

June 2020

Prepared for:

Department of Veterans Affairs

Veterans Health Administration

Health Services Research & Development Service

Washington, DC 20420 

Prepared by:

Evidence Synthesis Program (ESP) Center

Minneapolis VA Health Care System

Minneapolis, MN 

Timothy J. Wilt, MD, MPH, Director 

Wei Duan-Porter, MD, PhD, Associate Director

Care Coordination Models and Tools: 

A Systematic Review and Key 

Informant Interviews 

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Authors: 

Principal Investigator: 

Wei Duan-Porter, MD, PhD

Co-Investigators: 

Isomi Miake-Lye, PhD

Susan Diem, MD

Timothy J. Wilt, MD, MPH

Research Associates: 

Kristen Ullman, MPH

Brittany Majeski, BA

Evidence Synthesis Program
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PREFACE

The VA Evidence Synthesis Program (ESP) was established in 2007 to provide timely and accurate 

syntheses of targeted health care topics of importance to clinicians, managers, and policymakers as they 

work to improve the health and health care of Veterans. These reports help: 

• Develop clinical policies informed by evidence;

• Implement effective services to improve patient outcomes and to support VA clinical practice 

guidelines and performance measures; and 

• Set the direction for future research to address gaps in clinical knowledge.

The program is comprised of 4 ESP Centers across the US and a Coordinating Center located in 

Portland, Oregon. Center Directors are VA clinicians and recognized leaders in the field of evidence 

synthesis with close ties to the AHRQ Evidence-based Practice Center Program and Cochrane 

Collaboration. The Coordinating Center was created to manage program operations, ensure 

methodological consistency and quality of products, and interface with stakeholders. To ensure 

responsiveness to the needs of decision-makers, the program is governed by a Steering Committee 

comprised of health system leadership and researchers. The program solicits nominations for review 

topics several times a year via the program website. 

Comments on this evidence report are welcome and can be sent to Nicole Floyd, Deputy Director, ESP 

Coordinating Center at Nicole.Floyd@va.gov.

Recommended 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.
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ACKNOWLEDGMENTS 

This topic was developed in response to a nomination from the Office of Nursing Services and 

the Office of Care Management and Social Work Services to support the Coordinated Care and 

Integrated Case Management (CC&ICM) Initiative. The scope was further developed with input 

from the topic nominators (ie, Operational Partners), the ESP Coordinating Center, the review 

team, and the technical expert panel (TEP).

In designing the study questions and methodology at the outset of this report, the ESP consulted 

several technical and content experts. Broad expertise and perspectives were sought. Divergent 

and conflicting opinions are common and perceived as healthy scientific discourse that results in 

a thoughtful, relevant systematic review. Therefore, in the end, study questions, design, 

methodologic approaches, and/or conclusions do not necessarily represent the views of 

individual technical and content experts. 

The authors gratefully acknowledge the following individuals for their contributions to this 

project: 

Operational Partners

Operational partners are system-level stakeholders who have requested the report to inform 

decision-making. They recommend Technical Expert Panel (TEP) participants; assure VA 

relevance; help develop and approve final project scope and timeframe for completion; provide 

feedback on draft report; and provide consultation on strategies for dissemination of the report to 

field and relevant groups.

Lisa Perla, MSN, FNP, CNRN, CRRN

Co-lead, Data Management and Research Workgroup

Coordinated Care and Integrated Case Management Initiative

Janet Belisle, MHA, RHIA, FACHE

Co-lead, Data Management and Research Workgroup

Care Management and Social Work Services

Jimmy Boerschmann, RN, BSN, MSHC

Co-lead, Data Management and Research Workgroup

Office of Nursing Services

Elizabeth Sprinkle, LCSW, C-ASWCM, MVF-ASW

Field Advisor

Coordinated Care and Integrated Case Management Initiative

Technical Expert Panel (TEP)

To ensure robust, scientifically relevant work, the TEP guides topic refinement; provides input 

on key questions and eligibility criteria, advising on substantive issues or possibly overlooked 

areas of research; assures VA relevance; and provides feedback on work in progress. TEP 

members are listed below:
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Erica Abel, PhD 

Psychologist and Associate Investigator, Pain Research, Informatics, Multi-morbidities, and 

Education (PRIME) Center, VA Connecticut Healthcare System

Assistant Clinical Professor, Yale School of Medicine

Kristina Cordasco, MD, MPH, MSHS 

Core Investigator, Center for the Study of Healthcare Innovation, Implementation and Policy 

(CSHIP), VA Greater Los Angeles Healthcare System

Associate Clinical Professor of Medicine, University of California, Los Angeles

Denise Hynes, BSN, MPH, PhD, RN

Research Health Scientist, Investigator, Center to Improve Veteran Involvement in Care 

(CIVIC), VA Portland Health Care System

Professor, School of Social and Behavioral Health Sciences, College of Public Health and 

Human Sciences, Oregon State University

Kristin Mattocks, PhD, MPH 

Associate Chief of Staff/Research & Education, VA Central Western Massachusetts

Associate Professor, University of Massachusetts Medical School

Peer Reviewers

The Coordinating Center sought input from external peer reviewers to review the draft report and 

provide feedback on the objectives, scope, methods used, perception of bias, and omitted 

evidence. Peer reviewers must disclose any relevant financial or non-financial conflicts of 

interest. Because of their unique clinical or content expertise, individuals with potential conflicts 

may be retained. The Coordinating Center and the ESP Center work to balance, manage, or 

mitigate any potential nonfinancial conflicts of interest identified.
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TABLE OF CONTENTS 

Acknowledgments ......................................................................................................................... ii

EXECUTIVE SUMMARY .......................................................................................................... 1

Introduction ................................................................................................................................. 1

Methods....................................................................................................................................... 1

Results......................................................................................................................................... 4

Discussion................................................................................................................................... 7

Abbreviations Table.................................................................................................................... 11

EVIDENCE REPORT ................................................................................................................ 12

INTRODUCTION....................................................................................................................... 12

METHODS .................................................................................................................................. 13

Topic Development ................................................................................................................... 13

Conceptual Framework of Care Coordination Models ......................................................... 13

Key Questions (KQ) ............................................................................................................. 14

Search Strategy ......................................................................................................................... 15

Study Selection ......................................................................................................................... 15

Quality Rating & Data Abstraction ........................................................................................... 15

Data Synthesis for Systematic Reviews & Relevant Primary Studies ...................................... 16

Interviews with Key Informants who Implemented Care Coordination Models ...................... 16

Peer Review .............................................................................................................................. 17

RESULTS .................................................................................................................................... 17

Overview of Eligible Systematic Reviews ............................................................................... 17

KQ1—What are the key characteristics of care coordination models? .................................... 18

KQ2—What is the effect of implementing care coordination models? .................................... 19

KQ3—What are the characteristics of settings in which effective models have been 

implemented? ............................................................................................................................ 20

KQ4—What are the tools and approaches used by effective models? ..................................... 20

Key Informant Interviews ......................................................................................................... 20

SUMMARY AND DISCUSSION .............................................................................................. 27

Summary of Key Findings ........................................................................................................ 27

Implications for Policy .............................................................................................................. 28

Evidence Gaps and Future Research Needs .............................................................................. 29

Limitations ................................................................................................................................ 29

Conclusions ............................................................................................................................... 30
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REFERENCES ............................................................................................................................ 31

TABLES

Table 1: Adapted Framework for Care Coordination in Chronic and Complex 

Disease Management.* ............................................................................................................. 14

Table 2: Summary of Results for Key Questions 1 and 2 from High- and Medium-Quality 

Systematic Reviews .................................................................................................................. 22

Table 3: Primary Studies—Characteristics and Results of Effective Care 

Coordination Models. ............................................................................................................... 24

FIGURES

Figure 1: Search & Selection of Eligible Systematic Reviews ................................................. 18

Appendix 1. Search Strategies for Systematic Reviews ........................................................... 35

Appendix 2. Search Strategies for Primary Studies ................................................................ 37

Appendix 3. Study Selection Criteria ........................................................................................ 38

Appendix 4. Quality Assessment ............................................................................................... 39

Appendix 5. Key Informant Interview Guide .......................................................................... 42

Appendix 6. Peer Review Comments/Author Responses ........................................................ 44

Appendix 7. Detailed Characteristics and Results from Medium- and High-Quality 

Systematic Reviews ..................................................................................................................... 56
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EXECUTIVE SUMMARY

INTRODUCTION

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.

METHODS

To guide scope refinement and protocol development, we selected the framework for Care 

Coordination in Chronic and Complex Disease Management. This framework focuses on 

characteristics, processes, and interactions within and between health care teams. We adapted 

this framework in 2 areas: 1) specification that team roles include who contacted patients (and in 

what manner); and 2) reorganization of outcomes by patients (eg, patient experience, quality of 

life, and survival), health care teams (eg, work satisfaction and burnout), and health systems (eg, 

acute care utilization and costs). While health care utilization and costs may be measured at the 

patient level (eg, number of admissions or ED visits per person), we considered such outcomes 

to be oriented towards the priorities of the health care system.

Applying this framework and in accordance with the priorities of our VA partners, we defined 

effective care coordination interventions as those that reduced hospitalizations and/or ED visits. 

We sought information about the key characteristics of effective interventions, such as 

multidisciplinary teams (vs primarily single case manager), and home visits (vs telephone 

contacts and/or outpatient visits). To support ongoing implementation and evaluation of care 
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coordination programs in the VA, we also searched for evidence on tools and approaches that 

addressed patient trust, team integration, and patient-provider communication. Finally, to support 

interpretation of the evidence with regard to applicability, we sought information on the 

characteristics of health care systems and communities where effective interventions had been 

implemented.

Key Questions

For community-dwelling adults with a variety of ambulatory care sensitive conditions and/or at 

higher risk of having repeat hospitalization or ED visits:

KQ1—What are the key characteristics of care coordination models (of varying types) that aim 

to reduce hospitalization or ED visits?

KQ2—What is the effect of implementing these care coordination models on hospitalizations, 

ED visits, and patient experience (eg, Consumer Assessment of Healthcare Providers and 

Systems)?

KQ3—What are the characteristics of settings in which effective models have been 

implemented?

KQ4—Among effective models, which approaches/tools have been used to:

a) Measure patient trust or working alliance?

b) Measure team integration?

c) Improve communication between patients and providers?

To address these KQ, we first focused on identifying eligible SR on care coordination models. In 

order to address likely gaps in results from SR, particularly with regard to KQ 3 and 4, we also 

examined primary research studies of effective interventions and conducted key informant 

interviews with those who implemented interventions.

Search Strategy

We searched for English-language systematic reviews, from inception until September 2019, in 

MEDLINE, CINAHL, Embase, Cochrane Database of Systematic Reviews, Agency for 

Healthcare Research and Quality Evidence-based Practice Center reports, and VA ESP reports. 

We also identified relevant primary research studies included by reviews and conducted a search 

for randomized controlled trials (RCT) in MEDLINE and Embase, from 2018 until February 

2020. 

Study Selection

Using prespecified inclusion and exclusion criteria, SR search results were evaluated and 

excluded with the consensus of 2 reviewers. Eligible populations of interest included 

community-dwelling adults with a range of ambulatory care sensitive conditions (eg, heart 

failure and chronic lung disease) and/or at higher risk for acute care episodes. If a review focused 

exclusively on interventions for a single health condition, it was excluded. Eligible interventions 

covered different care coordination models, such as care or case management and home-based 

primary care. We required that eligible reviews reported inclusion of hospitalizations and/or ED 
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visits as outcomes of interest in objectives or results. At full-text review, 2 individuals separately 

determined inclusion and then resolved any conflicts through discussion. When consensus could 

not be reached, disagreements were discussed with a third reviewer.

From each eligible SR, we identified all included primary studies and 2 individuals evaluated 

them for potential relevance to KQ3 and 4. In addition to above criteria for SR, we also applied 

the following: conducted in US, and RCT or quasi-experimental observational studies (eg, 

comparative control cohort or interrupted time series). We also screened and reviewed results 

from an additional search of RCT published 2018 until February 2020. Two reviewers applied 

the same criteria used to evaluate SR, along with the additional requirement for RCT conducted 

in US.

Quality Rating & Data Abstraction

We assessed the quality of eligible SR using criteria adapted from AMSTAR 2 and rated overall 

quality as high, medium, or low. We abstracted data from reviews on: target population(s); dates 

of search queries; and number and characteristic of included primary studies (location, setting 

and study design). Additionally, from high- and medium-quality SR, we abstracted detailed 

results on: characteristics of care coordination model; pooled effects (or qualitative summaries) 

for hospitalizations, ED visits, and/or patient experience; characteristics of settings; and tools and 

approaches used to measure patient trust or working alliance, assess health care team integration, 

and/or improve communication between patients and providers. 

From relevant primary research studies on care coordination models, we abstracted data on 

effectiveness for main outcomes; participant, intervention and setting characteristics; and 

relevant tools and approaches. Because the primary studies frequently referenced other studies 

for information on intervention characteristics, we also reviewed these associated studies for 

relevant data.

Data Synthesis for Systematic Reviews & Relevant Primary Studies

We conducted qualitative syntheses of results from eligible SR and relevant primary studies. We 

focused on eligible SR to address key characteristics and effectiveness of care coordination 

models, particularly with regard to reduction of hospitalizations and/or ED visits. We also 

included strength of evidence determinations by SR, if these were reported. We describe 

information from relevant primary studies regarding: setting characteristics; and tools and 

approaches used to measure patient trust or working alliance, assess health care team integration, 

and/or improve communication between patients and providers. To address remaining gaps, we 

also abstracted results from associated articles (eg, methods papers) for this set of primary 

studies.

Key Informant Interviews

We conducted semi-structured interviews with research investigators and members of teams who 

implemented care coordination models, as described in relevant primary studies. We included all 

relevant interventions, regardless of effectiveness in reducing hospitalizations and/or ED visits. 

We initially invited 22 individuals by email, and contacted another 3 individuals per 

recommendations of respondents. We completed interviews with 11 participants. 
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The main focus of these interviews was to address gaps in the published literature regarding tools 

and approaches. We also addressed intervention uptake and sustainability, as this information 

may be particularly useful to our VA stakeholders. Interview guides included questions in each 

of these areas and were individually adapted using published or online information about the 

interventions. Interviews lasted about 30 minutes and were audio-recorded. We reviewed 

contemporaneous notes and audio-recordings to first develop summaries for each care 

coordination intervention. We then examined summaries for all interviews to provide overall 

themes.

RESULTS

Overview of Eligible Systematic Reviews 

Of 2,324 unique citations for SR, 72 underwent full-text review. We identified 16 eligible SR, 14 

of which examined case management or transitional care interventions, and 2 evaluated intensive 

primary care models (eg, home-based primary care). All SR included a variety of care 

coordination models within these 2 broad categories. Four SR included only RCT, while the 

others allowed both RCT and observational studies. Three SR included only US studies, and the 

remaining SR included studies conducted in several different countries. Seven SR focused 

specifically on patients at higher risk for acute care utilization (ie, high-utilizers), and 1 SR 

examined interventions for individuals with frailty. Six reviews were high quality, 6 were 

medium quality, and 4 were low quality. We focused on the 12 medium- and high-quality SR for 

detailed results. We provide descriptions of results for each KQ in the following text. 

KQ1: What Are the Key Characteristics of Care Coordination Models?

All SR provided general descriptions of different components included by interventions, with 

many providing some information on team composition and frequency of use of certain 

components (eg, multidisciplinary care plan). Outside of in-person contacts (whether in a clinical 

setting or at home), the other main form of communication with patients was via telephone. Four

SR specifically addressed whether there are key characteristics for care coordination 

interventions. Among these, 1 used qualitative comparative analysis to examine intervention 

characteristics of effective case management models, reporting that careful case-finding was 

necessary but not sufficient; selection of patients needed to be combined with either a highintensity model (defined by authors using caseload, frequency and types of contact with patients) 

or a multidisciplinary care plan. Another SR reported that interventions targeting specific risk 

factors were more likely to be effective. One SR conducted subgroup analyses by intervention 

duration and different approaches to address frailty, finding no significant differences in effect. 

The fourth SR examined home-based primary care and found no specific pattern of components 

that were associated with effective interventions. Additionally, 2 SR sought to determine the key 

components for care coordination models but were unable to draw conclusions; authors reported 

challenges due to lack of published information on components and fidelity of intervention 

implementation.

KQ2: What is the Effect of Implementing Care Coordination Models? 

Of 10 SR examining case or care management and/or transitional care interventions, 2 conducted 

quantitative meta-analyses, while remaining SR used qualitative syntheses. Six SR evaluated 

effects on hospitalization, with 5 reporting mixed or unclear results and 1 finding lack of 
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effectiveness. One SR pooled results for transitional care interventions (most involved nurses 

who called patients and/or made home visits) for diverse patient populations. Using data from 

11-35 RCT, this SR found no effect at 1 month (risk difference [RD] -0.03, 95% CI -0.05, 0) but 

some effects at 3-18 months (RD range -0.05 to -0.11). Another SR conducted meta-analyses to 

evaluate effects on hospitalization for a diverse set of case management interventions for frail 

community-dwelling older adults; pooled results from 5 RCT showed that case management did 

not reduce hospitalizations (odds ratio [OR] 1.13, 95% confidence interval [CI] 0.95, 1.35).

Seven SR examined effects of case or care management and/or transitional care interventions on 

ED visits. Two SR indicated that care coordination interventions reduced ED visits, and both 

provided descriptive information about included studies. One SR stated that 6 included studies 

reported reductions in ED visits, and the other found that the median rate ratio (of care 

coordination vs control) was 0.63, with interquartile range of 0.41-0.71. All 5 remaining SR 

reported unclear or mixed effects on ED visits, including 1 that conducted pooled meta-analyses 

over various timeframes (1-12 months). 

Only 1 SR on case management evaluated effects on patient experience, and using qualitative 

synthesis found inconsistent results. 

Two SR evaluated intensive primary care interventions, and both used qualitative synthesis. One 

SR focused on home-based primary care, reporting reduced hospitalizations. The other SR 

addressed several different models and described inconsistent results across studies. The SR on 

home-based primary care also found that there was improved patient and caregiver satisfaction 

(low strength of evidence). 

KQ3: What Are the Characteristics of Settings in Which Effective Models Have 

Been Implemented? 

Only 2 SR addressed characteristics of settings for interventions; 1 SR on case management 

stated that all but 1 of 16 included studies were single-site, usually in an urban setting. 3 3 The 

other SR sought to address organizational settings for home-based primary care but was unable 

to find published information.

To further address KQ 3 (and KQ 4), we identified 272 unique primary studies included by 

eligible SR, and found 18 RCT and 9 observational studies that were relevant. While 78% of 

relevant observational studies (n=7) reported reductions in hospitalizations and/or ED visits, only 

22% of RCT (n=4) demonstrated effectiveness. Additionally, we searched for RCT that were 

published after the most recent eligible SR. This search resulted in 1048 unique citations, of 

which 21 underwent full-text review. We identified 2 relevant RCT; both studies reported that 

interventions were not effective for reducing hospitalizations and/or ED visits.

We categorized the primary studies on effective interventions into transitional care, outpatient 

care or case management (led by nurse or social worker), or other intensive primary care models. 

These interventions were implemented in a variety of settings, including rural community 

hospitals and health systems, academic medical centers (in urban settings), and public hospitals 

serving largely poor and uninsured populations. There was no clear connection between 

differences in settings, types of intervention, and various patient populations.
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KQ4: What Are the Tools and Approaches Used by Effective Models?

No SR commented on tools and approaches used to measure patient trust or care team 

integration, or to improve communication between patients and providers. Primary research 

studies described several approaches to improve patient-provider communications, such as 

coaching patients on how to ask questions, making lists of key concerns, and role-playing visits 

with providers. In 2 studies, care coordinators supported communication by attending outpatient 

visits with patients and their providers. No primary research study described specific tools or 

measures to assess patient trust or care team integration. For 1 intervention, qualitative methods 

were used to evaluate patient experiences and relationship with care coordinators.

Key Informant Interviews

We conducted 11 interviews with investigators and other team members who implemented care 

models described by relevant primary research studies. Several interviewees described using 

approaches akin to health coaching (although not called that in the published studies) to improve 

patient communications with providers. None of the interviews provided additional information 

on specific tools or approaches used to assess patient trust, care team integration, or patientprovider communications. Review of additional intervention materials provided by some 

interviewees indicated that assessments of patient experience sometimes included factors 

conceptually related to patient trust (eg, perception that care coordinator was knowledgeable and 

understood patients’ needs). 

There was variation in the sustainability of care coordination interventions, with some stopping 

after completion of the research studies. Lack of financial viability was often a key factor in 

discontinuation. Others were substantially modified and adapted to meet changing health system 

priorities (eg, in targeted patient populations). Implementation teams had variable success in 

engaging stakeholders such as hospital leadership and front-line providers. Health care utilization 

and costs were high priority for those in leadership, and improved patient experiences were not 

usually sufficient for continuing interventions. 

In terms of key issues for future care coordination interventions, some key informants questioned 

whether acute care utilization by high-risk populations was truly preventable. For example, 1 

interviewee stated, “Everything that could be possibly going wrong is going wrong...A lot of 

these people are going to get readmitted no matter what you do.” There was concern with 

current readmission metrics and the ability to make substantial changes within a short timeframe: 

“30 days doesn’t give you sufficient time...especially in elderly patients with many issues.” Some 

also suggested that care coordination interventions may work better in those with less severe 

conditions and/or modifiable factors; an important challenge with such an approach is that the 

intervention may need to serve a large number of patients before there are appreciable 

differences in acute care utilization. One individual described it thus: “You can allocate a lot of 

resources to extremely high need patients...or you can allocate resources to a larger population 

and ... have a smaller impact on individual level, but on population level have greater impact...”
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DISCUSSION

Key Findings 

To inform the VA CC&ICM initiative, we conducted a multi-stage review of evidence for care 

coordination models. We identified 16 eligible SR addressing care coordination interventions, 

and further examined 29 relevant primary research studies. We also conducted 11 key informant 

interviews with those who have implemented care coordination models. Key findings include:

• 2 SR reported that a key component of effective care coordination models was patient 

selection criteria focused on specific risk factors and/or needs.

• 1 SR reported that high-intensity models and/or multidisciplinary plans were required for 

effectiveness (in combination with selection criteria noted above).

• Most SR reported unclear or inconsistent effects of care coordination models in reducing 

hospitalizations or ED visits.

• Primary studies reporting effective interventions were conducted in a variety of settings, 

including rural community hospitals, academic medical centers in urban settings, and 

public hospitals serving largely poor and uninsured populations.

• Approaches to improve patient-provider communication included coaching patients, roleplaying, and attending appointments with patients.

• SR, primary studies, and interviews provided little information on specific tools or 

approaches used to assess patient trust or health care team integration.

• Key informant interviews suggested variation in sustainability of care coordination 

interventions, with substantial adaptation occurring among many of those that have 

continued.

Care coordination models were complex and differed along multiple dimensions, thus presenting 

substantial challenges for SR authors in summarizing and comparing results across studies. Four

SR drew conclusions with regard to key intervention characteristics, with 2 highlighting 

selection criteria, 1 indicating importance of high-intensity (defined by lower caseload and more 

patient contacts) and multidisciplinary plans, and 2 finding no key characteristics. Several SR 

seeking to examine key characteristics and/or organizational settings of care coordination models 

reported difficulty finding sufficient published evidence to address these questions. 

Among 11 primary studies demonstrating effective care coordination models, none reported 

specific tools or approaches for measuring patient trust or health care team integration. Key 

informant interviews did not provide additional information on these areas. Interventions used a 

variety of approaches to improve communication between patients and providers, including 

coaching and role-playing. In some interventions, care coordinators also directly communicated 

with providers on patients’ behalf, including participation at outpatient appointments. 

Some interviewees described adaptation of the intervention over time to address evolving 

priorities for health care organizations. Some also highlighted the difficulty of modifying health 
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and social factors contributing to need for acute care utilization among many patients in the 

highest risk category. There were suggestions that there may be more benefit in focusing on 

patients at somewhat lower risk and improving health care processes for larger groups of 

patients.

Implications for Policy

It remains unclear whether care coordination interventions should be implemented in particular 

health care settings and how they may be adapted to improve effectiveness and sustainability. 

Two SR highlighted the importance of carefully selecting patients for care coordination 

interventions. The VA CC&ICM initiative has implemented several tools for evaluating Veteran 

needs and matching the level of care coordination services to those needs. It will be important for 

VA to evaluate the feasibility of applying these tools more widely, and the effects of 

implementing such tools on delivery of services and patient outcomes. Additionally, because VA 

medical centers and clinics are located in a variety of settings, it will be important to understand 

differences in utility of these tools across large and small sites, and those serving urban and more 

rural communities.

Understanding what type of services and programs are available at a particular facility may be 

challenging for Veterans, their caregivers, and VA clinical staff. A key goal of the CC&ICM 

initiative is to standardize care coordination across VA sites, and this may improve access and 

use of appropriate services for Veterans. However, the CC&ICM initiative acknowledges the 

importance of flexibility in adapting care coordination models to accommodate local 

circumstances. Our interview results also support the importance of local adaptations for uptake 

and sustainability of care coordination interventions. A potential avenue to achieving more 

consistency of services while allowing flexibility may be to align services and programs based 

on program goals and Veteran needs; this information could then be collected in a central hub 

that Veterans and/or VA staff can use to find appropriate services. Additionally, it may be 

valuable to provide educational materials as part of the CC&ICM initiative, to guide adaptations. 

Future evaluation of implementation should consider which adaptations were made and the 

rationale for these.

One SR indicated that a high-intensity (defined using case load and patient contacts) or 

multidisciplinary care coordination model was more likely to be successful. Our examination of 

effective primary research studies also found a high number and frequency of patient contacts, 

often involving home visits. Therefore, it may also be valuable to understand which VA 

programs or models are most similar to these high-intensity interventions, and consider whether 

it would be cost-effective to implement more broadly. 

Finally, there may be specific patient groups that would benefit more from models that go 

beyond additional care coordination services (eg, by a nurse and/or social worker). For example, 

VA Primary Care Mental Health Integration is a collocated, collaborative model implemented to 

improve access to mental health services for Veterans. The VA has also been interested in

potentially implementing different models of integrating oncology and palliative care for cancer 

patients.
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Research Gaps/Future Research

Our examination of primary research studies suggested that those with observational quasiexperimental designs were more likely to report reductions in hospitalizations and/or ED visits.

Observational studies may have residual confounding and are more likely to be affected by 

publication bias. 

Studies of effective care coordination models did not report standardized tools used to assess 

patient trust or care team integration. It may be that these interventions relied on informal 

assessment by study staff or that there was an assumption that these domains would all improve. 

However, descriptions of these tools and strategies for assessment will support health systems in 

evaluating their existing services and implementing new care coordination models. 

Finally, multiple SR raised concerns about lack of information on intervention implementation, 

including fidelity and frequency of various components. To improve evaluation and 

interpretation of the effectiveness of care coordination interventions, future studies should 

consider application of frameworks and designs with explicit consideration of implementation 

outcomes (eg, hybrid effectiveness-implementation designs, Consolidated Framework for 

Implementation Research [CFIR], and Reach, Effectiveness, Adoption, Implementation, and 

Maintenance [RE-AIM]). Studies using such frameworks should clearly define the “core” set of 

key components and describe the “adaptable periphery” of elements that can be adjusted to 

accommodate the local context.

Therefore, we recommend the following for future research:

• Evaluate future care coordination interventions using randomized designs.

• Consider application of standardized tools to assess patient trust or working alliance, 

health care team integration, and communication between patients and providers.

• Consider study designs that explicitly consider implementation outcomes in future studies 

of care coordination models.

• Define “core” intervention components and describe local adaptations, particularly in 

multi-site studies.

Limitations

To address the priorities of our VA partners, this work focused on care coordination models that 

were effective in reducing hospitalizations and/or ED visits; SR and studies that did not address 

these outcomes were excluded. While we acknowledge the importance of patient experience 

outcomes, our discussions with stakeholders and key informant interviews all supported the high 

priority of acute care utilization for health care system leadership, particularly with regard to 

sustainability of interventions. We prioritized high- and medium-quality reviews for abstracting 

detailed results. We relied on SR authors’ determination of overall effectiveness and strength of 

evidence for care coordination models. Because interventions in countries other than the US may 

be less relevant for the VA, we limited primary studies to those conducted in the US. It is 

possible that studies conducted in other countries may have been informative for VA policy, 

despite very substantial differences in health care financing and delivery. We were able to 
Care Coordination Implementation Evidence Synthesis Program

10

complete interviews with less than half of those whom we invited to participate; it is possible 

that there was unpublished information on tools and approaches that we were unable to identify.

Conclusions

Existing evidence on care coordination models indicates that they have inconsistent effects on 

reducing hospitalizations and/or ED visits for high-risk community-dwelling adults. It remains 

unclear whether such interventions should be implemented and how they may be adapted to 

different health care settings. Implementation of new care coordination services should be 

carefully evaluated, preferably using randomized designs. Policymakers should also consider 

whether, for certain patient populations, a larger-scale redesign of care models may be necessary 

to improve continuity and collaboration.
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ABBREVIATIONS TABLE

Abbreviation Definition

AHRQ Agency for Healthcare Research and Quality

CC&ICM Coordinated Care & Integrated Care Management initiative

CFIR Consolidated Framework for Implementation Research

CI Confidence interval

ED Emergency department

ESP Evidence Synthesis Program

KQ Key question

MeSH Medical subject heading

OR Odds ratio

RCT Randomized controlled trial

RD Risk difference

RE-AIM Reach, Effectiveness, Adoption, Implementation, and Maintenance

SR Systematic review(s)

TEP Technical expert panel

US United States of America

VA Department of Veterans Affairs
Care Coordination Implementation Evidence Synthesis Program

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EVIDENCE REPORT

INTRODUCTION

Complexity of health care services and care fragmentation contribute to adverse health outcomes

and poor patient experiences of care.1-4 Over the past 20 years, there has been substantial interest 

and investment in developing and implementing care coordination interventions, particularly for 

patients who have demonstrated high utilization of acute care services.5,6 Although there are 

multiple definitions for care coordination models, such interventions usually involve systematic 

strategies that aim to improve continuity and bridge transitions of care.5,7,8 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). While there have 

been a variety of care coordination models evaluated across diverse settings, it remains unclear 

whether these 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.

9 The main goals of this initiative are to standardize and integrate care 

coordination services across all VA facilities and points of care for Veterans. The CC&ICM 

initiative has developed several tools for identifying Veterans who may benefit from various 

levels of care coordination services; it is currently focused on evaluation of care coordination at 

pilot VA sites and implementation of additional tools to assist with team integration and 

communication with patients. To assist the CC&ICM initiative, the VA ESP was asked to review 

evidence on implementation and outcomes of various care coordination models. 

In this report, we summarize results 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 used 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.
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METHODS

TOPIC DEVELOPMENT

Conceptual Framework of Care Coordination Models 

To guide scope refinement and protocol development, we reviewed several existing resources on 

integrated care or care coordination, including the Agency for Healthcare Research and Quality 

(AHRQ) Care Coordination Atlas5 and a previous ESP report on care coordination frameworks.7

We examined specific frameworks, such as Care Coordination in Chronic and Complex Disease 

Management,

8 the Integrated Team Effectiveness Model,10 Rainbow Model for Integrated 

Care,11 and Coordination Networks.

12 In collaboration with VA stakeholders from the Office of 

Care Management and Social Work Services and the Office of Nursing Services, and our 

technical expert panel, we selected the framework for Care Coordination in Chronic and 

Complex Disease Management as the most applicable to the goals of this current review (Table 

1). This framework focuses on characteristics, processes, and interactions within and between 

health care teams. We considered that evidence addressing these areas would be most relevant to 

support the goals of the VA CC&ICM initiative. We further adapted this framework in 2 areas: 

1) specification that team roles include who contacted patients (and in what manner); and 2) 

reorganization of outcomes by patients (eg, patient experience, quality of life, and survival), 

health care teams (eg, work satisfaction and burnout), and health systems (eg, acute care 

utilization and costs). While health care utilization and costs may be measured at the patient level 

(eg, number of admissions or ED visits per person), we considered such outcomes to be oriented 

towards the priorities of the health care system (and payers).

Applying this framework and in accordance with the priorities of our VA partners, we defined 

effective care coordination interventions as those that reduced hospitalizations and/or ED visits. 

We sought information about the key characteristics of effective interventions, particularly with 

regard to elements depicted in the columns on Context & Setting and Coordinating Mechanisms 

(Table 1). For example, key characteristics may include multidisciplinary teams (vs primarily 

single case manager), and home visits (vs telephone contacts and/or outpatient visits). To support 

ongoing implementation and evaluation of care coordination programs in the VA, we also 

searched for evidence on tools and approaches that were used to assess Emergent Integrating 

Conditions (eg, trust within teams) and Coordinating Actions (eg, within team communication); 

such tools may assist programs in monitoring implementation progress before final outcomes are 

available. To these elements from the Care Coordination Framework, we additionally considered 

tools to assist with evaluating patient trust or working alliance with the care coordination team, 

and those to improve communication between patients and providers. Finally, to support 

interpretation of the evidence with regard to applicability to VA health care settings, we sought 

information on the characteristics of health care systems and communities where effective 

interventions have been implemented.
Care Coordination Implementation Evidence Synthesis Program

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Table 1: Adapted Framework for Care Coordination in Chronic and Complex 

Disease Management* 

Context & Setting Coordination

Mechanisms

Emergent 

Integrating

Conditions

Coordinating Actions Outcomes

Within 

Teams

• Team composition

• Experience &

history

• Power distribution

• Resources

• Plans, rules, &

tools

• Objects,

representations,

artifacts, &

information

systems

• Roles (eg, who

contacts patients

& how)

• Routines

• Proximity

• Accountability

• Predictability

• Common

understanding

• Trust

• Situation monitoring

• Communication

• Back-up behavior

• Patients

• (eg, patient

experience,

quality of life,

survival)

• Health care

teams (eg, job

satisfaction)

• Health systems

(eg, acute care 

utilization, 

costs) 

Between 

Teams

• Multiteam system

composition

• Linkages between

teams

• Alignment of

organizational

cultures/ climates

• Governance &

payment structure

• Boundary spanning

• Information

exchange

• Collective problemsolving & decisionmaking

• Negotiation

• Mutual adjustment

*Original framework by Weaver et al (2018)8

Key Questions (KQ)

For community-dwelling adults with a variety of ambulatory care sensitive conditions and/or at

higher risk of having repeat hospitalization or ED visits:

KQ1—What are the key characteristics of care coordination models (of varying types) that aim

to reduce hospitalization or ED visits?

KQ2—What is the effect of implementing these care coordination models on hospitalizations,

ED visits, and patient experience (eg, Consumer Assessment of Healthcare Providers and

Systems)?

KQ3—What are the characteristics of settings in which effective models have been

implemented?

KQ4—Among effective models, which approaches/tools have been used to:

a) Measure patient trust or working alliance?

b) Measure team integration?

c) Improve communication between patients and providers?

To address these KQ, we first focused on identifying eligible SR on care coordination models. 

We determined that a review of reviews would be appropriate given the broad scope and 

anticipated heterogeneity in types of care coordination models, as well as patient populations. In 

order to address likely gaps in SR results, particularly with regard to KQ 3 and 4, we also 
Care Coordination Implementation Evidence Synthesis Program

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examined primary research studies of effective interventions and conducted key informant 

interviews with those who implemented and evaluated interventions. 

SEARCH STRATEGY

We searched for English-language SR in the following databases, from inception until 

September 2019: MEDLINE, CINAHL, Embase, Cochrane Database of Systematic Reviews, 

AHRQ Evidence-based Practice Center reports, and VA ESP reports. The search terms included 

MeSH and free text for care coordination interventions (eg, care or case management, 

interdisciplinary care, and intensive primary care), and systematic reviews (Appendix 1). We 

anticipated that eligible SR may not provide sufficient information, particularly with regard to 

KQ3 and 4. Therefore, we supplemented results from eligible SR with: 1) examination of 

primary research studies included by SR; 2) search of MEDLINE and Embase from the year of 

the most recent eligible SR (2018) until February 2020 for relevant randomized controlled trials 

(RCT) on care coordination models (Appendix 2); and 3) interviews with investigators and/or 

teams who implemented interventions described in research studies thus identified (see below).

STUDY SELECTION

Duplicates were removed from SR search results and uploaded into DistillerSR (Evidence 

Partners, Ottawa, Canada). Using prespecified inclusion and exclusion criteria (Appendix 3), 

titles and abstracts were screened for eligibility. Eligible populations of interest included 

community-dwelling adults with a range of ambulatory care sensitive conditions (eg, heart 

failure and chronic lung disease) and/or at higher risk for acute care episodes. If a review focused 

exclusively on interventions for a single health condition, it was excluded. Eligible interventions 

covered different care coordination models, such as care or case management and home-based 

primary care (Appendix 3). We required that eligible reviews reported inclusion of 

hospitalizations and/or ED visits as outcomes of interest in objectives or results. Articles 

underwent full-text review if at least 1 reviewer deemed it eligible during abstract screening. 

Exclusion of articles at screening required agreement of 2 reviewers. At full-text review, 2 

individuals separately determined inclusion/exclusion and then resolved any conflicts through 

discussion. When consensus could not be reached, disagreements were discussed with a third 

reviewer.

From each eligible SR, we identified all included primary studies and 2 reviewers evaluated 

them for potential relevance to KQ3 and 4. In addition to the above criteria for SR, we applied 

the following: conducted in US, and RCT or quasi-experimental observational studies (eg, 

comparative control cohort or interrupted time series).

13 To supplement this group of relevant 

primary studies, we also screened search results for RCT of care coordination models from 2018 

until February 2020. Two reviewers applied the same criteria used to evaluate SR, along with the 

additional requirement for RCT conducted in US. 

QUALITY RATING & DATA ABSTRACTION

We assessed the quality of eligible SR using criteria adapted from AMSTAR 2,

14 and rated 

overall quality as high, medium, or low (Appendix 4). In general, a high-quality SR met all 

applicable criteria (ie, at least “partial Yes” for all questions). Two reviewers independently rated 

each SR, and consensus was reached through discussion. 
Care Coordination Implementation Evidence Synthesis Program

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We abstracted data from all eligible SR on: target population(s); dates of search queries; and 

number and characteristic of included primary studies (location, setting, and study design). 

Additionally, from medium- and high-quality SR, we abstracted detailed results on: description 

of care coordination model characteristics; pooled effects (or qualitative summaries) for 

hospitalizations, ED visits, and/or patient experience; characteristics of settings; and tools and 

approaches used to measure patient trust or working alliance, assess health care team integration, 

and/or improve communication between patients and providers.

From relevant primary studies on care coordination models, we abstracted data on effectiveness 

for main outcomes; participant, intervention and setting characteristics; and tools and 

approaches. Because the primary studies frequently referenced other studies for information on 

intervention characteristics, we also reviewed these associated studies for data relevant to KQ3 

and 4.

For both SR and primary studies, data abstraction was done by 1 reviewer and results overread 

by a second reviewer.

DATA SYNTHESIS FOR SYSTEMATIC REVIEWS & RELEVANT 

PRIMARY STUDIES

We focused on results from SR to evaluate KQ 1 and 2, because this allowed us to address a 

broad scope including many types of care coordination interventions across diverse high-risk 

populations. Given this heterogeneity, we undertook a qualitative synthesis of these results. We

summarized SR results on key characteristics of care coordination models, and effectiveness for 

hospitalizations, ED visits, and/or patient experience. We also included strength of evidence 

determinations by SR, if these were stated. Few SR provided information on KQ 3 and 4; we 

highlighted these results when provided.

For identified relevant primary studies, we focused on those reporting successful reductions in 

hospitalizations and ED visits, and summarized information from these studies that were relevant 

for KQ3 and 4. To address remaining gaps, we also included information from associated articles 

(eg, methods papers) and websites referenced by primary studies. 

INTERVIEWS WITH KEY INFORMANTS WHO IMPLEMENTED CARE 

COORDINATION MODELS 

We conducted semi-structured interviews with research investigators and members of teams who 

implemented care coordination models, as described in relevant primary studies (identified from 

both eligible SR and updated search for RCT). We included individuals from relevant primary 

studies, regardless of effectiveness in reducing hospitalizations and/or ED visits. We initially 

invited 22 individuals by email, and contacted another 3 individuals per recommendations of 

respondents. We completed interviews with 11 participants. 

The main focus of these interviews was to address gaps in the published literature regarding tools 

and approaches. We also addressed intervention uptake and sustainability, as this information 

may be particularly useful to our VA stakeholders. Interview guides included questions in each 

of these areas and were individually adapted using published or online information about the 
Care Coordination Implementation Evidence Synthesis Program

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interventions. A general version of the interview guide is provided in Appendix 5. Interviews 

lasted about 30 minutes and were audio-recorded. We reviewed contemporaneous notes and 

audio-recordings to first develop summaries for each care coordination intervention. We then 

examined summaries for all interviews to provide overall themes.

PEER REVIEW 

A draft version of this report was reviewed by 6 technical experts, as well as VA operational 

partners. Their comments and our responses are presented in Appendix 6. 

RESULTS 

OVERVIEW OF ELIGIBLE SYSTEMATIC REVIEWS 

Of 2324 unique citations, 72 underwent full-text review (Figure 1). We identified 16 eligible SR, 

14 of which examined case management or transitional care interventions,15-28 and 2 of which 

evaluated intensive primary care models (eg, home-based primary care).29,30 All SR included a 

wide range of interventions, using broad definitions for case coordination or intensive primary 

care models. Four SR included only RCT,15,21,22,27 while the others allowed both RCT and 

observational studies. Three SR included only US studies,16,20,24 and the remaining SR included 

studies conducted in several different countries. Seven SR focused specifically on patients at 

higher risk for acute care utilization (ie, high-utilizers),15,18-20,23,24,26 and 1 SR examined 

interventions for individuals with frailty.27 Six SR were high quality,19,22,23,25,26,30 6 were medium 

quality,

15,18,20,21,27,29 and 4 were low quality.16,17,24,28 We focused on the 12 medium- and highquality SR for detailed results addressing KQ. Key characteristics and summary of results from 

high- and medium-quality SR are shown in Table 2. We also provide descriptions of results for

KQ1 and 2 in the following text and in Appendix 7 (along with detailed SR characteristics). SR 

reported very limited information regarding KQ 3 and 4.
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Figure 1: Search & Selection of Eligible Systematic Reviews

KQ1—WHAT ARE THE KEY CHARACTERISTICS OF CARE

COORDINATION MODELS? 

All SR provided general descriptions of different components included by interventions, with 

many providing some information on team composition and frequency of use of certain 

components (eg, multidisciplinary care plan). Outside of in-person contacts (whether in a clinical 

setting or at home), the other main form of communication with patients was via telephone. Four 

SR19,25,27,30 specifically addressed whether there are key characteristics for care coordination 

interventions (Table 2). Hudon et al19 used qualitative comparative analysis to examine 

intervention characteristics of effective case management models, reporting “case-finding...and 

complexity of health care needs are necessary to produce a positive outcome.” Additionally, 

selection of cases needed to be combined with either a high-intensity model (defined by authors 

MEDLINE

N=809

Embase

N=937

CINAHL

N=510

COCHRANE

N=34

Duplicates Removed

N=735

Abstracts Excluded

N=1,517

Eligible Reviews

N=16

Ineligible Articles N=56:

Ineligible outcome=7

Ineligible study design=11

Ineligible intervention=16

Ineligible population=22

AHRQ

N=11

VA ESP

N=23

Case/Care 

Management & 

Transitional Care

N=14

Intensive 

Primary Care

N=2

Total Citations

N=2,324

Abstracts Screened

N=1,589

Full-text Reviewed

N=72
Care Coordination Implementation Evidence Synthesis Program

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using caseload and frequency and types of contact with patients) or a multidisciplinary care plan. 

Smith et al25 reported that interventions “targeted at specific risk factor management or focused 

areas...are more likely to be effective... [while] interventions that have a broader focus...seem 

less effective.” Van der Elst et al27 conducted subgroup analyses by intervention duration and 

different approaches to address frailty, finding no significant differences. Totten et al30 examined 

home-based primary care and stated “there is not an apparent pattern or cluster of services 

associated with differences in outcomes.” Additionally, 2 SR15,29 sought to determine the key

components for care coordination models but were unable to draw conclusions; authors reported 

challenges due to lack of published information on components and fidelity of intervention 

implementation.

KQ2—WHAT IS THE EFFECT OF IMPLEMENTING CARE 

COORDINATION MODELS?

Of 10 SR examining case or care management and/or transitional care interventions, 2 conducted 

quantitative meta-analyses,22,27 while the remaining SR used qualitative syntheses to describe 

results15,18-21,23,25,26 (Table 2). Six SR evaluated effects on hospitalization, with 5 reporting mixed 

or unclear results15,19,21,22,25 and 1 finding lack of effectiveness.27 Among these, Le Berre et al22

pooled results for transitional care interventions (most involved nurses who called patients and/or 

made home visits) for diverse patient populations. Pooled results from 11-35 RCT found no 

effect at 1 month (risk difference [RD] -0.03, 95% CI -0.05, 0) and some effects at 3-18 months

(RD range -0.05 to -0.11). Van der Elst et al27 conducted meta-analyses to evaluate effects on 

hospitalization but examined a diverse set of case management interventions for frail 

community-dwelling older adults; pooled results from 5 RCT showed that case management did 

not reduce hospitalizations (odds ratio [OR] 1.13, 95% confidence interval [CI] 0.95, 1.35).

Seven SR examined effects of case or care management and/or transitional care interventions on 

ED visits (Table 2). Two SR21,23 indicated that care coordination interventions reduced ED visits, 

and both provided descriptive information about included studies. One SR stated that 6 included 

studies reported reductions in ED visits,21 and the other found that the median rate ratio (of care 

coordination vs control) was 0.63, with interquartile range of 0.41-0.71.23 All 5 remaining SR18-

20,22,26 reported unclear or mixed effects on ED visits, including 1 that conducted pooled metaanalyses over various timeframes (1-12 months).

22

Only 1 SR on case management evaluated effects on patient experience and, using qualitative 

synthesis, found inconsistent results.

19

Two SR evaluated intensive primary care interventions, with the 1 focused on home-based 

primary care reporting reduced hospitalizations,30 and the other describing inconsistent results 

across studies29; both used qualitative syntheses (Table 2). The SR on home-based primary care 

also found that there was improved patient and caregiver satisfaction (low strength of 

evidence).30
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KQ3—WHAT ARE THE CHARACTERISTICS OF SETTINGS IN WHICH 

EFFECTIVE MODELS HAVE BEEN IMPLEMENTED?

Only 2 SR addressed characteristics of settings for interventions. 1 SR on case management 

stated that all but 1 of 16 included studies were single-site, usually in an urban setting.26 The 

other SR sought to address organizational settings for home-based primary care models but was 

unable to find published information.30

To further address KQ 3 (and KQ 4), we identified 272 unique primary studies included by 

eligible SR, and found 18 RCT31-48 and 9 observational studies49-57 that were relevant. While

78% of relevant observational studies (n=7)

49-53,55,56 reported reductions in hospitalizations 

and/or ED visits, only 22% of RCT (n=4)

34,39,42,44 demonstrated effectiveness. Additionally, we 

searched for RCT that were published after the most recent eligible SR. This search resulted in 

1048 unique citations, of which 21 underwent full-text review. We identified 2 relevant RCT47,48

but both studies reported that interventions were not effective for reducing hospitalizations 

and/or ED visits.

Characteristics of effective care coordination models described in these studies, their effects and 

the settings in which they were implemented are summarized in Table 3. We categorized the 

effective interventions into transitional care, outpatient care or case management (led by nurse or 

social worker), or other intensive primary care models. These interventions were implemented in 

a variety of settings, including rural community hospitals and health systems, academic medical 

centers (in urban settings), and public hospitals serving largely poor and uninsured populations.

There was no clear connection between differences in settings, types of intervention and various 

patient populations.

KQ4—WHAT ARE THE TOOLS AND APPROACHES USED BY 

EFFECTIVE MODELS?

No SR commented on tools and approaches used to measure patient trust or care team 

integration, or to improve communication between patients and providers. Primary research 

studies described several approaches to improve patient-provider communications, such as 

coaching patients on how to ask questions, making lists of key concerns, and role-playing visits 

with providers.34,42,51,55,58 In 2 studies, care coordinators supported communication by attending 

outpatient visits with patients and their providers.42,55 No primary research study described 

specific tools or measures to assess patient working alliance with care coordination staff, care 

team integration, or patient-provider communications. For 1 intervention, qualitative methods 

were used to evaluate patient experiences and relationship with care coordinators.

34,59

KEY INFORMANT INTERVIEWS

We conducted 11 interviews with investigators and other team members who implemented care 

models described by relevant primary research studies. Several interviewees described using 

approaches akin to health coaching (although not called that in the published studies) to improve 

patient communications with providers. None of the interviews provided additional information 

on specific tools or approaches used to assess patient working alliance with care coordination 

staff, care team integration, or patient-provider communications. Review of additional 
Care Coordination Implementation Evidence Synthesis Program

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intervention materials provided by some interviewees indicated that assessments of patient 

experience sometimes included factors conceptually related to patient trust (eg, perception that 

care coordinator was knowledgeable and understood patients’ needs).

Regarding the sustainability of care coordination interventions, we found great variation in longterm effects. In some cases, interventions were not continued after completion of the research 

studies. Lack of financial viability was often a key factor in discontinuation of these 

interventions. Others were substantially modified and adapted to meet changing health system 

priorities (eg, in targeted patient populations). There was variable success in engaging 

stakeholders such as hospital leadership and front-line providers. Health care utilization and 

costs were priorities for those in leadership, and improved patient experiences were not usually 

sufficient for continuing interventions. One interviewee indicated “a tension between reducing 

costs/hospitalizations and adding value to the patient.”

In terms of key issues to for future care coordination interventions, some key informants 

questioned whether acute care utilization by high-risk populations was truly preventable, as these 

patients often had multiple challenges and health needs that required hospitalization. For 

example, 1 interviewee stated, “Everything that could be possibly going wrong is going 

wrong...A lot of these people are going to get readmitted no matter what you do.” There was also

concern with current readmission metrics and the ability to make substantial changes within a 

short timeframe: “30 days doesn’t give you sufficient time...especially in elderly patients with 

many issues.” Some also suggested that care coordination interventions may work better in those 

with less severe conditions and/or modifiable factors; an important challenge with such an 

approach is that the intervention may need to serve a large number of patients before there are 

appreciable differences in acute care utilization. One individual described it thus: “You can 

allocate a lot of resources to extremely high need patients...or you can allocate resources to a 

larger population and ... have a smaller impact on individual level, but on population level have 

greater impact...”
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Table 2: Summary of Results for Key Questions 1 and 2 from High- and Medium-Quality Systematic Reviews

Author, Year

(Quality,

Year of 

Search)

Included 

Populations; 

Study Designs;

# Relevant Primary

Studies 

Synthesis

Method 

KQ1—What are the key 

characteristics of care coordination 

models?

KQ2—What is the effect of implementing care 

coordination models?

 Hospitalization?

(Y/N)

 ED Visits?

(Y/N)

 Patient

Experience?

(Y/N)

Case Management and Transitional Care Interventions

Di Mauro, 

201918

(Medium, 

2018)

High-utilizers; 

RCT, cohort; 3 

Qualitative 

synthesis

NR NR Unclear

(inconsistent 

across studies)

NR

Hudon, 201919

(High, 2017)

High-utilizers with 

chronic conditions; 

RCT, cohort, 

cross-sectional;

4 

Qualitative 

comparative 

analysis

Necessary characteristics:

“case-finding” (high utilization and/or 

complexity of needs)

AND

High-intensity or multidisciplinary care 

plan

Unclear (inconsistent 

across studies)

Unclear

(inconsistent 

across studies)

Unclear

(inconsistent 

across studies)

Iovan, 201920

(Medium,

2017)

High-utilizers; 

RCT, cohort; 6

Qualitative 

synthesis

NR NR Unclear

(inconsistent 

across studies)

NR

Van der Elst, 

201827

(Medium,

2016)

Frail older adults; 

RCT; 0

Quantitative 

meta-analysis

No significant results in subgroup 

analyses by: intervention duration; 

recruitment method; “multi- versus 

unidimensional approach to frailty”

N NR NR

Joo, 201721

(Medium, 

2016)

Chronic conditions; 

RCT; 1 

Qualitative 

synthesis

NR Unclear (inconsistent 

across studies)

Y NR

Baker, 201815

(Medium,

2015)

Multimorbidity, highutilizers; 

RCT; 4

Qualitative 

synthesis

“[C]ommon methodologic issues 

limited our ability to draw conclusions 

regarding the effectiveness of specific 

intervention components...”

Unclear (inconsistent 

across studies)

NR NR

Le Berre, 

201722

(High, 2015) 

Older adults with 

chronic conditions; 

RCT; 3

Quantitative 

meta-analysis

NR Unclear (inconsistent 

across studies)

Unclear

(inconsistent 

across studies)

NR
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Author, Year

(Quality,

Year of 

Search)

Included 

Populations; 

Study Designs;

# Relevant Primary

Studies 

Synthesis

Method 

KQ1—What are the key 

characteristics of care coordination 

models?

KQ2—What is the effect of implementing care 

coordination models?

 Hospitalization?

(Y/N) 

 ED Visits?

(Y/N) 

 Patient

Experience?

(Y/N)

Soril, 201526

(High, 2015)

High-utilizer;

RCT, cohort; 3

Qualitative 

synthesis

NR NR Unclear

(inconsistent 

across studies)

NR

Moe, 201723

(High, 2014)

High-utilizer; 

RCT, cohort; 3 

Median, IQR 

for RR

NR NR Y NR

Smith, 201625

(High, 2011)

Multimorbidity; RCT, 

cohort; 2

Qualitative 

synthesis

“[I]nterventions that are targeted at 

specific risk factor management or 

focused areas where patients have 

difficulties, such as with functional 

ability or medicines management, are 

more likely to be effective... [while] 

interventions that have a broader 

focus...seem less effective.”

N NR NR

Intensive Primary Care Interventions

Totten, 201630

(High, 2015)

Chronic conditions

and/or disabilities; 

RCT, cohort; 1

Qualitative 

synthesis

“There is wide variation in the services 

provided as part of [home-based 

primary care]. [T]here is not an 

apparent pattern or cluster of services 

associated with differences in 

outcomes...”

Y Y Y

Edwards, 

201729

(Medium, 

2017)

High risk for 

hospitalization or 

death; 

RCT, cohort; 7

Qualitative 

synthesis

“We had hoped to identify key 

program features... that may have 

contributed to the success or failure of 

these programs. Unfortunately, 

reporting of key intervention 

characteristics was inconsistent...”

Unclear (inconsistent 

across studies)

N NR

CI=confidence interval; ED=emergency department; IQR=interquartile range; NR=not reported; OR=odds ratio; RCT=randomized controlled trials; RD=risk 

difference; RR=risk (or rate) ratio
Care Coordination Implementation Evidence Synthesis Program

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Table 3: Primary Studies—Characteristics and Results of Effective Care Coordination Models 

Author,

Year; 

Study 

Design*;

N

Intervention Name;

Eligibility Criteria Description of Patient Contacts

Effects of care coordination interventions KQ3—Characteristics of 

settings in which 

effective models have 

Hospitalizations ED Visits been implemented? 

Transitional Care Interventions

Capp, 201749; 

Cohort;

I=406

C=3396

Bridges to Care; 

adults with ≥ 2 ED visits 

and/or hospitalizations in 

past 180 days

First home visit by community 

health worker within 24-72 hours, 

second visit by PCP within 1 week 

of ED or hospital discharge; 8 visits 

over 60 days (community health 

worker, nurse, primary care 

provider, and/or behavioral health 

provider) depending on patient 

needs.

Average # admissions 

per person, 180 days 

before enrollment: 

I=1.04, C=1.15

180 days after 60-day 

intervention: 

I=0.75, C=1.02 

Difference of 

differences= -0.16,

P<0.1

Average # visits per 

person, 180 days 

before enrollment: 

I=5.12, C=4.93

180 days after 60-

day intervention: 

I=2.79, C=3.60, 

Difference of 

differences=-1.01,

P=<0.01

Large urban academic 

medical center, Colorado

Hamar, 

201652; 

Cohort;

I=560

C=3340

Care Transition Solution;

adults admitted with ≥ 1 

condition (COPD, heart 

failure, myocardial 

infarction, pneumonia)

Initial visit in hospital with nurse 

before discharge, then 4 calls over 

4 weeks

Proportion with ≥ 1 

readmission at 30 days: 

AOR=0.56 (0.41-0.77)

At 6 months:

AOR=0.47 (0.35-0.65)

NR 14 community hospitals in 

north Texas

Gardner, 

201451; 

Cohort;

I=21

C=21

Care Transitions 

Intervention; adults 

participating in Medicare 

fee-for-service, admitted to 

hospital

Initial visit in hospital by nurse, 

home visit "shortly after discharge," 

2-3 phone calls during 30-day postdischarge period

Propensity score 

matched # readmissions 

at 6 months: 

I=0.65, C=0.93

P=0.01

Propensity score 

matched # visits at 6 

months: 

I=0.44, C=0.50

P=0.55

6 community hospitals, 

Rhode Island

Coleman,

200634; RCT;

I=379

C=371

Care Transitions 

Intervention; 

older adults (≥65) admitted 

with ≥ 1 condition (stroke, 

heart failure, diabetes 

mellitus, etc) 

Nurse met patients in hospital 

before discharge, home visit within 

48-72 hours of discharge, then 3

more times during 28-day postdischarge period.

Proportion with ≥ 1 

readmission at 30 days: 

I=0.08, C=0.12 

AOR=0.59 (0.35, 1.00), 

P=0.048

At 90 days: 

I=0.17, C=0.23

NR Community health system,

Colorado
Care Coordination Implementation Evidence Synthesis Program

25

Author,

Year; 

Study 

Design*;

N

Intervention Name;

Eligibility Criteria Description of Patient Contacts

Effects of care coordination interventions KQ3—Characteristics of 

settings in which 

effective models have 

Hospitalizations ED Visits been implemented? 

AOR=0.64 (0.42, 0.99), 

P=0.04

At 180 days:

I=0.26, C=0.31 

AOR=0.80 (0.54, 1.19), 

P=0.28

Naylor, 199939; 

RCT;

I=177

C=186

Transitional Care Model;

older adults (≥65) admitted 

with ≥ 1 condition (heart 

failure, respiratory 

infection, orthopedic 

procedure, etc.) 

Initial nurse visit within 48 hours of 

admission, visits at least every 48 

hours during admission, home 

visits after discharge (first within 48 

hours, second 7-10 days postdischarge, additional visits based 

on patients' needs), weekly nurseinitiated phone contact

Proportion with ≥ 1 

readmission at 24 

weeks:

I=0.20, C=0.37

P=<0.01

NR 2 urban hospitals affiliated 

with University of

Pennsylvania

Outpatient Care or Case Management

Shah, 201155; 

Cohort;

I=98

C=160

Care Management 

Program; 

adults aged 18-64, <200% 

federal poverty level, 

uninsured, “met frequent 

user criteria” 

Care managers (social worker or 

medical office assistant) met with 

patients at least monthly in the 

home and/or clinic, for variable 

lengths of time (care manager 

decided when patient graduated 

program) 

Adjusted ratio of # of 

admissions per year (I:C) 

was 0.81, P=0.38

Adjusted ratio of # of 

visits per year (I:C) 

was 0.67, P<0.001

Public safety-net hospital 

and clinics in Kern County, 

California

Peikes, 

200942; RCT;

Mercy Medical 

Center (1 of 15 

sites)—I=669, 

C=467

Medicare Coordinated 

Care Demonstration; adults 

participating in Medicare 

fee-for-service and with ≥ 1 

condition (heart failure, 

COPD, etc.) 

Nurse completed in-person 

evaluation within 2 weeks of 

enrollment, contacted patient at 

least monthly, 69% were in-person 

(either at home or during clinic 

visit)

Average # admissions 

per person per year:

I= 1.15, C=0.98

P=0.02

NR Mercy Medical Center—

rural community hospital, 

Iowa

Shumway, 

200819; RCT; 

I=167, C=85

Comprehensive case 

management; adults with ≥ 

5 ED visits in past 12 

months and had 

“psychosocial problems 

that could be addressed 

with case management”

Social workers completed 

assessments, individual and group 

supportive therapy, assistance to a 

variety of community resources, 

and “assertive community 

outreach” (frequency and schedule 

of patient contacts NR)

Effect size NR, P=0.08 

for treatment effect in 

adjusted model for visits 

over 2 years

Effect size NR, 

P<0.01 for treatment 

effect in adjusted 

model for visits over 

2 years

Urban public hospital in 

San Francisco, California
Care Coordination Implementation Evidence Synthesis Program

26

Author,

Year; 

Study 

Design*;

N

Intervention Name;

Eligibility Criteria Description of Patient Contacts

Effects of care coordination interventions KQ3—Characteristics of 

settings in which 

effective models have 

Hospitalizations ED Visits been implemented? 

Sommers, 

200056; Cohort

I=280

C=263

Senior Care Connections;

adults ≥65 with difficulty in 

≥1 instrumental activity of 

daily living and 2 ≥ chronic 

conditions

Initial home visit with case 

manager (nurse or social worker),

treatment plan drafted by care 

team (nurse, social worker, primary 

care provider), patients contacts 

via phone, home visits, small group 

sessions, or office/hospital visits at 

least once every 6 weeks

# of admissions per 

person per year at 

baseline: 

I=0.35, C=0.06

 

during year 1: 

I=0.38, C= 0.34

 

during year 2: 

I=0.36, C=0.52

P=0.03

Proportion with ≥1 

visit at baseline: 

I=0.09, C=0.06 

during year 1: 

I=0.20, C=0.17

during year 2: 

I=0.21, C=0.17 

P=0.77

Primary care clinics in San 

Francisco Bay area, 

California

Other Intensive Primary Care Models

Crane, 201250; 

Cohort;

I=34

C=36

Drop-in group medical 

appointments; uninsured, 

family income ≤ 200% 

federal poverty level, ≥ 6 

ED visits in past year

Twice-weekly groups sessions, 

short individual visit right after; 

direct phone access to nurse care 

manager; team included nurse, 

primary care and behavioral health 

providers

NR Median # visits per 

month during 1 year 

before: 

I=0.58, C=0.58

during 1 year after: 

I=0.23, C=0.42

Difference in 

differences: 

0.23, P=0.005

Rural community hospital, 

North Carolina

Meret-Hanke, 

201153; 

Cohort;

I=3889

C=3103

Program for All-Inclusive 

Care for the Elderly; 

adults >65, with functional 

limitations or dementia, 

income <300% 

Supplemental Security 

Income

Interdisciplinary care teams 

provided care management, 

clinical monitoring, and updated 

care plan in response to changes 

in enrollee’s health and functional 

status 

Propensity score 

matched any 

hospitalization at 6 

months: AOR 0.35,

P<0.01 

At 2 years: AOR 0.16, 

P<0.01

NR National US program 

AOR=adjusted odds ratio; C=control group; COPD=chronic obstructive pulmonary disease; ED=emergency department; I=intervention group; RCT=randomized 

controlled trial

*Study designs were either RCT or observational cohorts with comparative controls
Care Coordination Implementation Evidence Synthesis Program

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SUMMARY AND DISCUSSION

SUMMARY OF KEY FINDINGS

To inform the VA CC&ICM initiative, we conducted a multi-stage review of evidence for care 

coordination models. We identified 16 eligible SR addressing care coordination interventions, 

and further examined 29 relevant primary research studies. We also conducted 11 key informant 

interviews with those who have implemented care coordination models. Key findings include:

• One SR reported that high-intensity models and/or multidisciplinary plans were required 

for effectiveness (in combination with selection criteria noted above).

• Most SR reported unclear or inconsistent effects of care coordination models in reducing 

hospitalizations or ED visits.

• Primary studies reporting effective interventions were conducted in a variety of settings, 

including rural community hospitals, academic medical centers in urban settings, and 

public hospitals serving largely poor and uninsured populations.

• Approaches to improve patient-provider communication included coaching patients, roleplaying, and attending appointments with patients.

• SR, primary studies, and interviews provided little information on specific tools or 

approaches used to assess patient trust or working alliance or health care team 

integration.

• Key informant interviews suggested variation in sustainability of care coordination 

interventions, with substantial adaptation occurring among many of those that have 

continued.

Care coordination models were complex and differed along multiple dimensions, thus presenting 

substantial challenges for SR authors in summarizing and comparing results across studies. Four 

SR drew conclusions with regard to key intervention characteristics, with 2 highlighting 

selection criteria, 1 indicating importance of high-intensity model (defined by lower caseload 

and more patient contacts) and multidisciplinary plans, and 2 finding no key characteristics. 

Several SR seeking to examine key characteristics and/or organizational settings of care 

coordination models reported difficulty finding sufficient published evidence to address these

questions. 

Among 11 primary studies demonstrating effective care coordination models, none reported 

specific tools or approaches for measuring patient trust or health care team integration. Key 

informant interviews did not provide additional information on these areas. Interventions used a 

variety of approaches to improve communication between patients and providers, including 

coaching and role-playing. In some interventions, care coordinators also directly communicated 

with providers on patients’ behalf, including participation at outpatient appointments. 

Some interviewees described adaptation of the intervention over time to address evolving 

priorities for health care organizations. Some also highlighted the difficulty of modifying health 
Care Coordination Implementation Evidence Synthesis Program

28

and social factors contributing to need for acute care utilization among many patients in the 

highest risk category. There were suggestions that there may be more benefit in focusing on 

patients at somewhat lower risk and improving health care processes for larger groups of 

patients.

IMPLICATIONS FOR POLICY

It remains unclear whether care coordination interventions should be implemented in particular 

health care settings and how they may be adapted to improve effectiveness and sustainability. 

Two SR highlighted the importance of carefully selecting patients for care coordination 

interventions. The VA CC&ICM initiative has implemented several tools for evaluating Veteran 

needs and matching the level of care coordination services to those needs. The CC&ICM team 

has conducted site visits to assess the use of these tools and implementation of care coordination 

models at pilot VA facilities. It will be important for VA to evaluate the feasibility of applying 

these tools more widely, and the effects of implementing such tools on delivery of services and 

patient outcomes. Additionally, because VA medical centers and clinics are located in a variety 

of settings, it will be important to understand differences in utility of these tools across large and 

small sites, and those serving urban and more rural communities.

VA facilities differ in the number and types of care coordination services and programs that are 

offered. Understanding what is available at a particular facility may be challenging for Veterans, 

their caregivers, and VA clinical staff. A key goal of the CC&ICM initiative is to standardize 

care coordination across VA sites, and this may improve access and use of appropriate services 

for Veterans. However, the CC&ICM initiative also acknowledges the importance of flexibility 

to adapt care coordination models to accommodate local circumstances. Our interview results 

also support the importance of local adaptations for uptake and sustainability of care 

coordination interventions. A potential avenue to achieving more consistency of services while 

allowing flexibility may be to align services and programs based on program goals and Veteran 

needs; this information could then be collected in a central hub that Veterans and/or VA staff can 

use to find appropriate services. It may be also be valuable to provide educational materials as 

part of the CC&ICM initiative to guide adaptations (eg, highlighting the key program goals or 

outcomes, and distinguishing between core components and more flexible options). Additionally, 

evaluation of implementation should consider which adaptations were made and the rationale to 

support these.

One SR indicated that a high-intensity (defined using case load and patient contacts) or 

multidisciplinary care coordination model was more likely to be successful. Our examination of 

effective primary research studies also found a high number and frequency of patient contacts, 

often involving home visits. Therefore, it may also be valuable to understand which VA 

programs or models are most similar to these high-intensity interventions, and consider whether 

it would be cost-effective to implement more broadly. Currently, such high-intensity care 

coordination programs serve a limited number of Veterans with specific diagnoses (eg, VA 

Mental Health Intensive Case Management for those with bipolar disorder or schizophrenia).60

Finally, there may be specific patient groups that would benefit more from models that go 

beyond additional care coordination services (eg, by a nurse and/or social worker). For example,

VA Primary Care Mental Health Integration (PCMHI)61 is a collocated, collaborative model 

where mental health staff have frequent structured and informal communications with primary 
Care Coordination Implementation Evidence Synthesis Program

29

care staff. The national implementation of VA PCMHI sought to improve access to mental health 

services for Veterans and improve integration of mental health concerns with other aspects of 

care. The VA has also been interested in potentially implementing different models of integrating 

oncology and palliative care for cancer patients.62

EVIDENCE GAPS AND FUTURE RESEARCH NEEDS

Our examination of primary research studies suggested that those with observational quasiexperimental designs were more likely to report reductions in hospitalizations and/or ED visits.

Observational studies may have residual confounding and are more likely to be affected by 

publication bias, as there are no requirements for a priori registration (with explicit description of 

primary outcomes and analysis strategy). 

Studies of effective care coordination models did not report standardized tools used to assess 

patient trust or care team integration. It may be that these interventions relied on informal 

assessment by study staff or that there was an assumption that these domains would all improve. 

However, descriptions of these tools and strategies for assessment will support health systems in 

evaluating their existing services and implementing new care coordination models. 

Finally, multiple SR raised concerns about lack of information on intervention implementation, 

including fidelity and frequency of various components. To improve evaluation and 

interpretation of the effectiveness of care coordination interventions, future studies should 

consider application of frameworks and designs with explicit consideration of implementation 

outcomes (eg, hybrid effectiveness-implementation designs, Consolidated Framework for 

Implementation Research[CFIR], and Reach, Effectiveness, Adoption, Implementation, and 

Maintenance [RE-AIM]).

63-66 Studies using such frameworks should clearly define the “core” set 

of key components and describe the “adaptable periphery” of elements that can be adjusted to 

accommodate the local context.

Therefore, we recommend the following for future research:

• Evaluate future care coordination interventions using randomized designs.

• Consider application of standardized tools to assess patient trust or working alliance, 

health care team integration, and communication between patients and providers.

• Consider study designs that explicitly consider implementation outcomes in future studies 

of care coordination models.

• Define “core” intervention components and describe local adaptations, particularly in 

multi-site studies.

LIMITATIONS

To address the priorities of our VA partners, this work focused on care coordination models that 

were effective in reducing hospitalizations and/or ED visits; SR and studies that did not address 

these outcomes were excluded. While we acknowledge the importance of patient experience 

outcomes, our discussions with stakeholders and key informant interviews all supported the high 

priority of acute care utilization for health care system leadership, particularly with regard to 
Care Coordination Implementation Evidence Synthesis Program

30

sustainability of interventions. We prioritized high- and medium-quality reviews for abstracting

detailed results addressing KQ. However, we identified relevant primary studies from all eligible 

SR. We relied on SR authors’ determination of overall effectiveness and strength of evidence for

care coordination models. Because interventions in countries other than the US may be less 

relevant for the VA, we limited primary studies to those conducted in the US. It is possible that 

studies conducted in other countries may have been informative for VA policy, despite very 

substantial differences in health care financing and delivery. We were able to complete 

interviews with less than half of those whom we invited to participate; it is possible that there 

was unpublished information on tools and approaches that we were unable to identify.

CONCLUSIONS

Existing evidence on care coordination models indicate that they have inconsistent effects on 

reducing hospitalizations and/or ED visits for high-risk community-dwelling adults. It remains 

unclear whether such interventions should be implemented and how they may be adapted to 

different health care settings. Implementation of new care coordination services should be 

carefully evaluated, preferably using randomized designs. Policymakers should also consider 

whether for certain patient populations, a larger-scale redesign of care models may be necessary

to improve continuity and collaboration.
Care Coordination Implementation Evidence Synthesis Program

31

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61. Wray LO, Szymanski BR, Kearney LK, McCarthy JF. Implementation of primary caremental health integration services in the Veterans Health Administration: program 

activity and associations with engagement in specialty mental health services. J Clin 

Psychol Med Settings. 2012;19(1):105-116.

62. Fulton J, Williams J, LeBlanc T, et al. Integrated Outpatient Palliative Care in Oncology.

VA ESP;2017.

63. Curran GM, Bauer M, Mittman B, Pyne JM, Stetler C. Effectiveness-implementation 

hybrid designs: combining elements of clinical effectiveness and implementation 

research to enhance public health impact. Med Care. 2012;50(3):217-226.

64. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering 

implementation of health services research findings into practice: a consolidated 

framework for advancing implementation science. Implement Sci. 2009;4(1):50.

65. Rabin BA, McCreight M, Battaglia C, et al. Systematic, Multimethod Assessment of 

Adaptations Across Four Diverse Health Systems Interventions. Front Public Health. 

2018;6:102.

66. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health 

promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89(9):1322-

1327.
Care Coordination Implementation Evidence Synthesis Program

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APPENDIX 1. SEARCH STRATEGIES FOR SYSTEMATIC 

REVIEWS 

OVID MEDLINE 

1 (meta-analy$ or metaanaly$ or meta analy$).tw. or exp Meta-Analysis/ or (systematic adj (review$ or 

overview$)).tw. or (systematic review or literature review or rapid review or umbrella review or meta 

synthesis or metasynthesis or meta-analysis or meta-synthesis or integrative review or data synthesis or 

comparative effectiveness review).mp.

2 (case report or case series or letter or comment or editorial).tw.

3 1 not 2

4 Exp Case Management/ or ((care or case) adj1 management).ti,ab.

5 Exp transitional care/

6 (home based primary care).ti,ab. or (home based primary care).kw. or (home based primary care).sh

7 (intensive primary care).ti,ab. or (intensive primary care).kw. or (intensive primary care).sh.

8 ((integrat* or collaborat* or coordinat* or transition* or interdisciplin*) adj1 care).ti,ab.

9 or/4-8

10 3 and 9

11 Limit 9 to English

12 Limit 11 to yr=”2015-current”

OVID EMBASE

1 (meta-analy$ or metaanaly$ or meta analy$).tw. or exp Meta-Analysis/ or (systematic adj (review$ or 

overview$)).tw. or (systematic review or literature review or rapid review or umbrella review or meta 

synthesis or metasynthesis or meta-analysis or meta-synthesis or integrative review or data synthesis or 

comparative effectiveness review).mp.

2 (case report or case series or letter or comment or editorial).tw.

3 1 not 2

4 Exp Case Management/ or ((care or case) adj1 management).ti,ab.

5 Exp transitional care/

6 (home based primary care).ti,ab. or (home based primary care).kw. or (home based primary care).sh

7 (intensive primary care).ti,ab. or (intensive primary care).kw. or (intensive primary care).sh.

8 ((integrat* or collaborat* or coordinat* or transition* or interdisciplin*) adj1 care).ti,ab.

9 or/4-8

10 3 and 9

11 Limit 9 to English

12 Limit 11 to yr=”2015-current”

13 Limit 12 to conference abstract status

14 12 not 13

CINAHL

1 (TI (systematic* n3 review*)) or (AB (systematic* n3 review*)) or (TI (systematic* n3 literature)) or (AB 

(systematic* n3 literature)) or (TI (integrative n3 review)) or (AB (integrative n3 review)) or (TI (information 

n2 synthesis)) or (TI (data n2 synthesis)) or (AB (information n2 synthesis)) or (AB (data n2 synthesis)) 

or (TI (meta-analy* or metaanaly*)) or (AB (meta-analy* or metaanaly*)) or (TI (umbrella* n2 review*)) or (AB 

(umbrella* n2 review*)) or (TI (rapid* review*)) or (AB (rapid* review*)) or (TI (compar* effect* review)) or (AB 

(compar* effect* review))

2 (TI (care or case) n2 management) or (AB (care or case) n2 management)

3 (TI (transitional care)) or (AB (transitional care))

4 (TI (home based primary care)) or (AB (home based primary care))

5 (TI (intens* primary care)) or (AB (intens* primary care))

6 (TI ((integrat* or collaborat* or coordinat* or transition* or interdisciplin*) n2 care)) or (AB ((integrat* or 

collaborat* or coordinat* or transition* or interdisciplin*) n2 care))

7 MH transitional care
Care Coordination Implementation Evidence Synthesis Program

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8 MH case management

9 S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8

10 S1 AND S9 (Limiters: Research article, peer reviewed, published 2015 and later, human, English language)

COCHRANE REPORTS

1 ("case management"):ti,ab,kw OR ("care management"):ti,ab,kw OR ("intensive primary care"):ti,ab,kw OR 

(transition* next care):ti,ab,kw OR ("home based primary care"):ti,ab,kw OR (integrat* next care):ti,ab,kw OR 

(collaborat* next care):ti,ab,kw OR (coordinat* next care):ti,ab,kw OR (transition* next care):ti,ab,kw OR 

(interdisciplin* next care):ti,ab,kw

2 with Cochrane Library publication date from Jan 2015 to Oct 2019, in Cochrane Reviews

AHRQ REPORTS

1 Keyword search for:

Care coordination, case management, care management, collaborative care, integrative care, transitional 

care, home-based primary care, intensive primary care

2 Limited to 2015 and later

VA ESP REPORTS

1 Title search for:

Care, case, coordin*, manage*, collab*, integrat*, transit*, home-based*, intens*, interd*

2 Limited to 2015 and later
Care Coordination Implementation Evidence Synthesis Program

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APPENDIX 2. SEARCH STRATEGIES FOR PRIMARY 

STUDIES 

OVID MEDLINE AND EMBASE

1 Exp Case Management/ or ((care or case) adj1 management).ti,ab.

2 Exp transitional care/

3 (home based primary care).ti,ab. or (home based primary care).kw. or (home based primary 

care).sh

4 (intensive primary care).ti,ab. or (intensive primary care).kw. or (intensive primary care).sh.

5 ((integrat* or collaborat* or coordinat* or transition* or interdisciplin*) adj1 care).ti,ab.

6 ("delivery of health care, integrated" or "care continuity" or "continuum of care").ti,ab.

7 or/1-6

8 Randomized Controlled Trials as Topic/

9 randomized controlled trial.ti,ab,sh,kw,pt.

10 random allocation.ti,ab.

11 Double-Blind Method/

12 Single-Blind Method/

13 clinical trial/

14 clinical trial, phase i.pt.

15 clinical trial, phase ii.pt.

16 clinical trial, phase iii.pt.

17 clinical trial, phase iv.pt.

18 controlled clinical trial.pt.

19 clinical trial.pt.

20 exp Clinical trials as topic/

21 (clinical adj trial$).tw.

22 ((singl$ or doubl$ or treb$ or tripl$) adj (blind$3 or mask$3)).tw.

23 randomly allocated.tw.

24 (allocated adj2 random$).tw.

25 or/8-24

26 7 and 25

27 Limit 26 to English

28 Limit 27 to yr=”2018-current”

29 Remove duplicates from 28

CINAHL

1 TI "care management" or TI "case management" OR AB "care management" or AB "case

management"

2 TI "transition* care" OR AB "transition* care"

3 TI "home based primary care" OR AB "home based primary care"

4 TI "intensive primary care" OR AB "intensive primary care"

5 TI "integrat* care" OR AB "integrat* care"

6 TI "care continuity" OR AB "care continuity"

7 TI "continuum of care" OR AB "continuum of care"

8 TI "collaborat* care" OR AB "collaborat* care"

9 TI "coordinat* care" OR AB "coordinat* care"

10 TI "care coordinat*" OR AB "care coordinat*"

11 TI "interdisciplin* care" OR AB "interdisciplin* care"

12 S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10 OR S11

13 TI (randomized controlled trial or randomised controlled trial) OR AB (randomized controlled

trial or randomised controlled trial)

14 TI "random* allocat*" OR AB "random* allocat*"

15 S13 OR S14

16 S15 AND S12 (Limits applied: Peer reviewed; published 2018-current; English language; 

exclude MEDLINE records)
Care Coordination Implementation Evidence Synthesis Program

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APPENDIX 3. STUDY SELECTION CRITERIA

Inclusion Criteria Exclusion Criteria

Population Community-dwelling adults with a variety of 

ambulatory care sensitive conditions and/or at 

higher risk of having repeat hospitalization of 

emergency department [ED] visits

Restricted to single condition (eg, heart 

failure) or single combination (eg, diabetes 

and depression)

Intervention Care coordination models:

• Care or case management

• Transitional care (if involving patient contact 

≥ 1 month after discharge) 

• Home-based primary care

• Intensive primary care

• Integrated or interdisciplinary care

• Collaborative care model

Hospice and end-of-life care (if exclusive 

focus of intervention)

Comparator Any (active or inactive)

Outcomes • Primary—Hospitalization, ED visits

• Secondary—Patient experience; tools and 

approaches 

Timing Any duration

Setting Community-base, outpatient

Study Design • For KQ 1 & 2: Systematic review (SR) or 

Patient Level Meta-Analysis—must have 

search strategy, eligibility criteria, and 

analysis/synthesis plan; may include RCTs, 

observational studies, and/or qualitative 

studies

• For KQ 3&4: RCTs or quasi-experimental 

studies (eg, cohorts with comparative 

controls) 

Expert or narrative reviews

Other English Language
Care Coordination Implementation Evidence Synthesis Program

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APPENDIX 4. QUALITY ASSESSMENT

4.1 QUALITY ASSESSMENT CRITERIA FOR SYSTEMATIC REVIEWS 

(MODIFIED AMSTAR 2)

14
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Care Coordination Implementation Evidence Synthesis Program

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4.2. QUALITY ASSESSMENT FOR ALL ELIGIBLE SYSTEMATIC REVIEWS

Author, Year Research 

Questions 

include 

components 

of PICO?

Protocol 

established 

prior to 

conduct of 

review?

Explained 

selection of 

included 

study 

designs?

Comprehensive 

search strategy 

used?

Dual review 

for 

inclusion? 

Dual review 

for data 

extraction?

Assessed 

quality?

Meta analyses:

Appropriate 

statistical 

methods and 

investigation of 

publication bias?

Reported 

any 

potential 

conflicts of 

interest?

Overall 

Quality

Baker, 201815 Yes Partial Yes No Partial Yes Yes Yes NA Yes Medium

Bleich, 201516 Yes Partial Yes Yes No Yes No NA Yes Low

De Pourcq, 201717 No No Yes Yes Yes Partial Yes NA Yes Low

Di Mauro, 201818 Yes Partial Yes No Partial Yes Yes Yes NA Yes Medium

Edwards, 201729 Yes Partial Yes No Yes Yes Yes NA Yes Medium

Hudon, 201919 Yes Yes Yes Yes Yes Yes NA Yes High

Iovan, 201920 Yes Partial Yes No Yes Yes

No

No NA Yes Medium

Joo, 201721 Yes Partial Yes No Partial Yes Yes Yes NA Yes Medium

Le Berre, 201722 Yes Yes No Yes Yes Yes Yes Yes High

Moe, 201723 Yes Yes Yes Yes Yes Yes NA Yes High

Raven, 201624 Yes Yes No Yes No Partial Yes NA Yes Low

Smith, 201625 Yes Yes Yes Yes Yes Yes NA Yes High

Soril, 201526 Yes Partial Yes No Yes Yes Yes NA Yes High

Totten, 201630 Yes Yes Yes Yes Yes Yes NA Yes High

Van der Elst, 201827 Yes Yes No Partial Yes No

Yes

Yes Yes Yes Medium

Weeks, 201828 Yes No Yes Yes No Yes No Yes Low
Care Coordination Implementation Evidence Synthesis Program

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APPENDIX 5. KEY INFORMANT INTERVIEW GUIDE

A. INTERVENTION INFORMATION GAPS 

1. Thank you. In this first part of the interview we’d like to get your perspective on and experience 

with [name of intervention], as well as ask some specific questions about your project.

2. So to start, we have read your article in [journal], but could you please briefly tell us about 

your experience with this project?

3. Now I have some specific questions on your study. As a quick reminder, your responses to these 

might be connected to your study in the report. 

a. If unclear in published studies—Who was the team lead for care coordination? (eg, nurse, 

social worker, etc.)

b. Was there collaboration between clinical teams in primary care and specialty care? If so, 

please describe.

• Were tools or surveys used to assess team integration? 

c. Were there specific tools or approaches used to improve communication between patients and 

providers?

• Were tools or surveys used to assess quality of communication between patients and 

providers? 

d. Were tools or surveys used to assess patient trust or working alliance? 

e. How were community groups involved?

PROBE:

• Community service groups to assist older adults, community advocacy groups for 

uninsured

B. UPTAKE AND SUSTAINABILITY 

Now we’d like to ask some questions regarding the uptake and sustainability of your intervention. 

The responses on these questions will be kept private and reported only in summary (as in major 

themes).

1. Aside from team members, who were some of the stakeholders that influenced the planning, 

uptake and sustainability of your intervention?

a. What role did these stakeholders play?

b. How did you engage these stakeholders in discussions to determine which outcomes were 

important?
Care Coordination Implementation Evidence Synthesis Program

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PROBE: 

- Local leadership, frontline staff, providers, patients, other important groups or individuals?

2. Is this intervention still in place at your facility/institution?

If YES

a. What has the long-term impact been?

PROBE: 

- Could you elaborate more on the long-term provider and patient satisfaction?

- Is there ongoing (or future) evaluation planned?

IF NO

b. Why not?

C. OVERALL EXPERIENCE/REFLECTION ON INTERVENTION

1. To wrap up, we just have 2 final questions about your overall experience with this intervention. 

2. First, what about your intervention seemed to work well?

3. Lastly, what about your intervention would you do differently next time?

D. IS THERE ANYTHING ELSE YOU’D LIKE TO ADD THAT I DIDN’T ASK ABOUT?
Care Coordination Implementation Evidence Synthesis Program

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APPENDIX 6. PEER REVIEW COMMENTS/AUTHOR RESPONSES

Reviewer Comments Response and Revisions 

Reviewer 1

Are there any published or unpublished studies that we may have 

overlooked?

Hynes, DM, Fischer, M, Fitzgibbon, M, Porter, AC, Berbaum, M, Schiffer, 

L, Chukwudozie, IB, Nguyen, H, Arruda, J. Integrating a Medical Home in 

an Outpatient Dialysis Setting: Effects on Health-Related Quality of Life. J 

Gen Int Med. 2019; 34(10): 2130-2140. doi: 10.1007/s11606-019-05154-

9. PMID: 31342329.

Hynes DM, Fischer MJ, Schiffer LA, Gallardo R, Chukwudozie IB, Porter 

A, Berbaum M, Earheart J, Fitzgibbon ML. Evaluating a novel health 

system intervention for chronic kidney disease care using the RE-AIM 

framework: Insights after 2 years. Contemp Clin Trials. 2016 Oct 

18;52:20-26. DOI: 10.1016/j.cct.2016.10.003. [Epub ahead of print] 

PubMed PMID: 27769897.

Thank you for these suggestions. We reviewed these studies and have not included 

them because they are not systematic reviews. They also do not meet our criteria for 

relevant primary studies (eg, focused on a range of ambulatory care sensitive 

conditions).

[Page 1, line 53] Can you elaborate more on the scope—did your inquiry 

include PCMH, PACT, and variations of these models or was the 

definition of care coordination more narrow? One of our struggles in this 

space is definitions, so the more clear you are in explaining your inclusion 

and exclusion criteria, the more helpful this review will be

[Page 2, line 25] Please define what is meant by "primary studies"

[Page 4, lines 14-16] Did any mention any care management or 

communication tools used? software? processes? work flow? These 

process aspects are critical to care coordination and case management 

being successful

[Page 6, line 28, line 39] which reviews? Please cite. Need to know which 

frameworks you are referring to...implementation or theoretical 

frameworks? And which ones within these categories? 

[Page 7, lines 10-19] I would suggest having the recommendation on 

implementation to be last. I suggest this because I think of the basic 

science needed first that needs to inform an implementation. The other 3 

We agree with reviewer that describing and defining different care coordination models 

remains a challenge in interpreting results from these interventions. Our scope was 

very broad, and eligible systematic reviews included many types of care coordination 

interventions. We relied on review authors definitions and categorization of 

interventions, and provide this more detailed information for high and medium quality 

reviews in Appendix Table 7. 

Primary studies are research studies included by eligible reviews, or found through our 

updated search for RCTs. Primary studies are not reviews, whether systematic or 

narrative.

We agree that these are important characteristics of care coordination interventions, 

and we abstracted information from eligible systematic reviews, when available. 

However, no systematic review provided this level of detailed information in 

distinguishing between effective and non-effective interventions (KQ 1). 

Citations are provided in the main body of the report, and are not included in the 

Executive Summary. There are a variety of implementation frameworks which may be 

applied, and we have added specific examples to the Discussion section.

We appreciate reviewer’s suggestion. We believe that application of implementation 

frameworks helps in conceptualizing core vs peripheral components or characteristics. 
Care Coordination Implementation Evidence Synthesis Program

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Reviewer Comments Response and Revisions 

bullets are more foundation research needed prior to implementation 

studies, in my opinion. 

[Page 10, lines 50-51 and Page 13, lines 21-23] Did look for those at a 

patient level or at a system level. I would be very disappointed if this 

review excluded studies that examined patient level healthcare use...

Please clarify if studies that focused on health care use at an individual 

level was included or limited to studies that reported only health system 

level healthcare use? 

[Page 17, lines 35-36] Why was review limited to these outcomes? Were 

any patient reported outcomes considered? These K2-K4 were to be 

focused on other outcomes

[Table 3] I am getting confused about which KQ's are being addressed

Therefore, we have reordered the recommendation such that implementation 

frameworks are next to last.

As indicated in Table 3, outcomes such as hospitalization and ED visits were assessed 

in a variety of ways, including the proportion of patients who had any hospitalization 

and the average number of admissions or ED visits per person over a set period of 

time. In classifying these outcomes as system-level in our adaptation of the Care 

Coordination Framework, we intended to indicate that utilization outcomes are more 

from the perspective of health systems (and payers), as compared with patientcentered outcomes, including patient experience. We have clarified this point in the 

Methods.

As defined with our VA stakeholders and TEP, the main focus of this report was on 

care coordination models that had an impact on hospitalization and/or ED visits. When 

eligible systematic reviews (and primary research studies) provided information on 

patient experience, we also abstracted that information. However, few reviews or 

primary studies included results on patient experience. KQ 3 and 4 address settings 

and tools used by effective interventions, and do not define additional intervention 

outcomes.

In Table 3, we provide detailed information from research studies reporting effective 

care coordination models. The main goal of identifying and examining primary research 

studies was to address KQ 3 and 4, but no studies provided information on KQ 4. 

Therefore, relevant information in Table 3 mainly addresses KQ 3. We also provide 

descriptive information on the intervention, and main outcomes reported in these 

studies (KQ 2), in order to put results for KQ3 in context. We have clarified the Results.

Reviewer 2

Thank you for the opportunity to review this evidence synthesis on this 

important and timely topic. I think that the work presented has several 

strengths that, in the interest of brevity, I will not elaborate on. However, I 

am both confused and concerned that, somehow, an evidence synthesis 

entitled and aimed at synthesizing “Care Coordination Models” ended up 

being almost entirely about “Case Management Models.” I appreciate that 

case management models were likely of most interest to the operational 

partner, which makes this work very useful to them, but what I can not 

discern is if this focus on case management models happened because 

of decisions made for the synthesis (i.e., there was an intentional decision 

to focus on case management models) or if the search strategy only 

yielded these case management models (and a couple on intensive 

Our scope was very broad and we included a range of interventions. We relied on 

review authors categorization of different interventions, and as shown in Appendix 

Table 7, review authors often defined case or care management as collaborative 

and/or interdisciplinary. Thus, case or care management is itself a broad term that may 

include collaborative teams. Additionally, we also identified 2 reviews that were 

focused on different intensive primary care models. We did not exclude any systematic 

review based on our quality assessment, but notably, all low-quality eligible reviews 

also addressed case management and/or transitional care. The effective interventions 

described in primary research studies also varied, including case management led by a 

single nurse or social worker, variable involvement of primary care providers, and 

outpatient group visits. We have reorganized Table 3 and edited text in Results to 

highlight the variability in care coordination models included in this report.
Care Coordination Implementation Evidence Synthesis Program

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Reviewer Comments Response and Revisions 

primary care). If this is a result of decisions made to meet the needs of the 

partner, then this needs to be more clearly explained, and consider 

changing the title to a synthesis of case management models. If the 

search strategy was designed to capture the breadth of care coordination 

models (which is what it seems is the case, both from the text and from 

Appendix 1, which included “collaborat” and “interdisciplin”), I am left 

wondering what happened to the reviews of other models (why did they 

not get included)? Did your search terms garner any reviews on other 

care coordination models (e.g., collaborative/ team-based care models)? 

If not, why not? If the search did garner reviews, at what point did they get 

dropped in the exclusion criteria (were they not high quality enough 

reviews)? I think explicit description of how such models did not get 

included is warranted, and then discussing the implications. For example, 

if they are not included because there are no high quality reviews of these 

models, what does that tell us about the state of the literature in this area?

Reviewer 3

Overall, amazing job making sense of a great deal of information! The 

ESP team, with support from the TEP members, designed and conducted 

a thorough and rigorous review of evidence on care coordination 

interventions to inform the VA CC&ICM initiative. My comments and 

suggestions are offered in the spirit of improvement and listed in order of 

appearance in the draft manuscript.

Executive summary:

1. My understanding of the CC&ICM initiative is that it is a multilevel 

intervention designed to deliver care coordination support at a level 

appropriate to the care needs of Veterans. Given that the innovation of 

this program is its stratification of Veterans and services by need, I 

expected this ESP evidence review to distinguish programs by level of 

service. Was there no element of this in the review?

2. Was there any effort to speak with patients receiving these 

interventions? Before the VA takes up recommendations based on these 

programs, I think someone needs to hear directly from patients about their 

experience. If patient perspectives were not included in this review, you 

should say so in the limitations section.

Thank you.

In abstracting results from eligible systematic reviews, we looked for any description of 

stratification and matching different levels of care coordination services. However, this 

was not reported in the reviews, most likely because the underlying primary research 

studies did not describe such a strategy. In the primary research studies that we 

examined, we also did not see a multi-level stratification and systematic matching of 

services. Instead, studies most often used risk factors as eligibility criteria, and 

implemented the intervention for patients who met these criteria. 

As this is an evidence synthesis report, we focused on existing published studies to 

address KQ. If reported in eligible systematic reviews and relevant primary studies, 

results on patient experiences of care were abstracted. Because we anticipated that 

information for KQ 3 and 4 may not be included in papers, we took the additional step 

of seeking interviews with investigators and other team members who implemented 

care coordination models. Collecting primary data from patients regarding their 

experiences of care would be beyond the scope of this report (and not expected for 

evidence synthesis projects).
Care Coordination Implementation Evidence Synthesis Program

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Reviewer Comments Response and Revisions 

3. In defining effectiveness, I suggest you describe both sufficient and 

necessary conditions. Specifically, though not a sufficient condition, I think 

it’s important that the reviews considered patient experience as part of its 

definition of effectiveness. 

4. The methods prioritize studies of interventions that demonstrate 

effectiveness. However, the most valuable learning from the review of 

prior interventions for the VA may come from the quality of descriptive 

information about how, why, and under what conditions an intervention 

was or was not effective. Did or could the review identify studies that were 

rich in information about mechanisms or theory of change? In producing 

this ESP evidence review, did the authors seek to summarize this type of 

information?

5. On page 4 of the report, line 29, I am disappointed to see that only 1 

study used qualitative methods. Could that be accurate? If so, I hope that

1 of the recommendations is that there is a qualitative assessment of the 

CC&ICM.

6. The results don’t seem to differentiate programs according to the level 

of health needs of the patient populations served. I think the CC&ICM 

would benefit from understanding results stratified by levels of need 

similar to the levels in the VA initiative.

7. On page 6 of the report, line 18, the authors conclude that some local 

adaptations to the CC&ICM may be helpful for supporting uptake and 

We agree with reviewer that patient experiences of care is an important consideration 

in evaluating care coordination models. However, in consultation with our VA 

stakeholders and TEP, hospitalizations and ED visits were selected as the primary 

outcomes of interest; they defined whether a care coordination intervention would be 

considered effective. Our interviews with investigators and staff who implemented care 

coordination models also substantiated these decisions, as the sustainability and 

spread of these interventions were affected by whether they were able to change acute 

care utilization. We have clarified these choices in Methods and added to limitations in 

Discussion 

We agree that understanding the exact situation or context when an intervention is 

effective (or not) is an important goal. As note in Results, multiple eligible reviews 

sought to answer such questions, but they were unable to draw conclusions. The 

heterogeneity of intervention components, along with variation in populations and 

settings, has continued to present challenges in summarizing and interpreting the 

evidence on care coordination models. In our examination of the relevant primary 

research studies, we similarly could not draw clear conclusions on whether variation in 

specific intervention components, population characteristics, and/or types of settings 

were key in determining the effectiveness.

We agree that qualitative methods are important for the evaluation of these 

interventions, and they are often employed in implementation studies. We limited our 

search for additional information on assessment of patient relationships with the care 

team to those studies that were cited in the original articles identified from eligible 

reviews (and from the search for RCTs). We also examined any materials referred to 

us during interviews. However, if there were subsequent qualitative evaluations of 

interventions that were not cited in the original articles and we were unable to conduct 

an interview with the team, then we would have identified these.

As noted above, eligible systematic reviews and relevant primary research studies did 

not provide results on systematic stratification of patients and matching of needs. 

Thank you. We have added to the Discussion the suggestion regarding the importance 

of evaluating adaptations and education on program goals.
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Reviewer Comments Response and Revisions 

sustainability of CC&ICM. I couldn’t agree more, particularly because the 

populations served are likely to vary. The VA should make an effort to 

document supportive adaptations and the circumstances in which they 

apply, because while they may not apply everywhere, they are likely to 

apply somewhere. Also, in addition to the concept of core versus adaptive 

periphery, I think the findings suggest that the CC&ICM should consider 

the conditions under which adaptation is appropriate. Further, the findings 

suggest that in rolling out the CC&ICM intervention, education must focus 

on communicating the intent of the intervention, in addition to the 

recommended approach, to increase the likelihood that adaptations will 

be supportive.

8. On page 7 of the report, line 16, the authors conclude that future 

evaluations should use randomized designs. I respectfully disagree. 

Given the importance of implementation to the effectiveness of any 

intervention like CC&ICM, I don’t believe that a study designed to tell you 

whether an intervention that is implemented across a wide variety of 

settings and participants works is particularly informative. More helpful will 

be studies that describe where, why, and how they work when they do 

succeed.

Additional comments on the evidence report:

9. Can you provide additional information about why the expert panel felt 

that the Care Coordination in Chronic and Complex Disease Management 

framework was the most applicable to the goals of this current review and 

how the group of existing resources were identified? Also, did you use 

this framework for anything other than to effective care coordination? To 

do that, I would think it most appropriate to look across 

coordination/integration frameworks to understand which outcomes are 

considered most relevant.

10. KQ3 and KQ4 are potentially the most important. However, I don’t see 

much written about the answers to these questions in the executive 

summary. (Note, I see later that the interviews are designed to get at 

these questions. I hope when the analysis of transcripts is complete, there 

will be more to say.) While Table 3 describes settings in which 

interventions were implemented, what would be most helpful is 

understanding which interventions were implemented in which settings 

and whether there were any systematic differences in intervention by 

setting.

We agree with reviewer that understanding where, why, and how are important 

aspects of future work. However, we do not believe that this precludes the use of 

randomized designs, especially when quantitative patient-level outcomes are featured. 

Additionally, the use of randomization can address important threats to the internal 

validity of research studies. For example, the recent RCT of healthcare hotspotting 

(Finkelstein et al. NEJM 2020; 382:152-162) showed that this intervention was not 

effective, in contrast to previous observational studies that suggested positive impacts. 

Mixed-methods designs that combine rigorous quantitative and qualitative techniques 

will likely be the most helpful in the future.

In the Methods, we have clarified the rationale for selecting this framework, and how it 

informed the overall methodology of this report.

We have included more information from the completed interviews in Results. In 

examining the primary research studies for characteristics of settings for effective (and 

non-effective) care coordination models, we found great variation and no discernable 

systematic differences.
Care Coordination Implementation Evidence Synthesis Program

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Reviewer Comments Response and Revisions 

11. The most informative data may be in Table 3, the description of 

patient contacts, as this column describes the dose of the intervention. 

Could the team group the interventions targeting patients at different 

levels of need and then compare the intervention dosages applied. Most 

useful might be understanding the range of patient contacts attempted for 

a given level of need. Also, I presume these descriptions apply to the 

intervention as designed. If any information is available about fidelity to 

the intervention (I realize this is unlikely), this would make assessing the 

impact of these interventions more useful.

Aside from most studies including older adults, it was difficult to find commonalities that 

allowed us to clearly distinguish studies based on patient populations. We have 

reorganized Table 3 to indicate those interventions targeting those who were recently 

hospitalized (or discharged from ED). But there has been a range of patient contacts 

for this group of studies, as well as for those enrolling outpatients in general.

Reviewer 4

This is a well-done report focused on meeting an operational partner's 

specific needs. As such, it does not answer all potentially relevant 

questions to care coordination in the VA, but rather those that the partner 

had an interest in. There are just a few minor items that came to my 

attention while reading the draft. All comments I make below apply 

equally to the executive summary and the main report, but I will use 

pages and line numbers from the main report.

Page 10, lines 50-51. There is a disconnect between what is written here 

and the actual wording of KQ2 on the next page, which specifically 

mentions patient experience as if it had equal importance to 

hospitalizations/ED visits. Should patient experience be mentioned here, 

since it is in Table 1 as a patient outcome?

Page 13, lines 21-23. Related to the comment above: it appears that the 

review was delimited to only those reviews covering at least 

hospitalizations and/or ED visits as outcomes of interest. From this, it 

seems that patient experience is not on the same footing of importance as 

hospitalizations and ED visits, but that contradicts the wording of KQ2, 

which places them on an even footing. This probably relates to partner 

prioritization as mentioned earlier in the report, but further clarification 

would be helpful. I suspect that there might be some systematic reviews 

in the literature that only focus on patient experience and not on 

hospitalizations/ED visits, and those would have been missed by 

delimiting the search to requiring mention of hospitalizations and/or ED 

visits as an outcome of interest.

Thank you.

We appreciate reviewer suggestions, and as noted above, have clarified in Methods 

how we applied the care coordination framework (depicted in Table 1) to define scope 

and KQ.

We have clarified the decisions in determining effective interventions in Methods and 

added the limitation regarding evidence on patient experience to the Discussion.
Care Coordination Implementation Evidence Synthesis Program

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Reviewer Comments Response and Revisions 

Page 17, lines 44-47. I am not surprised that little was found on specific 

tools/measures in the published literature. Such things might show up in 

the grey literature or on the Web. Hopefully the rest of the key informant 

interviews will help, but it may be a limitation of the search strategy used 

that grey literature/websites were not searched (understandably given 

time constraints). 

Page 25, lines 38. "Goals and needs" are mentioned but I can't tell whose 

goals and needs are being referred to.

Page 27, lines 18-20. Is there actual data to support this final sentence? 

How do we know that redesigning primary and specialty care teams to 

improve continuity and collaboration would be more effective than the 

approaches used by the studies reviewed? I'm concerned about 

extrapolating beyond the scope of the review.

We identified websites associated with primary research studies of care coordination 

models, if these were cited by the studies or linked with the investigators (via searches 

online). We examined information provided on these websites and have included 

relevant information in the Results section on interviews. We have clarified this 

additional source of information in Methods

We have clarified this sentence in the Discussion.

In the Discussion, we noted several examples of health care redesign that went 

beyond adding on of care coordination services. We agree that evidence on whether 

they are superior to care coordination is lacking. Therefore, we have edited this 

sentence to indicate such redesign efforts may be considered an option.

Reviewer 5

No - Clarity of Objectives. It was difficult to find a paragraph or section 

where the study objectives were clearly and succinctly introduced. It 

appears objectives were stated on page 9, lines 35-45. 

The use of a header, along with clearer wording of objectives, would aid 

in clarification of objectives. 

Conceptual Framework. The conceptual framework (page 10, Table 1), 

while detailed, is not clearly linked to the key questions. Without these 

linkages, the scope of the synthesis is confusing. Some considerations for 

improving these linkages are as follows: 

• When considering KQ1, “What are the key characteristics of care 

coordination models that aim to reduce hospitalizations and ED visits?”: 

o Which, if any, of the categories shown in Table 1 represent key 

characteristics? 

o Page 16, lines 29-42 mentions an intervention component 

“multidisciplinary care plan” where would this fit in the conceptual 

framework? 

• When considering KQ3, “What are the characteristics of settings in 

which effective models have been implemented?”: 

o Which, if any, of the categories shown in Table 1 represent 

“characteristics of settings”? 

We clarified the goals presented in the Introduction. Additionally, KQ are described in 

Methods.

We are unsure which headers were confusing for the reviewer. In the Methods, we 

used standard headers and sections for ESP reports. We also reviewed sections in the 

Results and separated out relevant results per KQ. 

As noted above, we have clarified in the Methods how we applied the Care 

Coordination Framework to the methodology for this report. We agree with reviewer 

that characteristics of interventions (and of settings) are broadly defined, and could 

come from multiple columns listed in Table 1. We relied on authors of eligible 

systematic reviews to define what they considered to be key characteristics. Similarly, 

we sought to abstract any review results on characteristics of where interventions were 

implemented. We have also clarified the application of the Framework to KQ. KQ4 

addresses in part the column on Emergent Integrating Conditions, in seeking evidence 

on tools to assess team integration. The results shown in Table 3 are those reported 

by primary studies. To guide development of the methodology for this evidence review, 

the framework was selected before we had identified (or examined) all eligible reviews 

or relevant studies. It is best practice to define the protocol for the systematic review 

before seeing the results. 
Care Coordination Implementation Evidence Synthesis Program

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Reviewer Comments Response and Revisions 

o Why are the elements reported in Table 3 (and on page 17 lines 43-45) 

rural community hospitals, academic medical centers not accounted for in 

the model? 

• Do the categories “Emergent Integrating Conditions” and “Coordinating 

Actions” relate to any of the key questions? If not, perhaps those columns 

of Table 1 could be shaded and a note indicating that the scope of this 

study does not include these elements.

In sum, mapping the key questions to the conceptual framework will 

clarify the scope of the synthesis. In addition, the text should provide a bit 

more detail for the reader as to how the key questions relate to the 

conceptual framework.

Operational Definitions. The document could be strengthened by 

including operational definitions for the following terms: “key 

characteristics of care coordination models”; and “characteristics of 

settings”.

As noted above, we abstracted what eligible systematic reviews defined as key 

characteristics of interventions. For setting characteristics, we also abstracted a range 

of information about the health care system and the community. We have added some 

potential examples to the Methods.

Is there any indication of bias in our synthesis of the evidence?

Yes - Care coordination interventions are inherently complex and this 

evidence synthesis was very ambitious. The methodologic decisions to 

study a range of ambulatory care sensitive conditions and to study 

different care coordination models, likely increased the heterogeneity and 

complexity of this synthesis to a level where the noise was stronger than 

the signal. Perhaps narrowing the selection criteria to arrive at a more 

homogeneous sample of papers was not an option. Nonetheless, I’d like 

to see the authors address this limitation and possible source of bias in 

the final paper. In addition, I’d like them to offer ideas for some alterative 

choices in the search strategy that could lead to more homogeneous 

samples in the future that may advance our understanding of care 

coordination interventions.

We determined the search strategy and inclusion/exclusion criteria to optimize 

identification of the most relevant evidence to address the priorities and needs of our 

VA stakeholders. As the CC&ICM initiative is meant to streamline care coordination 

programs throughout VA facilities nationally, we sought evidence on models that could 

be widely implemented (and locally adapted, whenever possible). We do not believe 

that these decisions introduced bias into identification or interpretation of the evidence. 

If the evidence review was meant to address a different goal for either a more limited 

patient population (eg, how to improve outcomes for heart failure patients with 

comorbidities), or a specific definition of care coordination (eg, nurse-led intervention),

then the search strategy could be tailored to those needs. 

The findings of this literature synthesis underscore that the science 

behind care coordination is in its infancy. 

In hindsight, this review may have benefitted from the inclusion of 

published QI studies. This particularly true with respect to KQ1 the key 

components of interventions which are generally more thoroughly 

described in the QI literature.

We did not exclude systematic reviews based on the types of studies they included. 

Additionally, there is not a specific study design that is shared by all QI studies. For 

relevant primary studies, we required that these be RCT or quasi-experimental (eg, 

observational study with comparative cohort). QI studies could employ these various 

designs, and there are current efforts to include randomization in QI work [Horwitz et 

al. NEJM 2019; 381:1175-1179].

Reviewer 6

This is a rigorous evaluation of a complicated topic: care coordination 

models and tools. The challenge with a synthesis effort like this 1 is that 

the existing models are heterogeneous in the populations they focus on, 

Thank you.
Care Coordination Implementation Evidence Synthesis Program

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Reviewer Comments Response and Revisions 

structure, processes, goals, and outcomes. As such, most of the models 

develop their own care coordination tools and procedures, and there is 

likely variation in the degree to which their approaches are grounded in 

evidence vs reflective of home-grown practical clinical tools. The evidence 

synthesis reflects this challenge. Investigators found that existing 

evidence suggests that care coordination models have inconsistent

effects on reducing hospitalizations and/or ED visits and unfortunately 

there have been few clear-cut lessons about how to move this field 

forward. Overall, the evidence synthesis appears rigorous and 

comprehensive, but the findings are a bit disappointing in that they do not 

reveal many practical strategies or lessons for the VA and others to 

adopt, and their literature review and interviews did not identify any 

specific tools. 

Specific suggestions:

Pg 8/lines 50-52 (and Appendix 3): Add detail/clarification about inclusion 

criteria for patient populations. Did papers have to focus on patients with 

ACSCs in order to be eligible? What about papers focused on patients 

with mental health conditions or cancer (given the prevalence of these 

conditions among Veterans requiring care coordination)? Based on the 

final list of included papers, it looks like the review covers a wider range of 

patient populations/conditions than the inclusion criteria suggest.

Pg 11/line 22 (and elsewhere): clarify the term “observational study”- it 

looks like these studies needed to have a control group in order to be 

included?

Pg 11/line 34: I know interviews are still ongoing, but the purpose and 

value of these is unclear. The results don’t seem to address the main goal 

outlined on Pg 9 (addressing gaps regarding tools and approaches to 

assessing patient trust, team integration, and patient-provider 

communication). I am also surprised that these interviews did not reveal 

any tools, if you were able to contact individuals involved in the care 

coordination interventions/evaluations.

Pg 12/line 14: what is a high-intensity model?

We have clarified in Methods the inclusion and exclusion criteria for eligible systematic 

reviews. Reviews needed to include a range of conditions and/or a more general 

definition of higher-risk patients. Reviews that included studies which addressed 

patients with mental health conditions or cancer would have been included, if the 

reviews did not exclusively focus on a single or narrow set of conditions.

We have added some examples of what constituted quasi-experimental observational 

studies. The relevant primary studies included by reviews were either observational or 

RCT, and we required that observational studies used some form of quasiexperimental designs. Although there are a variety of potential designs, the selected 

studies all used comparative control cohorts.

We have clarified the goals of the key informant interviews in Methods. We note that 

we were able to conduct interviews with ~50% of those whom we invited. It is possible 

that those who were not interviewed would have provided more information on tools 

and approaches. Among those we interviewed, and based on published studies, it 

appears that formal assessment of these areas was not often incorporated into the 

evaluation of care coordination interventions.

In the Executive Summary and Discussion, we have added more information about 

how review authors defined this term. 
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Reviewer Comments Response and Revisions 

Pg 12/line 23-25: I am a little puzzled by the focus on tools/approaches 

that assess patient trust or working alliance and health care team 

integration. While these topics are important for care coordination, it 

seems like there are a lot of other practical tools for care coordination that 

would be valuable to review and share (e.g., assessing patient needs for 

care coordination, assessing patient goals and priorities, understanding 

social circumstances that are influence health and health care 

engagement, identifying modifiable risk factors for hospitalization/ED 

visits). It might not be possible to comment on these at this stage, but at 

the very least would justify the reason for focusing on the tools highlighted 

in the report. 

Pg 13/line 23-34: Here or elsewhere, consider mentioning some of the 

intensive outpatient programs in VA, including HBPC, MHICM, PIM. In 

addition to PC-MHI, the VA’s PACT patient-centered medical home model 

provides an opportunity for case management of patients with higher 

levels of need, when implemented well.

Pg 14/line 10-11: Here or elsewhere could refer to Hybrid effectivenessimplementation studies (Curran, Med Care, 2012- I see it listed in the 

references)

Pg 14/line 18-19: As above (Pg 12 comments), I don’t understand why 

these very specific domains are highlighted as necessary tools. 

Measuring “health care team integration” seems of interest from a 

research perspective, but not high on the list for a practical care 

coordination tool. Some of the specific examples pg 24/line 49-52 seem of 

higher value. 

Pg 24/line 31-33: To drive the point home, would add percentages for 7/9 

and 3/18.

Pg 24/lines 51-52: Is there any more work that could be done to identify 

tools/approaches? Given the number of papers reviewed, it seems hard 

to believe that none of the programs were able to share any effective 

tools. Even if the programs don’t have outcomes data for hospitalizations, 

if the tools were found to be valuable to patients/staff that could still be 

important information. I know a lot of work has already gone into this 

review, but I am wondering if the investigators tried contacting the clinical 

leads of some of the interventions that they reviewed? I would think these 

In the Methods, we have clarified the rationale for selecting these tools. These were 

topics that were particularly relevant to our VA stakeholders, whereas other tools (eg, 

for assessing patient needs) were not as salient given the current status of the 

CC&ICM initiative. For example, the initiative had already begun testing standardized 

assessments of patient needs and risk factors, and they were seeking evidence on 

how to evaluate (or further improve) various care coordination services.

We appreciate reviewer’s suggestions and have provided additional examples of VA 

programs that may be relevant for future care coordination efforts. 

We have added the names of specific implementation frameworks and categorization 

of studies that include implementation outcomes to the Discussion.

As noted above, we have clarified in Methods the rationale for addressing these types 

of tools or assessments. They were selected as relevant to the initiative in evaluating 

current pilot efforts and future implementation results.

We appreciate reviewer’s suggestion and have made these additions.

We agree that it is possible that tools or approaches used by interventions that did not 

assess hospitalizations or ED visits may still be valuable. However, that would have 

substantially expanded the scope of this review, and created additional challenges in 

interpreting the utility of these tools for the VA initiative. We invited lead authors of the 

identified relevant primary studies for interviews. We also sought referrals to other 

team members who may have greater knowledge about tools and approaches used to 

implement or evaluate these interventions. Our interviews suggested that formal 

assessments of these topics were often not conducted.
Care Coordination Implementation Evidence Synthesis Program

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Reviewer Comments Response and Revisions 

individuals would be able to share the practical tools that they used for 

care coordination.

Reviewer 7

Are there any published or unpublished studies that we may have 

overlooked?

Yes - I only selected yes to offer that for the qualitative interviews you 

might include the authors of this recently published protocol if it and they 

aren't included already: Miller, L.B., Sjoberg, H., Mayberry, A. et al. The 

advanced care coordination program: a protocol for improving transitions 

of care for dual-use veterans from community emergency departments 

back to the Veterans Health Administration (VA) primary care. BMC 

Health Serv Res 19, 734 (2019). https://doi.org/10.1186/s12913-019-

4582-3 

Full text link: https://rdcu.be/b4ao1

We appreciate this recommendation. We reviewed this study, and as it does not report 

results of the intervention, it would not meet the criteria for inclusion. 

Thank you for the opportunity to review/contribute to this ESP. The draft is 

excellent. 

I have some thoughts/suggestions:

1. re: the approaches to patient selection (as mentioned on p.16, line 34; 

24, lines 19-23 and especially p. 25, lines 20-28 and especially 

interviewee comments, p. 18 lines 20-24). There is an interesting topic for 

future research (as the interviewee describes). Future research could also 

include inquiry into care coordination to different populations (less and 

more complex). The interviewee snippet on p. 18, lines 19-21 is so apt as 

our Veterans often have multiple conditions and may still need hospital or 

increased care. 

2. re: outcomes, medical hospitalization and ED visits were the primary 

outcomes, I could see Veterans benefiting from case management and 

care coordination in other ways (e.g. reduced stress and mental health 

symptoms). So perhaps expanding the focus in future research to other 

utilization or severity of other conditions. (Recognize this might be outside 

of the current ESP scope). 

3. While not part of the initial scope, I wonder about the technology used 

in the different reviews/studies analyzed (i.e. telephone and video). While 

this review was conceived, developed and started before COVID-19, 

given there has been a tremendous shift to non-face to face visits and 

increased use of telehealth, it might be informative to add that into the 

Thank you.

Thank you.

We agree that there are potentially other benefits of improved care coordination. We 

selected hospitalizations and ED visits to address priorities of our stakeholders.

We agree that use of technology is a potentially important characteristic of care 

coordination interventions. Eligible systematic reviews provided mainly descriptive 

information about incorporation of technology (generally of telephone calls) and did not 

draw conclusions on whether technology impacted the effectiveness of interventions. 

We have added this information to the Results. In the relevant primary studies, 
Care Coordination Implementation Evidence Synthesis Program

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Reviewer Comments Response and Revisions 

study details and then tie that topic, as appropriate, into future research 

and/or policy (e.g. How has COVID-19 affect care coordination and case 

management integration and implementation.)

telephone was also the main technology used (as described in Table 3). It would be 

interesting for future studies to address use of video-conferencing in various care 

models.

Reviewer 8

Under Implications for Policy, lines 16-19, it is stated that the goal of the 

CC&ICM is standardization, which is a valid statement, however, this is 

currently balanced with the need for adaptability at the specific facility due 

to staffing, existing structure and practices. CC&ICM model 

recommendations are implemented with this flexibility and are reported to 

CC&ICM leadership for dissemination to the field as potential practices to 

implement or adapt as needed. As indicated further under Key Findings, 

lines 44-49, interviewees did indicate a lack of adaptability at the facility 

level in some circumstances. This was likely due to a variety of factors 

(facility leadership, resources, flexibility of staff, etc) but is not a result of 

"model" inflexibility. This slight misunderstanding leads to another issue in 

the same section, lines 28 - 34. This suggestion is in 

agreement/alignment with the CC&ICM model. The CC&ICM model is not 

for patient navigation (solely), but incorporates a wholistic, patient 

centered, collaborative approach which includes the components 

described in the Mental Health collaborative model. It would seem the 

authors are contrasting these similar VA models in this recommendation. 

There are several notations regarding ongoing interviews to compare 

tools and approaches used across models with only 6 of 22 conducted to 

date. However, under Key Informant Interview results (page 17 & 18, lines 

15-29) results are curiously concluded.

We appreciate reviewer clarification of CC&ICM goals. We have adjusted the 

Discussion to better describe these goals. We have also clarified that the PCMHI 

model is a co-located collaborative model between primary and specialty care (in this 

case, mental health). This is substantially different from care coordination services that 

are meant to be deployed to address a wide variety of potential risk factors and 

Veteran needs.

We provided draft results and conclusions based on interviews that had been 

completed at that time. We have now updated the relevant sections in the Results and 

Discussion to include additional interviews completed after the draft report.

Reviewer 9

Page 1 line 22 change VA Coordinated care to VA Care Coordination; 

Page 9 line 25 same as above

Updated to “VA Coordinated Care” as requested
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APPENDIX 7. DETAILED CHARACTERISTICS AND RESULTS FROM MEDIUM- AND 

HIGH-QUALITY SYSTEMATIC REVIEWS

Author, Year

(Quality,

Year of 

Search); 

# Relevant 

Primary 

Studies

Included 

Populations; 

Study Designs

 

Included Relevant Interventions

Main Objective(s)

Results Summary

Case Management and Transitional Care Interventions

Di Mauro, 

201918

(Medium, 

2018); 

3 

“[frequent user] adult 

patients who visit the 

ED”; 

RCT, cohort 

“Case Management...is a collaborative 

approach used to assess, plan, facilitate 

and coordinate healthcare related 

matters...It aims at meeting patients’ and 

their families’ health needs through 

communication and available resources, 

thus, improving individual and healthcare 

system outcomes...”

“to examine if and how the [case management] programs are implemented to 

reduce the number of [frequent user] visits to the ED.”

"Ten papers showed...decrease in visits to the ED (from 14% to 58.5%) and 

in... 3 studies the results were insufficient to prove this utility."

Hudon, 201919

(High, 2017);

4 

“adult frequent 

users...with physical 

chronic disease”; 

RCT, cohort, 

cross-sectional

 

“[Case management is] a collaborative 

approach to ensure, coordinate, and 

integrate care and services for patients, 

in which a case manager evaluates, 

plans, implements, coordinates, and 

prioritizes services on the basis of 

patients’ needs in close collaboration 

with other health care providers...”

“to identify characteristics of [case management] that yield positive outcomes 

among adult frequent users with chronic disease in primary care.”

“analysis revealed that the case-finding characteristic (ie, high frequency of 

health care visits) and complexity of health care needs are necessary...

[P]ositive outcomes were associated with the following 2 sufficient 

characteristics when each was combined with this necessary condition: highintensity [case management] intervention and presence of a 

multidisciplinary/interorganizational care plan”

Iovan, 201920

(Medium,

2017); 

6 

“population 

studied...was 

classified as

super-utilizer”; 

RCT, cohort

 

Case management:

• “Holistic approach to care 

considering a patient’s complex 

medical and social needs...

• Connects patients with existing 

community resources

• Creates a continuum of care that 

addresses medical, financial, 

psychosocial, and behavioral 

needs...

Care coordination:

“systematic review of interventions aimed at reducing prehospital and 

emergency care use among super-utilizer populations in the United States.”

“17 of 21 case management studies investigated intervention impact on ED use. 

Of those, 13 showed a reduction in utilization, yet only 5 of these 17 studies 

(29%) had a control group. Among the 5 studies with a control group, 3 showed 

some degree of positive impact of the intervention on ED utilization, including 2 

of the 3 RCTs... 

[M]ethodological and study design weaknesses—especially regression to the 

mean—were widespread and call into question reported positive findings.”
Care Coordination Implementation Evidence Synthesis Program

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“Thoughtful review of a patient’s medical 

needs, resulting in more effective 

transitions between providers...”

Van der Elst, 

201827

(Medium,

2016); 

0 

“60 years or older, 

diagnosed as frail, 

and communitydwelling”; 

RCT

 

“Case management – a collaborative 

process of assessment, planning, 

facilitation, care coordination, evaluation, 

and advocacy for options and services to 

meet an individual’s and family’s 

comprehensive health needs through 

communication and available resources 

to promote quality, cost-effective 

outcomes.”

“What effect do interventions have on frail community-dwelling older adults in 

terms of mortality, hospitalization... and institutionalization? [H]ow do age, study 

duration, and the multi- versus unidimensional approaches of frailty and 

recruitment influence the effect of an intervention?”

“pooled OR for hospitalization when allocated in the experimental group was 

1.13 [95% CI: 0.95, 1.35] for case management... 

The influence of duration of intervention...multi- versus unidimensional 

approach to frailty, and recruitment [method] on the effect of an intervention was 

explored...[in] sub-analyses... but with no significant results."

Joo, 201721

(Medium, 

2016); 

1 

“[adult] populations

who were diagnosed 

with chronic 

illnesses”; 

RCT

 

“Case managers, who often work with 

multidisciplinary teams, are located 

within the space of transitional care, 

which means they are able to do 

continuous follow-up care, timely 

transitional care and patient-centred care 

as patients move from hospitals to their 

communities...”

“synthesizes recent evidence of the effectiveness of case management in 

reducing hospital use by individuals with chronic illnesses”

"All [10] studies compared hospital readmission...in the intervention and control 

groups... Three of the studies reported statistically significant reductions in 

hospital readmissions... Three other studies...reported reduced readmissions 

but no statistically significant results... The remaining studies... reported no 

effect on readmission rates. 

Six studies reported the number of ED visits as an outcome.

Five studies found a statistically significant reduction in the number of ED visits 

in pre- and post-[case management] intervention analysis...[T]he sixth 

study...found reductions...for the [case management] group over the control 

group, [but] the results were not significant.”

Baker, 201815

(Medium,

2015); 

4 

Adults in 1 of 3 

categories: “a) 2 or 

more chronic 

medical conditions, 

b) at least 1 chronic 

medical condition + 

depression, and c) 

high past or 

predicted

utilization”; 

RCT

"patient-focused, comprehensive care 

management intervention (areas of focus 

included some combination of selfmanagement, healthcare system 

navigation, self-efficacy, symptom 

monitoring, symptom management, etc.) 

targeting the “whole” patient (e.g. 

including nurse- or case-manager led 

interventions, integrated care team 

strategies, group interventions)"

“What are the necessary components and appropriate intensity of effective care 

management interventions?”

"Seven studies measured hospital admissions and readmissions in the postintervention period; however, only 2 of these studies showed an improvement in 

[hospital readmission]... 

[C]ommon methodologic issues limited our ability to draw conclusions regarding 

the effectiveness of specific intervention components...[I]nsufficient detail on 

implementation fidelity and participant adherence to the interventions limited 

any substantive observations on the relationships between intervention content 

and intensity and any patient benefits."

Le Berre, 

201722

(High, 2015); 3

“Patients 65 years 

old or older with at 

least 1 [chronic 

disease] who have 

been hospitalized 

and are being 

"[Transitional care] interventions 

comprising all the following elements: (1) 

aimed at providing coordination and 

continuity of care; (2) pre-arranged

structured post-discharge follow-up (e.g., 

home visits, phone calls); (3) at least 1 

“to determine the effectiveness of interventions targeting transitions from 

hospital to the primary care setting for chronically ill older patients.”

“The risk of readmission in [transitional care] was lower than in [usual care] at 3 

months post-discharge (RD: -0.08 [-0.14, -0.03]; NNT: 7), 6 months postdischarge (RD: -0.05 [-0.09, -0.00]; NNT: 20), at 12 months post-discharge (RD: 
Care Coordination Implementation Evidence Synthesis Program

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discharged back to 

home”; 

RCT

follow-up starting within 30-days postdischarge."-0.11 [-0.17, -0.05]; NNT: 9), and at 18 months post-discharge (RD: -0.11 [-0.21, 

-0.01]; NNT: 9). No significant change was observed at 1 month... 

The risk of an ED visit... was lower... at 3 months post-discharge (RD: -0.08 [-

0.15, -0.01]; NNT: 13). No significant change was observed at 1, 6, and 12 

months..."

Soril, 201526

(High, 2015); 3

“general adult 

frequent ED user”; 

RCT, cohort 

"...case or care management is 

considered a comprehensive, 

interdisciplinary approach taken to 

assess, plan, personalize, and guide an 

individual’s health services to promote 

improved patient and health system 

outcomes."

“to establish the effectiveness of interventions aimed at reducing the ED 

utilization, in comparison to usual care, for individuals who are frequent users of 

the ED”

“Compared to the control groups, 1 RCT reported no change in the mean 

number of ED visits following [case management], whereas the second RCT 

reported a minor decrease in median ED visits among those in the intervention 

group. Of the 10 comparative cohort studies..., 9 studies reported outcomes 

related to the change in ED visits: 8 studies observed a decrease in the mean 

(between -0.66 and -37 ED visits) [or median number of ED visits (between -

2.28 and -20 ED visits) compared to the controls or before [case management]; 

and 1 study reported an increase of 2.79 median ED visits post-intervention...”

Moe, 201723

(High, 2014); 3

“adult frequent ED 

users”; 

RCT, cohort 

"Case management involved 

multidisciplinary teams, including 

physicians, nurses, psychologists, social 

workers, and/or housing and community 

resource liaisons, who developed 

tailored care strategies for patients and 

linked them to necessary services."

“to summarize experimental studies evaluating the effectiveness of 

interventions targeting adult frequent ED users at reducing ED visit frequency 

and improving hospital admissions...”

“Post- versus pre-intervention rate ratios were calculated for 25 studies and 

indicated a significant visit decrease in 21 (84%) of these studies. The median 

rate ratio was 0.63 (interquartile range = 0.41 to 0.71).”

Smith, 201625

(High, 2011); 2

“people... with 

multimorbidity”; 

RCT, cohort 

“...organizational changes delivered 

through practitioners or directly to 

patients. For example, any changes to 

care delivery such as case management 

or the addition of different healthcare 

workers such as a pharmacist...”

“To determine the effectiveness of health service or patient oriented 

interventions designed to improve outcomes in patients with multimorbidity in 

primary care and community settings”

“Five studies reported outcomes on health service utilization...[One] reported 

significant improvements for intervention group...relating to hospital admissions, 

whereas [four studies] found no significant difference in outcomes...

The results indicate that it is difficult to improve outcomes in this population but 

that interventions focusing on particular risk factors or functional difficulties in 

patients with co-morbid conditions or multimorbidity may be more effective.”

Intensive Primary Care Interventions

Totten, 201630

(High, 2015); 1

“Adults with chronic 

illnesses or 

disabilities”; RCT, 

cohort 

Home-based Primary Care:

“1) Visits by a primary care provider...

2) Visits to a patients home...

3) Longitudinal management...

4) Comprehensive primary care...”

“To assess the available evidence about home-based primary care (HBPC) 

interventions for adults with serious or disabling chronic conditions.”

“The strongest evidence (moderate) was that HBPC reduces hospitalizations 

and hospital days. Reductions in emergency and specialty visits and in costs 

were supported by less strong evidence, while no or unclear effects were 

identified on hospital readmissions and nursing home days...

HBPC had a positive impact on patient and caregiver experience, including 

satisfaction, quality of life, and caregiver needs, but the strength of evidence for 

these outcomes was low...
Care Coordination Implementation Evidence Synthesis Program

59

There is wide variation in the services provided as part of HBPC interventions. 

In the evidence presently available there is not an apparent pattern or cluster of 

services associated with differences in outcomes. Most included assessment 

and coordination...Four studies examined the incremental impact of additional 

services to HBPC.”

Edwards, 

201729

(Medium, 

2017); 7

“Patients identified 

as high risk for 

hospital

admission and/or 

death”; 

RCT, cohort 

“We classified programs as primary care 

replacement (home based), primary care 

replacement (clinic-based), or primary 

care augmentation, and assessed the 

impact of outcomes separately for each 

category...” 

“to classify interdisciplinary, multicomponent [intensive primary care] programs 

according to program characteristics, and to evaluate the effectiveness of these 

programs in reducing hospitalizations, emergency department...visits, and 

mortality among patients at high risk for hospitalization or death.”

“Most studies showed no impact of intensive primary care on mortality or 

emergency department use, and the effectiveness in reducing hospitalizations 

varied...The programs varied in the way they identified and screened patients 

for enrollment, though most focused on older adults with functional limitations... 

All programs utilized multidisciplinary staff to meet a range of patient needs, and 

most commonly included physicians, nurses, social workers, physical 

therapists, mental health providers, and pharmacists... Given the negative 

results of many of these studies, it is possible that attempts to manage complex 

care using large multidisciplinary teams may be ineffective for some high-needs 

patients, as the burden of coordination may outweigh the benefits of the 

specialized skills of each team member... We had hoped to identify key 

program features, such as patient selection criteria, that may have contributed 

to the success or failure of these programs. Unfortunately, reporting of key 

intervention characteristics was inconsistent... In addition, the data collected on 

intervention fidelity, implementation process, and contextual factors at individual 

intervention sites varied among studies.”

CI=confidence interval; ED=emergency department; NNT=number needed to treat; OR=odds ratio; RCT=randomized controlled trials; RD=risk difference