Center for Health Equity Research and Promotion

The RIVET QUERI Program helps primary care teams across multiple VA VISNs (regions) to increase use of effective care planning and health coaching practices for their highest-risk patients. These practices assist teams in coordinating their approach to providing optimal care for Veterans with complex needs. (Pre-pandemic photo by Alyssa Schukar for The Commonwealth Fund.org for illustrative purposes only)

VA CHERP Investigator Co-Leads National RIVET QUERI Program to Advance Primary Care for Veterans with Complex Care Needs


Launched in 2021, the 5-year, $4.1 million High-RIsk VETerans (RIVET) QUERI Program to determine the best strategies for using effective primary care practices for Veterans at high-risk for poor health outcomes. The Program is co-led by VA Pittsburgh CHERP investigator Dr. Ann-Marie Rosland, with three additional VA investigators from VA Medical Centers in Los Angeles, California and Puget Sound, Washington.

The Veterans at highest risk for declining health often have multiple ongoing health conditions and need care from several types of healthcare providers. Coordinating diversified care, however, can be difficult.

According to Dr. Rosland, “It can be challenging for primary care teams to get Veterans with multiple or complex health conditions all the care they need in a coordinated way. The RIVET QUERI Program provides VA primary care teams with the latest practices to meet the needs of these high-risk Veterans and lower their risk of worsening health and hospitalization.”

The RIVET QUERI Program helps primary care teams across multiple VA VISNs (regions) to increase use of effective care planning and health coaching practices for their highest-risk patients. These practices assist teams in coordinating their approach to providing optimal care for Veterans with complex needs.

• Comprehensive Assessment and Care Planning: Healthcare teams assess Veterans for modifiable risk factors, including medical, functional, and social needs, and create a comprehensive care plan.
• Phone-Based Health Coaching for Medication Adherence: Phone-based health coaches identify and attend to Veterans’ goals and preferences, as well as address barriers to taking medications.

Dr. Evelyn Chang, RIVET QUERI Implementation Lead, explained, “Healthcare systems have struggled for years to find the best ways to deliver high quality care to high-risk patients with complex care needs. Our program brings together a team of investigators with experience in primary care innovation and complex patient care to partner with VA clinicians and leaders to implement the best practices to meet this challenge.”

For more information, go to:  RIVET QUERI

Overall, the RIVET QUERI Program, in close partnership with the VA Office of Primary Care, addresses several VA priorities and quality goals. The Program also provides a Rapid Response Team to address short-term, high-impact evaluation needs in high-risk patient care, and a Mentoring Core to develop future leaders in the implementation of evidence-based practices for high-risk Veterans.

RIVET QUERI partners include the Office of Primary Care, Office of Patient-Centered Care and Cultural Transformation, Geriatrics and Extended Care, and VISNs 9, 10, and 12.


RIVET QUERI Multiple Principal Investigators:
Evelyn Chang, MD, MSHS Greater Los Angeles, CA
Ashok Reddy, MD, MSc Puget Sound, WA
Ann-Marie Rosland, MD, MS Pittsburgh, PA
Susan Stockdale, PhD Greater Los Angeles, CA











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