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EDU 08-428 – HSR&D Study

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EDU 08-428
PROVE: Program for Research on Outcomes of VA Education
Mark D Schwartz MD
Manhattan Campus of the VA NY Harbor Healthcare System, New York, NY
New York, NY
Funding Period: September 2010 - November 2014

BACKGROUND/RATIONALE:
Panel management (PM), systematically identifying and addressing care gaps across practice populations, is an emerging innovation in primary care. However, strategies and outcomes for best integrating panel management into primary care have not yet been demonstrated within VA's Patient Aligned Care Team (PACT) model. Therefore, the Program for Research on the Outcomes of VA Education (PROVE) study sought to understand the impact of PM and team-based education interventions on hypertension and smoking outcomes through the incorporation of a Panel Management Assistant (PMA) into VA's PACT model at the VA New York Harbor Healthcare System (NYHHS).

OBJECTIVE(S):
The major objectives for this study were: (1) to test the efficacy of increasingly intensive methods for implementing PM strategies among health care providers in VA primary care clinics by incorporating Panel Management Assistants (PMAs) into primary care teams with and without team-based panel management education; and (2) understand patient preferences and experiences for receiving proactive outreach for prevention and chronic disease management (panel management) through focus groups.

METHODS:
Objective 1: We used a multi-method, quasi-experimental design at VA NYHHS. In Phase 1, we developed the necessary data infrastructure (using Primary Care Almanac and Vista), interviewed providers to understand team microsystem functioning, and developed a PM toolkit. In Phase 2, we conducted an 8-month, clinical demonstration project in which 20 primary care PACT teams were randomly allocated to one of three intervention arms: 1) PM data, 2) PM data and support of a PMA), and 3) PM data, PMA, and PM education. Six PMAs joined the teams assigned to arms 2 and 3, who then presented data on hypertensive and smoking patients and performed toolkit interventions (e.g. mailings, coaching by phone, navigation) with the identified patients. We assessed the impact of these three strategies for implementing PM on primary patient outcomes in hypertension (BP) and smoking cessation (quit rates) using VINCI data and Vista. Secondary, intermediate outcomes included nicotine replacement therapy (NRT) rates and enrollment in disease management programs (MOVE! and Telehealth). We conducted pre and post surveys of primary care providers and RN Care Managers to compare change in knowledge and attitudes, self-efficacy, job satisfaction, collective efficacy, teamwork, data use, practice redesign, and use of PM strategies. A randomly selected, stratified sample of 1,000 patients was also surveyed pre and post to collect data on activation, adherence, and behavior change.

Objective 2: During Phase 3, we conducted a qualitative study of veterans with hypertension or current smoking, who had participated in the Phase 2 intervention. We recruited eligible patients by mail and phone, who were invited to participate in focus groups stratified by hospital, gender (6 male and 4 female groups), and age (under or over age 60). Participants completed brief questionnaires to ascertain their health status and supplemental demographic information. Discussion questions focused on facilitators and barriers to healthy behavior change, experience with proactive outreach, and preferences for receiving remote care in-between visits.

FINDINGS/RESULTS:
Objective 1: Change in mean blood pressure, blood pressure control, and smoking quit rates were similar across study groups. However, patients on intervention teams were more likely to receive NRT (OR=1.4; 95 % CI 1.2-1.6) and enroll in the disease management services MOVE! (OR=1.2; 95% CI 1.1-1.6) and Telehealth (OR=1.7, 95% CI 1.4-2.1) than patients on control teams. Patients who greater interaction with a PMA were more likely to have controlled BP (Pearson's r=0.68, p=0.016); During the intervention, PMAs reached 783 patients by phone (20% of all smokers and hypertensive patients), 3,088 patients by mail (79% of hypertensive and smoking patients). Of 535 patients contacted by a PMA to make a PC appointment, 49% scheduled one. Providers and RN Care Managers (survey response rate 76%) reported that PM self-efficacy declined for staff in the control group, but increased for those in the intervention groups. Having a PMA increased provider PM self-efficacy, controlling for baseline self-efficacy score (p=0.05). 80% of providers felt a PMA was useful, 73% wished to continue working with a PMA, and only 40% would continue doing PM once the PMA left the team. Patient activation and medication adherence did not increase from baseline rates.

Objective 2: 77 veterans participated in 10 focus groups. Most participants had hypertension (78%), or smoked at least 100 cigarettes in their lifetime (77%). Participants generally appreciated efforts to provide care in between visits including post-discharge phone calls and reminder letters, but they felt that these outreach efforts should be more tailored to their needs and preferences in terms of frequency, content, and mode of contact. Some had concerns about privacy. Most (75%) were open to non-clinicians contacting them as long as they had strong communication skills, empathy, and connection to the PC team. However, each focus group discussed that the individual should be a veteran or at least able to relate to their military experience. Avoiding medications was a consistent motivator for making lifestyle changes. Female veterans in particular wanted access to more holistic health options in VA or their communities.

IMPACT:
Panel Management support for primary care teams improved secondary outcomes, but not outcome variables among veterans with hypertension and smoking. Incorporating PMAs into teams was feasible and highly valued by the clinical staff but clinical impact may require a longer intervention. Further, we have concluded that veterans are receptive to proactive outreach for prevention and management of chronic conditions, especially when this outreach is personalized and flexible.

PUBLICATIONS:

Journal Articles

  1. Schwartz MD, Jensen A, Wang B, Bennett K, Dembitzer A, Strauss S, Schoenthaler A, Gillespie C, Sherman S. Panel Management to Improve Smoking and Hypertension Outcomes by VA Primary Care Teams: A Cluster-Randomized Controlled Trial. Journal of general internal medicine. 2015 Jul 1; 30(7):916-23.
  2. Strauss SM, Jensen AE, Bennett KJ, Skurksy N, Sherman SE, Schwartz MD. Clinicians’ panel management self-efficacy to support their patients’ smoking cessation and hypertension control needs. Translational behavioral medicine. 2014 Sep 16; 5(1):68-76.
  3. Savarimuthu SM, Jensen AE, Schoenthaler A, Dembitzer A, Tenner C, Gillespie C, Schwartz MD, Sherman SE. Developing a toolkit for panel management: improving hypertension and smoking cessation outcomes in primary care at the VA. BMC family practice. 2013 Nov 21; 14:176.
Conference Presentations

  1. Jensen AE, Skursky N, Sedlander E, Barboza K, Bennett K, Sherman SE, Schwartz MD. "We all have different stories": Veterans’ experiences and preferences for proactive in-between visit care. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2015 Apr 22; Toronto, Canada.
  2. Schwartz MD, Jensen AE, Wang B, Bennett K, Dembitzer A, Strauss S, Schoenthaler A, Gillespie C, Sherman SE. The Use of Panel Management Assistants to Improve Smoking Cessation and Hypertension Management by VA Primary Care Teams: A Cluster Randomized Controlled Trial. Presented at: AcademyHealth Annual Research Meeting; 2014 Jun 8; San Diego, CA.
  3. Jensen AE, Beyrouty M, Skursky N, Bennett K, Schwartz MD, Sherman SE. Panel Management in Primary Care: A Systematic Review. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2014 Apr 23; San Diego, CA.
  4. Schwartz MD, Jensen AE, Wang B, Bennett K, Dembitzer A, Strauss S, Schoenthaler A, Gillespie C, Sherman SE. The Use of Panel Management Assistants to Improve Smoking Cessation and Hypertension Management by VA Primary Care Teams: A Cluster Randomized Controlled Trial. Paper presented at: Society of General Internal Medicine Annual Meeting; 2014 Apr 23; San Diego, CA.
  5. Jensen A, Fox J, Bennett K, Dembitzer A, Gillespie C, Savarimuthu S, Sherman SE, Schwartz MD. Impact of Adding a Panel Management Assistant to Clinical Teams on Provider Self-Efficacy. Presented at: AcademyHealth Annual Research Meeting; 2013 Jun 25; Baltimore, MD.
  6. Blitzer R, Jensen A, Bennett K, Sherman SE, Schwartz MD. The Interdisciplinary Care Team: How Attitudes toward Teamwork Affect Panel Management. Presented at: AcademyHealth Annual Research Meeting; 2013 Jun 24; Baltimore, MD.
  7. Bennett KJ, Jensen A, Fox J, Savarimuthu S, Blitzer R, Dembitzer A, Sherman S, Schwartz MD. Incorporating a Panel Management Assistant and Toolkit into VA Patient Aligned Care Teams. Paper presented at: Society of General Internal Medicine Annual Meeting; 2013 Apr 27; Denver, CO.
  8. Dembitzer A, Gillespie C, Dreamer L, Jensen A, Blitzer R, Bennett K, Schwartz MD, Sherman S. Team-Based Education for Improving Panel Management in a Patient Centered Medical Home. Paper presented at: Society of General Internal Medicine Annual Meeting; 2013 Apr 24; Denver, CO.
  9. Dixon B, Jensen A, Bennett K, Sherman S, Schwartz MD. Measuring Clinician Information Literacy: Experiences with a Panel Management Intervention. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2013 Apr 24; Denver, CO.
  10. Jensen A, Bennett K, Blitzer R, Sherman S, Schwartz MD. Unmet Needs, Service Use and Patient Activation: Implications for Panel Management to Promote Self-Management of Chronic Illness. Paper presented at: Society of General Internal Medicine Annual Meeting; 2013 Apr 24; Denver, CO.
  11. Savarimuthu S, Bennett K, Fox J, Pekala K, Leung J, Dembitzer A, Sherman S, Gillespie C, Axtmayer A, Schwartz MD. Developing a Toolkit to Enhance PACT: Improving Hypertension and Smoking Outcomes through Panel Management Assistants. Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 17; National Harbor, MD.
  12. Fox J, Savarimuthu S, Bennett K, Pekala K, Leung J, Dembitzer A, Sherman S, Gillespie C, Axtmayer A, Schwartz MD. Developing a Toolkit to Enhance Patient Centered Medical Home Implementation: Improving Hypertension and Smoking Outcomes through Panel Management. Paper presented at: Society of General Internal Medicine Annual Meeting; 2012 May 11; Orlando, FL.
  13. Gillespie C, Fox J, Axtmayer A, Dembitzer A, Leung J, Sherman S, Schwartz MD. Panel Management in Primary Care: What Primary Care Providers Could Learn from Nurse Care Managers. Paper presented at: Society of General Internal Medicine Annual Meeting; 2012 May 11; Orlando, FL.


DRA: Health Systems
DRE: Treatment - Comparative Effectiveness
Keywords: Decision-Making, Effectiveness, Outcomes - Patient
MeSH Terms: none

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