The goal of the Quadruple Aim Quality Enhancement Research Initiative (QUERI) is to enhance Veteran outcomes and experience, clinician engagement, and cost of care by providing value-based care coordination between Veterans Health Administration (VA) and community settings for Veterans and stakeholders. Veterans increasingly receive care in the VA and the community. These dual-use Veterans are at risk for fragmented care coordination across healthcare settings, which contributes to adverse outcomes, experience, and cost of care. This proposal aims to transform care coordination in three high-risk populations through implementation of three evidence-based practices (EBPs): The Transitions Nurse Program for Home Health Care (TNP-HHC) is for Veterans who require skilled home health care after discharge from a VA. TNP-HHC is adapted from a previous TNP that included these key evidence-based components: 1) interact with Veterans in the hospital, 2) assess discharge readiness, 3) coordinate care across care settings, and 4) communicate with Veterans upon discharge. TNP improved access to primary care after discharge and reduced mortality for rural Veterans. The Community Care Network for Opioid Use Disorder (OUD) Treatment Program is for Veterans with OUD being treated in community care settings. The program will increase the use of evidence-based medications that have demonstrated lower mortality among patients with OUD. The Care Coordination and Management for Veterans Hospitalized in the Community aims to return Veterans back to the VA and VA assigned primary care for on-going care after hospitalization or emergency care services in the community. Evidence shows that case management for complex patients improves health and reduces hospital/emergency care admissions when a multidisciplinary team assesses level of need and utilizes a whole-person approach to health to develop a plan of care in collaboration with primary and specialty teams. These EBPs will be supported by two implementation strategy bundles: Iterative RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) and Relational Facilitation to scale-up and spread the EBPs. Iterative RE-AIM is a conceptually based adaptation of audit and feedback that incorporates periodic multi-method assessments to evaluate progress and optimize implementation outcomes. Relational Facilitation uses the theory of relational coordination to create and sustain high-quality relationships in healthcare teams. The QUERI Implementation Roadmap will guide implementation across all three EBPs: Aim 1: Pre- implementation: Engage clinical, operational and Veteran stakeholders; gather perspectives on context, key partners, engagement, and resources. Adapt core elements of the EBPs, make local adaptations, and finalize details of our implementation bundles. Aim 2: Implementation: Train teams on EBPs using implementation playbooks, implement EBPs at 18 + sites (6-10 per EBP) using randomized stepped-wedge design. Evaluate EBP and implementation outcomes using periodic iterative RE-AIM. Adapt intensity of Relation Facilitation to enhance VA quality metrics. Aim 3: Sustainability: Evaluate value-based including clinical and implementation outcomes, replication costs, and cost effectiveness as measured by RE-AIM outcomes. Plan for sustainment by monitoring changes to EBPs and revising our implementation playbooks to support scale-up and spread to new sites. This QUERI aligns with the VA?s modernization priorities to Implement the MISSION Act and Reduce Unwarranted Variation. National program offices and Veterans Integrated Service Network (VISN) leaders worked with us to design a program that provides optimal care for Veterans and clinicians at a lower cost.

I50HX003275

2020-10-01

2025-09-30