managers of these case study models were supportive of the collaboration and committed to long-term goals to achieve better outcomes.

Open Communication Key to effective collaborations was good communication among leaders, and frequent interaction among mid-level managers, directors, and care providers. The vision for the collaboration was established and communicated by leaders. This was achieved through joint meetings and planned exchanges of information and opportunities to solve problems encountered with the system of patient care, referrals, and services. Effective collaborations for specific services occurred when DoD and VA leaders worked together early and often to establish meaningful outcome measures.

Range of Collaborative Initiatives

Collaborative initiatives included one or more of the range of services expected from large health systems. No single facility or system included a full integration or merger of all patient care services available at one or the other DoD or VA facility involved in the collaboration. Likewise, within most of the joint venture collaboration models, some of the service operations were more effective than others. Many factors influenced success of individual services or departments of the joint venture.

Specific initiatives varied across the continuum of acute care subspecialties to outpatient clinics to programs of education and training of health care professionals. Many of the collaborative organizations emphasized emergency treatment, including different strategies to improve emergency services and to decrease wait times for patients. Several joint ventures were developed because of the need to build new facilities for increased capacity. Patient care services were then developed collaboratively to promote optimal use of buildings and local area facilities and to reduce the cost of health care facility construction to the DoD or the VA system. Both acute care and outpatient care systems evolved or were actively planned, including inpatient and outpatient surgery capabilities.

Mental health services were a present and growing concern for the DoD and the VA organizations. Demand for these services increased during the time of implementation of several of the collaborations. Different strategies were identified to cope with the challenges of treating behavioral health patients of different ages and affected by military experiences or stress-related illnesses. Evaluations of these approaches on health care quality, safety, access, efficiency, and patient outcomes were not available to make generalizable conclusions.

Support services, such as pharmacy, laboratory, radiology, physical therapy, and other ancillary specialty services, were included in some



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