RESUMO
BACKGROUND: Transitions of care are high risk for vulnerable populations such as rural Veterans, and adequate care coordination can alleviate many risks. Single-center care coordination programs have shown promise in improving transitional care practices. However, best practices for implementing effective transitional care interventions are unknown, and a common pitfall is lack of understanding of the current process at different sites. The rural Transitions Nurse Program (TNP) is a Veterans Health Administration (VA) intervention that addresses the unique transitional care coordination needs of rural Veterans, and it is currently being implemented in five VA facilities. OBJECTIVE: We sought to employ and study process mapping as a tool for assessing site context prior to implementation of TNP, a new care coordination program. DESIGN AND PARTICIPANTS: Observational qualitative study guided by the Lean Six Sigma approach. Data were collected in January-March 2017 through interviews, direct observations, and group sessions with front-line staff, including VA providers, nurses, and administrative staff from five VA Medical Centers and nine rural Patient-Aligned Care Teams. KEY RESULTS: We integrated key informant interviews, observational data, and group sessions to create ten process maps depicting the care coordination process prior to TNP implementation at each expansion site. These maps were used to adapt implementation through informing the unique role of the Transitions Nurse at each site and will be used in evaluating the program, which is essential to understanding the program's impact. CONCLUSIONS: Process mapping can be a valuable and practical approach to accurately assess site processes before implementation of care coordination programs in complex systems. The process mapping activities were useful in engaging the local staff and simultaneously guided adaptations to the TNP intervention to meet local needs. Our approach-combining multiple data sources while adapting Lean Six Sigma principles into practical use-may be generalizable to other care coordination programs.