# Value-Based Care to Improve the Quadruple Aim for Veterans and Stakeholders

> **NIH VA I50** · VA EASTERN COLORADO HEALTH CARE SYSTEM · 2021 · —

## Abstract

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 de...

## Key facts

- **NIH application ID:** 10069977
- **Project number:** 1I50HX003275-01
- **Recipient organization:** VA EASTERN COLORADO HEALTH CARE SYSTEM
- **Principal Investigator:** Catherine T Battaglia
- **Activity code:** I50 (R01, R21, SBIR, etc.)
- **Funding institute:** VA
- **Fiscal year:** 2021
- **Award amount:** —
- **Award type:** 1
- **Project period:** 2020-10-01 → 2025-09-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10069977

## Citation

> US National Institutes of Health, RePORTER application 10069977, Value-Based Care to Improve the Quadruple Aim for Veterans and Stakeholders (1I50HX003275-01). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/10069977. Licensed CC0.

---

*[NIH grants dataset](/datasets/nih-grants) · CC0 1.0*