in care and improve patient outcomes.

The VA Care Coordination and Integrated Case Management (CC&ICM) initiative was launched in 2016, as a collaboration between the VA Offices of Care Management and Social Work, and Nursing Services. The main goals of this initiative are to standardize and integrate care coordination services across all VA facilities and points of care for Veterans. To assist the CC&ICM initiative, the VA ESP was asked to review evidence on implementation and outcomes of various care coordination models.

We summarize evidence from eligible systematic reviews (SR) on key characteristics and effectiveness of care coordination interventions for diverse adult populations at high risk for adverse outcomes. Additionally, we present results from primary research studies of effective interventions (ie, those able to reduce hospitalizations and/or emergency department [ED] visits) regarding tools and approaches to assess patient trust and care team integration, and to improve communication between patients and providers. To better understand which results may be most applicable to VA, we also provide information about the settings in which effective care coordination models were implemented. Finally, we present results from key informant interviews to address remaining gaps in the published literature, particularly with regard to tools and approaches used by various interventions.

Contents

• PREFACE
• ACKNOWLEDGMENTS
• EXECUTIVE SUMMARY
  • INTRODUCTION
  • METHODS
  • RESULTS
  • DISCUSSION
  • ABBREVIATIONS TABLE
• INTRODUCTION
• METHODS
  • TOPIC DEVELOPMENT
  • SEARCH STRATEGY
  • STUDY SELECTION
  • QUALITY RATING & DATA ABSTRACTION
  • DATA SYNTHESIS FOR SYSTEMATIC REVIEWS & RELEVANT PRIMARY STUDIES
  • INTERVIEWS WITH KEY INFORMANTS WHO IMPLEMENTED CARE COORDINATION MODELS
  • PEER REVIEW
• RESULTS
  • OVERVIEW OF ELIGIBLE SYSTEMATIC REVIEWS
  • KQ1. WHAT ARE THE KEY CHARACTERISTICS OF CARE COORDINATION MODELS?
  • KQ2. WHAT IS THE EFFECT OF IMPLEMENTING CARE COORDINATION MODELS?
  • KQ3. WHAT ARE THE CHARACTERISTICS OF SETTINGS IN WHICH EFFECTIVE MODELS HAVE BEEN IMPLEMENTED?
  • KQ4. WHAT ARE THE TOOLS AND APPROACHES USED BY EFFECTIVE MODELS?
  • KEY INFORMANT INTERVIEWS
• SUMMARY AND DISCUSSION
  • SUMMARY OF KEY FINDINGS
  • IMPLICATIONS FOR POLICY
  • EVIDENCE GAPS AND FUTURE RESEARCH NEEDS
  • LIMITATIONS
  • CONCLUSIONS
• REFERENCES
• APPENDIX 1. SEARCH STRATEGIES FOR SYSTEMATIC REVIEWS
• APPENDIX 2. SEARCH STRATEGIES FOR PRIMARY STUDIES
• APPENDIX 3. STUDY SELECTION CRITERIA
• APPENDIX 4. QUALITY ASSESSMENT
• APPENDIX 5. KEY INFORMANT INTERVIEW GUIDE
• APPENDIX 6. PEER REVIEW COMMENTS/AUTHOR RESPONSES
• APPENDIX 7. DETAILED CHARACTERISTICS AND RESULTS FROM MEDIUM- AND HIGH-QUALITY SYSTEMATIC REVIEWS

Suggested 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: https://www.hsrd.research.va.gov/publications/esp/reports.cfm.

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.