Health Services Research & Development

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2017 HSR&D/QUERI National Conference Abstract

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4091 — Effect of intensive outpatient program on high-need Veterans' end-of-life care

Lead/Presenter: Cindie Slightam, COIN - Palo Alto
All Authors: Slightam CA (VA Palo Alto HCS) Hummel D (VA Palo Alto HCS and Stanford Hospital) Wu F (Kaiser Permanente) Wong A (VA Palo Alto HCS) Asch SM (VA Palo Alto HCS) Zulman DM (VA Palo Alto HCS)

Objectives:
To evaluate the effects of an Intensive management Patient Aligned Care Team (ImPACT) on end-of-life care for Veterans at high-risk for hospitalization.

Methods:
ImPACT was implemented at a single VA facility to augment PACT for Veterans whose costs or risk for hospitalization were in the top 5%. The ImPACT program conducted a comprehensive intake assessment and offered intensive outpatient case management, including advanced care planning and goals discussions, when appropriate. A random sample of eligible Veterans (N = 140) were invited to participate in ImPACT; remaining eligible patients (N = 405) received usual PACT care and served as a control group. We used chart review to identify ImPACT and PACT patients who died during a 22-month follow-up period, and abstracted information about date and location of death, advance directive (AD) documentation, and hospice referrals from the electronic health record. We compared rates of AD documentation, hospice referral, days in hospice, and location of death among ImPACT and PACT patients.

Results:
There were 19 (14%) ImPACT and 63 (16%) PACT patients who died in the 22 months after ImPACT implementation (p = 0.571); there were no between-group differences in age, sex, number of chronic conditions, and baseline risk of hospitalization. Among those who died, ImPACT patients were more likely than PACT patients to have a newly documented AD during the intervention period (89% vs. 62%, p = 0.024), and more likely to be referred to hospice (74% vs. 44%, p = 0.025). The median and mean (SD) number of days in hospice were 31 and 48 (53) for ImPACT and 23 and 78 (131) for PACT patients (p = 0.408). Among the 18 ImPACT and 57 PACT patients whose location of death could be confirmed, ImPACT patients were more likely than PACT patients to die in inpatient hospice or at home with hospice (78% vs. 49%, p = 0.025).

Implications:
An intensive outpatient program for high-risk Veterans was associated with higher rates of advance directive documentation and hospice care for patients at end of life.

Impacts:
High-risk Veterans may benefit from an intervention that augments PACT efforts to address end-of-life care needs.