HSR&D Home » Research » IIR 15-316 – HSR&D Study
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 ReporterGrant Number: I01HX002127-01A2
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DRA: Health Systems
DRE: TRL - Applied/Translational
Keywords: Care Coordination
MeSH Terms: none