VA Primary Care High Risk Investigator Network

Table of Contents

The VA PCAT Primary Care High Risk Investigator Network is a national network of scientific experts in complex, high risk care. Network members work collaboratively across a number of key projects related to complex, high risk patient care with direct applicability to OPC priorities. Members share expertise, conduct coordinated analyses, and inform program development and evaluation. Network members represent VA research and evaluation centers across the country with a broad range of expertise in areas including: targeted clinical programs, multimorbidity, care coordination, risk prediction, Home Based Primary Care (HBPC), palliative care, integrated mental health care, and social determinants of health.  Our Core and Affiliate Members are listed below with their Key Areas of Interest.  

Core Members

Core Investigator Locations Key Areas of Interest
Timothy Bober, MD Pittsburgh, PA Digital Healthcare Tools, Metabolic Syndrome in primary care patients, Health Equity, Patient Safety
Evelyn Chang, MD, MSHS Los Angeles, CA Mental Health, Substance Use, Complex and Multi-Morbid Veterans
Franya Hutchins, PhD Pittsburgh, PA Fairness in Machine Learning, Health Equity, Epidemiology, Multimorbidity, Latent Class Analysis, Health Services Research
Lucinda Leung, MD, PhD, MPH Los Angeles, CA Primary Care, Mental Health, Collaborative Care Models, Virtual Care, Quality Measurement
Matthew Maciejewski, PhD Durham, NC Big Data, Cost, Methods
Amol Navathe, MD, PhD Philadelphia, PA Algorithmic Fairness, Health Equity, Behavioral Economics
Karin Nelson, MD, MSHS Puget Sound, WA Primary Care Policy, Peer Support, Chronic Disease Self-Management; Director, Primary Care Analytics Team
Ashok Reddy, MD, MS Puget Sound, WA Healthcare Policy and Delivery, Primary Care, Chronic Disease Management, Behavioral Economics; Associate Director, PCAT
Ann-Marie Rosland, MD, MS Pittsburgh, PA Complex Patient Primary Care, Population Segmentation and Latent Class Analysis, Patient-Centered Medical Home Implementation, Panel Management, COVID Impacts on Complex Primary Care, Chronic Disease Care, Social Support
Linnaea Schuttner, MD, MS Puget Sound, WA Primary Care Quality, Patient-Centered Care, Clinical Interventions
Joshua Thorpe, PhD, MPH Durham, NC Geriatric Health Services Research, End-of-Life Care, Medication Safety and Access, Vulnerable Populations, Psychometrics, Machine Learning, Latent Variable Models
Jean Yoon, PhD, MHS Palo Alto, CA Chronic Disease Management and Cost, Cost-Effectiveness of Novel Treatments, Healthcare Access & Disparities
Donna Zulman, MD, MS Palo Alto, CA Virtual Care, Care Fragmentation, Social Determinants of Health


Affiliate Members 

Affiliate Member Locations Key Areas of Interest
Vishal Ahuja, PhD, MASc, MBA Dallas, TX Healthcare Operations, Data Analytics, Optimization, Econometrics, Diabetes Care
Rachel Bachrach, PhD, MS Pittsburgh, PA Unhealthy Alcohol Use, Health Disparities, Co-occurring disorders, Implementation Science, Access to Evidence-Based Care
David Bekelman, MD, MPH Denver, CO Patient-Oriented Research, Complex Interventions, Healthcare Delivery, Palliative and Psychosocial Care
Daniel Blalock, PhD Durham, NC Processes of Behavior Change & Self-Regulation, Medication Adherence, Alcohol Use, Patient Reported Outcomes & Psychometric Measurement
Stuti Dang, MD, MPH Miami, FL Geriatrics, High-Risk, High-Need Veterans & their Caregivers, Technology-based Interventions, Chronic Disease Management, Peers in PACT
Stefanie Deeds, MD Puget Sound, WA Quality Improvement, Clinical Efficiency, Healthcare Delivery, Electronic Medical Record Tools, Primary Care Training, Preventative Health, Mixed Methods; Director, Primary Care Innovation Labs
Sandesh Dev, MD, MS Phoenix, AZ Heart Failure, Group Appointments, Nudges, Decision Support, Cardiac Amyloid
Samuel Edwards, MD, MPH Portland, OR Quality of Primary Care for High-Need Individuals, Home-Based Primary Care (HBPC), Work Climate Burnout in Primary Care, Realist and Complexity Science Informed Approaches to Evaluation
Jacqueline Ferguson, PhD, MHS      Palo Alto, CA Data Science, Epidemiology, Health Disparities, Social Determinants of Health
Stephan D. Fihn, MD, MPH, FACP Seattle, WA Health Status Measurement, Quality Improvement, Healthcare Analytics, Clinical Epidemiology, Ischemic Heart Disease, Health Sciences Research
Benjamin Han, MD, MPH San Diego, CA Substance Use Disorder, Geriatrics, Multimorbidity, Social Determinants of Health, Integrated Models of Care
Elvira Jimenez, PhD Los Angeles, CA Project Design, Implementation and Evaluation, High Risk & Socially Complex Patients, Dementia Caregiving, Peer-Model Research, Qualitative Methods
Arpan Patel, MD, PhD Los Angeles, CA Liver Disease, Cirrhosis, Liver Cancer
Ravi Parikh, MD, MPP, FACP Philadelphia, PA Quality of Life in Survivorship Care, Disparities & Health Equity, Behavioral Economics/Behavioral Change, Payment Reform of Advanced Illnesses, Medical Technology Adoption & Diffusion
Mayuree Rao, MD, MS Puget Sound, WA Community Health Worker/Peer Education Programs, Social Determinants of Health, Virtual Care, Qualitative/Quantitative Work
Lisa Rubenstein, MD, MSPH Los Angeles, CA Implementation and Quality Improvement Sciences, Evidence-Based Healthcare, Mental Health
Susan Stockdale, PhD Santa Monica, CA Primary Care, Evidence-Based Quality Improvement, Implementation Science, Workforce Burnout
Jessica Tobin, PhD, MS Los Angeles, CA Chronic Disease Prevention & Management, Healthcare Policy and Delivery, Health Disparities
Ranak Trivedi, PhD, MS, MA Palo Alto, CA Caregivers in Chronic Disease Management, Mental Health Assessment/Treatment in Primary Care Settings, Psychosocial Antecedents, Consequences of Cardiovascular Disease, Serious Illness/Palliative Care
Melissa Wei, MD, MPH, MS Los Angeles, CA Multimorbidity, Functional Status, Health-Related Quality of Life, Health Services, Clinical Epidemiology
Michelle Wong, PhD Los Angeles, CA Health Disparities, Social Determinants of Health, Race/Ethnicity, Neighborhoods, Housing
Xinhua Zhao, PhD Pittsburgh, PA Panel Data Analysis, Propensity Score Methods, Latent Class Analysis, Novel Statistical Applications, Dual Use VA-Medicare Drug Benefits, Medications-Based Risk Adjustment, Quality, and Safety, Quality of Care in Nursing Homes
Boback Ziaeian, MD, PhD Los Angeles, CA  Heart Failure, Rural Access to Care, Cardiovascular Outcomes Disparities

VA Operations Partners

Office of Primary Care (OPC)

VA Operations Partner Title, Office
Angela Denietolis, MD Executive Director, Primary Care Operations
Scott Pawlikowski, MD Director of Improvement & Innovation

Clinical Assessment Reporting and Tracking (CART) Program*

VA Operations Partner Title, Office
Meg Plomondon, PhD, MSPH Director
Tom LaFontaine, MS Administrative Officer
Rebecca Piegari, MS Statistician

*Formerly Clinical System Development & Evaluation (CSDE)

High Risk Care Investigator Resources

Our VA High Risk Core generates informational and methodological resources to support the conduct of complex, high risk patient care research and evaluation. To access the below resources or learn more, please contact the High Risk team at VA-affiliated High Risk Investigators can directly access several of these resources via the internal VA SharePoint site at this link.

  • High Risk Patient Care Literature Library

​A searchable and sharable database in Zotero that is updated routinely. The repository can be shared as an importable file for citation managers (e.g. EndNote, Mendeley) or as a free read-only Zotero account.

  • Prescription for Designing Population Segmentation Analyses

​Recommended steps for applying clustering models to high risk patients within healthcare systems based on a systemic review of studies using health system data to ‘segment’ high risk patient populations Arnold, et al, 2021.

  • VA High Risk Patient Database

​A customized and clinically vetted data source including approximately two million active high CAN primary care patients that aggregates an array of innovative metrics clinically relevant to high risk Primary Care, including: clinical diagnosis indicators customized to clinical needs of high risk patients; VA utilization measures customized to patterns of high risk patient care; and 2014, 2018, and 2020-based comorbidity group membership of high risk patients. 

  • Chronic Disease Diagnosis Indicator Definitions

​A spreadsheet of primary care relevant diagnosis indicators for 27 chronic medical conditions, based on ICD-10 diagnosis codes, with corresponding SAS programming language to extract the codes from the VA Corporate Data Warehouse (CDW).

  • EHR-Based Social and Functional Indicators 

​A compilation of EHR-data based indicators of social determinants of health (Housing Instability, Food Insecurity, Income, Unemployment, Transgender Status, Rurality, Social Support) and functional status (Visual Impairment, Hearing Impairment, Falls) including data type, data source, measure details, references. Some metrics are VA-specific.

  • Overview of COVID Pandemic Impacts on Chronic Condition Care, 2020 

​A slide deck summarizing key findings from literature on changes to primary care chronic disease management during the early COVID pandemic. Last updated October 2020. An accompanying Zotero citation library is also available.

VA High Risk Newsletters

March 2023

January 2023

November 2022

September 2022

July 2022

May 2022

Contact the High Risk Network Team

For more information or to subscribe to our newsletter, please contact the High Risk Investigator Network leadership team:


The VA Primary Care Analytics Team (PCAT) serves as the analytic unit for the Office of Primary Care (OPC), working closely with office leadership providing operational support through analytics and program evaluation. Our current focus provides meaningful analysis related to the top Primary Care priorities of (a) Fidelity to the PACT Model, (b) High Risk Patients, and (c) Virtual Care. PCAT allows decision-makers to learn from high performing programs to better provide care for our Veterans. OPC-PCAT funds the High Risk Investigator Network.