• Vanneman ME, Yoon J, Singer SJ, Wagner TH, Goldstein MK, Hu J, Boothroyd D, Greene L, Zulman DM. Anticipating VA/non-VA care coordination demand for Veterans at high risk for hospitalization. Medicine. 2022 Feb 18; 101(7):e28864.
• Connor KI, Siebens HC, Mittman BS, Ganz DA, Barry F, McNeese-Smith DK, Cheng EM, Vickrey BG. Implementation fidelity of a nurse-led RCT-tested complex intervention, care coordination for health promotion and activities in Parkinson's disease (CHAPS) in meeting challenges in care management. BMC neurology. 2022 Jan 24; 22(1):36.
• Duan-Porter W, Ullman K, Majeski B, Miake-Lye I, Diem S, Wilt TJ. Care Coordination Models and Tools-Systematic Review and Key Informant Interviews. Journal of general internal medicine. 2022 May 1; 37(6):1367-1379.
• Berinstein JA, Cohen-Mekelburg SA, Greenberg GM, Wray D, Berry SK, Saini SD, Fendrick AM, Adams MA, Waljee AK, Higgins PDR. A Care Coordination Intervention Improves Symptoms But Not Charges in High-Risk Patients With Inflammatory Bowel Disease. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2022 May 1; 20(5):1029-1038.e9.
• Penney LS, Bharath PS, Miake-Lye I, Leng M, Olmos-Ochoa TT, Finley EP, Chawla N, Barnard JM, Ganz DA. Toolkit and distance coaching strategies: a mixed methods evaluation of a trial to implement care coordination quality improvement projects in primary care. BMC health services research. 2021 Aug 14; 21(1):817.

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• Early Expansion of Benefits under Choice Act Increased Community Hospital Use but Did Not Change Mortality
  This study examined changes in VA enrollees’ use of VA and non-VA hospitals from 2012-2017, as well as mortality associated with policies intended to increase access to care, such as the Choice Act. Findings showed that over the five-year study period, Veterans increased their use of community hospitals paid by VA and Medicaid and decreased their use of VA hospitals when access to non-VA care expa...
  
  Date: June 10, 2022
• Challenges and Strain on VA System Associated with VA-Funded Community Care for Veterans with Advanced Kidney Disease
  This study sought to further the understanding of the internal challenges of cross-system healthcare use to the VA healthcare system and enrolled Veterans. Three dominant themes pertaining to VA-financed community care were identified. Themes described VA as mothership, the hidden work of Veterans, and strain on the VA system. ‘VA as mothership’ describes extensive care coordination by VA staff me...
  
  Date: May 16, 2022
• Genetic Consultation Provided by VA Facilities or Centralized VA Virtual Care More Timely and Better Coordinated than Community Care Options
  This study assessed care coordination and equity in the delivery of genetic care for the care models available to VA patients (i.e., VA-traditional, centralized VA-telehealth, and non-VA care). Findings showed that VA genetic care models – both traditional and centralized telehealth – had better care coordination than non-VA care. Veterans referred to non-VA care completed their consult only 57% o...
  
  Date: April 11, 2022
• Specialized Primary Care Homes Effective in Treatment of Patients with Serious Mental Illness
  This project studied the implementation and effectiveness of a primary care medical home specifically designed to improve the healthcare of Veterans with serious mental illness. SMI PACTs (Patient Aligned Care Teams) include a specialized, integrated team that can provide both primary and psychiatric care. Findings showed that a primary care medical home for Veterans with SMI can be safe and more ...
  
  Date: April 5, 2022
• For High-Risk Veterans, Fragmented Care from Multiple Providers Does Not Increase Risk of Hospitalization and May Lower Hospitalization for Ambulatory Care-Sensitive Conditions
  This longitudinal study sought to examine outpatient care fragmentation and its association with future hospitalization among Veterans at high risk for hospitalization. Findings showed that among this cohort, fragmented outpatient care did not increase Veterans’ likelihood of future admission and, in fact, was associated with a lower likelihood of hospitalization for ambulatory care-sensitive cond...
  
  Date: February 18, 2022

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• Care Coordination || In Progress

  Veterans Choice Program.1 Thus, coordinating care between VA and non-VA providers...providers is critical. VA defines care coordination as the...improve clinical decision-making and care, inform patients, evaluate changes in...various topics. In This Issue: Care Coordination Overview Ongoing HSR&D Studies

• Overview: VA Care Coordination || In Progress

  Veterans Choice Program.1 Thus, coordinating care between VA and non-VA providers...providers is critical. VA defines care coordination as the...This Issue: Care Coordination » Table of Contents VA Care Coordination Overview...Veterans Choice Program.1 Thus, coordinating care between VA and non-VA providers

• Identifying and Delivering Point-of-Care Information to Improve Care Coordination with Hepatocellular Cancer || In Progress

  Veterans Choice Program.1 Thus, coordinating care between VA and non-VA providers...providers is critical. VA defines care coordination as the...June 2018 In This Issue: Care Coordination » Table of Contents Identifying and...Delivering Point-of-Care Information to Improve Care Coordination Feature Article

• Integrated Outpatient Palliative Care in Oncology

  Integrated Outpatient Palliative Care in Oncology...Palliative Care in Oncology Integrated Outpatient Palliative Care in Oncology...3312258 #2 "Hospice and Palliative Care Nursing"[Mesh] OR "Palliative Medicine"[Mesh]

• Forum Fall 2017: Role of Nurses in Managing Care

  ...serves a large population requiring care for chronic diseases such as diabetes...psychosocial issues. These Veterans require care delivery designed to improve their quality...purpose of the PEI is to improve Veteran care by informing the QUERI program and ONS...with Chief Nurse Executives, RNTTP Coordinators, and their teams at 19 medical centers

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• Care Fragmentation in VA Home Based Primary Care 08/25/2022

Other Resources

• Visit the VA’s Office of Community Care to learn more about requesting care coordination services with community providers.
• Visit the Care Coordination Quality Enhancement Research Initiative to learn more about their work.
• Learn more about care coordination at the Agency for Healthcare Research & Quality.