DESCRIPTION (provided by applicant): In this application, we present the Bridging the Care Continuum QUERI (hereafter, the BridgeQUERI). Veterans with social vulnerabilities face grave challenges negotiating, or "bridging" the Continuum of Care - a Continuum that extends from community populations, to diagnosis and linkage, engagement, and high quality treatment, and ultimately to improved health outcomes. Why do Veterans, who have good health coverage, face this difficulty? The Blueprint for Excellence makes the case, and provides compelling rationale for the BridgeQUERI: "Individuals with multiple health vulnerabilities - like age, poverty, social isolatio, physical and mental illness, substance use, and homelessness - fare poorly even with robust insurance coverage." Poverty, justice system involvement, homelessness, and social circumstances make Veterans more vulnerable to serious health problems requiring specialized, often highly complex care. The challenges of negotiating the Care Continuum were recognized by President Obama in his 2013 Executive Order establishing this model for HIV. Consequently, the continuum has dramatically shaped VHA policy for programs to connect needy Veterans to specialized care, and is now being applied to hepatitis C and other diseases. BridgeQUERI will implement and test models of care to help vulnerable Veterans negotiate the Care Continuum. We target several selected sets of problems (comorbid substance use and mental illness, hepatitis, incarceration) as case examples - not because they address all health vulnerabilities, but because they are important opportunities for improvement. The problems are serious, disproportionately prevalent in vulnerable Veterans, and require complex, specialized services. The BridgeQUERI Impact Goal is to improve vulnerable Veterans' use of services across the Care Continuum, "bridging" the Continuum by improving outreach and diagnosis, linkage and engagement with specialty care, and health outcomes. This impact goal will contribute to BPE Strategy 3, developing "...models of healthcare delivery to optimize individual and population outcomes". We will accomplish this goal through 4 projects, and the Implementation Core, over 4 years. Specific Aims of the projects and the Core are guided by the following conceptual models: (1) the Care Continuum for Vulnerable Veterans (Policy Framework), (2) the Consolidated Framework for Implementation Research (CFIR; the Theoretical Framework), and (3) Facilitation (the Implementation Strategy). Programs for system improvement may be primarily disease-focused, or alternatively may organize around social challenges these Veterans face. We have intentionally chosen two projects using each of these two organizing conceptual frames, believing that each has advantages, and that both will lead to insights. 1) Liver Disease Outreach (QI) is a local QI project. Through established partnerships with VISN1, the New England VA Engineering Resource Center (VERC), and support and complementary funding from the HIV, Hepatitis and Public Health Pathogens Program (HHPHP), we will employ QI and Lean management to improve local practices, expanding hepatitis C testing and linkage to care to prevent cirrhotic liver disease. 2) Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking (MISSION) integrates mental health and substance treatment, engaging homeless Veterans in health care, and will be implemented in LA Homeless-PACT clinics to understand facilitation in implementing a complex intervention. 3) Veterans Justice Reentry (Post-Incarceration) will use contextual analysis and network mapping to prepare for, and implement, peer-support that links and engages Veterans with VHA and community health care after release from incarceration. This two state comparative implementation will occur in VISNs 1 and 4. 4) Cirrhosis Management (Cirrhosis) will use a primarily informatics approach to filling gaps in the care continuum for vulnerable Veterans with late-stage disease. We will refine and deploy a dashboard tool for cirrhosis management and evaluate its implementation across 3 large, geographically distinct VAs.

There is high prevalence of social/behavioral/economic vulnerability among Veterans, which impacts health and the need for specialized care services. The VA's Blueprint for Excellence recognizes the importance of meeting the needs of highly vulnerable Veterans and the priority of developing “…models of healthcare delivery to optimize individual and population outcomes.” The Bridging the Care Continuum QUERI (BridgeQUERI) will develop and use evidence to implement programs assuring delivery of complex but crucial specialty care services. The BridgeQUERI Impact Goal is to improve vulnerable Veterans' use of services across the Care Continuum, “bridging” the Continuum by improving outreach and diagnosis, linkage and engagement with specialty care, and ultimately health outcomes. We will conduct 3 implementation- effectiveness studies and one quality improvement project over a total of four years to meet this goal.