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2015 HSR&D/QUERI National Conference Abstract

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1075 — Randomized Controlled Evaluation of an Intensive Management Patient Aligned Care Team (ImPACT) for High-Need, High-Cost Primary Care Patients

Zulman DM, VA Palo Alto and Stanford University; Pal Chee C, VA Palo Alto; Ezeji-Okoye SC, VA Palo Alto and Stanford University; Shaw JG, VA Palo Alto and Stanford University; Kahn JS, VA Palo Alto and Stanford University; Asch SM, VA Palo Alto and Stanford University;

Objectives:
To evaluate an Intensive management Patient Aligned Care Team (ImPACT) intervention's effect on high-need, high-cost (HNHC) patients' satisfaction, acute care utilization, and costs.

Methods:
In 2013, the Palo Alto VA launched ImPACT, a multidisciplinary team that offers HNHC PACT patients enhanced access, chronic disease and acute deterioration support, social work, and recreation therapy. We identified 583 VA patients as eligible (costs or risk for hospitalization in the top 5% for the facility), and invited 150 randomly selected individuals to enroll in ImPACT; the remaining eligible patients served as the control, receiving standard PACT care. We evaluated changes in hospital admissions, emergency department visits, and costs among ImPACT and PACT patients across 16-month baseline and 17-month follow-up periods. For all patients and prespecified subgroups, we performed an intention-to-treat analysis within a difference-in-differences framework; a secondary analysis estimated the effect of the intervention on patients who actively participated in ImPACT (using randomization as an instrument for participation). Among enrollees, we assessed changes in VA care satisfaction using the Patient Satisfaction Questionnaire at baseline and 6 months after enrollment.

Results:
Two-thirds of invited patients (n = 101) enrolled in ImPACT, 87% of whom remained actively engaged at 9 months. Rates of hospitalizations and emergency department visits declined at similar rates in both groups. There was no significant difference in average monthly costs between ImPACT and PACT in intention to treat analyses or analyses estimating effect of engagement. Modest, but non-statistically significant, greater cost reductions were observed for certain subpopulations in ImPACT, including individuals with heart failure, diabetes, or COPD, individuals under age 65, and individuals at high risk for hospitalization who were hospitalized in the six months prior to enrollment. Among patients who engaged in ImPACT, there were significant increases in clinical contact and improvements in satisfaction with overall VA care and communication (response rate 55%; p < 0.05).

Implications:
This pilot intensive management program for HNHC individuals did not achieve greater reductions in costs or acute care utilization compared with standard PACT care, but the program improved access, communication, and satisfaction for patients who engaged.

Impacts:
Although this pilot did not achieve cost savings, lessons learned about patient selection and program design are informing a multi-site demonstration program to enhance care for HNHC VA patients.