Impact of policies and performance measurement on development of organizational coordinating strategies for chronic care delivery

Objective: To examine the impact of policy directives and performance feedback on the organization (specifically the coordination) of foot care programs for veterans, as mandated by public law within the Department of Veterans Affairs Health Care System (VA). Study Design: Case study of 10 VA medical centers performing diabetes-related amputations. Patients and Methods: Based on expert consensus, we identified 16 recommended foot care delivery coordination strategies. Structured interview protocols developed for primary care, foot care, and surgical providers, as well as administrators, were adapted from a prior study of surgical departments. Results: Although performance measurement results for foot risk screening and referral were high at all study sites over 2 calendar years (average 85%, range 69% to 92%), the number of coordination strategies implemented by any site was relatively low, averaging only 5.4 or 34% (range 1-12 strategies). No facility had systematically collected data to evaluate whether preventive foot care was provided to patients with high-risk foot conditions, or whether these patients had unmet foot care needs. Conclusions: Although foot care policies and data feedback resulted in extremely high rates of adherence to foot-related performance measurement, there remained opportunities for improvement in the development of coordinated, technology-supported, data-driven, patient-centered foot care programs.