3047 — Differences in Patient-Aligned Care Team (PACT) Performance in Urban and Rural VA Primary Care Clinics

Lampman MA, Center for Comprehensive Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System; VISN 23 PACT Demonstration Lab; Vaughan Sarrazin MS, Center for Comprehensive Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System; VISN 23 PACT Demonstration Lab; Rosenthal GR, Center for Comprehensive Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System; VISN 23 PACT Demonstration Lab;

Objectives:
Examine relationships between PACT performance metrics and rural status in VA primary care clinics.

Methods:
Associations between rural location and performance on PACT Compass metrics were evaluated in a national sample of 891 VA primary care clinics during FY2013. Six metrics reflecting panel management, access, continuity, and care coordination were selected as endpoints. Clinics were classified as Urban (n = 549), Large Rural (n = 228), and Small/Isolated Rural (n = 114) based on the clinic zipcode using Rural-Urban Commuting Area (RUCA) Codes. Generalized Estimating Equations (GEE) with repeated measures were used to estimate associations between rural location and monthly performance before and after adjusting for patient characteristics (i.e. percent of lower priority patients, and average panel complexity level) and clinic structural capacity (i.e. primary care staffing ratio, average PCP panel size, and clinic classification).

Results:
Unadjusted GEE models identified significant (p < .05) differences between rural and urban clinics for each of the 6 performance metrics. Adjusting for both patient characteristics and clinic capacity diminished differences in performance on metrics reflecting access and continuity. However, several differences between rural and urban clinics remained significant. Clinics in Small/Isolated Rural areas had a higher proportion of patients enrolled in Chronic Condition Home Telehealth than Urban clinics (b = 0.36, p < 0.003). Clinics in Large Rural areas had a lower rate of non-traditional encounters than Urban clinics (b = -1.38, p < 0.02); and clinics in Small/Isolated or Large Rural areas had a lower percentage of patients contacted within 2 days of discharge from a VA hospital than Urban clinics (b = -5.47, p < 0.01; b = -3.84, p < 0.02).

Implications:
Differences in implementing processes related to key PACT principles exist between rural and urban clinics. PACTs in rural areas exhibited better performance one metric related to panel management; however, such clinics may be more likely to struggle with enhancing access through use of non-traditional encounters and facilitating care coordination through post-discharge follow-up compared to urban clinics.

Impacts:
Identifying differences in PACT performance between rural and urban facilities calls attention to the possibility of unique challenges for PACTs delivering care to rural Veterans. Efforts to improve PACT implementation and performance should account for the specific challenges encountered in urban and rural practices.