College of Health

In the Veterans’ Health Administration (VA), care coordination is described as facilitating integration of, and navigation through, healthcare services, within and across care settings, to help patients receive the care they need and want without unnecessary duplication of services or avoidable inconvenience.¹ VA coordinates care within VA and with non-VA providers across a continuum of service intensity—from basic care coordination (for all Veterans), to care management (for Veterans with chronic medical illnesses), to highly resource-intensive case management (for Veterans with biopsychosocially complex conditions).² Coordinating care is essential for improving patients’ clinical outcomes, enhancing patients’ experiences of care, increasing provider satisfaction, and decreasing costs.³

The VA faces a plethora of care coordination challenges. Many Veterans have multiple conditions and providers, and many get a portion of their care in the community, a number that will only grow as recent legislation expands options for private care. These challenges have spawned new VA initiatives for redesigning care to meet them, described in this supplement in an editorial by Hosenfeld and colleagues.⁴ The VA Health Services Research and Development (HSR&D) service, in partnership with VA’s Office of Primary Care, and Office of Community Care, sponsored a State of the Art (SOTA) conference with the goals of (a) summarizing what is known about care coordination relevant to Veterans’ care; (b) identifying care coordination approaches ready for wider dissemination and implementation within VA; and (c) identifying a research agenda and recommendations, as appropriate, for increasing VA’s knowledge and use of evidence-based approaches for coordinating care. Held in March 2018, the SOTA was jointly planned by VA HSR&D and Offices of Primary Care, Community Care, Nursing Services, and Care Management and Social Work, and convened VA and non-VA health services researchers, clinicians, and policy makers. This supplement presents recommendations from the SOTA as well as original research papers on care coordination strategies within VA and between VA and non-VA providers.