FORUM - Translating research into quality health care for Veterans

Fall 2016

In This Issue

Director's Letter

Director's Letter
by David Atkins, MD, MPH, Acting Chief Research and Development Officer

The Chronic Care Model is now close to 20 years old.¹ In it, Ed Wagner and his co-authors outlined six elements necessary to support an effective partnership between clinicians and patients to optimize care of chronic conditions: support for self-management skills of patients; clinical decision support based on evidence-based guidelines; electronic data infrastructure to track individual and population progress; a delivery system designed to promote collaboration; and supportive health systems and community resources where efforts and incentives are aligned...

Commentary

Unraveling the "Black Box" of Case Management
By Thomas P. O'Toole, MD, National Center on Homelessness among Veterans, VACO Homeless Program Office

How many times have we reviewed a clinical case, attempted to navigate a complex treatment plan with a patient and his or her family, or tried to communicate with a provider outside the VA system only to be left with a sense of frustration and futility? Our conditioned response has often been to refer the patient for case management...

Response to Commentary

The Who, Where, When, How, and What of Case Management and Integrated Care
By Kurt Kroenke, MD, HSR&D Center for Health Information and Communication, Indianapolis, Indiana

Dr. O'Toole nicely highlights key components of effective case management and identifies both gaps and opportunities in this increasingly important aspect of integrated health care. Building upon his commentary, I highlight additional factors that might enhance the effectiveness not only of case management but also of integrated care writ large...

Research Highlights

The Potential Role of Secure Messaging in Care Management
By Thomas K. Houston, MD, MPH, and Timothy P. Hogan, PhD, both with HSR&D's Center for Healthcare Organization and Implementation Research and eHealth Partnered Evaluation Initiative, Bedford, Massachusetts

In line with this FORUM's focus on care management, we report on recent research related to Secure Messaging's potential to support care management and shared decision making outside the "bricks and mortar" of in-person clinic visits. VA serves a Veteran population with a heavy burden of chronic illness. As the Veteran population ages, the prevalence of VA users with multiple chronic conditions will continue to rise...

Enhancing Primary Care to Serve Veterans with Serious Mental Illness: SMI PACT
By Alexander S. Young, MD, MSHS, and Amy N. Cohen, PhD, HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, and VA Desert Pacific Mental Illness Research, Education, and Clinical Center, both in Los Angeles, California

Health care systems are interested in identifying patients at high risk of hospitalization or poor outcomes and proactively improving their care. This high-risk patient population includes a large proportion of individuals with mental illness or substance use disorders. Individuals with serious mental illness (SMI) have not benefited from improvements in prevention and primary care that have reduced mortality in the rest of the population over recent decades...

Potential Role of Peer Support in Care Management
By Marcia Valenstein, MD, MS, VA Serious Mental Illness Treatment Resource and Evaluation Center and HSR&D Center for Clinical Management Research, Ann Arbor, Michigan

The intersection between peer support and care management is of increasing interest to mental health services researchers, leaders, and policymakers. Care management is a key part of team-based mental health care, including mental health care that is delivered in specialty settings or in primary care. Collaborative care, an evidence-based model of primary care, emphasizes ongoing care management for persons with mental health conditions treated in primary care....

The ED-PACT Tool: Supporting Care Management
By Kristina M. Cordasco, MD, MPH, MSHS, and David A. Ganz, MD, PhD, VA Care Coordination QUERI and the HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, Los Angeles, California

Multiple studies have documented that poor communication leads to poor patient outcomes, or "near misses," after patients are discharged from hospital care.1 Researchers have given less attention to the transition of care between emergency department (ED) and ambulatory care settings. However, the limited literature available suggests that patients' failures to receive follow-up care after being sent home from an ED visit are associated with poor patient outcomes...

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