Talk to the Veterans Crisis Line now
U.S. flag
An official website of the United States government

VA Health Systems Research

Go to the VA ORD website
Go to the QUERI website

IIR 15-316 – HSR Study

IIR 15-316
Care Coordination for High-Risk Patients with Multiple Chronic Conditions
Donna M Zulman, MD MS
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: January 2018 - December 2021
Care 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 in the current policy environment that increasingly encourages Veterans' dual use of VA and community care. When patient care is dispersed across providers, clinics, and health systems, it increases risks of information loss, medication interactions, and unwieldy treatment regimens, leading to health deterioration. 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.

The objective of this study is to advance the understanding of care fragmentation and care coordination's potential among Veterans who are at high-risk for hospitalization. To achieve the study goals, we will first describe care fragmentation prevalence and variation in a national cohort of high-risk patients (Aim 1). We will then examine the relationships between care fragmentation and outcomes, including acute care utilization (Aim 2.1) and patient-reported care experience (Aim 3.1). Finally, we will evaluate whether randomization to comprehensive care coordination mitigates the effects of fragmentation (Aims 2.2 and 3.2).

This project will first identify a cohort of Veterans with Care Assessment Needs hospitalization risk scores >= 90th percentile in FY14, and examine their primary care, outpatient care, and health system fragmentation, using validated and adapted measures of care fragmentation and discontinuity (Aim 1.1). After using a theoretical approach to compare and refine the measure list, we will examine variation in care fragmentation by patient characteristics (e.g., age, sex, chronic conditions, housing instability, distance from VA, and enrollment in care coordination programs) (Aim 1.2). In Aim 2, we will use select fragmentation measures identified in Aim 1 to evaluate the relationship between care fragmentation and acute care utilization among high-risk Veterans. We will first determine whether care fragmentation is independently associated with higher rates of acute care utilization (including emergency department visits and hospitalizations) (Aim 2.1). Then we will take advantage of an ongoing randomized evaluation of an Office of Primary Care PACT-Intensive Management (PIM) Demonstration Program to test whether comprehensive care coordination influences the relationship between fragmentation and acute care outcomes (Aim 2.2). In Aim 3, we will analyze findings from a patient survey that was conducted for the PIM Demonstration Program to examine the relationship between care fragmentation and patient experiences with care. We will assess whether greater fragmentation is associated with low satisfaction, poor perceived care coordination, and patient-reported challenges with access, communication, and self-management (Aim 3.1), and determine whether comprehensive care coordination offered through PIM influenced the relationship between fragmentation and patient experience (Aim 3.2).

Not available; project began 1/1/2018.

Veterans are increasingly facing care fragmentation, a challenge that will likely intensify in a policy environment that encourages Veterans to use both VA and community care. Veterans who are at high-risk for hospitalization and individuals with functional limitations or resource constraints may be especially vulnerable to negative consequences from fragmented care. Our findings will inform both current and future efforts to improve and streamline care for high-risk Veterans with multiple chronic conditions.

External Links for this Project

NIH Reporter

Grant Number: I01HX002127-01A2

Dimensions for VA

Dimensions for VA is a web-based tool available to VA staff that enables detailed searches of published research and research projects.

Learn more about Dimensions for VA.

VA staff not currently on the VA network can access Dimensions by registering for an account using their VA email address.
    Search Dimensions for this project


Journal Articles

  1. Zulman DM, Slightam CA, Brandt K, Lewis ET, Asch SM, Shaw JG. "They are interrelated, one feeds off the other": A taxonomy of perceived disease interactions derived from patients with multiple chronic conditions. Patient education and counseling. 2020 May 1; 103(5):1027-1032. [view]
  2. Leung LB, Rubenstein LV, Post EP, Trivedi RB, Hamilton AB, Yoon J, Jaske E, Yano EM. Association of Veterans Affairs Primary Care Mental Health Integration With Care Access Among Men and Women Veterans. JAMA Network Open. 2020 Oct 1; 3(10):e2020955. [view]
  3. Dang S, Penney LS, Trivedi R, Noel PH, Pugh MJ, Finley E, Pugh JA, Van Houtven CH, Leykum L. Caring for Caregivers During COVID-19. Journal of the American Geriatrics Society. 2020 Oct 1; 68(10):2197-2201. [view]
  4. Pershing S, Henderson VW, Goldstein MK, Lu Y, Bundorf MK, Rahman M, Stein JD. Cataract Surgery Complexity and Surgical Complication Rates Among Medicare Beneficiaries With and Without Dementia. American Journal of Ophthalmology. 2021 Jan 1; 221:27-38. [view]
  5. Wong ES, Guo R, Yoon J, Zulman DM, Asch SM, Ong MK, Chang ET. Impact of VHA's primary care intensive management program on dual system use. Healthcare (Amsterdam, Netherlands). 2020 Sep 1; 8(3):100450. [view]
  6. Yank V, Gale RC, Nevedal A, Okwara L, Koenig CJ, Trivedi RB, Dupke NJ, Kabat M, Asch SM. Improving Uptake of a National Web-Based Psychoeducational Workshop for Informal Caregivers of Veterans: Mixed Methods Implementation Evaluation. Journal of medical Internet research. 2021 Jan 7; 23(1):e16495. [view]
  7. Zulman DM, Wong EP, Slightam C, Gregory A, Jacobs JC, Kimerling R, Blonigen DM, Peters J, Heyworth L. Making connections: nationwide implementation of video telehealth tablets to address access barriers in veterans. JAMIA open. 2019 Oct 1; 2(3):323-329. [view]
  8. Trivedi RB, Post EP, Piegari R, Simonetti J, Boyko EJ, Asch SM, Mori A, Arnow BA, Fihn SD, Nelson KM, Maynard C. Mortality Among Veterans with Major Mental Illnesses Seen in Primary Care: Results of a National Study of Veteran Deaths. Journal of general internal medicine. 2020 Jan 1; 35(1):112-118. [view]
  9. Jacobs J, Ferguson JM, Van Campen J, Yefimova M, Greene L, Heyworth L, Zulman DM. Organizational and External Factors Associated with Video Telehealth Use in the Veterans Health Administration Before and During the COVID-19 Pandemic. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2022 Feb 1; 28(2):199-211. [view]
  10. Zulman DM, Maciejewski ML, Grubber JM, Weidenbacher HJ, Blalock DV, Zullig LL, Greene L, Whitson HE, Hastings SN, Smith VA. Patient-Reported Social and Behavioral Determinants of Health and Estimated Risk of Hospitalization in High-Risk Veterans Affairs Patients. JAMA Network Open. 2020 Oct 1; 3(10):e2021457. [view]
  11. Schalet BD, Reise SP, Zulman DM, Lewis ET, Kimerling R. Psychometric evaluation of a patient-reported item bank for healthcare engagement. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation. 2021 Aug 1; 30(8):2363-2374. [view]
  12. Fields B, Lee A, Piette JD, Trivedi R, Mor MK, Obrosky DS, Heisler M, Rosland AM. Relationship between adult and family supporter health literacy levels and supporter roles in diabetes management. Families, systems & health : the journal of collaborative family healthcare. 2021 Jun 1; 39(2):224-233. [view]
  13. Blalock DV, Grubber J, Smith VA, Zulman DM, Weidenbacher HJ, Greene L, Dedert EA, Maciejewski ML. The association of alcohol use with all-cause and cardiovascular disease-related hospitalizations or death in older, high-risk Veterans. Alcoholism, clinical and experimental research. 2021 Jun 1; 45(6):1215-1224. [view]
  14. Chang ET, Zulman DM, Nelson KM, Rosland AM, Ganz DA, Fihn SD, Piegari R, Rubenstein LV. Use of General Primary Care, Specialized Primary Care, and Other Veterans Affairs Services Among High-Risk Veterans. JAMA Network Open. 2020 Jun 1; 3(6):e208120. [view]
  15. Maitra A, Kamdar MR, Zulman DM, Haverfield MC, Brown-Johnson C, Schwartz R, Israni ST, Verghese A, Musen MA. Using ethnographic methods to classify the human experience in medicine: a case study of the presence ontology. Journal of the American Medical Informatics Association : JAMIA. 2021 Aug 13; 28(9):1900-1909. [view]
  16. Stockdale SE, Katz ML, Bergman AA, Zulman DM, Denietolis A, Chang ET. What Do Patient-Centered Medical Home (PCMH) Teams Need to Improve Care for Primary Care Patients with Complex Needs? Journal of general internal medicine. 2021 Sep 1; 36(9):2717-2723. [view]

DRA: Health Systems
DRE: TRL - Applied/Translational
Keywords: Care Coordination
MeSH Terms: none

Questions about the HSR website? Email the Web Team

Any health information on this website is strictly for informational purposes and is not intended as medical advice. It should not be used to diagnose or treat any condition.