QUERI – Quality Enhancement Research Initiative

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The Care Coordination QUERI: Improving Patient-Centered Care Coordination for High-Risk Veterans in PACT

Los Angeles, CA

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The Care Coordination QUERI aims to improve care coordination and experience of care across settings for high-risk Veterans in PACT (Patient-Aligned Care Teams) – and to develop novel approaches to coordinating care between the Veteran, his or her primary care team, and other settings, including specialty care, the emergency department, and home and community resources. Through three different focused efforts, Care Coordination QUERI will evaluate the effectiveness of care coordination tools, facilitation, and organizational readiness assessment as improvement approaches.

Findings and Expected Impacts

  • Improving PACT Coordination across Settings and Services: Coordination Toolkit and Coaching (CTAC) will clarify the most effective strategies for improving care coordination between PACT, specialty care, and community care.
  • Improving Emergency Department (ED) Coordination with PACT (ED-PACT Tool) aims to improve coordination between ED and PACT for Veterans with urgent or specific ED follow-up care needs.
    • A supplemental project is evaluating the ED-Rapid Access Clinics (ED-RAC) program, which aims to spread an innovation to improve coordination for Veterans with post-ED and specialty care needs.
  • Improving Hospital to Community (H2C) Coordination will improve coordination of services for chronically ill Veterans between the VA and non-VA community agencies at hospital discharge.

Principal Investigators: David Ganz, MD, PhD (Corresponding PI [David.Ganz@va.gov]); Kristina Cordasco, MD, MPH, MSHS; and Michael Ong, MD, PhD (VA Los Angeles).

Operations Partner(s):

Patient Care Services (Offices of Primary Care, Care Management and Social Work); Office of Quality, Safety and Value (National Center for Patient Safety); Geriatrics and Extended Care (GEC); Office of the Assistant Deputy Under Secretary for Health (ADUSH) for Clinical Operations; Office of Veterans Access to Care (OVAC); Office of Emergency Medicine (Specialty Care Services); and the VA Greater Los Angeles Healthcare System.