Center for Health Equity Research and Promotion
QUERI RIVET Advances Primary Care for Veterans with Complex Care Needs
Addressing the complex needs of high-risk Veterans
The High-RIsk VETerans (RIVET) QUERI Program aims to advance VA primary care’s ability to provide comprehensive, evidence-based care for high-risk Veterans with complex needs. RIVET will support VA as a learning organization through data-driven priority setting, leveraging virtual care to enhance mental and whole health and standardizing care to reduce inefficiency and clinical variation.
(Stock photo for illustrative purposes only)
Implementing evidence-based practices in primary care
The top 5% of Veterans at the highest risk for hospitalizations account for almost 50% of VA health care costs, have significant multimorbidity, and are at high risk for poor health outcomes. Evidence-based practices (EBPs) are available to address common needs among high-risk Veterans, such as assessing for functional, behavioral, and social needs and developing a cohesive treatment plan. Increasing use of these practices in primary care can significantly impact health outcomes and quality of care for these high-risk Veterans.
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Comprehensive Assessment and Care Planning Health care staff assess for modifiable risk factors and create a comprehensive care plan that addresses Veteran needs. |
Primary care delivery of evidence-based practices will: · Increase shared-decision making and whole health approach to care · Address barriers to medication adherence · Reduce hospitalizations for ambulatory care-sensitive conditions |
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Phone-Based Health Coaching for Medication Adherence Phone-based health coaching allows staff to virtually identify and address Veteran goals, preferences, and barriers related to taking medications. |
Supporting sites with evidence-based tools and strategies
Evidence-Based Quality Improvement (EBQI) is a bundle of implementation strategies that engages national-, VISN-, and facility-level leadership and frontline staff in identifying challenges and developing agendas based on data.
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EBQI: Individual Consultation – Tailored individual consultation with each participating site |
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EBQI: Learning Collaborative – Learning collaborative with multiple sites |
Developing future implementation leaders
The RIVET Mentoring Core is providing training and mentoring opportunities in the implementation of evidence-based practices for high-risk Veterans.
- Mentors are collaborating to develop mentees’ knowledge and experience through participation in implementation and evaluation of quality improvement initiatives.
- Mentees will enhance their skills in: continuous quality improvement, stakeholder engagement, implementation study design and evaluation, and advanced qualitative and quantitative evaluation techniques.
Advancing primary care’s ability to serve Veterans
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GOAL: Provide comprehensive, reliable, high-quality care for complex high-risk patients |
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• Implementation playbooks • Return on investment analyses • Regular briefings to national and VISN partners
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Principal Investigators: Evelyn Chang, MD, MSHS (Los Angeles, CA) Susan Stockdale, PhD (Los Angeles, CA) Ashok Reddy, MD, MSc (Puget Sound, WA) Ann-Marie Rosland, MD, MS (Pittsburgh, PA) |
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