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Publication Briefs

Study Shows Majority of High-Risk Veterans Assigned to General Primary Care Rather than Specialized Primary Care

Patients at high risk for hospitalization typically have multiple chronic medical conditions, often compounded by mental health conditions. A frequent assumption has been that complex, high-risk patients receive care mostly through medical specialists, while primary care is predominantly directed at a lower-risk population. This retrospective study sought to characterize patterns of care for the top 5% highest-risk patients enrolled in VA healthcare nationally (based on Care Assessment Needs – CAN – score). Specifically, investigators compared: primary care encounters (face-to-face, telephone, and secure messages) among high-risk versus low-risk patients; proportions of high-risk patients assigned to general versus specialized primary care; and utilization of primary care and medical (non-surgical) specialty care visits among high-risk patients assigned to general versus specialized primary care. The study cohort included all VA patients assigned to primary care (either general or specialized) in FY2015 (n=4,309,192); of these Veterans, 351,012 were defined as high-risk. Investigators also examined patient demographics, comorbidities, housing stability and “add-on” care (i.e., telehealth, hospice).


  • Most high-risk Veterans (88%) were cared for in general primary care rather than in specialized primary care; the remaining 12% were assigned to specialized primary care (i.e., women’s health, geriatrics, home-based primary care, homeless primary care)
  • High-risk Veterans assigned to general primary care had more mental health and primary care visits than medical specialty care visits.
  • Compared to low-risk patients, high-risk patients had 2.5 times the face-to-face, 4 times the telephone, and twice the number of secure messaging encounters in primary care during the year prior to being identified as being high risk for hospitalization.


  • Approaches to support high-risk patients will likely need to be embedded within general primary care and mental healthcare if they are to improve outcomes for this population. This may be more beneficial than carve-out specialized or intensive primary care programs. Building on efforts currently underway in VA, training and support from specialists at a distance or expansion of add-on services (i.e., telehealth services, palliative or hospice care, housing services) also could potentially improve general primary care for high-risk patients.


  • This study does not address causation.
  • Investigators studied only how many encounters of particular types occurred, without potentially relevant modeling information, i.e., patient functional status or distance to specialized care settings.

Dr. Chang is part of HSR&D’s Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP) in Los Angeles, CA; Dr. Zulman is with HSR&D’s Center for Innovation to Implementation (Ci2i) in Palo Alto, CA: and Dr. Nelson is with HSR&D’s Denver/Seattle Center of Innovation for Veteran-Centered & Value-Driven Care.

Chang E, Zulman D, Nelson K, et al. Use of General Primary Care, Specialized Primary Care, and other Veterans Affairs Services among High-Risk Veterans. JAMA Network Open. June 29, 2020;3(6):e208120.

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HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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