Primary Health Care, Health Care Costs
Conditions
Brief summary
This evaluation will examine the feasibility, implementation, and effectiveness of a quality improvement intervention-Intensive Management Patient Aligned Care Team (ImPACT)-for high-risk patients.
Detailed description
Background: VA's highest-utilizing patients generally have complicated health care needs-including complex and multiple chronic conditions, comorbid mental health conditions, and social stressors-that contribute to high rates of hospitalization, emergency services, and specialty care use. Inspired by emerging intensive primary care models for high-utilizers, VA Palo Alto launched a quality improvement program to augment existing VA primary care (provided by Patient Aligned Care Teams, PACT) with intensive care delivered by a multidisciplinary team. The Intensive management PACT (ImPACT) intervention encompasses a number of evidence-based strategies, including a comprehensive intake process, coordination of specialty care, chronic condition case management, provision of social services, rapid response to deteriorations in health, and facilitation of transitions after high-acuity events. The ImPACT program was designated as quality improvement (non-research) by the Palo Alto VA. A retrospective evaluation using deidentified data was approved by the Stanford University IRB. Objectives: The objectives of this evaluation are to assess ImPACT's feasibility, implementation, and effectiveness, and lay the groundwork for future larger-scale efforts and evaluations within the VA system. Methods: We will partner with the implementation team of VA Palo Alto's ImPACT clinic to conduct a Hybrid Type 1 evaluation of the program's feasibility, implementation, and effectiveness. Specifically, the evaluation will aim to: 1. Evaluate the feasibility and implementation of the pilot ImPACT intervention. Using semi-structured interviews with ImPACT and PACT team members and leadership, we will evaluate the success of intervention delivery, including patient identification, recruitment, and retention; provision and uptake of planned services; and monitoring of patient participation and key outcomes. 2. Evaluate ImPACT's effect on utilization and costs of care. We will use a difference-in-differences approach, wherein we compare changes in VA health care costs (total, as well as inpatient, outpatient, and fee-basis) and utilization (including hospitalizations, emergency department visits, and specialty care) among ImPACT patients and high-utilizing patients who are receiving usual PACT care. 3. Examine the association between ImPACT participation and patient-centered outcomes. Using data from surveys administered in the ImPACT clinic, we will assess patient satisfaction with the ImPACT intervention and overall care, as well as changes in patient-reported outcomes, including health status, symptom burden, and function.
Interventions
OTHERImPACT
The ImPACT team offers the following services: * An intensive intake process, including a home visit if deemed appropriate * Frequent contact (in-person, telephone, or secure messaging) tailored to a patient's needs * After-hours access to on-call team member in order to avoid unnecessary emergency care * Optimization of chronic condition management using evidence-based protocols * Navigation of transitions between hospital and home * Coordination of specialty care, including contact with specialists when indicated * Rapid response to signs of health status deterioration or other stressful events * Assess patient goals, advance directives, Physician Orders for Life-Sustaining Treatment
Sponsors
VA Palo Alto Health Care System
Veteran Affairs Office of Patient Care Services
VA Office of Research and Development
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Patient receives care from one of 14 primary care providers (MDs, NPs) who have at least three half-days of clinic per week * Total VA healthcare costs in the top 5% for VA Palo Alto facility during the 9-month eligibility phase (10/1/11-6/30/12) AND/OR * Risk for one-year hospitalization in November 2012 in the top 5% (using the VA's Care Assessment Need risk-prediction algorithm)
Exclusion criteria
* Enrollment in VA's mental health intensive case management program, home-based primary care, or palliative care programs * Recipient of inpatient care for over half of the 9-month eligibility phase (10/1/11-6/30/12). * Total VA healthcare costs in the lowest cost decile in the 9-month eligibility phase (10/1/11-6/30/12) * Risk for one-year hospitalization in November 2012 in the lowest risk quartile (using the VA's Care Assessment Need risk-prediction algorithm).
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| VA Health Care Costs | 17 months | Estimated programs effect on cost among all patients, and correspond to the change in monthly costs among patients in impact minus the change in costs for patients in PACT. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Hospitalization | 17 months | Admission rates and length of stay of acute medical/surgical, acute mental health, extended medical, and extended mental health inpatient care. Outcome reported is mean(SD) number of hospital admissions using intent to treat analysis between both groups. |
| Emergency Department Utilization | 17 months | Number of Emergency Department visits |
| Outpatient Utilization | 17 months | Number of visits to primary, specialty, and mental health clinics. Number reported is mean primary care visits between ImPACT and PACT. |
Other
| Measure | Time frame | Description |
|---|---|---|
| Health Status (Patient-reported) | up to 9 months | We will assess patient-reported health status through a patient survey administered at time of enrollment and 4-9 months after enrollment. Outcome measure includes mean patient activation scores between baseline and follow up survey periods. Activation is measured on a scale from 0-100, with higher numbers corresponding to higher levels of patient activation. |
| Feasibility: Time to Enrollment | 9 months | To evaluate ImPACT's feasibility, we will assess time to enrollment for invited participants. Number is reported is number of participants still enrolled in ImPACT program after 9 months |
| Functional Status (Patient-reported) | 9 months | We will assess changes in patient-reported functional status through a patient survey administered at time of enrollment and 4-9 months after enrollment. The outcome measure includes percentage of patients(from 0-100%) who indicated having some difficulty, much difficulty, or inability to perform tasks due to functional limitations. A higher score indicates more functional limitations |
| Symptom Burden (Patient-reported) | up to 9 months | We will assess changes in patient-reported symptom burden, including pain through a patient survey administered at time of enrollment and 4-9 months after enrollment. Outcome measure below is the mean number of participants who rate their pain in the last weeks on a 10 point scale where 0=None and 10=severe pain, a higher value indicates worse symptom burden. |
| Feasibility: Participation | 9 months | We will evaluate proportion of patients who participate in ImPACT and the frequency of their contact with ImPACT team members. Outcome measure is the average number of patient-ImPACT provider in person contacts per month from 2/2013-6/2014 |
| Implementation Process | 9 months | Interviews with ImPACT team members, PACT providers, and VA facility leadership will be used to understand the ImPACT program implementation process. Outcome measure is number of participants enrolled and completed interviews. |
| Patient Satisfaction | 9 months | We will assess patient satisfaction with the ImPACT intervention and changes in satisfaction with overall care. The Patient Satisfaction Questionnaires ask: Please describe your satisfaction with ImPACT Clinical Services 1. Medical care 2. Social work services 3. Recreational and community services 4. After-hours services The 4 items were combined to create a mean overall satisfaction with ImPACT care score, which ranges from 1-4, 4 indicating better satisfaction with the program. The scale is measured on a 4 point scale with 1 meaning strongly disagree and 4 meaning strongly agree. |
Participant flow
Recruitment details
Recruitment into ImPACT completed by ImPACT staff at VAPAHCS
Participants by arm
| Arm | Count |
|---|---|
| ImPACT Patients in ImPACT receive intensive outpatient care from the ImPACT team. The ImPACT team augments existing PACT primary care with intensive services delivered by a multidisciplinary team (including a physician, nurse practitioner, social worker, recreational therapist, and program coordinator). ImPACT program elements include a comprehensive patient assessment, identification and tracking of patients' goals and priorities, care management for medical and social service needs, co-attendance at specialty care appointments, and coordination of care with VA and non-VA providers, including during and after hospitalization. | 140 |
| PACT Patients in PACT receive usual VA primary care through the VA's Patient Centered Medical Home. VA primary care is delivered by PACT teamlets that comprise a primary care provider, nurse, clinical associate, and administrative associate who are supported by social work, pharmacy, and behavioral health services. | 405 |
| Total | 545 |
Withdrawals & dropouts
| Period | Reason | FG000 | FG001 |
|---|---|---|---|
| Overall Study | Death | 8 | 23 |
| Overall Study | not eligible upon chart review | 2 | 5 |
Baseline characteristics
| Characteristic | PACT | ImPACT | Total |
|---|---|---|---|
| Age, Categorical <=18 years | 0 Participants | 0 Participants | 0 Participants |
| Age, Categorical >=65 years | 193 Participants | 76 Participants | 269 Participants |
| Age, Categorical Between 18 and 65 years | 212 Participants | 64 Participants | 276 Participants |
| Age, Continuous | 65.7 years STANDARD_DEVIATION 13 | 66.4 years STANDARD_DEVIATION 14 | 66.05 years STANDARD_DEVIATION 13.5 |
| Region of Enrollment United States | 405 Participants | 140 Participants | 545 Participants |
| Sex: Female, Male Female | 40 Participants | 10 Participants | 50 Participants |
| Sex: Female, Male Male | 365 Participants | 130 Participants | 495 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | — / — | — / — |
| other Total, other adverse events | 0 / 140 | 0 / 405 |
| serious Total, serious adverse events | 0 / 140 | 0 / 405 |
Outcome results
Primary
VA Health Care Costs
Estimated programs effect on cost among all patients, and correspond to the change in monthly costs among patients in impact minus the change in costs for patients in PACT.
Time frame: 17 months
Population: Program's effect on monthly person level costs
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| ImPACT | VA Health Care Costs | Baseline monthly costs | 6139 US Dollars | Standard Deviation 2312 |
| ImPACT | VA Health Care Costs | Follow-up monthly costs | 4850 US Dollars | Standard Deviation 1780 |
| PACT | VA Health Care Costs | Baseline monthly costs | 5821 US Dollars | Standard Deviation 2217 |
| PACT | VA Health Care Costs | Follow-up monthly costs | 4618 US Dollars | Standard Deviation 1741 |
Secondary
Emergency Department Utilization
Number of Emergency Department visits
Time frame: 17 months
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| ImPACT | Emergency Department Utilization | Baseline | 3.4 visits | Standard Deviation 3.3 |
| ImPACT | Emergency Department Utilization | Follow-up | 2.1 visits | Standard Deviation 2.9 |
| PACT | Emergency Department Utilization | Baseline | 3.3 visits | Standard Deviation 3.3 |
| PACT | Emergency Department Utilization | Follow-up | 2.1 visits | Standard Deviation 2.9 |
Secondary
Hospitalization
Admission rates and length of stay of acute medical/surgical, acute mental health, extended medical, and extended mental health inpatient care. Outcome reported is mean(SD) number of hospital admissions using intent to treat analysis between both groups.
Time frame: 17 months
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| ImPACT | Hospitalization | Baseline | 1.3 Admissions | Standard Deviation 1.5 |
| ImPACT | Hospitalization | Follow-up | 0.7 Admissions | Standard Deviation 1.2 |
| PACT | Hospitalization | Baseline | 1.3 Admissions | Standard Deviation 1.5 |
| PACT | Hospitalization | Follow-up | 0.7 Admissions | Standard Deviation 1.2 |
Secondary
Outpatient Utilization
Number of visits to primary, specialty, and mental health clinics. Number reported is mean primary care visits between ImPACT and PACT.
Time frame: 17 months
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| ImPACT | Outpatient Utilization | Baseline | 10.9 visits | Standard Deviation 7.7 |
| ImPACT | Outpatient Utilization | Follow up | 21.8 visits | Standard Deviation 17.4 |
| PACT | Outpatient Utilization | Baseline | 10.6 visits | Standard Deviation 7.8 |
| PACT | Outpatient Utilization | Follow up | 7.4 visits | Standard Deviation 7.5 |
Other Pre-specified
Feasibility: Participation
We will evaluate proportion of patients who participate in ImPACT and the frequency of their contact with ImPACT team members. Outcome measure is the average number of patient-ImPACT provider in person contacts per month from 2/2013-6/2014
Time frame: 9 months
Population: This analysis was only conducted on the ImPACT group.
| Arm | Measure | Value (MEAN) |
|---|---|---|
| ImPACT | Feasibility: Participation | 2.4 encounters |
Other Pre-specified
Feasibility: Time to Enrollment
To evaluate ImPACT's feasibility, we will assess time to enrollment for invited participants. Number is reported is number of participants still enrolled in ImPACT program after 9 months
Time frame: 9 months
Population: This analysis was only conducted on the ImPACT group.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| ImPACT | Feasibility: Time to Enrollment | 80 participants |
Other Pre-specified
Functional Status (Patient-reported)
We will assess changes in patient-reported functional status through a patient survey administered at time of enrollment and 4-9 months after enrollment. The outcome measure includes percentage of patients(from 0-100%) who indicated having some difficulty, much difficulty, or inability to perform tasks due to functional limitations. A higher score indicates more functional limitations
Time frame: 9 months
Population: The survey was only given to ImPACT enrollees.
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| ImPACT | Functional Status (Patient-reported) | Baseline | 52 percentage of participants |
| ImPACT | Functional Status (Patient-reported) | Follow up | 56 percentage of participants |
Other Pre-specified
Health Status (Patient-reported)
We will assess patient-reported health status through a patient survey administered at time of enrollment and 4-9 months after enrollment. Outcome measure includes mean patient activation scores between baseline and follow up survey periods. Activation is measured on a scale from 0-100, with higher numbers corresponding to higher levels of patient activation.
Time frame: up to 9 months
Population: This analysis was only conducted on the ImPACT group.
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| ImPACT | Health Status (Patient-reported) | Baseline | 62.7 units on a scale | Standard Deviation 17.7 |
| ImPACT | Health Status (Patient-reported) | Follow up | 66.8 units on a scale | Standard Deviation 18.2 |
Other Pre-specified
Implementation Process
Interviews with ImPACT team members, PACT providers, and VA facility leadership will be used to understand the ImPACT program implementation process. Outcome measure is number of participants enrolled and completed interviews.
Time frame: 9 months
Population: This analysis was only conducted on the ImPACT group.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| ImPACT | Implementation Process | 15 Participants |
Other Pre-specified
Patient Satisfaction
We will assess patient satisfaction with the ImPACT intervention and changes in satisfaction with overall care. The Patient Satisfaction Questionnaires ask: Please describe your satisfaction with ImPACT Clinical Services 1. Medical care 2. Social work services 3. Recreational and community services 4. After-hours services The 4 items were combined to create a mean overall satisfaction with ImPACT care score, which ranges from 1-4, 4 indicating better satisfaction with the program. The scale is measured on a 4 point scale with 1 meaning strongly disagree and 4 meaning strongly agree.
Time frame: 9 months
Population: The survey was only given to ImPACT enrollees.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| ImPACT | Patient Satisfaction | 3.16 units on a scale | Standard Deviation 0.6 |
Other Pre-specified
Symptom Burden (Patient-reported)
We will assess changes in patient-reported symptom burden, including pain through a patient survey administered at time of enrollment and 4-9 months after enrollment. Outcome measure below is the mean number of participants who rate their pain in the last weeks on a 10 point scale where 0=None and 10=severe pain, a higher value indicates worse symptom burden.
Time frame: up to 9 months
Population: The survey was only given to ImPACT enrollees.
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| ImPACT | Symptom Burden (Patient-reported) | Baseline | 4.6 Units on a scale | Standard Deviation 3.3 |
| ImPACT | Symptom Burden (Patient-reported) | Follow up | 4.7 Units on a scale | Standard Deviation 3.2 |