Lead/Presenter: Evelyn Chang,
COIN - Los Angeles
All Authors: Chang ET (LA COIN), Yoon J (HERC), , Zulman D (Palo Alto COIN), Rubenstein L (LA COIN), Ong M (LA COIN), Stockdale S (LA COIN), Park A (HERC), Jimenez E (LA COIN), Atkins D (HSR&D), Denietolis A (VHA Primary Care), Asch S (Palo Alto COIN), on behalf of the PACT Intensive Management (PIM) Demonstration Sites, PIM National Evaluation Center, and PIM Executive Committee
VHA operational leaders partnered with five demonstration sites and an evaluation team in a quality improvement initiative to determine whether augmenting PACT with Primary care Intensive Management (PIM) decreases healthcare costs among patients at high risk for hospitalization. PIM was cost-neutral in the first year, so we further investigated health care costs in the second year after the intervention began to assess for potential cost-savings.
PIM programs included interdisciplinary teams, comprehensive patient assessment, and care coordination services. We drew a random sample of 2210 Veterans who were at top 10th percentile of risk for 90-day hospitalization based on a validated VHA risk algorithm and allocated half to PIM and usual PACT care. We excluded patients not either seen in a VHA emergency department visit or hospitalized during the past six months. We used an intent-to-treat design with difference-in-differences methods to compare the change in mean VHA inpatient and outpatient utilization and costs (including PIM expenses) per patient for the 12-month period before allocation and 12-month period at 13-24 months after allocation.
PIM was significantly associated with an increase in primary care, care management, telehealth, mental health and substance use, and home care encounters compared to usual care in PACT (all p < 0.05). PIM was associated with a decrease in triage (p = 0.02) and mental health assertive community treatment (p = 0.03) encounters compared to PACT. There was no significant difference in ED visits (p = 0.68). There were also no significant differences in mean costs of outpatient care, ($1902, p = 0.12), mean hospitalizations (p = 0.17), or inpatient costs in Year 2 ($1148, p = 0.79) for PIM relative to PACT. Total mean health care costs were similar between the two groups during Year 2 (mean difference = $3050, p = 0.47).
Intensive care management increased access to primary care, mental health, telehealth, and home care for high-risk patients. However, approaches such as PIM that target patients solely based on high risk of hospitalization are unlikely to reduce acute care use in VHA, which already offers patient-centered medical homes.
Additional work is needed to develop strategies to identify a subset of high-risk patients whose admissions are truly preventable and to design the strategies that will prevent them.