2019 HSR&D/QUERI National Conference

4004 — Greater PACT Implementation Was Associated with Lower Attrition from VA Primary Care

Lead/Presenter: Jean Yoon,  Resource Center - HERC
All Authors: Yoon J (HERC, VA Palo Alto), Rubenstein LV (RAND Corporation), Nelson K (Seattle-Denver Center of Innovation in Veteran-Centered and Value-Driven Care, VA Puget Sound) Rose DE (Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles) Leung LB (Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles) Chow A (HERC, VA Palo Alto) Stockdale SE (Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles)

The VA Patient Aligned Care Team (PACT) model aims to improve primary care by providing accessible, comprehensive, and continuous team-based care. Practices that adhere to medical home principles have been found to exhibit higher patient satisfaction. We examine whether fidelity to the PACT model was associated with greater retention of patients and lower attrition from VA primary care.

We obtained a national cohort of 1.5 million nonelderly patients who used primary care from 863 VA practices during fiscal year (FY) 2015 and had chronic conditions. We measured attrition as not receiving VA primary care in 2 subsequent years. We measured PACT implementation of patients' practices using the PACT Implementation Progress Index (Pi2) and conducted multilevel logistic regressions to examine the association of attrition with PACT implementation after adjusting for patient and practice characteristics.

The overall attrition rate was 4.4%. In adjusted analyses patients had significantly higher probabilities of attrition if they were treated in practices with the lowest versus highest PACT implementation scores (4.8% and 4.0%, respectively; difference = -0.8 (95% CI: -1.3, -0.2)). Patients seen in practices with low staff-to-provider ratios, long mean waiting times for appointments, and a medical-center based location also had higher attrition rates (P < 0.05 for all comparisons). Patient characteristics associated with higher attrition included: younger age, male gender, 0% service-connected disabilities, lower comorbidity, having a mental health condition, being married, living far from VA primary care, lower prior-year VA costs, or living in an urban or high-mean income area (P < 0.05 for all comparisons).

Two-year VA attrition rates among nonelderly patients with chronic conditions were low. Greater fidelity to the PACT model in VA primary care practices predicted better retention of patients. Lower attrition among older, sicker, and rural veterans suggests VA primary care remains a key provider for vulnerable groups.

Routine measurement of attrition can aid in keeping rates low and may be important in monitoring practices for quality and access barriers. As nonelderly veterans face greater choices for care among VA and community-based providers, VA providers may continue to retain patients if they provide accessible, comprehensive, and team-based care.