Veterans with multiple chronic conditions (MCCs) face complex self-care challenges and account for a disproportionate share of the VA's health care utilization and costs. Given the increasing prevalence of multimorbidity within the VA healthcare system, there is a need for innovative and low-cost interventions that address these patients' needs, improve their quality of care and outcomes, support appropriate utilization, and prevent use of unnecessary costly services.
To understand self-management and health care navigation challenges faced by Veterans with MCCs, and to identify eHealth technology and health care delivery interventions that best address their needs.
This CDA harnessed mixed methods to inform the development health care delivery and eHealth interventions for Veterans with MCCs. Formative research included focus groups with patients with MCCs, development and validation of a multimorbidity conceptual framework, and analyses of multimorbidity and utilization patterns among high-cost VA patients. Subsequent work involved the development, implementation, and evaluation of an intensive outpatient program for high-risk Veterans, evaluation of a 5-site PACT-Intensive Management Demonstration Project, and assessments of patient engagement strategies used by programs serving complex, multimorbid patients.
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Veterans are increasingly multimorbid, and there is a critical need for cost-effective mechanisms to help them overcome the challenges associated with managing MCCs. This research identified several health care delivery strategies and eHealth interventions that improve the health and health care experience of patients with MCCs, and that facilitate disease management and prevent unnecessary use of costly acute care.
- Zulman DM, O'Brien CW, Slightam C, Breland JY, Krauth D, Nevedal AL. Engaging High-Need Patients in Intensive Outpatient Programs: A Qualitative Synthesis of Engagement Strategies. Journal of general internal medicine. 2018 Nov 1; 33(11):1937-1944.
- Yoon J, Chang E, Rubenstein LV, Park A, Zulman DM, Stockdale S, Ong MK, Atkins D, Schectman G, Asch SM. Impact of Primary Care Intensive Management on High-Risk Veterans' Costs and Utilization: A Randomized Quality Improvement Trial. Annals of internal medicine. 2018 Jun 19; 168(12):846-854.
- Yoon J, Chee CP, Su P, Almenoff P, Zulman DM, Wagner TH. Persistence of High Health Care Costs among VA Patients. Health services research. 2018 Oct 1; 53(5):3898-3916.
- Ganz DA, Barnard JM, Smith NZY, Miake-Lye IM, Delevan DM, Simon A, Rose DE, Stockdale SE, Chang ET, Noël PH, Finley EP, Lee ML, Zulman DM, Cordasco KM, Rubenstein LV. Development of a web-based toolkit to support improvement of care coordination in primary care. Translational behavioral medicine. 2018 May 23; 8(3):492-502.
- O'Brien CW, Breland JY, Slightam C, Nevedal A, Zulman DM. Engaging high-risk patients in intensive care coordination programs: the engagement through CARInG framework. Translational behavioral medicine. 2018 May 23; 8(3):351-356.
- Chang ET, Zulman DM, Asch SM, Stockdale SE, Yoon J, Ong MK, Lee M, Simon A, Atkins D, Schectman G, Kirsh SR, Rubenstein LV, PIM Executive Committee and Demonstration Sites. An operations-partnered evaluation of care redesign for high-risk patients in the Veterans Health Administration (VHA): Study protocol for the PACT Intensive Management (PIM) randomized quality improvement evaluation. Contemporary clinical trials. 2018 Jun 1; 69:65-75.
- Chen J, Druhl E, Polepalli Ramesh B, Houston TK, Brandt CA, Zulman DM, Vimalananda VG, Malkani S, Yu H. A Natural Language Processing System That Links Medical Terms in Electronic Health Record Notes to Lay Definitions: System Development Using Physician Reviews. Journal of medical Internet research. 2018 Jan 22; 20(1):e26.
- Wu FM, Slightam CA, Wong AC, Asch SM, Zulman DM. Intensive Outpatient Program Effects on High-need Patients' Access, Continuity, Coordination, and Engagement. Medical care. 2018 Jan 1; 56(1):19-24.
- Rosland AM, Wong E, Maciejewski M, Zulman D, Piegari R, Fihn S, Nelson K. Patient-Centered Medical Home Implementation and Improved Chronic Disease Quality: A Longitudinal Observational Study. Health services research. 2018 Aug 1; 53(4):2503-2522.
- Chang ET, Raja PV, Stockdale SE, Katz ML, Zulman DM, Eng JA, Hedrick KH, Jackson JL, Pathak N, Watts B, Patton C, Schectman G, Asch SM. What are the key elements for implementing intensive primary care? A multisite Veterans Health Administration case study. Healthcare (Amsterdam, Netherlands). 2018 Dec 1; 6(4):231-237.
- Heisler M, Burgess J, Cass J, Chardos JF, Guirguis AB, Jeffery SM, Strohecker LA, Tremblay AS, Wu WC, Zulman DM. The Shared Health Appointments and Reciprocal Enhanced Support (SHARES) study: study protocol for a randomized trial. Trials. 2017 May 26; 18(1):239.
- Slightam CA, Brandt K, Jenchura EC, Lewis ET, Asch SM, Zulman DM. "I had to change so much in my life to live with my new limitations": Multimorbid patients' descriptions of their most bothersome chronic conditions. Chronic Illness. 2018 Mar 1; 14(1):13-24.
- Zivin K, Sen A, Plegue MA, Maciejewski ML, Segar ML, AuYoung M, Miller EM, Janney CA, Zulman DM, Richardson CR. Comparative Effectiveness of Wellness Programs: Impact of Incentives on Healthcare Costs for Obese Enrollees. American journal of preventive medicine. 2017 Mar 1; 52(3):347-352.
- Zulman DM, Pal Chee C, Ezeji-Okoye SC, Shaw JG, Holmes TH, Kahn JS, Asch SM. Effect of an Intensive Outpatient Program to Augment Primary Care for High-Need Veterans Affairs Patients: A Randomized Clinical Trial. JAMA internal medicine. 2017 Feb 1; 177(2):166-175.
- Singh K, Drouin K, Newmark LP, Filkins M, Silvers E, Bain PA, Zulman DM, Lee JH, Rozenblum R, Pabo E, Landman A, Klinger EV, Bates DW. Patient-Facing Mobile Apps to Treat High-Need, High-Cost Populations: A Scoping Review. JMIR mHealth and uHealth. 2016 Dec 19; 4(4):e136.
- Conley J, O'Brien CW, Leff BA, Bolen S, Zulman D. Alternative Strategies to Inpatient Hospitalization for Acute Medical Conditions: A Systematic Review. JAMA internal medicine. 2016 Nov 1; 176(11):1693-1702.
- Whealin JM, Jenchura EC, Wong AC, Zulman DM. How Veterans With Post-Traumatic Stress Disorder and Comorbid Health Conditions Utilize eHealth to Manage Their Health Care Needs: A Mixed-Methods Analysis. Journal of medical Internet research. 2016 Oct 26; 18(10):e280.
- Zulman DM, Shah NH, Verghese A. Evolutionary Pressures on the Electronic Health Record: Caring for Complexity. JAMA. 2016 Sep 6; 316(9):923-4.
- Bayliss EA, McQuillan DB, Ellis JL, Maciejewski ML, Zeng C, Barton MB, Boyd CM, Fortin M, Ling SM, Tai-Seale M, Ralston JD, Ritchie CS, Zulman DM. Using Electronic Health Record Data to Measure Care Quality for Individuals with Multiple Chronic Medical Conditions. Journal of the American Geriatrics Society. 2016 Sep 1; 64(9):1839-44.
- Wagner TH, Burstin H, Frakt AB, Krein SL, Lorenz K, Maciejewski ML, Pizer SD, Weiner M, Yoon J, Zulman DM, Asch SM. Opportunities to Enhance Value-Related Research in the U.S. Department of Veterans Affairs. Journal of general internal medicine. 2016 Apr 1; 31 Suppl 1:78-83.
- Zulman DM, Grant RW. Transforming Care for Complex Patients: Addressing Interconnected Medical, Social, and Behavioral Challenges. Journal of general internal medicine. 2016 Mar 1; 31(3):263-4.
- Holmes TH, Zulman DM, Kushida CA. Adjustment for Variable Adherence Under Hierarchical Structure: Instrumental Variable Modeling Through Compound Residual Inclusion. Medical care. 2017 Dec 1; 55(12):e120-e130.
- Breland JY, Asch SM, Slightam C, Wong A, Zulman DM. Key ingredients for implementing intensive outpatient programs within patient-centered medical homes: A literature review and qualitative analysis. Healthcare (Amsterdam, Netherlands). 2016 Mar 1; 4(1):22-9.
- Zulman DM, Martins SB, Liu Y, Tu SW, Hoffman BB, Asch SM, Goldstein MK. Using a Clinical Knowledge Base to Assess Comorbidity Interrelatedness Among Patients with Multiple Chronic Conditions. AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 2015 Nov 5; 2015:1381-9.
- Vaks Y, Bensen R, Steidtmann D, Wang TD, Platchek TS, Zulman DM, Malcolm E, Milstein A. Better health, less spending: Redesigning the transition from pediatric to adult healthcare for youth with chronic illness. Healthcare (Amsterdam, Netherlands). 2016 Mar 1; 4(1):57-68.
- Gidwani R, Zulman D. Association Between Acute Medical Exacerbations and Consuming or Producing Web-Based Health Information: Analysis From Pew Survey Data. Journal of medical Internet research. 2015 Jun 23; 17(6):e145.
- Hunter G, Yoon J, Blonigen DM, Asch SM, Zulman DM. Health Care Utilization Patterns Among High-Cost VA Patients With Mental Health Conditions. Psychiatric services (Washington, D.C.). 2015 Sep 1; 66(9):952-8.
- Zulman DM, Pal Chee C, Wagner TH, Yoon J, Cohen DM, Holmes TH, Ritchie C, Asch SM. Multimorbidity and healthcare utilisation among high-cost patients in the US Veterans Affairs Health Care System. BMJ open. 2015 Apr 16; 5(4):e007771.
- Breland JY, Greenbaum MA, Zulman DM, Rosen CS. The effect of medical comorbidities on male and female Veterans' use of psychotherapy for PTSD. Medical care. 2015 Apr 1; 53(4 Suppl 1):S120-7.
- Leung TI, Jalal H, Zulman DM, Dumontier M, Owens DK, Musen MA, Goldstein MK. Automating Identification of Multiple Chronic Conditions in Clinical Practice Guidelines. AMIA Summits on Translational Science proceedings. 2015 Mar 25; 2015:456-60.
- Zulman DM, Jenchura EC, Cohen DM, Lewis ET, Houston TK, Asch SM. How Can eHealth Technology Address Challenges Related to Multimorbidity? Perspectives from Patients with Multiple Chronic Conditions. Journal of general internal medicine. 2015 Aug 1; 30(8):1063-70.
- Zulman DM, Ezeji-Okoye SC, Shaw JG, Hummel DL, Holloway KS, Smither SF, Breland JY, Chardos JF, Kirsh S, Kahn JS, Asch SM. Partnered research in healthcare delivery redesign for high-need, high-cost patients: development and feasibility of an Intensive Management Patient-Aligned Care Team (ImPACT). Journal of general internal medicine. 2014 Dec 1; 29 Suppl 4:861-9.
- Breland JY, Chee CP, Zulman DM. Racial Differences in Chronic Conditions and Sociodemographic Characteristics Among High-Utilizing Veterans. Journal of racial and ethnic health disparities. 2015 Jun 1; 2(2):167-75.
- Kalanithi L, Tai W, Conley J, Platchek T, Zulman D, Milstein A. Better health, less spending: delivery innovation for ischemic cerebrovascular disease. Stroke. 2014 Oct 1; 45(10):3105-11.
- Turvey C, Klein D, Fix G, Hogan TP, Woods S, Simon SR, Charlton M, Vaughan-Sarrazin M, Zulman DM, Dindo L, Wakefield B, Graham G, Nazi K. Blue Button use by patients to access and share health record information using the Department of Veterans Affairs' online patient portal. Journal of the American Medical Informatics Association : JAMIA. 2014 Jul 1; 21(4):657-63.
- Yoon J, Zulman D, Scott JY, Maciejewski ML. Costs associated with multimorbidity among VA patients. Medical care. 2014 Mar 1; 52 Suppl 3:S31-6.
- Zulman DM, Asch SM, Martins SB, Kerr EA, Hoffman BB, Goldstein MK. Quality of care for patients with multiple chronic conditions: the role of comorbidity interrelatedness. Journal of general internal medicine. 2014 Mar 1; 29(3):529-37.
- Zulman DM, Damschroder LJ, Smith RG, Resnick PJ, Sen A, Krupka EL, Richardson CR. Implementation and evaluation of an incentivized Internet-mediated walking program for obese adults. Translational behavioral medicine. 2013 Dec 1; 3(4):357-69.
- Ritchie CS, Zulman DM. Research priorities in geriatric palliative care: multimorbidity. Journal of palliative medicine. 2013 Aug 1; 16(8):843-7.
- Zulman DM, Piette JD, Jenchura EC, Asch SM, Rosland AM. Facilitating out-of-home caregiving through health information technology: survey of informal caregivers' current practices, interests, and perceived barriers. Journal of medical Internet research. 2013 Jul 10; 15(7):e123.
- Turvey CL, Zulman DM, Nazi KM, Wakefield BJ, Woods SS, Hogan TP, Weaver FM, McInnes K. Transfer of information from personal health records: a survey of veterans using My HealtheVet. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2012 Mar 1; 18(2):109-14.
- Bensen R, Steidtmann D, Vaks Y, Malcolm E, Zulman DM, Milstein A. Bridging The Gap: A New Model of Transition Care for Young Adults With Serious Chronic Conditions. [Abstract]. The Journal of adolescent health : official publication of the Society for Adolescent Medicine. 2015 Feb 20; 56(2S1):S34-S35.
- Zulman DM, Humphreys KN. You’re Never too Old to be Studied (Op-Ed). The New York Times. 2014 May 23: A: 23.
- Zulman DM. Intensive Management for High-Risk Patients. Briefings for VA leadership in Patient Care Services, HSR&D, Mental Health Operations, and Women’s Health Services. 2015 Apr 16.
- Zulman DM, Chee CP. Randomized controlled evaluation of an Intensive Management Patient Aligned Care Team (ImPACT) for high-need, high-cost Veterans Affairs patients. [Cyberseminar]. 2015 Apr 15.
- Javorka M, Wong AC, Lewis ET, Zulman DM, Kimerling R. Differences in engagement in VA health care among Veterans with and without Posttraumatic Stress Disorder. Poster session presented at: International Society for Traumatic Stress Studies Annual Symposium; 2016 Nov 10; Dallas, TX.
- Kimerling R, Lewis ET, Wong AC, Javorka M, Zulman DM. The rules of engagement: veteran interactions with healthcare. Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Sep 19; Boston, MA.
- Maciejewski ML, Prenovost S, Vijan S, Zulman D, Chang E, Trivedi R, Nelson K, Warin N, Fihn S, Rosland AM. Subgroups of Patients at High-Risk for Hospitalization: An Empirical Approach. Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Jun 27; Boston, MA.
- Prenovost K, Maciejewski M, Sandeep V, Zulman D, Chang E, Trivedi R, Nelson K, Wawrin N, Fihn S, Rosland AM. Subgroups of Patients at High-Risk for Hospitalization: An Empirical Approach. Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Jun 26; Boston, MA.
- Stockdale S, Katz ML, Zulman D, Hedrick K, Rubenstein LV, Chang ET, Roy S. Optimizing Health for Veterans: Engaging High-Risk Patients in a 5-Site Intensive Primary Care Management Program. Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Jun 26; Boston, MA.
- Eng J, Pathak N, Chang ET, Jackson J, Shaw J, Watts B, Zulman D. Population-Based Intensive Management Programs For High-Risk Patients: Experiences in the VA System. Presented at: Society of General Internal Medicine Annual Meeting; 2016 May 11; Hollywood, FL.
- Rosland A, Wong ES, Zulman D, Piegari R, Prenovost K, Fihn SD, Nelson KM. Higher Level of Patient-Centered Medical Home Implementation Associated with Larger Improvements in Clinical Quality in the PACT Initiative. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 10; Philadelphia, PA.
- Stockdale S, Katz ML, Raja P, Chang ET, Collier C, Zulman D, Kirsh S, Rubenstein LV. Can VHA Improve Primary Care for High Risk High Need Patients? Lessons Learned During Early Implementation of PACT Intensive Management (PIM) Programs. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 10; Philadelphia, PA.
- Cronkite RC, Halvorson M, Maisel NC, Bi X, Weitlauf JC, Timko C, Blonigen DM, Hayashi KP, Zulman DM, Finney JW. Evaluating a Model of Mentorship Outcomes of HSR&D Career Development Awardees. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA.
- Cronkite RC, Asch SM, Zulman DM. CDA Enhancement Initiative. Career Development in a Veteran-Centered Learning Organization. Presented at: VA HSR&D Career Development Annual Meeting; 2015 Jul 8; Philadelphia, PA.
- Rosland A, Wong E, Zulman DM, Piegari R, Prenovost K, Fihn S, Nelson K. Higher Level of Patient-Centered Medical Home Implementation Associated with Improvements in Clinical Quality of Care in the Nation-Wide VHA PACT Initiative. Paper presented at: AcademyHealth Annual Research Meeting; 2015 Jun 14; Minneapolis, MN.
- Rosland AM, Wong ES, Zulman D, Piegari R, Prenovost K, Fihn SD, Nelson KM. Higher Level of Patient-Centered Medical Home Implementation Associated with Improvements in Clinical Quality of Care in the Nation-Wide VHA PACT Initiative. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2015 Apr 22; Toronto, Canada.
- Zulman DM. Measuring the Impact of Complex Care Interventions. Presented at: California HealthCare Foundation Northern California Complex Care Workshop; 2014 Jul 30; Oakland, CA.
- Hunter G, Yoon J, Blonigen DM, Asch SM, Zulman DM. Prevalence of Mental Health Conditions and Associated Patterns of Health Care Utilization among High Cost VA Patients. Poster session presented at: AcademyHealth Annual Research Meeting; 2014 Jun 10; San Diego, CA.
- Zulman DM, Chee CP, Wagner TH, Yoon J, Cohen D, Holmes T, Ritchie C, Asch SM. Multimorbidity and Health Care Utilization among High-Cost Patients: Implications for Intensive Primary Care Programs. Poster session presented at: AcademyHealth Annual Research Meeting; 2014 Jun 9; San Diego, CA.
- Zulman DM, Jenchura EC, Cohen DM, Lewis ET, Houston TK, Asch SM. How can eHealth technology address multimorbidity challenges? Perspectives from patients with multiple chronic conditions. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2014 Apr 25; San Diego, CA.
- Hunter G, Yoon J, Blonigen DM, Asch SM, Zulman DM. Prevalence of mental health conditions and associated patterns of health care utilization among high-cost VA patients. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2014 Apr 23; San Diego, CA.
- Yoon J, Zulman DM, Scott J. Costs Associated with Multimorbidity in VA Patients. Paper presented at: AcademyHealth Annual Research Meeting; 2013 Jun 24; Baltimore, MD.
- Zulman DM, Yoon J, Cohen DM, Wagner TH, Ritchie C, Asch SM. Multimorbidity and health care utilization among high-cost patients: Implications for care coordination. Paper presented at: Society of General Internal Medicine Annual Meeting; 2013 Apr 24; Denver, CO.
- Zulman DM, Jenchura EC, Cohen D, Lewis ET, Asch SM. Opportunities to optimize eHealth technology for patients with multiple chronic conditions. Poster session presented at: Society of Behavioral Medicine Annual Meeting and Scientific Sessions; 2013 Mar 1; San Francisco, CA.
- Jenchura EC, Asch SM, Cohen D, Lewis ET, Zulman DM. Health-related technology use and preferences among Veterans with PTSD. Poster session presented at: Western Psychological Association Annual Convention; 2013 Jan 4; Reno, NV.
- Zulman DM, Goldstein MK, Musen MA, Rocha RA. Clinical decision complexity in multimorbid patients. Panel: Opportunities to Support Complex Medical Decisions Through Informatics. Presented at: American Medical Informatics Association Annual Symposium; 2012 Nov 1; San Francisco, CA.
- Jenchura EC, Asch SM, Cohen DM, Lewis ET, Zulman DM. Optimizing eHealth technology for patients with multiple chronic conditions. Poster session presented at: Stanford Medicine X Annual Conference; 2012 Sep 28; Stanford, CA.
Technology Development and Assessment