Inside the Teams That Keep High-Risk Patients Out of the Hospital

For the millions of patients juggling diabetes, heart failure, chronic pain, and mental illness at the same time, the greatest danger is not any single disease. It is the seams between them: the missed referrals, the contradictory medication advice, the specialist who never learns what the primary care clinician decided. A new qualitative evaluation published in the Journal of General Internal Medicine offers one of the most detailed looks yet at how a specific kind of team, the primary care intensive management team, actually stitches those seams together for patients at high risk of hospitalization, and it confirms that a federal framework developed by the Agency for Healthcare Research and Quality can map every element of that work.

The study, led by Karleen F. Giannitrapani of the VA Palo Alto Health Care System and Stanford University School of Medicine, drew on interviews from the PACT Intensive Management national demonstration project of the Veterans Health Administration. The researchers analyzed semi-structured interviews with 29 team members and 51 patients across five demonstration sites in five different states. Their question was deceptively simple: when these teams and their patients describe what makes intensive primary care valuable, do the activities they mention amount to care coordination, and can those activities be sorted into the nine domains of the AHRQ care coordination framework?

The technical answer is a resounding yes. Using primary qualitative content analysis, the team first identified all activities meeting a broad definition of care coordination, then conducted a secondary analysis to test whether the AHRQ framework could categorize them. The data validated the importance of all nine AHRQ domains as critical components of the care these teams delivered. Six of the nine domains were mentioned by interviewees at each of the five geographically diverse sites, a striking consistency for qualitative work. Perhaps most tellingly, no activity proved challenging to classify: every element of coordination described by teams or patients fit cleanly into one of the nine domains, evidence of the framework’s construct validity.

Why does this matter beyond the VA? Care coordination has become one of the most invoked, and least precisely measured, concepts in American medicine. Patients with multiple chronic conditions routinely see many clinicians, and fragmented care patterns are associated with avoidable hospitalizations, duplicated tests, and treatment burdens that fall hardest on the sickest. Yet few studies document the performance of specific care coordination activities that together comprise coordination for high-risk patients. Interventions are often labeled as coordination without anyone specifying which activities they actually perform. The new evaluation tackles that ambiguity head-on by anchoring the description of team activities to a validated federal taxonomy.

The intensive management model itself is worth understanding. In the VA demonstration, primary care teams augmented standard Patient Aligned Care Team operations for a small panel of high-risk veterans, patients whose clinical complexity and prior utilization marked them as likely to be hospitalized. Rather than adding a parallel specialty clinic, the model intensifies primary care: smaller panels, closer monitoring, and deliberate attention to the social and behavioral drivers of health. Prior quantitative evaluations of the demonstration have examined effects on costs and utilization and on patient experiences, but the new study zooms in on the mechanism, the day-to-day coordination activities that teams perform and that patients perceive as the critical advantages of intensive management.

The multisite design gives the findings unusual weight for qualitative research. Because the five sites operated in different states with different local resources and patient populations, activities mentioned consistently across sites are unlikely to be artifacts of one team’s culture or one region’s referral landscape. The consistency across sites, with six of nine AHRQ domains garnering mention everywhere, suggests that the core repertoire of coordination activities is reproducible, a property that implementation scientists prize when deciding whether to spread a model nationally.

The AHRQ framework that served as the analytical lens has a history. It emerged from the agency’s Closing the Quality Gap series and its Care Coordination Measure Atlas, efforts to bring order to a measurement landscape in which coordination was defined differently by nearly every study. The framework’s nine domains span activities such as establishing accountability, communicating among team members, facilitating transitions, assessing needs and goals, and monitoring and follow-up. By testing whether real-world team activities could be identified and categorized within those domains, the researchers performed a construct validity check that most coordination interventions never undergo. The result supports using the framework both to describe what teams do and to build quality measures for primary care.

For patients, the practical translation is concrete. The interviews captured what high-risk veterans themselves considered the advantages of intensive primary care: having a team that knows their full picture, tracks their needs and goals over time, communicates across their many clinicians, and follows up after transitions rather than letting them fall through the cracks. For health systems designing programs for their own high-risk populations, the study offers a validated vocabulary for specifying, training, and measuring coordination activities, rather than hoping that a new role or a new clinic will somehow produce coordination by name alone.

The findings also carry implications for the clinicians doing this work. Earlier analyses from the same demonstration examined care coordination and provider stress, an acknowledgment that intensive management of complex patients can burden the very teams that perform it. A framework that cleanly categorizes the activities of coordination gives operations leaders a tool for workload design, staffing decisions, and quality improvement, specifying which domains a team covers well and which need reinforcement. As health systems nationwide confront aging populations with mounting multimorbidity, the VA experience suggests that the path to keeping high-risk patients out of the hospital runs through primary care teams whose coordination work can finally be named, measured, and spread.

Subject of Research: Health

Article Title: How Primary Care Intensive Management Teams Coordinate Care for High-Risk Patients: A Multisite Evaluation Using the AHRQ Framework

Article References: Giannitrapani, K. F., Ross, R. L., Holliday, J., Connell, N. B., Lugar, T. M., Wong, E. P., Zulman, D. M., Stockdale, S. E., Rubenstein, L. V., & Chang, E. T. (2026). How Primary Care Intensive Management Teams Coordinate Care for High-Risk Patients: A Multisite Evaluation Using the AHRQ Framework. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10783-y

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10783-y

Keywords: care coordination, primary care, Veterans Health Administration, AHRQ framework, high-risk patients, qualitative research, Journal of General Internal Medicine, multimorbidity, Primary, Care, Intensive, Management