Improving care coordination for high-risk Veterans
Official title: Care Coordination and Outcomes for High Risk Patients: Building the Evidence for Implementation
Funded at Portland VA Medical Center · NIH-11311259 · Data updated 2026-11-12
This project tests ways to match high-risk Veterans with the right care coordination services to help them get needed care and better health outcomes.
Quick facts
| Grant type | NIH-funded research |
|---|---|
| Study type | NIH-funded research |
| Funding institution | Portland VA Medical Center NIH-funded |
| Lab location | 1 site (Portland, United States) |
| Project start | October 1, 2021 |
| Project end | September 30, 2026 |
| Funding year | 2026 |
| NIH project number | 5I01HX003261-05 |
| Project ID | NIH-11311259 on NIH RePORTER |
Who could benefit from this research
✓Could help
Ideal candidates are high-need, high-risk Veterans who receive care through the VA and have complex clinical and psychosocial needs.
✕Less likely to help
People who are not Veterans, who do not use VA services, or who have low-risk, routine care needs are unlikely to see direct benefit from this project.
What this research studies
If I am a Veteran with complex medical and social needs, the team will use the VA's care coordination needs assessment (CCNA) data already collected about me along with my healthcare use records to understand what help I need. They will also gather feedback from Veterans and providers to learn how coordination is working in real clinics. The project links routinely collected data to measures of access, experience, and costs to see which coordination practices lead to better results. The goal is to build practical guidance so VA teams can give the right level of coordination to the right people.
Why it matters
Potential benefit: If successful, this work could help high-risk Veterans get more timely, better-matched care coordination that improves health and experience while avoiding unnecessary services.
How similar studies have gone: VA models like the Patient Aligned Care Team have improved patient experience and reduced costs, but the specific CCNA tools and matching processes in this project are new and have not yet been tested.
Where this research is happening
-
Portland VA Medical Center
Portland, United States Active
Researchers
- Principal investigator: Hynes, Denise M. — Portland VA Medical Center
- Study coordinator: Hynes, Denise M.
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About this research
- This is an active NIH-funded research project — typically early-stage science, not a clinical trial accepting patient enrollment.
- Some NIH-funded labs run parallel clinical studies or seek volunteers for related work. To check, contact the principal investigator or institution listed above.
- For full project details, budget, and progress reports, visit the official NIH RePORTER page.