Overview

The VA currently offers primary care through patient-centered medical homes, or Patient Aligned Care Teams (PACT) for all enrolled Veterans. Selected demonstration sites augmented the medical homes with interdisciplinary intensive primary care (IPC) models, called PACT Intensive Management programs (PIMs) to reduce healthcare expenditures and hospital admissions for Veterans requiring complex care.

 

 

 

 

 

In collaboration with Healthcare: The Journal of Delivery Science and Innovation

Organization Name

Veterans Health Administration

Organization Type

• Government organization
• Integrated healthcare system/network

Local/Organizational Context

• Only a fraction of Veterans (5%) account for almost half of VHA costs, driven mainly by hospital admissions.
• A large majority of patients (88%) at highest risk for hospitalization are cared for by general medical homes rather than by special population medical homes.
• Evaluations suggest that medical homes alone may not be able to adequately address the needs of high-risk patients, who require prompt, frequent, and comprehensive care coordination.
• As general medical homes are also responsible for managing all primary care patients, general primary care experiences significant strain.

Patient Population Served and Payor Information

• The Veterans Health Administration is a single-payer healthcare system and the patients served by them are covered by VA healthcare.

Leadership

• Principal investigators: Evelyn Chang, MD, MSHS and Lisa Rubenstein, MD, MSPH
• The PACT intensive management program sites leads are:
  • Parag Dalsania, MD
  • Jessica Eng, MD, MS
  • Nate Ewigman, PhD
  • Deborah Henry, MD
  • Jeffrey Jackson, MD, MPH
  • Neha Pathak, MD
  • Kimberly Schaub, PhD
  • Brook Watts, MD, MS
  • Melissa Klein, MD

Funding

• Funding was provided by the VHA Office of Patient Care Services.

Research + Planning

• The VHA issued a Request for Proposal (RFP) calling for demonstration sites to implement IPC models that build on existing patient-centered medical homes.
• Five sites were selected and were given autonomy to design their own approaches to IPC.
• Four of these five sites proposed a collaborative approach with primary care, and one assumed all primary care and care management responsibility for a panel of high-risk patients.
• Before the sites began enrolling patients, each site proposed using interdisciplinary care teams (with mental health providers), home visits, comprehensive patient assessment and evaluation, care coordination and case management, and televideo conferencing.

Tools or Products Developed

• CAN Risk Prediction Model: A risk prediction model called the Care Assessment Need (CAN) Score to identify the Veterans at the highest risk of hospitalization. Factors considered in the score are previous inpatient and outpatient utilization over preceding year, labs, medications, laboratory data, and clinical diagnosis.
• PACT: Patient Aligned Care Teams (PACT) which is a patient-centered medical home model with core staff consisting of a primary care provider, nurse care manager, a licensed practical nurse and an administrative clerk.

Training

• Four sites received team training in Whole Health, offered by VHA Office of Patient-Centered Care. This is a proactive, patient-centered model that includes understanding patients’ goals, values, and preferences, creating personalized care plans, and performing motivational interviewing. The fifth site received training in health coaching and motivational interviewing.
• Three sites trained peer support specialists to engage veterans, to perform health coaching, and to offer navigation services.
• Three intensive primary care teams were trained to run chronic disease self-management groups which were designed to educate patients about chronic diseases and teach self-management skills.

Tech Involved

• Electronic medical record
• Telephone

Team Members Involved

• Mental Health Provider
• NPs
• PAs
• Peer Navigator
• Physicians
• Health Support Specialist
• Psychologist
• RNs
• Social Worker
• Support Staff

Workflow Steps

• The programs at each of these demonstration sites evolved over time to implement the following elements:
  • An interdisciplinary care team with social workers and mental health providers
  • Chronic disease management
  • Comprehensive patient assessment and evaluation
  • Care and case management
  • Transitional care support
  • Preventive home visits
  • Pharmaceutical services
  • Chronic disease self-management
  • Caregiver support services
  • Health coaching
  • Advanced care planning

• The Intensive Primary Care teams performed the following services:
  • Home visits: as a part of the comprehensive assessment, the teams:
    • Gained insight into the patient’s environment
    • Conducted home safety evaluation and fall risk assessments
    • Performed medical reconciliation
    • Occasionally provided acute care at home (this was provided by two of the five sites)
  • Case management services:
    • Provide direct communication with patients’ medical specialists to facilitate follow-up and adherence
    • Include IPC team members (‘co-attends’) accompanying the patients to certain specialty medical visits to clarify treatment plans with the specialists act as advocates on behalf of the patient
    • Connect patients with VHA programs for specific high-risk populations such as Home-Based Primary Care, Homeless Primary Care, Palliative Care, substance abuse programs, pain clinics, and Geriatric Clinic
    • Refer patients to VHA social and non-VHA social services as needed
  • Pharmaceutical services:
    • Direct collaboration with pharmacists for medication management and adherence
    • Medication reviews to identify medication discrepancies
  • Caregiver support:
    • Education for caregivers about VHA and community benefits, navigation of VHA system, medications, and rationale for the treatment plan
  • Chronic disease management services:
    • Education about chronic diseases and self-management skills via chronic disease self-management groups
    • Remote monitoring of chronic medical conditions by the home telehealth program
    • Routine referral to chronic disease-specific clinics and pharmacists
  • Advanced care planning services:
    • Teams assisted caregivers with understanding options of care and facilitated end-of-life conversations
• An Implementation Coordinator was involved in facilitating regular meetings among all sites to discuss challenges and best practices, met weekly with each site, conducted site visits to observe team processes, and met with IPC staff and facility-level leaders.
• The initially proposed teleconferencing was not able to be implemented by any of the sites due to technical difficulties in setting up portable equipment which was a necessity at the time the progress was gathered.
  • Advances in technology since then has made it possible for VA to offer teleconferencing with mobile devices.

Budget Details

• Cost of hiring physicians, nurse practitioners, nurses, psychologists and/or psychiatrists, social workers, mental health care providers, former military medics, and peer support specialists as necessary for each team.
• Cost of hiring an implementation coordinator to facilitate interaction between the five sites.

Where We Are

• In August 2013, VHA issued a Request for Proposal calling for demonstration sites to implement IPC models to build on existing patient-centered medical homes
• In November 2013, five sites were selected.
• The study is ongoing with an estimated completion date of September 2019.

Outcomes

• A survey was distributed to the PIM staff in which respondents were asked to rate key features of the IPC team based on 1) impact for veterans, 2) impact for primary care, 3) difficulty with implementation and then provide an overall summary score.
• The most highly rated features included those closely related to evidence-based medicine like:
  • Conducting a comprehensive patient assessment that includes physical, psychological, and social needs.
  • Conducting home visits for comprehensive initial assessment of needs.
• The least highly rated features included:
  • Being available to patients and families after hours, developing service agreements with other clinical partners.
  • Visiting veterans at a VHA emergency room or non-VHA hospital.
  • Discharging patients who had not made progress after three months of enrollment.
  • Providing suggestions to primary care providers, particularly through face-to-face meetings.

Future Outcomes

• The estimated study completion date is September 2019 with the following outcomes to be measured:
  • Primary outcome measures:
    • Total VA healthcare cost including inpatient, outpatient, pharmacy and fee-basis services.
  • Secondary outcome measures:
    • Healthcare utilization of hospital, emergency and outpatient primary and specialty care.
  • Other outcome measures:
    • Engagement by looking at patient PIM enrollment data using the VA central repository data center.
    • Physical, social, and mental functional status of the patients obtained through patient reports collected as a part of their medical visit.
    • Quality of life status obtained through patient assessment of their quality of life collected as a part of their medical care.
    • Symptom burden obtained through patient assessment of their mental and physical health symptom burden collected as a part of their medical care.
    • Implementation outcome and its challenges obtained through two waves of stakeholder interviews, including demonstration site staff and facility leaders.
    • Primary Care staff job satisfaction assessed in two waves (at baseline and one year later) by both online and paper-and-pen versions of the survey. Primary Care staff job satisfaction is measured by a single item “Overall, I am satisfied with my job,” rated on a 5-point Likert agreement scale.
    • Primary Care staff intention to stay at the VA assessed in two waves (at baseline and one year later) by both online via RedCap and paper-and-pen versions of the survey. Intention to Stay at the VA is measured by a single item “I intend to continue working in PC at the VA for the next two years,” rated on a 5-point Likert agreement scale.

Benefits

• Key program elements that emerged include an interdisciplinary team with social workers and mental health care providers, comprehensive patient assessments, and weekly interdisciplinary team meetings.
• Standardization of complex medical care of high-risk Veteran patients can be achieved through multi-site quality improvement projects such as this.

Unique Challenges

• Determining the following proved to be challenges:
  • Which patients seem to be the best fit for the program.
  • How to stratify patients for more or less intensive management.
  • When and how to graduate patients safely back to primary care.
  • Which patients require a home visit.
  • The extent to which underlying factors are modifiable.

Sources

• Chang ET, Raja PV, Stockdale SE, Katz ML et al. Healthcare. 2018; 6:231-237.
• Wong, E.S., Rosland, AM., Fihn, S.D. et al. J Gen Internal Med. 2016; 31: 1467. https://doi.org/10.1007/s11606-016-3833-9
• https://clinicaltrials.gov/ct2/show/NCT03100526