T he Institute of Medicine has stated that the healthcare system is comprised of multiple inter- acting systems of care (including emergency, ambulatory, inpatient, imaging, laboratory, and phar- macy), delivered by networks of individuals, teams, and payer systems that “function in such diverse and diffuse management, accountability, and information systems that the overall term health system is today a mis- nomer.” 1 Consequently, the Institute stated that a radi- cal re-engineering of the American healthcare system is needed to deliver high-quality, patient-centered care. The Institute envisioned a central microsystem of care (ie, a unit that actually provides medical care), driven by systems-oriented approaches utilizing information technology to increase the rate of knowledge diffusion to clinicians, in order to standardize the provision of evidence-based medicine and to promote patient-cen- tered care. Other conceptual frameworks to implement care for chronic disease have been proposed, including the Chronic Disease Model. 2 This model, which incorpo- rates evidence-based medicine and informatics, results in productive patient-provider interactions and improved patient outcomes. The Joint Commission on Accreditation of Healthcare Organizations relied on this model when it developed its Disease Management Certification Standards, which include program man- agement, clinical information management, supporting self-management, delivering or facilitating clinical care, and performance measurement. 3 However, the organi- zational factors that lead to the development and imple- mentation of successful disease management programs remain poorly understood. 4 Coordination of care has been proposed as a key organizational factor for improving the quality of chron- VOL. 10, NO. 2 THE AMERICAN JOURNAL OF MANAGED CARE 171 POLICY Impact of Policies and Performance Measurement on Development of Organizational Coordinating Strategies for Chronic Care Delivery Leonard Pogach, MD, MBA; Martin P. Charns, MBA, DBA; James S. Wrobel, DPM, MS; Jeffrey M. Robbins, DPM; Kristin M. Bonacker, BA; Linda Haas, PhC, RN, CDE; and Gayle E. Reiber, MPH, PhD Objective: To examine the impact of policy directives and per- formance feedback on the organization (specifically the coordina- tion) 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 identi- fied 16 recommended foot care delivery coordination strategies. Structured interview protocols developed for primary care, foot care, and surgical providers, as well as administrators, were adapt- ed 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 cal- endar 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 per- formance measurement, there remained opportunities for improve- ment in the development of coordinated, technology-supported, data-driven, patient-centered foot care programs. (Am J Manag Care. 2004;10(part 2):171-180) From the Department of Veterans Affairs New Jersey Health Care System, Center for Healthcare Knowledge Management, East Orange, NJ (LP); the University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, NJ (LP); the VA Management Decision & Research Center and the Program on Health Policy and Management, Boston University School of Public Health, Boston, Mass (MPC); the VA Medical and Regional Office Center, Department of Veterans Affairs, White River Junction, Vt (JSW); the Department of Community and Family Medicine, Dartmouth Medical School, Hanover, NH (JSW); the Cleveland VA Medical Center, Department of Veterans Affairs, Cleveland, OH (JMR); Health Services and Research and Development (KMB, GER), and Primary and Specialty Medical Care Services (LH), VA Puget Sound Health Care System, Department of Veterans Affairs, Seattle, Wash; and the Departments of Health Services and Epidemiology, University of Washington, Seattle, Wash (GER). This research was supported by grant DIS-99037 from the Department of Veterans Affairs, Health Services Research and Development. The views expressed in this article are those of the authors and do not neces- sarily represent the views of the agencies providing support. Address correspondence to: Leonard Pogach, MD, MBA, VA New Jersey Health Care System, Health Services Research Center for Healthcare Knowledge Management, East Orange VAMC, Room 9-160 (111), 385 Tremont Avenue, East Orange, NJ 07018. E-mail: leonard.pogach@med.va.gov.