High-Risk Veteran Initiative

NCT05050643 | Active Not Recruiting

• 1 other identifier: QUX 21-005
• Study Type: interventional
• Target: 17
• Locations: 1 country
• Sites: 3

Brief Summary

Veterans at high-risk for hospitalization, including those with complex care needs, represent a large population of VHA patients who often do not receive evidence-based primary care practices that would help them avoid the hospital and improve their health. The high-RIsk VETerans (RIVET) Program will implement evidence-based practices that can support VHA Primary Care teams to deliver more comprehensive and patient-centered care, better strategies to manage medications, and avoid unnecessary hospitalizations. The RIVET Program is designed to find the most effective approaches to increasing use of evidence-based practices for high-risk Veterans in primary care, provide rapid data feedback to VHA on high-risk patient care, build capacity for the implementation of evidence-based practices, and train future leaders in high-risk Veteran care.

Conditions

Multimorbidity

Keywords

Primary Health Care; Multimorbidity; Medication Adherence; Needs Assessment; Mentoring

Outcome Measures

Primary Outcomes (1)

• Change in the proportion of team-assigned primary care patients in the upper 90th percentile of acute hospitalization risk (identified via VA CAN score) who received the Evidence Based Practice (EBP)

  This primary outcome aims to measure reach of the evidence practices to implement the EBP.

  18

Secondary Outcomes (17)

• Number of PACT encounters from social worker, pharmacist, nurse and integrated mental health

  18 months

• Number of encounters from PACT pharmacist, social worker, nurse and integrated mental health

  18 months

• Comprehensiveness of Care questions from the RIVET Patient Survey- consisting of three items, which was sourced from the SHEP

  18 months

• Self-Management Support questions from the RIVET Patient Survey- sourced from the SHEP, which is two items in the survey.

  18 months

• PACT provider perceived support for high-risk patient care questions from the RIVET Clinician Survey- three survey items assessing confidences, skills and strain/satisfaction with caring for high-risk patients

  18 months

Study Arms (4)

CACP-EBQI-IC

ACTIVE COMPARATOR

Individual (ongoing) consultation (IC), often described as coaching or supervision, is endorsed by implementation experts as an effective implementation strategy for EBP #1, Comprehensive Assessment and Care Planning (CACP) for High-Risk Veterans.

Other: EBQI-IC

CACP-EBQI-LC

ACTIVE COMPARATOR

Learning collaboratives (LC) are widely used in healthcare settings, as an effective implementation strategy. The LC will be used to increase uptake of EBP #1, Comprehensive Assessment and Care Planning (CACP) for High-Risk Veterans.

Other: EBQI-LC

HCMA-EBQI-IC

ACTIVE COMPARATOR

Individual (ongoing) consultation (IC), often described as coaching or supervision, is endorsed by implementation experts as an effective implementation strategy for EBP # 2,Phone-Based Health Coaching for Medication Adherence (HCMA).

Other: EBQI-IC

HCMA-EBQI-LC

ACTIVE COMPARATOR

Learning collaboratives (LC) are widely used in healthcare settings, as an effective implementation strategy. The LC will be used to increase uptake of EBP # 2,Phone-Based Health Coaching for Medication Adherence (HCMA).

Other: EBQI-LC

Interventions

EBQI-IC OTHER

Individual (ongoing) consultation (IC), often described as coaching or supervision, is endorsed by implementation experts as an effective implementation strategy

Also known as: Individual Consultation

CACP-EBQI-IC; HCMA-EBQI-IC

EBQI-LC OTHER

A Learning Collaborative is a systematic approach to process improvement based on the Institute for Healthcare Improvement Breakthrough Series Collaborative model. During the Collaborative, organizations will test and implement system changes and measure their impact. They will share their experiences to accelerate learning and broader implementation of best practices.

Also known as: Learning Collaborative

CACP-EBQI-LC; HCMA-EBQI-LC

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• Any VA site nationwide

You may not qualify if:

• Not a VA site nationwide

Sponsors & Collaborators

• VA Office of Research and Development: lead
• Veterans Health Administration Office of Primary Care: collaborator
• Veterans Health Administration Office of Patient Centered Care & Cultural Transformation: collaborator
• US Department of Veterans Affairs: collaborator
• Veterans Integrated Service Network 10: collaborator
• Veterans Integrated Service Network 12: collaborator
• VA MidSouth Healthcare Network: collaborator

Study Sites (3)

VA Greater Los Angeles Healthcare System, Sepulveda, CA

Sepulveda, California, 91343, United States

Location

VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA

Pittsburgh, Pennsylvania, 15240, United States

Location

VA Puget Sound Health Care System Seattle Division, Seattle, WA

Seattle, Washington, 98108-1532, United States

Location

Related Publications (1)

• Jimenez EE, Rosland AM, Stockdale SE, Reddy A, Wong MS, Torrence N, Huynh A, Chang ET. Implementing evidence-based practices to improve primary care for high-risk patients: study protocol for the VA high-RIsk VETerans (RIVET) type III effectiveness-implementation trial. Implement Sci Commun. 2024 Jul 15;5(1):75. doi: 10.1186/s43058-024-00613-9.

  PMID: 39010160 DERIVED

MeSH Terms

Conditions

Medication Adherence

Condition Hierarchy (Ancestors)

Patient Compliance; Patient Acceptance of Health Care; Treatment Adherence and Compliance; Health Behavior; Behavior

Study Officials

• Evelyn T Chang, MD MSHS

  VA Greater Los Angeles Healthcare System, Sepulveda, CA

  PRINCIPAL INVESTIGATOR

• Susan E Stockdale, PhD MA

  VA Greater Los Angeles Healthcare System, Sepulveda, CA

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: NONE
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: PARALLEL
• Sponsor Type: FED
• Responsible Party: SPONSOR

Model Details: The investigators will conduct a mixed-methods type 3 hybrid implementation-effectiveness evaluation using a Concurrent Stepped Wedge design to compare two implementation strategies to increase adoption of the EBPs in primary care in 16 sites: Evidence-Based Quality Improvement (EBQI)-Individual Consultation (EBQI-IC) and EBQI-Learning Collaborative (EBQI-LC). Each VISN will implement a single EBP \[Comprehensive Assessment and Care Planning (CACP) for High-Risk Veterans or Phone-Based Health Coaching for Medication Adherence (HCMA)\]. Implementation strategies will be randomized by site. Time periods without active implementation will serve as the usual care periods for both EBQI conditions.

Study Record Dates

• First Submitted: September 9, 2021
• First Posted: September 20, 2021
• Study Start: July 23, 2021
• Primary Completion: September 30, 2025
• Study Completion (Estimated): December 30, 2026
• Last Updated: October 23, 2025

Record last verified: 2025-10

Data Sharing

• IPD Sharing: Will not share

Locations

US (3)