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2019 HSR&D/QUERI National Conference Abstract

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1011 — Outcomes of Intensive Care Management for Veterans at High Risk for Hospitalizations in Year 2

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

Objectives:
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.

Methods:
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.

Results:
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).

Implications:
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.

Impacts:
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.