1
|
Chang ET, Huynh A, Yoo C, Yoon J, Zulman DM, Ong MK, Klein M, Eng J, Roy S, Stockdale SE, Jimenez EE, Denietolis A, Needleman J, Asch SM. Impact of Referring High-Risk Patients to Intensive Outpatient Primary Care Services: A Propensity Score-Matched Analysis. J Gen Intern Med 2024:10.1007/s11606-024-08923-3. [PMID: 39075268 DOI: 10.1007/s11606-024-08923-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 06/26/2024] [Indexed: 07/31/2024]
Abstract
BACKGROUND Many healthcare systems have implemented intensive outpatient primary care programs with the hopes of reducing healthcare costs. OBJECTIVE The Veterans Health Administration (VHA) piloted primary care intensive management (PIM) for patients at high risk for hospitalization or death, or "high-risk." We evaluated whether a referral model would decrease high-risk patient costs. DESIGN Retrospective cohort study using a quasi-experimental design comparing 456 high-risk patients referred to PIM from October 2017 to September 2018 to 415 high-risk patients matched on propensity score. PARTICIPANTS Veterans in the top 10th percentile of risk for 90-day hospitalization or death and recent hospitalization or emergency department (ED) visit. INTERVENTION PIM consisted of interdisciplinary teams that performed comprehensive assessments, intensive case management, and care coordination services. MAIN OUTCOMES AND MEASURES Change in VHA and non-VHA outpatient utilization, inpatient admissions, and costs 12 months pre- and post-index date. KEY RESULTS Of the 456 patients referred to PIM, 301 (66%) enrolled. High-risk patients referred to PIM had a marginal reduction in ED visits (- 0.7; [95% CI - 1.50 to 0.08]; p = 0.08) compared to propensity-matched high-risk patients; overall outpatient costs were similar. High-risk patients referred to PIM had similar number of medical/surgical hospitalizations (- 0.2; [95% CI, - 0.6 to 0.16]; p = 0.2), significant increases in length of stay (6.36; [CI, - 0.01 to 12.72]; p = 0.05), and higher inpatient costs ($22,628, [CI, $3587 to $41,669]; p = 0.02) than those not referred to PIM. CONCLUSIONS AND RELEVANCE VHA intensive outpatient primary care was associated with higher costs. Referral to intensive case management programs targets the most complex patients and may lead to increased utilization and costs, particularly in an integrated healthcare setting with robust patient-centered medical homes. TRIAL REGISTRATION PIM 2.0: Patient Aligned Care Team (PACT) Intensive Management (PIM) Project (PIM2). NCT04521816. https://clinicaltrials.gov/study/NCT04521816.
Collapse
Affiliation(s)
- Evelyn T Chang
- VHA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA.
- Department of Medicine, VHA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.
| | - Alexis Huynh
- VHA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA
| | - Caroline Yoo
- VHA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA
| | - Jean Yoon
- VHA Health Economics Resource Center (HERC), Menlo Park, CA, USA
- Department of General Internal Medicine, UCSF School of Medicine, San Francisco, CA, USA
| | - Donna M Zulman
- VHA HSR Center for Innovation to Implementation, Menlo Park, CA, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael K Ong
- VHA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA
- Department of Medicine, VHA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
- Department of Health Policy and Management, Fielding School of Public Health, University of California at Los Angeles, Los Angeles, CA, USA
| | - Melissa Klein
- Department of Medicine, VHA Northeast Ohio Healthcare System, Cleveland, OH, USA
| | - Jessica Eng
- On Lok Program of All-Inclusive Care for the Elderly (PACE), San Francisco, CA, USA
- Division of Geriatrics, University of California, San Francisco, CA, USA
| | - Sudip Roy
- VHA Salisbury Healthcare System, Salisbury, NC, USA
| | - Susan E Stockdale
- VHA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, USA
| | - Elvira E Jimenez
- VHA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA
- Behavioral Neurology, Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Angela Denietolis
- VHA Office of Primary Care, 810 Vermont Ave, Washington, DC, 20420, USA
| | - Jack Needleman
- Department of Health Policy and Management, Fielding School of Public Health, University of California at Los Angeles, Los Angeles, CA, USA
| | - Steven M Asch
- VHA HSR Center for Innovation to Implementation, Menlo Park, CA, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| |
Collapse
|
2
|
Hulen E, Laliberte AZ, Katz ML, Giannitrapani KF, Chang ET, Stockdale SE, Eng JA, Jimenez E, Edwards ST. Patient selection strategies in an intensive primary care program. HEALTHCARE (AMSTERDAM, NETHERLANDS) 2022; 10:100627. [PMID: 35421803 DOI: 10.1016/j.hjdsi.2022.100627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 03/30/2022] [Accepted: 04/05/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intensive primary care programs have had variable impacts on clinical outcomes, possibly due to a lack of consensus on appropriate patient-selection. The US Veterans Health Administration (VHA) piloted an intensive primary care program, known as Patient Aligned Care Team Intensive Management (PIM), in five medical centers. We sought to describe the PIM patient selection process used by PIM teams and to explore perspectives of PIM team members regarding how patient selection processes functioned in context. METHODS This study employs an exploratory sequential mixed-methods design. We analyzed qualitative interviews with 21 PIM team and facility leaders and electronic health record (EHR) data from 2,061 patients screened between July 2014 and September 2017 for PIM enrollment. Qualitative data were analyzed using a hybrid inductive/deductive approach. Quantitative data were analyzed using descriptive statistics. RESULTS Of 1,887 patients identified for PIM services using standardized criteria, over half were deemed inappropriate for PIM services, either because of not having an ambulatory care sensitive condition, living situation, or were already receiving recommended care. Qualitative analysis found that team members considered standardized criteria to be a useful starting point but too broad to be relied on exclusively. Additional data collection through chart review and communication with the current primary care team was needed to adequately assess patient complexity. Qualitative analysis further found that differences in conceptualizing program goals led to conflicting opinions of which patients should be enrolled in PIM. CONCLUSIONS A combined approach that includes clinical judgment, case review, standardized criteria, and targeted program goals are all needed to support appropriate patient selection processes.
Collapse
Affiliation(s)
- Elizabeth Hulen
- Center to Improve Veteran to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA.
| | - Avery Z Laliberte
- Center to Improve Veteran to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
| | - Marian L Katz
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Health Care System, Los Angeles, CA, USA
| | - Karleen F Giannitrapani
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA; Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Evelyn T Chang
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Health Care System, Los Angeles, CA, USA; Division of General Internal Medicine, Department of Medicine, Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA; Department of Medicine, VA Greater Los Angles Health Care System, Los Angeles, CA, USA
| | - Susan E Stockdale
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Health Care System, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, USA
| | - Jessica A Eng
- Geriatrics, Palliative, and Extended Care Service, San Francisco VA Medical Center, San Francisco, CA, USA; Division of Geriatrics, University of California San Francisco, San Francisco, CA, USA
| | - Elvira Jimenez
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Health Care System, Los Angeles, CA, USA; Behavioral Neurology, Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Samuel T Edwards
- Center to Improve Veteran to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA; School of Medicine, Oregon Health and Science University, Portland, OR, USA; Section of General Internal Medicine, VA Portland Health Care System, Portland, OR, USA
| |
Collapse
|
3
|
Wong MS, Luger TM, Katz ML, Stockdale SE, Ewigman NL, Jackson JL, Zulman DM, Asch SM, Ong MK, Chang ET. Outcomes that Matter: High-Needs Patients' and Primary Care Leaders' Perspectives on an Intensive Primary Care Pilot. J Gen Intern Med 2021; 36:3366-3372. [PMID: 33987789 PMCID: PMC8606366 DOI: 10.1007/s11606-021-06869-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 04/29/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Quantitative evaluations of the effectiveness of intensive primary care (IPC) programs for high-needs patients have yielded mixed results for improving healthcare utilization, cost, and mortality. However, IPC programs may provide other value. OBJECTIVE To understand the perspectives of high-needs patients and primary care facility leaders on the effects of a Veterans Affairs (VA) IPC program on patients. DESIGN A total of 66 semi-structured telephone interviews with high-needs VA patients and primary care facility leaders were conducted as part of the IPC program evaluation. PARTICIPANTS High-needs patients (n = 51) and primary care facility leaders (n = 15) at 5 VA pilot sites. APPROACH We used content analysis to examine interview transcripts for both a priori and emergent themes about perceived IPC program effects. KEY RESULTS Patients enrolled in VA IPCs reported improvements in their experience of VA care (e.g., patient-provider relationship, access to their team). Both patients and leaders reported improvements in patient motivation to engage with self-care and with their IPC team, and behaviors, especially diet, exercise, and medication management. Patients also perceived improvements in health and described receiving assistance with social needs. Despite this, patients and leaders also outlined patient health characteristics and contextual factors (e.g., chronic health conditions, housing insecurity) that may have limited the effectiveness of the program on healthcare cost and utilization. CONCLUSIONS Patients and primary care facility leaders report benefits for high-needs patients from IPC interventions that translated into perceived improvements in healthcare, health behaviors, and physical and mental health status. Most program evaluations focus on cost and utilization, which may be less amenable to change given this cohort's numerous comorbid health conditions and complex social circumstances. Future IPC program evaluations should additionally examine IPC's effects on quality of care, patient satisfaction, quality of life, and patient health behaviors other than utilization (e.g., engagement, self-efficacy).
Collapse
Affiliation(s)
- Michelle S Wong
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles HSR&D, Los Angeles, CA, USA.
| | - Tana M Luger
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles HSR&D, Los Angeles, CA, USA.,Covenant Health Network, Phoenix, AZ, USA
| | - Marian L Katz
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles HSR&D, Los Angeles, CA, USA
| | - Susan E Stockdale
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles HSR&D, Los Angeles, CA, USA.,Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Jeffrey L Jackson
- Department of Medicine, Zablocki VA Medical Center, Milwaukee, WI, USA.,Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Donna M Zulman
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Healthcare System, Palo Alto, CA, USA.,Division of Primary Care and Population Health, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Steven M Asch
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Healthcare System, Palo Alto, CA, USA.,Division of Primary Care and Population Health, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Michael K Ong
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles HSR&D, Los Angeles, CA, USA.,Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA.,Division of General Internal Medicine & Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.,Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Evelyn T Chang
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles HSR&D, Los Angeles, CA, USA.,Division of General Internal Medicine & Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.,Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| |
Collapse
|
4
|
Chang ET, Yoon J, Esmaeili A, Zulman DM, Ong MK, Stockdale SE, Jimenez EE, Chu K, Atkins D, Denietolis A, Asch SM. Outcomes of a randomized quality improvement trial for high-risk Veterans in year two. Health Serv Res 2021; 56 Suppl 1:1045-1056. [PMID: 34145564 PMCID: PMC8515223 DOI: 10.1111/1475-6773.13674] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 04/14/2021] [Accepted: 04/17/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE The Veterans Health Administration (VHA) conducted a randomized quality improvement evaluation to determine whether augmenting patient-centered medical homes with Primary care Intensive Management (PIM) decreased utilization of acute care and health care costs among patients at high risk for hospitalization. PIM was cost-neutral in the first year; we analyzed changes in utilization and costs in the second year. DATA SOURCES VHA administrative data for five demonstration sites from August 2013 to March 2019. DATA SOURCES Administrative data extracted from VHA's Corporate Data Warehouse. STUDY DESIGN Veterans with a risk of 90-day hospitalization in the top 10th percentile and recent hospitalization or emergency department (ED) visit were randomly assigned to usual primary care vs primary care augmented by PIM. PIM included interdisciplinary teams, comprehensive patient assessment, intensive case management, and care coordination services. We compared the change in mean VHA inpatient and outpatient utilization and costs (including PIM expenses) per patient for the 12-month period before randomization and 13-24 months after randomization for PIM vs usual care using difference-in-differences. PRINCIPAL FINDINGS Both PIM patients (n = 1902) and usual care patients (n = 1882) had a mean of 5.6 chronic conditions. PIM patients had a greater number of primary care visits compared to those in usual care (mean 4.6 visits/patient/year vs 3.7 visits/patient/year, p < 0.05), but ED visits (p = 0.45) and hospitalizations (p = 0.95) were not significantly different. We found a small relative increase in outpatient costs among PIM patients compared to those in usual care (mean difference + $928/patient/year, p = 0.053), but no significant differences in mean inpatient costs (+$245/patient/year, p = 0.97). Total mean health care costs were similar between the two groups during the second year (mean difference + $1479/patient/year, p = 0.73). CONCLUSIONS Approaches that target patients solely based on the high risk of hospitalization are unlikely to reduce acute care use or total costs in VHA, which already offers patient-centered medical homes.
Collapse
Affiliation(s)
- Evelyn T. Chang
- VA Center for the Study of Healthcare InnovationImplementation and Policy (CSHIIP)Los AngelesCaliforniaUSA
- Department of MedicineVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
- Department of MedicineDavid Geffen School of Medicine, University of California at Los AngelesLos AngelesCaliforniaUSA
| | - Jean Yoon
- VA Health Economics Resource Center (HERC)Menlo ParkCaliforniaUSA
- Department of General Internal MedicineUCSF School of MedicineSan FranciscoCaliforniaUSA
| | - Aryan Esmaeili
- VA Health Economics Resource Center (HERC)Menlo ParkCaliforniaUSA
| | - Donna M. Zulman
- VA HSR&D Center for Innovation to ImplementationMenlo ParkCaliforniaUSA
- Division of Primary Care and Population HealthStanford University School of MedicineMenlo ParkCaliforniaUSA
| | - Michael K. Ong
- Department of MedicineVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
- Department of MedicineDavid Geffen School of Medicine, University of California at Los AngelesLos AngelesCaliforniaUSA
- Department of Health Policy and ManagementFielding School of Public Health, University of California at Los AngelesLos AngelesCaliforniaUSA
| | - Susan E. Stockdale
- VA Center for the Study of Healthcare InnovationImplementation and Policy (CSHIIP)Los AngelesCaliforniaUSA
- Department of Psychiatry and Biobehavioral SciencesUniversity of CaliforniaLos AngelesCaliforniaUSA
| | - Elvira E. Jimenez
- VA Center for the Study of Healthcare InnovationImplementation and Policy (CSHIIP)Los AngelesCaliforniaUSA
- Behavioral NeurologyGeffen School of Medicine, University of California at Los AngelesLos AngelesCaliforniaUSA
| | - Karen Chu
- VA Center for the Study of Healthcare InnovationImplementation and Policy (CSHIIP)Los AngelesCaliforniaUSA
| | - David Atkins
- VA Health Services Research and DevelopmentWashingtonDistrict of ColumbiaUSA
| | | | - Steven M. Asch
- VA HSR&D Center for Innovation to ImplementationMenlo ParkCaliforniaUSA
- Division of Primary Care and Population HealthStanford University School of MedicineMenlo ParkCaliforniaUSA
| | | |
Collapse
|
5
|
Stockdale SE, Katz ML, Bergman AA, Zulman DM, Denietolis A, Chang ET. What Do Patient-Centered Medical Home (PCMH) Teams Need to Improve Care for Primary Care Patients with Complex Needs? J Gen Intern Med 2021; 36:2717-2723. [PMID: 33511564 PMCID: PMC8390729 DOI: 10.1007/s11606-020-06563-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 12/22/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Intensive primary care (IPC) programs for patients with complex needs do not generate cost savings in most settings. Strengthening existing patient-centered medical homes (PCMH) to address the needs of these patients in primary care is a potential high-value alternative. OBJECTIVES Explore PCMH team functioning and characteristics that may impact their ability to perform IPC tasks; identify the IPC components that could be incorporated into PCMH teams' workflow; and identify additional resources, trainings, and staff needed to better manage patients with complex needs in primary care. METHODS We interviewed 44 primary care leaders, PCMH team members (providers, nurses, social workers), and IPC program leaders at 5 VA IPC sites and analyzed a priori themes using a matrix analysis approach. RESULTS Higher-functioning PCMH teams were described as already performing most IPC tasks, including panel management and care coordination. All sites reported that PCMH teams had the knowledge and skills to perform IPC tasks, but not with the same intensity as specialized IPC teams. Home visits/assessments and co-attending appointments were perceived as not feasible to perform. Key stakeholders identified 6 categories of supports and capabilities that PCMH teams would need to better manage complex patients, with care coordination/management and fully staffed teams as the most frequently mentioned. Many thought that PCMH teams could make better use of existing VA and non-VA resources, but might need training in identifying and using those resources. CONCLUSIONS PCMH teams can potentially offer certain clinic-based services associated with IPC programs, but tasks that are time intensive or require physical absence from clinic might require collaboration with community service providers and better use of internal and external healthcare system resources. Future studies should explore the feasibility of PCMH adoption of IPC tasks and the impact on patient outcomes.
Collapse
Affiliation(s)
- Susan E Stockdale
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA.
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA.
| | - Marian L Katz
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA
| | - Alicia A Bergman
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA
| | - Donna M Zulman
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
- Department of Medicine, Stanford University, Stanford, CA, USA
| | | | - Evelyn T Chang
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA
- VA Greater Los Angeles Healthcare System, Division of General Internal Medicine, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| |
Collapse
|
6
|
Blalock DV, Maciejewski ML, Zulman DM, Smith VA, Grubber J, Rosland AM, Weidenbacher HJ, Greene L, Zullig LL, Whitson HE, Hastings SN, Hung A. Subgroups of High-Risk Veterans Affairs Patients Based on Social Determinants of Health Predict Risk of Future Hospitalization. Med Care 2021; 59:410-417. [PMID: 33821830 PMCID: PMC8034377 DOI: 10.1097/mlr.0000000000001526] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Population segmentation has been recognized as a foundational step to help tailor interventions. Prior studies have predominantly identified subgroups based on diagnoses. In this study, we identify clinically coherent subgroups using social determinants of health (SDH) measures collected from Veterans at high risk of hospitalization or death. STUDY DESIGN AND SETTING SDH measures were obtained for 4684 Veterans at high risk of hospitalization through mail survey. Eleven self-report measures known to impact hospitalization and amenable to intervention were chosen a priori by the study team to identify subgroups through latent class analysis. Associations between subgroups and demographic and comorbidity characteristics were calculated through multinomial logistic regression. Odds of 180-day hospitalization were compared across subgroups through logistic regression. RESULTS Five subgroups of high-risk patients emerged-those with: minimal SDH vulnerabilities (8% hospitalized), poor/fair health with few SDH vulnerabilities (12% hospitalized), social isolation (10% hospitalized), multiple SDH vulnerabilities (12% hospitalized), and multiple SDH vulnerabilities without food or medication insecurity (10% hospitalized). In logistic regression, the "multiple SDH vulnerabilities" subgroup had greater odds of 180-day hospitalization than did the "minimal SDH vulnerabilities" reference subgroup (odds ratio: 1.53, 95% confidence interval: 1.09-2.14). CONCLUSION Self-reported SDH measures can identify meaningful subgroups that may be used to offer tailored interventions to reduce their risk of hospitalization and other adverse events.
Collapse
Affiliation(s)
- Dan V. Blalock
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC
| | - Matthew L. Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University, Durham NC
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC
| | - Donna M. Zulman
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford CA
| | - Valerie A. Smith
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University, Durham NC
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC
| | - Janet Grubber
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
| | - Ann-Marie Rosland
- VA Pittsburgh Center for Health Equity Research and Promotion, Pittsburgh PA
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh PA
| | - Hollis J. Weidenbacher
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
| | - Liberty Greene
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford CA
| | - Leah L. Zullig
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University, Durham NC
| | - Heather E. Whitson
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, NC
- Center for the Study of Human Aging and Development, Duke University, Durham, NC
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Susan N. Hastings
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University, Durham NC
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, NC
- Center for the Study of Human Aging and Development, Duke University, Durham, NC
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Anna Hung
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University, Durham NC
- Duke Clinical Research Institute, Duke University, Durham, NC
| |
Collapse
|
7
|
Meredith LS, Azhar G, Chang ET, Okunogbe A, Simon A, Han B, Rubenstein LV. Can Using an Intensive Management Program Improve Primary Care Staff Experiences With Caring for High-Risk Patients? Fed Pract 2021; 38:68-73. [PMID: 33716482 PMCID: PMC7953852 DOI: 10.12788/fp.0090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Complex, high-risk patients present challenges for primary care staff. Intensive outpatient management teams aim to serve as a resource for usual primary care to improve care for high-risk patients without adding burden to the primary care staff. Whether such assistance can influence the primary care staff experiences is unknown. The objective of this study was to examine improvement in job satisfaction and intent to stay for primary care staff at the US Department of Veterans Affairs (VA) who sought assistance from an intensive management program. METHODS Longitudinal analysis of a staff cohort that completed 2 cross-sectional surveys 18 months apart, controlling for outcomes at time 1. Participants included 144 primary care providers at 5 geographically diverse VA health care systems who completed both surveys. Measured outcomes included job satisfaction and intent to stay within primary care at the VA (measured at time 2). Predictors included likelihood of using intensive management teams (measured at time 1). Covariates included outcomes and professional/practice characteristics (measured at time 1). RESULTS The response rate for primary care staff that completed both surveys was 21%. Staff who indicated at time 1 that they were more likely to use intensive management teams for high-risk patients reported significantly higher satisfaction and intention to stay at VA primary care at time 2 (both P < .05). CONCLUSIONS A VA primary care workforce might benefit from assistance from intensive management teams for high-risk patients. Additional work is needed to understand the mechanisms by which primary care staff benefit and how to optimize them.
Collapse
Affiliation(s)
- Lisa S Meredith
- is a Senior Behavioral Scientist at the RAND Corporation, Professor, Pardee RAND Graduate School, and Research Scientist at the VA Center for the Study of Healthcare Innovation, Implementation & Policy in Santa Monica, California. is a Senior Fellow, Futures Health Scenarios at the Institute for Health Metrics and Evaluation, University of Washington and an Adjunct Policy Researcher at RAND. is a Primary Care Physician and Health Services Researcher at VA Greater Los Angeles Health System (VAGLAHS) and an Assistant Clinical Professor in Health Sciences at University of California in Los Angeles (UCLA). is a Health Systems Specialist at RTI International, Washington, DC. is a Health Science Specialist at the VAGLAHS. is a Senior Statistician at the RAND Corporation in Santa Monica, California. is Professor Emeritus at UCLA Geffen School of Medicine and UCLA Fielding School of Public Health, and Physician Policy Researcher at RAND
| | - Gulrez Azhar
- is a Senior Behavioral Scientist at the RAND Corporation, Professor, Pardee RAND Graduate School, and Research Scientist at the VA Center for the Study of Healthcare Innovation, Implementation & Policy in Santa Monica, California. is a Senior Fellow, Futures Health Scenarios at the Institute for Health Metrics and Evaluation, University of Washington and an Adjunct Policy Researcher at RAND. is a Primary Care Physician and Health Services Researcher at VA Greater Los Angeles Health System (VAGLAHS) and an Assistant Clinical Professor in Health Sciences at University of California in Los Angeles (UCLA). is a Health Systems Specialist at RTI International, Washington, DC. is a Health Science Specialist at the VAGLAHS. is a Senior Statistician at the RAND Corporation in Santa Monica, California. is Professor Emeritus at UCLA Geffen School of Medicine and UCLA Fielding School of Public Health, and Physician Policy Researcher at RAND
| | - Evelyn T Chang
- is a Senior Behavioral Scientist at the RAND Corporation, Professor, Pardee RAND Graduate School, and Research Scientist at the VA Center for the Study of Healthcare Innovation, Implementation & Policy in Santa Monica, California. is a Senior Fellow, Futures Health Scenarios at the Institute for Health Metrics and Evaluation, University of Washington and an Adjunct Policy Researcher at RAND. is a Primary Care Physician and Health Services Researcher at VA Greater Los Angeles Health System (VAGLAHS) and an Assistant Clinical Professor in Health Sciences at University of California in Los Angeles (UCLA). is a Health Systems Specialist at RTI International, Washington, DC. is a Health Science Specialist at the VAGLAHS. is a Senior Statistician at the RAND Corporation in Santa Monica, California. is Professor Emeritus at UCLA Geffen School of Medicine and UCLA Fielding School of Public Health, and Physician Policy Researcher at RAND
| | - Adeyemi Okunogbe
- is a Senior Behavioral Scientist at the RAND Corporation, Professor, Pardee RAND Graduate School, and Research Scientist at the VA Center for the Study of Healthcare Innovation, Implementation & Policy in Santa Monica, California. is a Senior Fellow, Futures Health Scenarios at the Institute for Health Metrics and Evaluation, University of Washington and an Adjunct Policy Researcher at RAND. is a Primary Care Physician and Health Services Researcher at VA Greater Los Angeles Health System (VAGLAHS) and an Assistant Clinical Professor in Health Sciences at University of California in Los Angeles (UCLA). is a Health Systems Specialist at RTI International, Washington, DC. is a Health Science Specialist at the VAGLAHS. is a Senior Statistician at the RAND Corporation in Santa Monica, California. is Professor Emeritus at UCLA Geffen School of Medicine and UCLA Fielding School of Public Health, and Physician Policy Researcher at RAND
| | - Alissa Simon
- is a Senior Behavioral Scientist at the RAND Corporation, Professor, Pardee RAND Graduate School, and Research Scientist at the VA Center for the Study of Healthcare Innovation, Implementation & Policy in Santa Monica, California. is a Senior Fellow, Futures Health Scenarios at the Institute for Health Metrics and Evaluation, University of Washington and an Adjunct Policy Researcher at RAND. is a Primary Care Physician and Health Services Researcher at VA Greater Los Angeles Health System (VAGLAHS) and an Assistant Clinical Professor in Health Sciences at University of California in Los Angeles (UCLA). is a Health Systems Specialist at RTI International, Washington, DC. is a Health Science Specialist at the VAGLAHS. is a Senior Statistician at the RAND Corporation in Santa Monica, California. is Professor Emeritus at UCLA Geffen School of Medicine and UCLA Fielding School of Public Health, and Physician Policy Researcher at RAND
| | - Bing Han
- is a Senior Behavioral Scientist at the RAND Corporation, Professor, Pardee RAND Graduate School, and Research Scientist at the VA Center for the Study of Healthcare Innovation, Implementation & Policy in Santa Monica, California. is a Senior Fellow, Futures Health Scenarios at the Institute for Health Metrics and Evaluation, University of Washington and an Adjunct Policy Researcher at RAND. is a Primary Care Physician and Health Services Researcher at VA Greater Los Angeles Health System (VAGLAHS) and an Assistant Clinical Professor in Health Sciences at University of California in Los Angeles (UCLA). is a Health Systems Specialist at RTI International, Washington, DC. is a Health Science Specialist at the VAGLAHS. is a Senior Statistician at the RAND Corporation in Santa Monica, California. is Professor Emeritus at UCLA Geffen School of Medicine and UCLA Fielding School of Public Health, and Physician Policy Researcher at RAND
| | - Lisa V Rubenstein
- is a Senior Behavioral Scientist at the RAND Corporation, Professor, Pardee RAND Graduate School, and Research Scientist at the VA Center for the Study of Healthcare Innovation, Implementation & Policy in Santa Monica, California. is a Senior Fellow, Futures Health Scenarios at the Institute for Health Metrics and Evaluation, University of Washington and an Adjunct Policy Researcher at RAND. is a Primary Care Physician and Health Services Researcher at VA Greater Los Angeles Health System (VAGLAHS) and an Assistant Clinical Professor in Health Sciences at University of California in Los Angeles (UCLA). is a Health Systems Specialist at RTI International, Washington, DC. is a Health Science Specialist at the VAGLAHS. is a Senior Statistician at the RAND Corporation in Santa Monica, California. is Professor Emeritus at UCLA Geffen School of Medicine and UCLA Fielding School of Public Health, and Physician Policy Researcher at RAND
| |
Collapse
|
8
|
Wong ES, Guo R, Yoon J, Zulman DM, Asch SM, Ong MK, Chang ET. Impact of VHA's primary care intensive management program on dual system use. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2020; 8:100450. [PMID: 32919588 DOI: 10.1016/j.hjdsi.2020.100450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 06/11/2020] [Accepted: 06/30/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Edwin S Wong
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, MS S-152, Seattle, WA, 98108, USA; Department of Health Services, University of Washington, Magnuson Health Sciences Center, Room H-68, 1959 NE Pacific St., Seattle, WA, 98195, USA.
| | - Rong Guo
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Health Care System, 11301 Wilshire Blvd (151), 90073, Los Angeles, CA, USA; Division of General Internal Medicine, David Geffen School of Medicine, University of California Los Angeles, 1100 Glendon Ave #850, Los Angeles, CA, 90024, USA
| | - Jean Yoon
- Health Economics Resource Center, VA Palo Alto Healthcare System, 795 Willow Road (152 MPD), Menlo Park, CA, 94025, USA; Department of General Internal Medicine, UCSF School of Medicine, 1545 Divisadero St., San Francisco, CA, 94115, USA
| | - Donna M Zulman
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152 MPD), Menlo Park, CA, 94025, USA; Division of Primary Care and Population Health, Stanford University, 1265 Welch Road, Stanford, CA, 94305, USA
| | - Steven M Asch
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152 MPD), Menlo Park, CA, 94025, USA; Division of Primary Care and Population Health, Stanford University, 1265 Welch Road, Stanford, CA, 94305, USA
| | - Michael K Ong
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Health Care System, 11301 Wilshire Blvd (151), 90073, Los Angeles, CA, USA; Division of General Internal Medicine, David Geffen School of Medicine, University of California Los Angeles, 1100 Glendon Ave #850, Los Angeles, CA, 90024, USA
| | - Evelyn T Chang
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Health Care System, 11301 Wilshire Blvd (151), 90073, Los Angeles, CA, USA; Division of General Internal Medicine, David Geffen School of Medicine, University of California Los Angeles, 1100 Glendon Ave #850, Los Angeles, CA, 90024, USA
| |
Collapse
|
9
|
Facilitating ethical quality improvement initiatives: Design and implementation of an initiative-specific ethics committee. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2020; 8:100425. [PMID: 32553523 DOI: 10.1016/j.hjdsi.2020.100425] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 02/28/2020] [Accepted: 04/09/2020] [Indexed: 11/22/2022]
Abstract
Like all facets of healthcare practice, quality improvement (QI) should be conducted in an ethically responsible manner. For methodologically complex QI, accountability and thoughtful ethical monitoring might be particularly important. Yet, access to ethical guidance for QI, as opposed to research, is often limited. Available mechanisms tend to be ill-equipped to accommodate the rapid cycle nature of QI, and monitoring standards for QI are not well defined. Providing appropriate ethical guidance for complex, multi-site QI initiatives can be especially challenging, as the body providing guidance must be familiar with QI methods, recognize the competing interests of stakeholder groups, respond to numerous requests, and understand the initiative's design. This case report describes our solution-an initiative-specific QI Ethics Committee that provided ethical guidance and consultation to a Veterans Administration QI initiative employing local innovations and a centralized evaluation. Enhanced by multiple tables, we discuss structuring and staffing the committee, the committee's role, functions and activities, requests for ethics guidance, and our strategy applying initiative-specific ethical principles to guide recommendations. Supported by feedback obtained from stakeholder interviews, we share key insights regarding the value of: • Clarifying and marketing the committee's role to users. • Reconciling conflicting interests between site-based team members and cross-site evaluators. • Separating ethics guidance from regulatory oversight. • Addressing the ethics of evaluative design. • Adjusting the intensity of the committee's work over time. • Creating tangible products. Our approach shows promise in supporting the ethical practice of methodologically complex QI, especially in institutions that lack applicable ethics monitoring mechanisms. Building on this approach, other complex QI initiatives can develop effective and feasible methods to protect participants from unintentional ethical lapses.
Collapse
|
10
|
Zulman DM, Chang ET, Wong A, Yoon J, Stockdale SE, Ong MK, Rubenstein LV, Asch SM. Effects of Intensive Primary Care on High-Need Patient Experiences: Survey Findings from a Veterans Affairs Randomized Quality Improvement Trial. J Gen Intern Med 2019; 34:75-81. [PMID: 31098977 PMCID: PMC6542922 DOI: 10.1007/s11606-019-04965-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Intensive primary care programs aim to coordinate care for patients with medical, behavioral, and social complexity, but little is known about their impact on patient experience when implemented in a medical home. OBJECTIVE Determine how augmenting the VA's medical home (Patient Aligned Care Team, PACT) with a PACT-Intensive Management (PIM) program influences patient experiences with care coordination, access, provider relationships, and satisfaction. DESIGN Cross-sectional analysis of patient survey data from a five-site randomized quality improvement study. PARTICIPANTS Two thousand five hundred sixty-six Veterans with hospitalization risk scores ≥ 90th percentile and recent acute care. INTERVENTION PIM offered patients intensive care coordination, including home visits, accompaniment to specialists, acute care follow-up, and case management from a team staffed by primary care providers, social workers, psychologists, nurses, and/or other support staff. MAIN MEASURES Patient-reported experiences with care coordination (e.g., health goal assessment, test and appointment follow-up, Patient Assessment of Chronic Illness Care (PACIC)), access to healthcare services, provider relationships, and satisfaction. KEY RESULTS Seven hundred fifty-nine PIM and 768 PACT patients responded to the survey (response rate 60%). Patients randomized to PIM were more likely than those in PACT to report that they were asked about their health goals (AOR = 1.26; P = 0.046) and that they have a VA provider whom they trust (AOR = 1.35; P = 0.005). PIM patients also had higher mean (SD) PACIC scores compared with PACT patients (2.91 (1.31) vs. 2.75 (1.25), respectively; P = 0.022) and were more likely to report 10 out of 10 on satisfaction with primary care (AOR = 1.25; P = 0.048). However, other effects on coordination, access, and satisfaction did not achieve statistical significance. CONCLUSIONS Augmenting VA's patient-centered medical home with intensive primary care had a modestly positive influence on high-risk patients' experiences with care coordination and provider relationships, but did not have a significant impact on most patient-reported access and satisfaction measures.
Collapse
Affiliation(s)
- Donna M Zulman
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA. .,Division of Primary Care and Population Health, Stanford University School of Medicine, 1265 Welch Road, Stanford, CA, 94305, USA.
| | - Evelyn T Chang
- VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA.,Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.,Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Ava Wong
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Jean Yoon
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.,VA Health Economics Resource Center, Menlo Park, CA, USA
| | - Susan E Stockdale
- VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA.,Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, USA
| | - Michael K Ong
- VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA.,Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.,Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Lisa V Rubenstein
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.,RAND, Santa Monica, CA, USA
| | - Steven M Asch
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, 1265 Welch Road, Stanford, CA, 94305, USA
| |
Collapse
|
11
|
McDonald KM, Singer SJ, Gorin SS, Haggstrom DA, Hynes DM, Charns MP, Yano EM, Lucatorto MA, Zulman DM, Ong MK, Axon RN, Vogel D, Upton M. Incorporating Theory into Practice: Reconceptualizing Exemplary Care Coordination Initiatives from the US Veterans Health Delivery System. J Gen Intern Med 2019; 34:24-29. [PMID: 31098965 PMCID: PMC6542860 DOI: 10.1007/s11606-019-04969-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
This perspective paper seeks to lay out an efficient approach for health care providers, researchers, and other stakeholders involved in interventions aimed at improving care coordination to partner in locating and using applicable care coordination theory. The objective is to learn from relevant theory-based literature about fit between intervention options and coordination needs, thereby bringing insights from theory to enhance intervention design, implementation, and troubleshooting. To take this idea from an abstract notion to tangible application, our workgroup on models and measures from the Veterans Health Administration (VA) State of the Art (SOTA) conference on care coordination first summarizes our distillation of care coordination theoretical frameworks (models) into three common conceptual domains-context of an intervention, locus in which an intervention is applied, and specific design features of the intervention. Then we apply these three conceptual domains to four cases of care coordination interventions ("use cases") chosen to represent various scopes and stages of interventions to improve care coordination for veterans. Taken together, these examples make theory more accessible and practical by demonstrating how it can be applied to specific cases. Drawing from theory offers one method to anticipate which intervention options match a particular coordination situation.
Collapse
Affiliation(s)
- Kathryn M McDonald
- Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford University, Stanford, CA, USA.
| | - Sara J Singer
- Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford University, Stanford, CA, USA
- Stanford University Graduate School of Business, Stanford, CA, USA
| | - Sherri Sheinfeld Gorin
- New York Physicians against Cancer (NYPAC), New York, NY, USA
- The University of Michigan Medical School, Ann Arbor, MI, USA
| | - David A Haggstrom
- Indianapolis VA Medical Center, Indianapolis, IN, USA
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Denise M Hynes
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, USA
- College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA
| | - Martin P Charns
- VA HSR&D Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
- Boston University School of Public Health, Boston, MA, USA
| | - Elizabeth M Yano
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | | | - Donna M Zulman
- Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford University, Stanford, CA, USA
- VA Palo Alto, Palo Alto, CA, USA
| | - Michael K Ong
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - R Neal Axon
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
- Medical University of South Carolina, Charleston, SC, USA
| | - Donna Vogel
- VA Office of Nursing Services, Washington, DC, USA
| | - Mark Upton
- VHA Office of Community Care, Denver, CO, USA
| |
Collapse
|
12
|
Chan B, Edwards ST, Devoe M, Gil R, Mitchell M, Englander H, Nicolaidis C, Kansagara D, Saha S, Korthuis PT. The SUMMIT ambulatory-ICU primary care model for medically and socially complex patients in an urban federally qualified health center: study design and rationale. Addict Sci Clin Pract 2018; 13:27. [PMID: 30547847 PMCID: PMC6295087 DOI: 10.1186/s13722-018-0128-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 12/05/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Medically complex urban patients experiencing homelessness comprise a disproportionate number of high-cost, high-need patients. There are few studies of interventions to improve care for these populations; their social complexity makes them difficult to study and requires clinical and research collaboration. We present a protocol for a trial of the streamlined unified meaningfully managed interdisciplinary team (SUMMIT) team, an ambulatory ICU (A-ICU) intervention to improve utilization and patient experience that uses control populations to address limitations of prior research. METHODS/DESIGN Participants are patients at a Federally Qualified Health Center in Portland, Oregon that serves patients experiencing homelessness or who have substance use disorders. Participants meet at least one of the following criteria: > 1 hospitalization over past 6 months; at least one medical co-morbidity including uncontrolled diabetes, heart failure, chronic obstructive pulmonary disease, liver disease, soft-tissue infection; and 1 mental health diagnosis or substance use disorder. We exclude patients if they have < 6 months to live, have cognitive impairment preventing consent, or are non-English speaking. Following consent and baseline assessment, we randomize participants to immediate SUMMIT intervention or wait-list control group. Participants receiving the SUMMIT intervention transfer care to a clinic-based team of physician, complex care nurse, care coordinator, social worker, and pharmacist with reduced panel size and flexible scheduling with emphasis on motivational interviewing, patient goal setting and advanced care planning. Wait-listed participants continue usual care plus engagement with community health worker intervention for 6 months prior to joining SUMMIT. The primary outcome is hospital utilization at 6 months; secondary outcomes include emergency department utilization, patient activation, and patient experience measures. We follow participants for 12 months after intervention initiation. DISCUSSION The SUMMIT A-ICU is an intensive primary care intervention for high-utilizers impacted by homelessness. Use of a wait-list control design balances community and staff stakeholder needs, who felt all participants should have access to the intervention, while addressing research needs to include control populations. Design limitations include prolonged follow-up period that increases risk for attrition, and conflict between practice and research; including partner stakeholders and embedded researchers familiar with the population in study planning can mitigate these barriers. Trial registration ClinicalTrials.gov NCT03224858, Registered 7/21/17 retrospectively registered https://clinicaltrials.gov/ct2/show/NCT03224858.
Collapse
Affiliation(s)
- Brian Chan
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, 3181 SW Sam Jackson Park Road L475, Portland, OR, 97239-3098, USA.
- Central City Concern, Portland, OR, USA.
| | - Samuel T Edwards
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, 3181 SW Sam Jackson Park Road L475, Portland, OR, 97239-3098, USA
- Portland VA Medical Center, Portland, OR, USA
| | - Meg Devoe
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, 3181 SW Sam Jackson Park Road L475, Portland, OR, 97239-3098, USA
- Central City Concern, Portland, OR, USA
| | - Richard Gil
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, 3181 SW Sam Jackson Park Road L475, Portland, OR, 97239-3098, USA
- Central City Concern, Portland, OR, USA
| | | | - Honora Englander
- Central City Concern, Portland, OR, USA
- Division of Hospital Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Christina Nicolaidis
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, 3181 SW Sam Jackson Park Road L475, Portland, OR, 97239-3098, USA
- School of Social Work, Portland State University, Portland, OR, USA
| | - Devan Kansagara
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, 3181 SW Sam Jackson Park Road L475, Portland, OR, 97239-3098, USA
- Portland VA Medical Center, Portland, OR, USA
| | - Somnath Saha
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, 3181 SW Sam Jackson Park Road L475, Portland, OR, 97239-3098, USA
- Portland VA Medical Center, Portland, OR, USA
| | - P Todd Korthuis
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, 3181 SW Sam Jackson Park Road L475, Portland, OR, 97239-3098, USA
| |
Collapse
|
13
|
Yoon J, Chang E, Rubenstein LV, Park A, Zulman DM, Stockdale S, Ong MK, Atkins D, Schectman G, Asch SM. Impact of Primary Care Intensive Management on High-Risk Veterans' Costs and Utilization: A Randomized Quality Improvement Trial. Ann Intern Med 2018; 168:846-854. [PMID: 29868706 DOI: 10.7326/m17-3039] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Primary care models that offer comprehensive, accessible care to all patients may provide insufficient resources to meet the needs of patients with complex conditions who have the greatest risk for hospitalization. OBJECTIVE To assess whether augmenting usual primary care with team-based intensive management lowers utilization and costs for high-risk patients. DESIGN Randomized quality improvement trial. (ClinicalTrials.gov: NCT03100526). SETTING 5 U.S. Department of Veterans Affairs (VA) medical centers. PATIENTS Primary care patients at high risk for hospitalization who had a recent acute care episode. INTERVENTION Locally tailored intensive management programs providing care coordination, goals assessment, health coaching, medication reconciliation, and home visits through an interdisciplinary team, including a physician or nurse practitioner, a nurse, and psychosocial experts. MEASUREMENTS Utilization and costs (including intensive management program expenses) 12 months before and after randomization. RESULTS 2210 patients were randomly assigned, 1105 to intensive management and 1105 to usual care. Patients had a mean age of 63 years and an average of 7 chronic conditions; 90% were men. Of the patients assigned to intensive management, 487 (44%) received intensive outpatient care (that is, ≥3 encounters in person or by telephone) and 204 (18%) received limited intervention. From the pre- to postrandomization periods, mean inpatient costs decreased more for the intensive management than the usual care group (-$2164 [95% CI, -$7916 to $3587]). Outpatient costs increased more for the intensive management than the usual care group ($2636 [CI, $524 to $4748]), driven by greater use of primary care, home care, telephone care, and telehealth. Mean total costs were similar in the 2 groups before and after randomization. LIMITATIONS Sites took up to several months to contact eligible patients, limiting the time between treatment and outcome assessment. Only VA costs were assessed. CONCLUSION High-risk patients with access to an intensive management program received more outpatient care with no increase in total costs. PRIMARY FUNDING SOURCE Veterans Health Administration Primary Care Services.
Collapse
Affiliation(s)
- Jean Yoon
- U.S. Department of Veterans Affairs Health Economics Resource Center and Center for Innovation to Implementation, Menlo Park, California, and University of California, San Francisco, School of Medicine, San Francisco, California (J.Y.)
| | - Evelyn Chang
- U.S. Department of Veterans Affairs Center for the Study of Healthcare Innovation, Implementation and Policy, University of California, Los Angeles, and VA Greater Los Angeles Healthcare System, Los Angeles, California (E.C., M.K.O.)
| | - Lisa V Rubenstein
- University of California, Los Angeles, Los Angeles, California, and RAND Corporation, Santa Monica, California (L.V.R.)
| | - Angel Park
- U.S. Department of Veterans Affairs Health Economics Resource Center, Menlo Park, California (A.P.)
| | - Donna M Zulman
- U.S. Department of Veterans Affairs Center for Innovation to Implementation, Menlo Park, California, and Stanford University School of Medicine, Stanford, California (D.M.Z., S.M.A.)
| | - Susan Stockdale
- U.S. Department of Veterans Affairs Center for the Study of Healthcare Innovation, Implementation and Policy and University of California, Los Angeles, Los Angeles, California (S.S.)
| | - Michael K Ong
- U.S. Department of Veterans Affairs Center for the Study of Healthcare Innovation, Implementation and Policy, University of California, Los Angeles, and VA Greater Los Angeles Healthcare System, Los Angeles, California (E.C., M.K.O.)
| | - David Atkins
- U.S. Department of Veterans Affairs Health Services Research and Development, Washington, DC (D.A.)
| | - Gordon Schectman
- U.S. Department of Veterans Affairs Primary Care, Washington, DC (G.S.)
| | - Steven M Asch
- U.S. Department of Veterans Affairs Center for Innovation to Implementation, Menlo Park, California, and Stanford University School of Medicine, Stanford, California (D.M.Z., S.M.A.)
| |
Collapse
|