# Improving Care for Complex, High-Risk Patients in Primary Care

> **NIH VA I50** · VA GREATER LOS ANGELES HEALTHCARE SYSTEM · 2021 · —

## Abstract

The top 5% of Veterans at the highest risk for hospitalizations account for almost 50% of VHA healthcare
costs, have significant multimorbidity, and are at high risk for poor health outcomes. In the VHA, most (88%)
high-risk patients are managed by general primary care teams (i.e., Patient-Aligned Care Teams; PACTs). Few
PACTs, however, have implemented evidence-based practices (EBPs) known to address the most common
issues among high-risk Veterans. Some evidence indicates that usual implementation strategies, such as
dissemination of toolkits and training are not effective for improving uptake of EBPs. The most effective
implementation strategies to achieve evidence-based care for high-risk patients, however, are unknown.
The overall impact goal of the high-RIsk VETerans (RIVET) QUERI Program is to improve VHA primary care
capacity to provide comprehensive, evidence-based care for complex, high-risk Veterans. We will test 2
implementation strategies to implement two EBPs: 1) Comprehensive Assessment and Care Planning (CACP),
and 2) Phone-Based Health Coaching for Medication Adherence (HCMA). CACP is based on the
Comprehensive Geriatric Assessment and guides teams in systematically addressing patients’ cognitive,
functional, and social needs through a comprehensive care plan. HCMA addresses common challenges to
medication adherence using a patient-centered approach through virtual encounters. Both comprehensive
assessments and health coaching have demonstrated efficacy in randomized, controlled trials and have been
implemented by two of our national partners in geriatrics and Whole Health teams. However, both EBPs have
had low uptake in primary care. Implementing these practices in primary care has the potential to improve
quality of care for the large majority of high-risk Veterans.
To improve implementation of EBPs in primary care we will compare two strategies: Evidence-Based Quality
Improvement-Individual Consultation (EBQI-IC) and EBQI-Learning Collaborative (EBQI-LC) (Aim 1). EBQI
has been successfully used to implement complex evidence-based practices in primary care, such as the
PACT model and primary care-mental health integration. EBQI core components include engaging VISN- and
facility-level multidisciplinary stakeholders in evidence-based agenda setting and fostering structured front-line
innovation directed towards agenda goals. Some EBQI initiatives have focused on using EBQI core
components in combination with individual site-level consultation, while others have leveraged group facilitation
through learning collaboratives. These two approaches have not been directly compared, leaving implementers
without guidance on how best to implement EBQI. We will test how EBQI delivered using individual site
consultation (EBQI-IC) or delivered within groups of sites functioning as a learning collaborative (EBQI-LC) will
increase EBP uptake and sustainment.
We will conduct a mixed methods type 3 hybrid effectiveness-implementation design to te...

## Key facts

- **NIH application ID:** 10181667
- **Project number:** 1I50HX003204-01A1
- **Recipient organization:** VA GREATER LOS ANGELES HEALTHCARE SYSTEM
- **Principal Investigator:** Evelyn T Chang
- **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/10181667

## Citation

> US National Institutes of Health, RePORTER application 10181667, Improving Care for Complex, High-Risk Patients in Primary Care (1I50HX003204-01A1). Retrieved via AI Analytics 2026-05-24 from https://api.ai-analytics.org/grant/nih/10181667. Licensed CC0.

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