• Hempel S, Ganz D, Saluja S, Bolshakova M, Kim T, Turvey C, Cordasco K, Basu A, Page T, Mahmood R, Motala A, Barnard J, Wong M, Fu N, Miake-Lye IM. Care coordination across healthcare systems: development of a research agenda, implications for practice, and recommendations for policy based on a modified Delphi panel. BMJ open. 2023 May 17; 13(5):e060232.
• Monty GR, Benson SK, Deeds SA, Callegari LS, Katon JG, Cordasco KM, Gray KE. "We Are Working Harder, Not Smarter:" a Qualitative Inquiry Into Care Coordination for Department of Veterans Affairs Mammograms Referred to the Community. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2022 Dec 15.
• Gopisetty DD, Shaw JG, Gray C, Frayne S, Phibbs C, Shankar M. Veteran Postpartum Health: VA Care Team Perspectives on Care Coordination, Health Equity, and Trauma-Informed Care. Military medicine. 2022 Sep 16.
• McCreight M, Rohs C, Lee M, Sjoberg H, Ayele R, Battaglia C, Glasgow RE, Rabin BA. Using a longitudinal multi-method approach to document, assess, and understand adaptations in the Veterans Health Administration Advanced Care Coordination program. Frontiers in Health Services. 2022 Sep 9; 2(2022 Sep 9):970409.
• Crowley MJ, Tarkington PE, Bosworth HB, Jeffreys AS, Coffman CJ, Maciejewski ML, Steinhauser K, Smith VA, Dar MS, Fredrickson SK, Mundy AC, Strawbridge EM, Marcano TJ, Overby DL, Majette Elliott NT, Danus S, Edelman D. Effect of a Comprehensive Telehealth Intervention vs Telemonitoring and Care Coordination in Patients With Persistently Poor Type 2 Diabetes Control: A Randomized Clinical Trial. JAMA internal medicine. 2022 Sep 1; 182(9):943-952.

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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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• Advanced Wound Care Therapies for

  Advanced Wound Care Therapies for Non-Healing Diabetic, Venous, and Arterial...Advanced Wound Care Therapies for Department of Veterans Affairs Health Services...Program November 2012 Advanced Wound Care Therapies for Non-Healing Diabetic,

• Evaluating Care Coordination for Community Hospitalized Veterans || In Progress

  ...team approach to primary care through Patient Aligned Care Teams or PACTs, which...a primary care provider, clinical pharmacist, registered nurse care manager,...VA Primary Care » Table of Contents Evaluating Care Coordination for Community...enhance best practices for hospital care transitions, clarify the factors associated

• VA Maternity Care Coordination || In Progress

  Table of Contents VA Maternity Care Coordination Feature Article A substantial...healthcare, including pregnancy-related care. Recent evidence suggests the number

• https://www.hsrd.research.va.gov/publications/esp/care-coordination-models.cfm

  ...Care Coordination Models and Tools: A Systematic Review and Key Informant Interviews...(ESP) Center Minneapolis VA Health Care System Minneapolis, MN Timothy J. Wilt

• Care Coordination Models and Tools: A Systematic Review and Key Informant Interviews

  ...Care Coordination Models and Tools: A Systematic Review and Key Informant Interviews...Care Coordination Models and Tools: A Systematic Review and Key Informant Interviews...(ESP) Center Minneapolis VA Health Care System Minneapolis, MN Timothy J. Wilt

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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.