HSR&D’s Center for the Study of Healthcare Innovation, Implementation & Policy
), led by Elizabeth Yano, PhD, MSPH, and located in Los Angeles, CA, works to develop and test innovations that markedly improve the effectiveness and value of VA healthcare – from system, provider, and Veterans’ perspectives, while advancing the implementation and spread of evidence-based practice.
A large percentage of healthcare dollars in the United States is spent on the care of a small proportion of patients. These "high-needs" patients may have more than one chronic disease as well as functional limitations and unmet social needs. To address the complex health and social needs of these patients, healthcare systems have piloted "intensive primary care" (IPC) programs that facilitate care coordination, provide care management and additional social services, and aim to engage patients and caregivers in their healthcare. While IPC programs have shown promise, quantitative evaluations in both VA and non-VA settings suggest that few have reduced healthcare use, cost, and mortality beyond usual care. However, it is likely that patients may benefit from IPC programs in other ways.
Dr. Michelle Wong
Dr. Michelle Wong, part of HSR&D’s Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), led a qualitative evaluation that explored the perspectives of Veterans and healthcare facility leaders in identifying additional important outcomes that could augment utilization and cost studies of IPC programs for high-needs patients. In 2014, VA’s Office of Primary Care funded five sites to develop and implement their own IPC programs. Investigators in this study conducted phone interviews with high-needs Veterans and primary care facility leaders at the five pilot sites, which all had interdisciplinary care teams that included a physician lead, nurse, psychologist and/or psychiatrist, social workers, and, in some instances, a peer-support specialist.
The study included 51 high-needs VA patients and 15 primary care facility leaders (i.e., primary care chief or nurse executive, lead physicians, and nurse managers) at the five pilot sites: Georgia, North Carolina, Ohio, Wisconsin, and California. Veterans were eligible to participate in study interviews if they had at least four encounters with the IPC team and at least one in the previous month.
Veterans enrolled in VA intensive primary care programs reported improvements in their experience of VA care (e.g., patient-provider relationship, access to their team). Both patients and leaders reported improvements in patient motivation to engage with self-care and with their IPC team, and behaviors, especially diet, exercise, and medication management. Veterans also perceived improvements in health and described receiving assistance with social needs. Despite this, patients and leaders also outlined patient health characteristics and contextual factors (e.g., chronic health conditions, housing insecurity) that may have limited the effectiveness of the program on healthcare cost and utilization.
The following includes specific theme-related feedback from Veterans and facility leaders.
Improved experience of VA healthcare
Many Veterans emphasized the importance of relationships, communication with their providers, and access to care and providers. Further, they commonly described that the process of obtaining VA care was easier through the program – they could readily contact their IPC team, who could then facilitate care coordination.
They found out that I got arthritis in my back, stenosis…. And immediately, they got me a consult… They got me hooked up to—I got the physical therapy now…. They really got it done. ––Veteran participant
Increased motivation to care for health and increased engagement with care team
Several Veterans noted that their positive relationships with IPC team members increased their motivation and their sense of accountability to take care of their health. Some patients described that trusting relationships with and reliable access to their IPC team led them to proactively check-in with their IPC team when health concerns arose.
I feel that they care about me, and I should care about myself if they do, too.
robably do the things I need to do that keep me… being able to do what I got to do. –Veteran participant
As old people… you’re going to go run and see the doctor the minute you feel a slight ache…. If I do need to get in, he knows somebody that can get me an appointment in the primary care so I don’t have to go to ER (emergency room). –Veteran participant
Several primary care leaders agreed that high-needs Veterans seemed to become more involved in their self-care through IPC. One leader described changes in patients’ attitudes as “an awakening in our patients,” where patients were “more in tune to their care.”
Improvements in health behaviors
High-needs Veterans commonly cited improvements in their health behaviors, especially lifestyle changes and medication adherence and management, as one of the effects of the program.
The team has helped me to realize certain things… [my medication] is not a cure, because if it was a cure, then I would take it and wouldn’t have to take it anymore. But I still have to take my medication. –Veteran participant
We are encouraging them to do a little bit more exercise… and we’re seeing some improvements. –Facility leader
Improvements in perceived physical and mental health and well-being
Some Veterans noted physical improvements in health, particularly with chronic conditions such as diabetes, due to IPC-facilitated improvements in medication management and health behaviors. Veterans also frequently described feeling less anxious and depressed and often attributed this improvement to having better relationships with their providers.
My health, believe it or not, has gotten a little better since they took over because they
got me on the right prescriptions, the right medications, and… they showed me the proper foods
that I need to eat for my diabetes. –Veteran participant
[IPC] is definitely a tool that can help diabetics that are uncontrolled, kind of a multidisciplinary approach [that] can help lower A1Cs, and I think that is certainly a med center priority. –Facility leader
That [call/check-in on patient] is helpful in the way that you don’t feel so alone. The average person doesn’t understand what I’m going through because they haven’t been through it…. But they [IPC team members] know that it’s a very stressful time and they try to let me know if there’s anything that I can think of that I need…to let them know, and they would help me.” –Veteran participant
Patients’ social circumstances and assistance with social needs
A few Veterans noted facing challenges posed by social needs, such as transportation, housing, and food. These patients valued the IPC team’s help with addressing these issues by providing information and contacts for local assistance.
Now she has helped me locate food banks so I can go and get food. She tried to help me, my trailer is not in the best of repair so we’ve reached out to different organizations. –Veteran participant
Patient-level factors that mitigated IPC’s impact on decreasing program cost and utilization
Both Veterans and primary care leaders described patient-level factors apart from the IPC program that could impact high needs patients’ health and healthcare use. First, Veterans and primary care leaders both recognized that high-needs patients have multiple and complex health needs, many of which are chronic physical and mental health conditions that require continual management. Veterans and primary care leaders also noted that many high-needs patients previously “fell through the cracks,” sustaining delays in care that might have contributed to their current serious health needs. These patients may have increased utilization upon IPC enrollment as they became connected to VA care and received previously deferred care. Second, Veterans’ difficult social circumstances may limit the effect of the IPC pilot by preventing them from participating, regardless of IPC efforts and services.
We’ve found some patients who… they’ve kind of fallen through the cracks, and we have been able to go into those patients’ records and see a condition or a diagnosis or something [that] was identified years ago, and it just wasn’t followed up on. And now, here we are five or eight years later… We’re able to pick it up now and try to address it and get the patient the help that they need. We’ve had several cases like that. –Facility leader
I’ve had problems with flooding in my house for the past two years… Everything has just been on my mind about my house, so I haven’t really been able to participate [in IPC] the way I should. –Veteran participant
Intensive primary care programs may yield benefits beyond healthcare cost and use, including improved quality of care, patient satisfaction, quality of life, and patient health behaviors.
As healthcare systems continue to develop and implement IPC pilots as a means to improve care for “high-needs” patients, evaluations of these pilots can include other outcomes beyond cost and utilization, such as patient experiences, patient engagement, patient health behaviors and quality of life, as well as longer-term evaluations of cost, utilization, and chronic disease metrics.
Wong M, Luger T, Katz M, et al. Outcomes that Matter: High-Needs Patients’ and Primary Care Leaders’ Perspectives on an Intensive Primary Care Pilot. Journal of General Internal Medicine. May 13, 2021; online ahead of print.