Improving Healthcare for Veterans

Select VA HSR&D Contributions

VA is making significant strides toward improving the quality of healthcare provided to Veterans, 

particularly in regard to enhancing the delivery of care, increasing access to care, and monitoring 

care to see where improvements can be made. HSR&D researchers play a vital role in these efforts by 

examining the organization, delivery, and financing of healthcare. HSR&D research is enhanced by 

strong collaborations with VA clinicians, managers, and operations. Below are several brief descriptions 

of how HSR&D research has made an impact on the quality of healthcare for Veterans.

Advancing Quality and Care for Women Veterans 

A body of HSR&D research indicates that resources needed to care for women Veterans differ from those 

needed to care for male Veterans and has contributed to the re-organization of care for women Veterans. 

HSR&D’s evaluation of the impact of VA practice structures and primary care delivery on the quality of care 

for women Veterans has played a key role in the Women Veterans Health Strategic Health Care Group’s 

development of a national plan for comprehensive practice redesign of primary care delivery for women. 

Translating Initiatives for Depression into Effective Solutions (TIDES)

VA/HSR&D’s Mental Health Quality Enhancement Research Initiative (QUERI) 

group developed the Translating Initiatives for Depression into Effective 

Solutions (TIDES) model for collaborative depression management in the 

primary care setting. Implementation of the model in three VISNs showed 

70% recovery of depression after six months among Veterans in primary care. 

TIDES is now part of VA’s Mental Health Primary Care Integration Initiative, 

which aims to implement improved mental health care models in all VISNs.

HSR&D Helps Evaluate VA Patient-Centered Medical Home

The Patient-Centered Medical Home (PCMH) is a team-based model of care. Utilizing the expertise of HSR&D 

investigators, and their partnerships with clinical leaders, five Demonstration Labs will evaluate the effectiveness 

and impacts of the VA Patient-Centered Medical Home, as this model is adapted and implemented within the VA 

healthcare system. PCMH Demonstration Labs are co-located at established HSR&D Centers of Excellence.

Improving End-of-Life Care

Several HSR&D research projects have worked to improve end-of-life care for Veterans. The Veterans Hospice 

Care Study served as the focal point for efforts to improve end-of-life care throughout the VA healthcare system 

in the late ‘90s by describing Veteran and family satisfaction with care and identifying barriers to obtaining care. 

Currently, the PROMISE (Performance Reporting and Outcomes Measurement to Improve the Standard of care at 

End-of-Life) project is an integral part of VA’s Comprehensive End-of-Life Care Initiative, a new, large-scale effort to 

increase access to high-quality hospice and palliative care services among Veterans. 

The HSR&D-developed 

TIDES model for depression 

treatment is now part of 

VA’s Mental Health Primary 

Care Integration Initiative.

Improving Healthcare for Veterans - Select VA HSR&D Contributions May 2010
Improving HIV Screening with Rapid Testing

VA/HSR&D’s HIV/Hepatitis Quality Enhancement Research Initiative (QUERI) group has shown that administering a 

rapid HIV test to Veterans, along with streamlined counseling, greatly increases both testing and receipt of results. 

Rapid HIV testing has been implemented in one VISN, and if cost-effectiveness and increased testing turn out as 

expected, rapid testing will be implemented in VA facilities across the country.

Improving Influenza and Pneumonia Vaccination

HSR&D research presented evidence of the effectiveness of the influenza vaccine 

and the importance of yearly vaccination for Veterans and VA employees. 

Investigators recommended immunization programs that ultimately helped to 

increase vaccination rates across VA. Subsequently, VA/HSR&D’s Spinal Cord Injury 

Quality Enhancement Research Initiative (QUERI) group identified the life-saving 

benefits of influenza and pneumonia vaccination among Veterans with spinal cord 

injury, developing and implementing an intervention to increase vaccination rates that is now in use at all 23 VA SCI 

centers. This work has resulted in significant increases in vaccination rates over time, a modification of the clinical 

reminder for vaccination, and changes in VA vaccination policy. 

Improving Colorectal Screening and Follow-up 

As a first step to improving care for colorectal cancer (CRC), HSR&D and QUERI investigators worked to better 

understand the primary care practice and patient-level characteristics predictive of better screening and follow-up. 

Collaborating with the Office of Quality and Performance, investigators took advantage of VA’s focus on primary 

care delivery, comprehensive electronic health record, and incentivized performance audit-and-feedback to develop 

new quality improvement initiatives that led to greatly increased CRC screening rates among Veterans. Also as a 

result of this successful collaboration, a new performance monitor was put into place that focuses on follow-up of 

positive FOBTs within 60 days.

HSR&D Researcher Co-Chairs Primary Care Diabetes System Redesign

The Co-Clinical Coordinator for VA/HSR&D’s Diabetes Mellitus Quality Enhancement Research Initiative (QUERI) 

group is co-chairing the Primary Care Diabetes System Redesign effort, which is a VACO Primary Care Service 

Initiative to identify best practices for diabetes management that can be implemented at VAMCs nationally. 

Making an Impact on Glycemic Performance Measures

Despite advocacy for a “one size fits all” performance measurement approach to hemoglobin A1c control (i.e., 

all patients recommended to meet one specific blood level) by several national organizations, a body of HSR&D 

research indicates this practice could have unintended consequences. These findings were disseminated to VHA’s 

Under Secretary for Health and the Performance Measurement Workgroup by the Chief Consultant, Patient Care 

Services. Based on this work, HSR&D investigators have a leadership role working with VA’s Office of Quality and 

Performance to develop specifications for possible glycemic control measures. 

HSR&D Research Informed Implementation of Primary Care throughout VA

A body of HSR&D work contributed to the effective implementation and evaluation of VA’s landmark reorganization 

into a primary care-focused system. Findings assisted VA facilities in understanding primary care and deploying 

interdisciplinary primary care models — and impacted VA networks’ planning, reorganization, and oversight. 

Findings also provided evidence regarding organizational features that support good primary care delivery.

SCI-QUERI’s work, now 

in use at all 23 VA SCI 

centers, has resulted in 

significant increases in 

vaccination rates.

Improving Healthcare for Veterans - Select VA HSR&D Contributions May 2010
Tracking System for Veterans Undergoing Invasive Cardiac and Vascular Procedures

Collaborating with VA’s Patient Care Services, the Office of Quality and Performance, and the Office of Information 

Technology, VA/HSR&D’s Ischemic Heart Disease Quality Enhancement Research Initiative (QUERI) group developed 

the Clinical Assessment, Reporting, and Tracking System for Cardiac Catheterization Laboratories (CART-CL), a 

national VA reporting system for procedures performed in VA cardiac catheterization clinics. The system has been 

installed at all 75 VA catheterization labs and data are reported monthly to VA’s Chief Consultant for Cardiology, to 

help monitor the use and safety of several coronary procedures.

Improving Surgical Quality

The National VA Surgical Risk Study, funded collaboratively by HSR&D and VA’s Office of Quality Management (now the 

Office of Quality and Performance) identified opportunities for improving surgical care throughout VA. This led directly 

to the National VA Surgical Quality Improvement Program (NSQIP), also collaboratively funded, which significantly 

improved mortality and complication rates after surgery, as well as many other facets of surgical care. It was the first 

national, validated, outcome-based, risk-adjusted program for the measurement and enhancement of surgical care. 

HSR&D Develops Adult Day Care Assessment Tools Widely Used Within and Outside VA

HSR&D instruments for measuring the structure and process of adult day healthcare programs were used in a 

national study mandated by Congress to evaluate these VA and contract programs. HSR&D research on VA adult day 

healthcare programs contributed to the reorganization of those programs to maximize resource use, and to identify 

Veterans who might be served more cost-effectively in such programs, vs. in hospital or nursing home care. 

Geriatric Evaluation Improves Outcomes and Costs among 

Elderly Hospitalized Veterans

HSR&D research provided evidence that a hospital-based geriatric evaluation 

intervention improved long-term hospitalization outcomes and significantly 

reduced costs among elderly Veterans. These findings resulted in the wide 

dissemination of geriatric evaluation units within and outside VA in the late 

90’s. Current HSR&D research shows that Veterans treated in these units were 

significantly less likely to have any long-term care admissions (e.g. to nursing homes) following their initial discharge 

from the hospital, and that these units do not increase the costs of care for elderly Veterans. 

HSR&D Research Facilitates Cross-System Comparisons of Health Status 

A health status measure developed by HSR&D to measure and evaluate Medicare Advantage Plans was included 

in HEDIS by the Centers for Medicare and Medicaid Services (CMS). The data are being used to compare outcomes 

of VA care with other healthcare settings. VA is partnering with CMS in the CMS Hospital Compare program which 

provides public information about performance of subscribing hospitals on selected measures.

Polytrauma Rehabilitation Centers’ Family Care Map

VA/HSR&D’s Polytrauma/Blast-Related Injuries Quality Enhancement Research Initiative (QUERI) group led the 

development of the “Family Care Map,” a web-based tool for staff and family caregivers that describes the inpatient 

rehabilitation process at VA’s Polytrauma Rehabilitation Centers, and how family members can help their loved ones 

during their inpatient stay. The map has been incorporated into the nurse training programs and interdisciplinary 

plans on polytrauma inpatient units, and has been recognized as a valuable resource by VA’s Polytrauma Action 

Committee and the Center for Ethics, as well as the Government Accountability Office (GAO).

HSR&D research 

resulted in the wide 

dissemination of 

geriatric evaluation units 

within and outside VA.

Improving Healthcare for Veterans - Select VA HSR&D Contributions May 2010
National Dissemination of a Clinical Reminder for Brief Alcohol Counseling

Increases Counseling Rates 

Brief alcohol counseling has been shown to be effective in reducing hazardous drinking. With a goal to improve 

rates of brief alcohol counseling among Veterans, VA/HSR&D’s Substance Use Disorders Quality Enhancement 

Research Initiative (QUERI) group developed a clinical reminder for brief alcohol counseling for implementation in 

VA’s computerized patient record system (CPRS). The clinical reminder was pilot-tested at eight sites, underwent 

evaluation, and was revised based on user feedback. The reminder was then recommended for use to meet new 

FY2008 performance measures for follow-up patients screening positive for alcohol misuse and was disseminated 

nationally. Evaluation of VA data shows there was a substantial increase in rates of brief alcohol counseling for 

eligible Veterans during the 2nd and 3rd quarters of FY2008 (19% and 37%, respectively).

QUERI and Office of Mental Health Services Partner to Improve 

Antipsychotic Management 

Treatment with some “second generation” antipsychotics is associated with metabolic side effects. Failure to 

appropriately monitor and manage these side effects can have a potentially devastating impact on patient safety, 

health outcomes, and wellness. The MIRECC Initiative on Antipsychotic Management Improvement (MIAMI Project) 

is a two-year national program designed to ensure proper monitoring and documentation of metabolic side effects in 

Veterans taking antipsychotics. Funded by VA’s Office of Mental Health Services, the MIAMI Project is led by a Mental 

Health QUERI investigator. In addition, a number of tools and resources from MH-QUERI studies are being adapted 

for use in the MIAMI Project, including educational materials and manuals, clinical reminders, quality improvement 

planning tools, and computer routines that help providers identify Veterans due for metabolic side-effect monitoring.

Evaluating Community-Based Outpatient Clinics (CBOCs)

HSR&D researchers played a key role in the national evaluation of then newly 

created Community-Based Outpatient Clinics (CBOCs), which was requested by 

VA’s Under Secretary for Health in the late 90’s. Findings showed that CBOCs 

aided VA in its shift from specialty to primary care, and appeared to generate 

greater access to care and lower total direct cost per patient compared with 

their parent VAMCs. Investigators presented the results from the study to VHA 

leadership at a National Leadership Board meeting. There were just 139 CBOCs at the time of the evaluation, and 

today there are over 650 CBOCs nationwide.

Inpatient Evaluation Center 

Annually, VA hospitals admit more than a half million patients to acute care, and more than 100,000 to their 

intensive care units. The VA Inpatient Evaluation Center (IPEC) reports outcomes and process for patients 

hospitalized at all VA hospitals, creating benchmarks. The outcomes are risk adjusted using a methodology 

developed with HSR&D funding. Several HSR&D investigators lead the IPEC methodology steering group. 

Specifically, HSR&D investigators collaborate on updating and improving the IPEC methods, and in planning 

implementation strategies. Such implementation strategies have resulted in a significant decrease in certain blood 

stream infections and pneumonias. IPEC builds on methodology validated by HSRD researchers whenever possible, 

including measurement of hyperglycemia, hypoglycemia, and patient safety indicators. They also are collaborating 

to examine triggers for adverse drug events. 

Health Services Research and Development Service

Office of Research and Development

Department of Veterans Affairs

810 Vermont Ave., NW, Washington D.C. 20420

Email: cider.boston@va.gov - www.hsrd.research.va.gov

HSR&D researchers played 

a key role in the national 

evaluation of then newly 

created Community-Based 

Outpatient Clinics (CBOCs).

06-2010