QUERI – Quality Enhancement Research Initiative

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Bridging the Care Continuum QUERI

Bedford, MA

Principal Investigators: Allen Gifford, MD (Corresponding PI, Bedford VA); Keith McInnes (Bedford VA), ScD, MPH, Amanda Midboe, PhD (VA Palo Alto), David Smelson (Bedford VA), PsyD

Principal Operational Partners: VA's Clinical Public Health Group, VA National Center on Homelessness among Veterans, Health Care for Re-entry Veterans (HCRV) Program, and the Office of Health Equity.

Executive Summary:

Veterans with social vulnerabilities face grave challenges negotiating or "bridging" the Continuum of Care that extends from diagnosis to treatment, and ultimately to improved health outcomes. Why do Veterans with good health coverageface this difficulty? The VA Blueprint for Excellence makes the case that "Individuals with multiple health vulnerabilities - age, poverty, social isolation, physical andmental 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 - HIV Care Continuum Initiative, which established this model for HIV care.

Program MyVA Goals: Ending homelessness and enhancing strategic partnerships with the justice system. The MyVA initiative will reorient VA around Veterans' needs and empower employees to assist them in delivering excellent customer service to improve their experience with VA healthcare.

Program Objectives:

Bridge QUERI will implement and test models of care to help vulnerable Veterans negotiate the Care Continuum. Several selected sets of problems will be targeted, including comorbid substance use and mental illness, hepatitis, and incarceration - 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 goal of BridgeQUERI is to improve vulnerable Veterans' use of services across the Care Continuum, "bridging" the Continuum by improving outreach and diagnosis, as well as linkage and engagement with specialty care, which will lead to better health outcomes.

Program Methods:

This QUERI program is guided by the following conceptual models:

  • Care Continuum for Vulnerable Veterans (Policy Framework),
  • Consolidated Framework for Implementation Research (CFIR), and
  • Facilitation (the Implementation Strategy).

Programs for system improvement may be primarily disease-focused, or may organize around social challenges faced by these Veterans.

Project Summaries:

Project 1 (Quality Improvement): Liver Disease Outreach is a local quality improvement (QI) project. Through established partnerships with VISN 1, the New England VA Engineering Resource Center (VERC), and support and complementary funding from the HIV, Hepatitis and Public Health Pathogens Programs (HHPHP), this project will employ QI and Lean management to improve local practices, and expand hepatitis C testing and linkage to care in order to prevent cirrhotic liver disease.

Project 2: Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking (MISSION) integrates mental health and substance treatment, engaging homeless Veterans in healthcare. This project will be implemented in LA Homeless-PACT clinics to understand facilitation in implementing a complex intervention.

Project 3: Veterans Justice Reentry (Post-Incarceration) will use contextual analysis and network mapping to prepare for and implement peer-support that links and engages Veterans with VA and community healthcare after release from incarceration. This two-state comparative implementation will occur in VISNs 1 and 4.