Improving care for high-risk veterans

Improving Care for Complex, High-Risk Patients in Primary Care (QUE 20-018)

NA · VA Office of Research and Development · NCT05050643

This study is trying out new ways to help high-risk veterans get better primary care and manage their medications to see if it can keep them healthier and out of the hospital.

Quick facts

PhaseNA
Study typeInterventional
Enrollment16 (estimated)
Ages18 Years and up
SexAll
SponsorVA Office of Research and Development (fed)
Locations3 sites (Sepulveda, California and 2 other locations)
Trial IDNCT05050643 on ClinicalTrials.gov

What this trial studies

The High-Risk Veteran Initiative aims to enhance primary care for veterans at high risk of hospitalization due to multimorbidity. This program will implement evidence-based practices to support healthcare teams in delivering comprehensive, patient-centered care and effective medication management. By testing two specific implementation strategies, the initiative seeks to improve the uptake of Comprehensive Assessment and Care Planning and Phone-Based Health Coaching for Medication Adherence. The goal is to reduce unnecessary hospitalizations and improve health outcomes for this vulnerable population.

Who should consider this trial

Good fit: Ideal candidates for this initiative are veterans identified as being in the top 5% at risk for hospitalization due to complex health needs.

Not a fit: Patients who are not part of the VA healthcare system or those who do not meet the high-risk criteria may not benefit from this initiative.

Why it matters

Potential benefit: If successful, this initiative could significantly reduce hospitalizations and improve health outcomes for high-risk veterans.

How similar studies have performed: Other studies have shown success in implementing evidence-based practices in veteran care, indicating a promising approach for this initiative.

Eligibility criteria

Show full inclusion / exclusion criteria
Inclusion Criteria:

Any VA site nationwide

Exclusion Criteria:

Not a VA site nationwide

Where this trial is running

Sepulveda, California and 2 other locations

Study contacts

How to participate

  1. Review the eligibility criteria above with your treating physician.
  2. Visit the official trial page on ClinicalTrials.gov for the most current contact information and recruitment status.
  3. Contact the listed study coordinator or principal investigator to request pre-screening. Pre-screening is free and never obligates you to enroll.

View on ClinicalTrials.gov →

Conditions: Multimorbidity, Primary Health Care, Medication Adherence, Needs Assessment, Mentoring

Last reviewed 2026-05-15 by the Find a Trial editorial team. Information on this page is for educational purposes and is not medical advice. Always consult qualified healthcare professionals about clinical trial participation.