DESCRIPTION (provided by applicant): In this application, we present the Bridging the Care Continuum QUERI (hereafter, the BridgeQUERI). Veterans with social vulnerabilities face grave challenges negotiating, or "bridging" the Continuum of Care - a Continuum that extends from community populations, to diagnosis and linkage, engagement, and high quality treatment, and ultimately to improved health outcomes. Why do Veterans, who have good health coverage, face this difficulty? The Blueprint for Excellence makes the case, and provides compelling rationale for the BridgeQUERI: "Individuals with multiple health vulnerabilities - like age, poverty, social isolatio, physical and mental illness, substance use, and homelessness - fare poorly even with robust insurance coverage." Poverty, justice system involvement, homelessness, and social circumstances make Veterans more vulnerable to serious health problems requiring specialized, often highly complex care. The challenges of negotiating the Care Continuum were recognized by President Obama in his 2013 Executive Order establishing this model for HIV. Consequently, the continuum has dramatically shaped VHA policy for programs to connect needy Veterans to specialized care, and is now being applied to hepatitis C and other diseases. BridgeQUERI will implement and test models of care to help vulnerable Veterans negotiate the Care Continuum. We target several selected sets of problems (comorbid substance use and mental illness, hepatitis, incarceration) as case examples - not because they address all health vulnerabilities, but because they are important opportunities for improvement. The problems are serious, disproportionately prevalent in vulnerable Veterans, and require complex, specialized services. The BridgeQUERI Impact Goal is to improve vulnerable Veterans' use of services across the Care Continuum, "bridging" the Continuum by improving outreach and diagnosis, linkage and engagement with specialty care, and health outcomes. This impact goal will contribute to BPE Strategy 3, developing "...models of healthcare delivery to optimize individual and population outcomes". We will accomplish this goal through 4 projects, and the Implementation Core, over 4 years. Specific Aims of the projects and the Core are guided by the following conceptual models: (1) the Care Continuum for Vulnerable Veterans (Policy Framework), (2) the Consolidated Framework for Implementation Research (CFIR; the Theoretical Framework), and (3) Facilitation (the Implementation Strategy). Programs for system improvement may be primarily disease-focused, or alternatively may organize around social challenges these Veterans face. We have intentionally chosen two projects using each of these two organizing conceptual frames, believing that each has advantages, and that both will lead to insights. 1) Liver Disease Outreach (QI) is a local QI project. Through established partnerships with VISN1, the New England VA Engineering Res...