Table 1.

Summary of Manuscripts Provided to Workgroup Participants in Advance of the Conference

High-need Veteran subpopulation	Description of study/review	Summary of study/review findings
Veterans with multiple chronic conditions	Systematic review of comprehensive care programs for patients with multiple chronic conditions or frailty (Hopman et al. 2016)20	Evidence for the effectiveness of comprehensive care for multimorbid/frail patients is insufficient.
Veterans with high-intensity, focused, specialty care service needs	Systematic review and meta-analysis of cancer care coordination (Gorin et al. 2017)18	Cancer care coordination improves care quality, patient experience, and appropriate care utilization; patient navigation, home telehealth, and nurse care management are frequently used coordination strategies.
	Semi-structured interviews with VA HIV clinic providers and patients (Fix et al. 2014)19	Patients in HIV clinics delivering patient-centered medical home-principled care reported more satisfaction with their care.
Veterans experiencing transitions following hospitalization or emergency department use	Systematic review of hospital/post-hospital transitional care interventions (Kansagara et al. 2016)21	Successful interventions are comprehensive, extend beyond the hospital stay, and have flexibility to respond to individual patient needs.
	Report on findings from National Quality Forum environmental scan, key informant interviews, and expert panel findings on measuring and improving emergency department transitions of care (NQF 2017)22	ED transitions measures and concepts in need of development are infrastructure and linkages; health information technology; payment models; and a research agenda.
Veterans with severe mental illness	Key informant interviews at two VA medical centers with mental health staff embedded in primary care clinics (Lipshitz et al. 2017) [23]	Barriers to optimal implementation include organizational competing priorities, finding assertive care managers to hire, cross-discipline integration and collaboration, and primary care provider burden; formal structural attention to care management may improve the reliability of care management functions.
Veterans with homelessness and substance use disorder	Secondary (latent class) data analysis of 16,912 homeless Veterans who were acute care “super-utilizers” (Symkowiak et al. 2017)23	Persistent acute care superutilizers were more likely to be older, rural, male, non-Hispanic White, unmarried, and have more service-connected disabilities and medical, mental health and substance use morbidities.
Across Veteran subpopulations	Original study: cross-sectional correlation analysis assessing if implementation of a newly developed care coordination model was associated with more effective care coordination in safety net primary care practices (Wagner et al. 2014)24	Suggested that the care coordination model elements may have enabled the safety net clinic to better coordinate care.