Seattle-Denver Center of Innovation (COIN)

COIN Investigators & Staff

COIN Investigators

Ashok Reddy, MD, MS, BS

Title: Veterans Health Administration (VHA) Patient-Aligned Care Teams (PACT)
Assistant Professor, General Internal Medicine, University of Washington

Contact: Ashok.Reddy@va.gov

Location: Seattle

University of Washington webpage

Research Interests

Ashok Reddy, MD, MSc, is a primary care physician and health services researcher at the VA Puget Sound Health Care System. He is Assistant Professor of Medicine at the University of Washington (UW) School of Medicine and Core Investigator at the Seattle Health Services Research & Development (HSR&D) Center of Innovation (COIN). Dr. Reddy is the Associate Director of the Primary Care Analytics Team (PCAT) for the VHA’s Office of Primary Care. His research focuses on improving primary care delivery for multimorbid patients and understanding the impacts of changes in primary care payment and delivery. Dr. Reddy received his medical degree from University of Washington and his Masters in Health Policy Research from University of Pennsylvania.

See Dr. Reddy's Dimensions profile that includes: publications, grants, datasets, patents and clinical trials

The following images visualize Dr. Reddy's work. The word cloud is drawn from publication titles. The research collaboration map shows research relationships (click the image to enlarge):

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Grants & Funding

A Mobile Virtual Health Resource Center-Plus Pilot to Address Multiple Digital Access Barriers Among Rural Veterans

Role: PI
Funder: Veterans Administration, Office of Connected Care

Equity Among American Indian, Alaska Native, Native Hawaiian, Pacific Islander Communities under COVID-19 Telehealth Policy

Role: PI
Funder: University of Washington Population Health Initiative

COVID-19 Preventive Health Inventory: Evaluating a primary care approach to catching-up on needed chronic and preventive care for Veterans

Role: PI
The COVID-19 pandemic dramatically disrupted primary care causing profound impacts on morbidity and mortality related to chronic and preventive disease care. Department of Veterans Affairs (VA) Office of Primary Care (OPC) provides primary care to over 6 million Veterans. It is responsible for mitigating chronic and preventive care effects caused by these disruptions.
On March 1st, 2020, OPC launched a multi-component care coordination intervention called Preventative Health Inventory (PHI). Early data suggests increasing adoption across the VA. However, significant knowledge gaps remain around PHI implementation and outcomes.
Our proposal is a rapid-cycle evaluation to fill these knowledge gaps and support OPC in mitigating the impact of COVID-19 on chronic and preventive care.
Funder: Veterans Administration, HSR&D
NIH website

Value System Science Laboratory – Primary Care Utilization Health

Role: Co-I
Funder: Washington State Health Care Authority

Value System Science Laboratory – Audio-Only Telemedicine Evaluation

Role: Co-I
Funder: Washington State Office of Insurance Commissioner

Improving Care for Complex, High-Risk Patients in Primary Care

Role: Co-PI
Veterans at high risk for hospitalization, including those with complex care needs, represent a large population of VHA patients. These patients often do not receive evidence-based primary care practices that would help them avoid the hospital and improve their health.
The high-RIsk VETerans (RIVET) Program will implement evidence-based practices that can support VHA Primary Care teams to deliver more comprehensive and patient-centered care, better strategies to manage medications, and avoid unnecessary hospitalizations.
The RIVET Program finds the most effective approaches to increasing the use of evidence-based practices for high-risk Veterans in primary care, providing rapid data feedback to VHA on high-risk patient care, building capacity for implementing evidence-based practices and training future leaders in high-risk Veteran care.
Funder: Veterans Administration
NIH website
Publications of note:
— Factors Associated with Patient-Centered Medical Home Teams’ Use of Resources for Identifying and Approaches for Managing Patients with Complex Needs

Multiphase Optimization Trial of Incentives for Veterans to Encourage Walking

Role: Co-I; PI's: Katherine Hoerster & Paul Hebert
Regular physical activity is associated with reduced risk of several diseases important to Veterans, including cardiovascular disease and diabetes. Physical activity is also associated with better mental health. Walking is a safe and effective way to get the recommended amount of physical activity.
Unfortunately, more than 1 in 3 Veterans over age 45 meet the definition of physically inactive. Behavioral economics suggests that our inability to start and stick to an exercise routine may result from “present bias,” which is a tendency to value the immediate reward of remaining sedentary over large rewards of long-run physical activity. Patient incentives may overcome present bias by moving the rewards for healthy behaviors forward in time.
In the proposed study, we will determine the optimal design for an incentive program that gives Veterans tangible, timely rewards for walking an average target number of steps per day. If effective, an incentive program may be an economical way to improve Veterans’ physical and mental health without taxing the healthcare delivery system.
Funder: Veterans Affairs
NIH website

Understanding the Impact of Health Information Exchange-Enabled Care Plans to Coordinate Care among High-Need, High-Cost Patients

Role: PI
High-need, high-cost patients (HNHC) experience poor coordination of care, a key driver of increased cost and utilization. Healthcare organizations and policymakers are investing in care coordination interventions that combine broad approaches (health information exchanges) and specific coordinating activities (care plans) to fix the fragmented care HNHC patients receive. Still, the evidence for these approaches needs to be more extensive.
This proposal takes advantage of a natural experiment in Washington State to understand the impact of health information exchange-enabled care plans to coordinate care for HNHC patients.
Funder: Agency for Healthcare Research and Quality
NIH website
Publications of note:
— Impact of a statewide Emergency Department Information Exchange on health care use and expenditures

Primary Care Analytics Team (PCAT)

Role: Associate Director
Funder: Veterans Administration, HSR&D

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Recent Publications

2023

Marcotte LM, Deeds S, Wheat C, Gunnink E, Gray K, Rojas J, Finch C, Nelson K, Reddy A. Automated Opt-Out vs Opt-In Patient Outreach Strategies for Breast Cancer Screening: A Randomized Clinical Trial. JAMA Intern Med. 2023 Sep 11. doi: 10.1001/jamainternmed.2023.4321. Epub ahead of print.
PMID: 37695621.
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Rubenstein LV, Curtis I, Wheat CL, Grembowski DE, Stockdale SE, Kaboli PJ, Yoon J, Felker BL, Reddy AS, Nelson KM. Learning from national implementation of the Veterans Affairs Clinical Resource Hub (CRH) program for improving access to care: protocol for a six year evaluation. BMC Health Serv Res. 2023 Jul 25;23(1):790. doi: 10.1186/s12913-023-09799-5.
PMID: 37488518.
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Deeds S, Liu T, Schuttner L, Wheat C, Gunnink E, Geyer J, Beste L, Chen A, Dominitz JA, Nelson K, Reddy A. A Postcard Primer Prior to Mailed Fecal Immunochemical Test Among Veterans: a Randomized Controlled Trial. J Gen Intern Med. 2023 Jun 8:1–7. doi: 10.1007/s11606-023-08248-7. Epub ahead of print. PMCID: PMC10249919.
PMID: 37291363.
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Wheat CL, Gunnink EJ, Rojas J, Shah A, Nelson KM, Wong ES, Gray KE, Stockdale SE, Rosland AM, Chang ET, Reddy A. Changes in Primary Care Quality Associated With Implementation of the Veterans Health Administration Preventive Health Inventory. JAMA Netw Open. 2023 Apr 3;6(4):e238525. doi: 10.1001/jamanetworkopen.2023.8525.
PMID: 37067799
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Reddy A, Maynard C, Kaboli P, Rinne ST, Henrikson NB, Nelson KM, Liu CF, Sterling R, Wong E. Identifying Individual and Clinic Characteristics Associated With Primary Care Provider Turnover During Implementation of the Veterans Health Administration Patient-Centered Medical Home. J Ambul Care Manage. 2023 Apr 7. doi: 10.1097/JAC.0000000000000469. Epub ahead of print.
PMID: 37026706
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Swankoski KE, Reddy A, Grembowski D, Chang ET, Wong ES. Intensive care management for high-risk veterans in a patient-centered medical home - do some veterans benefit more than others? Healthc (Amst). 2023 Feb 8;11(2):100677. doi: 10.1016/j.hjdsi.2023.100677. Epub ahead of print.
PMID: 36764053
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Golob AL, Geyer J, O'Keeffe C, Nelson K, Song C, Vanderwarker C, Britton J, Reddy A, Wong E, Schuttner L. Automatic medication refills to improve glycaemic control among patients with diabetes and low medication adherence. BMJ Open Qual. 2023 Feb;12(1):e001985. doi: 10.1136/bmjoq-2022-001985.
PMID: 36746551.
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2022

Deeds SA, Moore CB, Gunnink EJ, Wheat CL, Robinson AE, Bomsztyk MD, Geyer JR, Chen A, Godbout RM, Nelson KM, Dominitz JA, Reddy A. Implementation of a mailed faecal immunochemical test programme for colorectal cancer screening among Veterans. BMJ Open Qual. 2022 Nov;11(4):e001927. doi: 10.1136/bmjoq-2022-001927. PMCID: PMC9670919.
PMID: 36384879
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Chen A, Beste LA, Strack K, Geyer J, Wheat C, Nelson K, Reddy A. COVID-19 Vaccinations Among US Veterans with Mental Illness: a Retrospective Cohort Study. J Gen Intern Med. 2022 Aug 15. doi: 10.1007/s11606-022-07763-3. Epub ahead of print.
PMID: 35970960
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Sabbatini AK, McConnell KJ, Parrish C, Frogner BK, Reddy A, Zatzick DF, Kreuter W, Basu A. Impact of a statewide Emergency Department Information Exchange on health care use and expenditures. Health Serv Res. 2022 Mar 2. doi: 10.1111/1475-6773.13963. Epub ahead of print.
PMID: 35235203
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Gray KE, Rao M, Gunnink E, Eschenroeder L, Geyer JR, Nelson KM, Reddy A. Home Telehealth in the Veterans Health Administration: Trends and Correlates of Length of Enrollment from 2010 to 2017. J Gen Intern Med. 2022 Mar 1:1–8. doi: 10.1007/s11606-022-07452-1. Epub ahead of print. PMCID: PMC8886698.
PMID: 35230624
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Moldestad M, Sayre G, Rinne S, Kaboli PJ, Reddy A, Sanders KM, Mao J, Henrikson NB, Sterling R, Nelson KM, Wong ES. Perspectives on Training and Working in the VHA: Implications for Primary Care Physician Recruitment and Retention. Acad Med. 2022 Feb 8. doi: 10.1097/ACM.0000000000004619. Epub ahead of print.
PMID: 35139527.
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2021

Schuttner L, Haraldsson B, Maynard C, Helfrich CD, Reddy A, Parikh T, Nelson KM, Wong E. Factors Associated With Low-Value Cancer Screenings in the Veterans Health Administration. JAMA Netw Open. 2021 Oct 1;4(10):e2130581. doi: 10.1001/jamanetworkopen.2021.30581.
PMID: 34677595.

Beste LA, Chen A, Geyer J, Wilson M, Schuttner L, Wheat C, Rojas J, Nelson K, Reddy A. Best Practices for an Equitable Covid-19 Vaccination Program. NEJM Catal Innov Care Deliv. 2021 Sep 15;2(10):10.1056/CAT.21.0238. doi: 10.1056/CAT.21.0238.
PMCID: PMC8443122.

Sterling R, Rinne ST, Reddy A, Moldestad M, Kaboli P, Helfrich CD, Henrikson NB, Nelson KM, Kaminetzky C, Wong ES. Identifying and Prioritizing Workplace Climate Predictors of Burnout Among VHA Primary Care Physicians. J Gen Intern Med. 2021 Jul 29:1–8. doi: 10.1007/s11606-021-07006-x. Epub ahead of print. PMCID: PMC8321506.
PMID: 34327656

Reddy A, Nelson KM, Wong ES. Primary Care Spending in the Veterans Health Administration in 2014 and 2018. JAMA Netw Open. 2021 Jul 1;4(7):e2117533. doi: 10.1001/jamanetworkopen.2021.17533.
PMID: 34279651

Nelson K, Reddy A, Stockdale SE, Rose D, Fihn S, Rosland AM, Stewart G, Denietolis A, Curtis I, Mori A, Rubenstein L. The Primary Care Analytics Team: Integrating research and clinical care within the Veterans Health Administration Office of Primary Care. Healthc (Amst). 2021 Jun;8 Suppl 1:100491. doi: 10.1016/j.hjdsi.2020.100491. Epub 2021 Jun 23.
PMID: 34175100

Marcotte LM, Reddy A, Zhou L, Liao JM. Nationwide Use of Telehealth Among Commercially Insured Individuals 2007-2017. J Gen Intern Med. 2021 May 4:1–3. doi: 10.1007/s11606-021-06816-3. Epub ahead of print. PMCID: PMC8096139.
PMID: 33948797

Marcotte LM, Reddy A, Zhou L, Razliff A, Unützer J, Chang D, Liao JM. Provision of Collaborative Care Model and General Behavioral Health Integration Services in Medicare. Psychiatr Serv. 2021 Apr 15:appips202000265. doi: 10.1176/appi.ps.202000265. Epub ahead of print. PMID: .
PMID: 33853381

2020

Hwang CS, Reddy A, Liao JM. Bridging to value with codes that promote care management. Am J Manag Care. 2020 Nov 1;26(11):e344-e346. doi: 10.37765/ajmc.2020.88528.
PMID: 33196284

Moldestad M, Greene PA, Sayre GG, Neely EL, Sulc CA, Sales AE, Reddy A, Wong ES, Liu CF. Comparable, but distinct: Perceptions of primary care provided by physicians and nurse practitioners in full and restricted practice authority states. J Adv Nurs. 2020 Nov;76(11):3092-3103. doi: 10.1111/jan.14501. Epub 2020 Sep 2.
PMID: 32875584

Deeds SA, Hagan SL, Geyer JR, Vanderwarker C, Grandjean MW, Reddy A, Nelson KM. Leveraging an electronic health record note template to standardize screening and testing for COVID-19. Healthc (Amst). 2020 Sep;8(3):100454. doi: 10.1016/j.hjdsi.2020.100454. Epub 2020 Jul 22. PMCID: PMC7375319.
PMID: 32919584

Reddy A, Gunnink E, Deeds SA, Hagan SL, Heyworth L, Mattras TF, Nelson KM. A rapid mobilization of 'virtual' primary care services in response to COVID-19 at Veterans Health Administration. Healthc (Amst). 2020 Dec;8(4):100464. doi: 10.1016/j.hjdsi.2020.100464. Epub 2020 Aug 18. PMCID: PMC7434426.
PMID: 32992109

Schuttner L, Wong ES, Rosland AM, Nelson K, Reddy A. Association of the Patient-Centered Medical Home Implementation with Chronic Disease Quality in Patients with Multimorbidity. J Gen Intern Med. 2020 Oct;35(10):2932-2938. doi: 10.1007/s11606-020-06076-7. Epub 2020 Aug 6. PMCID: PMC7572962.
PMID: 32767035

Hebert PL, Wong ES, Reddy A, Batten A, Gunnink E, Wagner TH, Liu CF. Events Associated With Changes in Reliance on the Veterans Health Administration Among Medicare-eligible Veterans. Med Care. 2020 Aug;58(8):710-716. doi: 10.1097/MLR.0000000000001328.
PMID: 32265354

Schuttner L, Reddy A, White AA, Wong ES, Liao JM. Quality in the Context of Value: Reliability of Quality Metrics in an Academic Health System Shifting Toward Value-Based Payments. Am J Med Qual. 2020 Dec;35(6):465-473. doi: 10.1177/1062860620917205. Epub 2020 May 5.
PMID: 32367726

Liu CF, Hebert PL, Douglas JH, Neely EL, Sulc CA, Reddy A, Sales AE, Wong ES. Outcomes of primary care delivery by nurse practitioners: Utilization, cost, and quality of care. Health Serv Res. 2020 Apr;55(2):178-189. doi: 10.1111/1475-6773.13246. Epub 2020 Jan 13. PMCID: PMC7080399.
PMID: 31943190

Reddy A, Gunnink E, Taylor L, Wong E, Batten AJ, Fihn SD, Nelson KM. Association of High-Cost Health Care Utilization With Longitudinal Changes in Patient-Centered Medical Home Implementation. JAMA Netw Open. 2020 Feb 5;3(2):e1920500. doi: 10.1001/jamanetworkopen.2019.20500.
PMID: 32022880

Wong ES, Schuttner L, Reddy A. Does machine learning improve prediction of VA primary care reliance? Am J Manag Care. 2020 Jan;26(1):40-44. doi: 10.37765/ajmc.2020.42144.
PMID: 31951358

Schuttner L, Reddy A, Rosland AM, Nelson K, Wong ES. Association of the Implementation of the Patient-Centered Medical Home with Quality of Life in Patients with Multimorbidity. J Gen Intern Med. 2020 Jan;35(1):119-125. doi: 10.1007/s11606-019-05429-1. Epub 2019 Oct 30. PMCID: PMC6957610.
PMID: 31667750

2019

Wong ES, Maciejewski ML, Hebert PL, Reddy A, Liu CF. Predicting Primary Care Use Among Patients in a Large Integrated Health System: The Role of Patient Experience Measures. Med Care. 2019 Aug;57(8):608-614. doi: 10.1097/MLR.0000000000001155.
PMID: 31295190

Meo N, Liao JM, Reddy A. Hospitalized After Medical Readiness for Discharge: A Multidisciplinary Quality Improvement Initiative to Identify Discharge Barriers in General Medicine Patients. Am J Med Qual. 2020 Jan/Feb;35(1):23-28. doi: 10.1177/1062860619846559. Epub 2019 May 5.
PMID: 31055946

Moore M, Conrick KM, Reddy A, Allen A, Jaffe C. From Their Perspective: The Connection between Life Stressors and Health Care Service Use Patterns of Homeless Frequent Users of the Emergency Department. Health Soc Work. 2019 May 1;44(2):113-122. doi: 10.1093/hsw/hlz010. PMCID: PMC6642452.
PMID: 30855682

Reddy A, Fihn SD, Liao JM. The VA MISSION Act - Creating a Center for Innovation within the VA. N Engl J Med. 2019 Apr 25;380(17):1592-1594. doi: 10.1056/NEJMp1815209.
PMID: 31018067

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