# Care Coordination for High-Risk Patients with Multiple Chronic Conditions

> **NIH VA I01** · VETERANS ADMIN PALO ALTO HEALTH CARE SYS · 2021 · —

## Abstract

Background. Care fragmentation is a mounting challenge for Veterans, many of whom face multiple chronic
conditions requiring care from different providers and clinics. This issue is likely to intensify in light of a policy
environment that increasingly encourages Veterans’ dual use of VA and community care. When patient care
is dispersed across providers, clinics, and health systems, it increases risks of information loss, medication
interactions, and unwieldy treatment regimens, leading to health deterioration. Veterans in poor health and
those with functional limitations or resource constraints may be especially vulnerable, yet little is known about
fragmentation patterns and care coordination needs in these high-risk patients.
Project Objectives. The objective of this study is to advance understanding of care fragmentation and care
coordination’s potential among high-risk Veterans with multiple chronic conditions.
Project Methods. To achieve the study goals, we will first describe care fragmentation prevalence and
variation in a national cohort of high-risk patients (Aim 1). We will then examine the relationships between
care fragmentation and outcomes, including acute care utilization (Aim 2.1) and patient-reported care
experience (Aim 3.1). Finally we will evaluate whether randomization to comprehensive care coordination
mitigates the effects of fragmentation (Aims 2.2 and 3.2).
 Aim 1. We will use 2014-2015 VA, VA purchased care (including Veterans Access, Choice, and
 Accountability Act), and Medicare data from a national sample of high-risk patients (Care Assessment
 Needs hospitalization risk score ≥ 90th percentile). In Aim 1.1, we will describe primary care, outpatient
 care, and health system fragmentation, using validated and adapted measures of care fragmentation and
 discontinuity. Using a theoretical approach to compare measures, we will select a primary fragmentation
 measure within each domain for use in subsequent aims. In Aim 1.2, we will use these select measures to
 examine variation in care fragmentation by patient characteristics (e.g., age, sex, chronic conditions,
 housing instability, distance from VA, and enrollment in care coordination programs).
 Aim 2. Using select fragmentation measures identified in Aim 1.1, we will evaluate the relationship between
 care fragmentation and acute care utilization among high-risk Veterans. In Aim 2.1, we will determine
 whether care fragmentation is independently associated with higher rates of acute care utilization (including
 emergency department visits and hospitalizations). In Aim 2.2, we will take advantage of an ongoing
 randomized evaluation of an Office of Primary Care PACT-Intensive Management (PIM) Demonstration
 Program to test whether comprehensive care coordination influences the relationship between
 fragmentation and acute care outcomes.
 Aim 3. In Aim 3, we will analyze findings from an operations-supported survey administered to high-risk
 patients in the PIM De...

## Key facts

- **NIH application ID:** 9883779
- **Project number:** 5I01HX002127-03
- **Recipient organization:** VETERANS ADMIN PALO ALTO HEALTH CARE SYS
- **Principal Investigator:** Donna Michelle Zulman
- **Activity code:** I01 (R01, R21, SBIR, etc.)
- **Funding institute:** VA
- **Fiscal year:** 2021
- **Award amount:** —
- **Award type:** 5
- **Project period:** 2018-01-01 → 2021-12-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/9883779

## Citation

> US National Institutes of Health, RePORTER application 9883779, Care Coordination for High-Risk Patients with Multiple Chronic Conditions (5I01HX002127-03). Retrieved via AI Analytics 2026-05-24 from https://api.ai-analytics.org/grant/nih/9883779. Licensed CC0.

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