VA Provider Perspectives on Coordinating COPD Care Across Health Systems

  • Seppo T. Rinne
  • Kirsten Resnick
  • Renda Soylemez Wiener
  • Steven R. Simon
  • A. Rani Elwy
Original Research



More and more Veterans are receiving care from community providers, increasing the need for effective coordination across health systems. For Veterans with chronic obstructive pulmonary disease (COPD), this need is intensified by complex comorbidity patterns that often include multiple providers co-managing patient care.


We sought to understand how VA providers perceive coordination with community providers for Veterans with COPD.


Qualitative study of VA providers.


We selected six geographically diverse VA sites and conducted semi-structured telephone interviews with providers practicing in inpatient and/or outpatient settings who care for Veterans with COPD.

Main Measures

Interviews focused on communication with community providers about discharge information and clinic management. We analyzed responses according to the principles of conventional content analysis, allowing inductive themes to emerge.

Key Results

We interviewed 25 providers during the period of June to October 2017. Qualitative data analysis yielded five themes: (1) VA providers perceive communication challenges between VA and community providers, including difficult, inadequate, and delayed communication; (2) communication is facilitated by personal relationships across health systems; (3) the lack of electronic health record (EHR) interoperability impairs communication, resulting in transmission of unstructured data; (4) poor communication leads to duplicative efforts and wasted resources; and (5) providers frequently rely on patients to communicate about care taking place in the community.


VA providers described major challenges in coordinating with community providers, leading to perceptions of delayed, missed, or duplicative care and jeopardizing the overall quality, safety, and efficiency of Veteran care. Our study highlights the need for system-level solutions to support coordination across health systems for Veterans with COPD and may have implications for other conditions that lead to recurrent hospitalization and/or care in the community.


coordination interdisciplinary communication qualitative research chronic obstructive pulmonary disease electronic health record 


Compliance with Ethical Standards

The project was approved by the Edith Nourse Rogers Memorial Veterans Hospital Institutional Review Board.

Conflict of Interest

The authors declare that they do not have a conflict of interest.


The views expressed in this article are those of the authors and do not necessarily represent the position or policy of the Department of Veterans Affairs or the US government.


  1. 1.
    Pham HH, O’Malley AS, Bach PB, Saiontz-Martinez C, Schrag D. Primary care physicians’ links to other physicians through Medicare patients: the scope of care coordination. Ann Intern Med. 2009;150(4):236–242.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Frandsen BR, Joynt KE, Rebitzer JB, Jha AK. Care fragmentation, quality, and costs among chronically ill patients. Am J Manag Care. 2015;21(5):355–362.PubMedGoogle Scholar
  3. 3.
    Cebul RD, Rebitzer JB, Taylor LJ, Votruba ME. Organizational fragmentation and care quality in the U.S healthcare system. J Econ Perspect. 2008;22(4):93–113.CrossRefPubMedGoogle Scholar
  4. 4.
    Department of Veterans Affairs. Expanded Access to Non-VA Care Through the Veterans Choice Program. Federal Register. 2015;80(209):66419–66429.Google Scholar
  5. 5.
    The VA Mission Act of 2018. In: VA, ed.Google Scholar
  6. 6.
    Hussey PS, Schneider EC, Rudin RS, Fox DS, Lai J, Pollack CE. Continuity and the costs of care for chronic disease. JAMA Intern Med. 2014;174(5):742–748.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Han MK, Martinez CH, Au DH, et al. Meeting the challenge of COPD care delivery in the USA: a multiprovider perspective. Lancet Respir Med. 2016;4(6):473–526.CrossRefPubMedGoogle Scholar
  8. 8.
    Rinne ST, Elwy AR, Bastian LA, Wong ES, Wiener RS, Liu CF. Impact of Multisystem Health Care on Readmission and Follow-up Among Veterans Hospitalized for Chronic Obstructive Pulmonary Disease. Med Care. 2017;55 Suppl 7 Suppl 1:S20-S25.CrossRefGoogle Scholar
  9. 9.
    Wang L, Porter B, Maynard C, et al. Predicting risk of hospitalization or death among patients receiving primary care in the Veterans Health Administration. Medical care. 2013;51(4):368–373.CrossRefPubMedGoogle Scholar
  10. 10.
    Pope CA, Davis BH, Wine L, et al. Perceptions of U.S. Veterans Affairs and community healthcare providers regarding cross-system care for heart failure. Chronic Illn. 2017;14(4):1742395317729887.Google Scholar
  11. 11.
    LaCoursiere Zucchero T, McDannold S, McInnes DK. “Walking in a maze”: community providers’ difficulties coordinating health care for homeless patients. BMC health services research. 2016;16:480.CrossRefGoogle Scholar
  12. 12.
    Gaglioti A, Cozad A, Wittrock S, et al. Non-VA primary care providers’ perspectives on comanagement for rural veterans. Mil Med. 2014;179(11):1236–1243.CrossRefPubMedGoogle Scholar
  13. 13.
    Zuchowski JL, Chrystal JG, Hamilton AB, et al. Coordinating Care Across Health Care Systems for Veterans With Gynecologic Malignancies: A Qualitative Analysis. Medical care. 2017;55 Suppl 7 Suppl 1:S53-S60.CrossRefPubMedGoogle Scholar
  14. 14.
    Tsai J, Yakovchenko V, Jones N, et al. “Where’s My Choice?” An Examination of Veteran and Provider Experiences With Hepatitis C Treatment Through the Veteran Affairs Choice Program. Medical Care. 2017;55 Suppl 7 Suppl 1:S13-S19.CrossRefPubMedGoogle Scholar
  15. 15.
    Mattocks KM, Mengeling M, Sadler A, Baldor R, Bastian L. The Veterans Choice Act: A Qualitative Examination of Rapid Policy Implementation in the Department of Veterans Affairs. Medical care. 2017;55 Suppl 7 Suppl 1:S71-S75.CrossRefPubMedGoogle Scholar
  16. 16.
    Valerio MA, Rodriguez N, Winkler P, et al. Comparing two sampling methods to engage hard-to-reach communities in research priority setting. BMC Med Res Methodol. 2016;16(1):146.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Panagioti M, Scott C, Blakemore A, Coventry PA. Overview of the prevalence, impact, and management of depression and anxiety in chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis. 2014;9:1289–1306.PubMedPubMedCentralGoogle Scholar
  18. 18.
    Charmez K. Constructing Grounded Theory. Sage Publications Ltd; 2014.Google Scholar
  19. 19.
    Feemster LC, Au DH. Penalizing hospitals for chronic obstructive pulmonary disease readmissions. Am J Respir Crit Care Med. 2014;189(6):634–639.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    NVivo qualitative data analysis Software [computer program]. Version 11: QSR International Pty Ltd; 2016.Google Scholar
  21. 21.
    Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–1288.CrossRefPubMedGoogle Scholar
  22. 22.
    Mayring P. Qualitative content analysis. Forum: Qualitative Social Research. 2000;1(2).Google Scholar
  23. 23.
    Jones CD, Vu MB, O’Donnell CM, et al. A failure to communicate: a qualitative exploration of care coordination between hospitalists and primary care providers around patient hospitalizations. J Gen Intern Med. 2015;30(4):417–424.CrossRefPubMedGoogle Scholar
  24. 24.
    Van Houdt S, Heyrman J, Vanhaecht K, Sermeus W, De Lepeleire J. An in-depth analysis of theoretical frameworks for the study of care coordination. Int J Integr Care. 2013;13:e024.PubMedPubMedCentralGoogle Scholar
  25. 25.
    Care Coordination Model. The MacColl Institute for Healthcare Innovation;2010.Google Scholar
  26. 26.
    Bodenheimer T, Ghorob A, Willard-Grace R, Grumbach K. The 10 building blocks of high-performing primary care. Ann Fam Med. 2014;12(2):166–171.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Wagner EH, Sandhu N, Coleman K, Phillips KE, Sugarman JR. Improving care coordination in primary care. Med Care. 2014;52(11 Suppl 4):S33–38.CrossRefPubMedGoogle Scholar
  28. 28.
    Lee SJC, Jetelina KK, Marks E, et al. Care coordination for complex cancer survivors in an integrated safety-net system: a study protocol. BMC Cancer. 2018;18(1):1204.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Dajczman E, Robitaille C, Ernst P, et al. Integrated interdisciplinary care for patients with chronic obstructive pulmonary disease reduces emergency department visits, admissions and costs: a quality assurance study. Can Respir J. 2013;20(5):351–356.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Chang ET, Raja PV, Stockdale SE, et al. What are the key elements for implementing intensive primary care? A multisite Veterans Health Administration case study. Healthc (Amst). 2017.Google Scholar
  31. 31.
    Ayele RA, Lawrence E, McCreight M, et al. Study protocol: improving the transition of care from a non-network hospital back to the patient’s medical home. BMC health services research. 2017;17(1):123.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Centers for Medicare and Medicaid Services, Medicare and Medicaid Programs, and Electroic Health Record Incentive Program: Final Rule. In. Vol 75. Federal Register 2010:44314–44358.Google Scholar
  33. 33.
    Richardson JE, Vest JR, Green CM, Kern LM, Kaushal R, Investigators H A needs assessment of health information technology for improving care coordination in three leading patient-centered medical homes. J Am Med Inform Assoc. 2015;22(4):815–820.CrossRefPubMedGoogle Scholar
  34. 34.
    VA, Cerner Announce Agreement to Provide Seamless Care for Veterans [press release]. Cerner Corporation, May 17, 2018 2018.Google Scholar
  35. 35.
    Hawkins MA. Clinical integration across multiple hospitals: the agony, the ecstasy. Adv Pract Nurs Q. 1998;4(1):16–26.PubMedGoogle Scholar
  36. 36.
    Rogers A, Sheaff R. Formal and informal systems of primary healthcare in an integrated system: evidence from the United Kingdom. Healthc Pap. 2000;1(2):47–58; discussion 104-107.CrossRefPubMedGoogle Scholar
  37. 37.
    Friedman L, Goes J. Why integrated health networks have failed. Front Health Serv Manage. 2001;17(4):3–28.CrossRefPubMedGoogle Scholar
  38. 38.
    Chew LD, Griffin JM, Partin MR, et al. Validation of screening questions for limited health literacy in a large VA outpatient population. J Gen Intern Med. 2008;23(5):561–566.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Wallace E, Salisbury C, Guthrie B, Lewis C, Fahey T, Smith SM. Managing patients with multimorbidity in primary care. BMJ. 2015;350:h176.CrossRefPubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2019

Authors and Affiliations

  • Seppo T. Rinne
    • 1
  • Kirsten Resnick
    • 1
  • Renda Soylemez Wiener
    • 1
  • Steven R. Simon
    • 1
  • A. Rani Elwy
    • 1
  1. 1.BedfordUSA

Personalised recommendations