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The mission of the Veterans Health Administration's (VHA) quality enhancement research initiative (QUERI) is to enhance the quality of VHA health care by implementing clinical research findings into routine care. This paper presents lessons that QUERI investigators have learned through their initial attempts to pursue the QUERI mission. The lessons in this paper represent those that were common across multiple QUERI projects and were mutually agreed on as having substantial impact on the success of implementation. While the lessons are consistent with commonly recognized ingredients of successful implementation efforts, the examples highlight the fact that, even with a thorough knowledge of the literature and thoughtful planning, unexpected circumstances arise during implementation efforts that require flexibility and adaptability. The findings stress the importance of utilizing formative evaluation techniques to identify barriers to successful implementation and strategies to address these barriers. [ABSTRACT FROM AUTHOR]

Objective: To assess differences in risk (measured by expected costs associated with sociodemographic and clinical profiles) between Veterans receiving outpatient services through two community care (CC) programs: the Fee program ("Fee") and the Veterans Choice Program ("Choice").Data Sources/study Setting: Administrative data from VHA's Corporate Data Warehouse in fiscal years (FY) 2014-2015.Study Design: We compared the clinical characteristics of Veterans across three groups (Fee only, Choice only, and Fee & Choice). We classified Veterans into risk groups based on Nosos risk scores and examined the relationship between type of outpatient utilization and risk within each CC group. We also examined changes in utilization of VHA and CC in FY14-FY15. We used chi-square tests, t tests, and ANOVAs to identify significant differences between CC groups.Principal Findings: Of the 1,400,977 Veterans using CC in FY15, 91.4 percent were Fee-only users, 4.4 percent Choice-only users, and 4.2 percent Fee & Choice users. Mean concurrent risk scores were higher for Fee only and Fee & Choice (1.9, SD = 2.7; 1.8, SD = 2.2) compared to Choice-only users (1.0, SD = 1.2) (p < .0001). Most CC users were "dual users" of both VHA and CC in FY14-FY15.Conclusions: As care transitions from VHA to CC, VHA should consider how best to coordinate care with community providers to reduce duplication of efforts, improve handoffs, and achieve the best outcomes for Veterans. [ABSTRACT FROM AUTHOR]