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Health Services Research & Development

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HSR&D In Progress

June 2018

In This Issue: Care Coordination
» Table of Contents

Care Coordination for High-Risk Patients with Multiple Chronic Conditions

Feature Article

Healthcare fragmentation is a mounting challenge for Veterans, many of whom face multiple chronic conditions requiring care from different providers and clinics. This issue is likely to intensify as more Veteran use both VA and non-VA healthcare. When patient care is dispersed across providers, clinics, and health systems, it increases the risk of information loss, medication interactions, and unwieldy treatment regimens, which can worsen health outcomes. Veterans in poor health and those with functional limitations or resource constraints may be especially vulnerable, yet little is known about fragmentation patterns and care coordination needs in these high-risk patients.

This ongoing HSR&D study seeks to advance our understanding of care fragmentation and care coordination's potential among Veterans at high-risk for hospitalization by:

  • Describing care fragmentation prevalence and variation in a national cohort of high-risk patients;
  • Examining relationships between care fragmentation and outcomes, including acute care utilization and patient-reported care experience; and
  • Evaluating whether randomization to comprehensive care coordination mitigates the effects of fragmentation.

To accomplish these goals, investigators have identified a cohort of Veterans with high hospitalization risk scores in FY2014. They are examining primary care, outpatient care, and health system fragmentation patterns, and will assess variation in care fragmentation by patient characteristics (e.g., age, sex, chronic conditions, housing instability, distance from VA facilities, and enrollment in care coordination programs). Investigators will then examine the relationship between fragmentation and acute care use among high-risk Veterans; for example, determining whether or not care fragmentation is independently associated with higher rates of acute care use (i.e., emergency department visits and hospitalizations). Finally, patient survey data will be used to examine the relationship between care fragmentation and patient experiences with care, seeking to learn how fragmentation influences patient satisfaction, perceived care coordination, and challenges with access, communication, and self-management. Investigators also will harness the ongoing PACT-Intensive Management Randomized Demonstration Program to determine whether intensive care coordination mitigates the consequences of fragmented care.


This project began in January 2018; there are no findings thus far.

Veterans at high-risk for hospitalization and individuals with functional limitations or resource constraints may be especially vulnerable to negative consequences from fragmented healthcare. Study findings will inform both current and future efforts to improve and streamline VA care for high-risk Veterans with multiple chronic conditions.

Principal InvestigatorDonna Zulman, MD, is an HSR&D Career Development Awardee and part of HSR&D’s Center for Innovation to Implementation (Ci2i) in Palo Alto, CA.


None at this time.

Care Coordination for High-Risk Patients with Multiple Chronic Conditions project abstract


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