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PPO 13-117 – HSR&D Study

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PPO 13-117
Evaluating Innovative Care Models for High-Utilizing Patients
Donna M Zulman MD MS
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: December 2013 - May 2015

BACKGROUND/RATIONALE:
VA's highest-utilizing patients generally have complicated health care needs-including complex and multiple chronic conditions, comorbid mental health conditions, and social stressors-that contribute to high rates of hospitalization, emergency services, and specialty care. Inspired by emerging intensive primary care models for high-utilizers, VA Palo Alto obtained FY2012-FY2013 Office of Specialty Care Transformation (OSCT) funding to launch a novel program that augments the existing PACT model with intensive care delivered by a multidisciplinary team. The Intensive Management PACT (ImPACT) intervention encompasses a number of evidence-based strategies, including a comprehensive intake process, coordination of specialty care, chronic condition case management, rapid intervention in response to deteriorations in health, and facilitation of transitions after high-acuity events.

OBJECTIVE(S):
The objective of this study was to evaluate the implementation and effectiveness of the ImPACT intervention at VA Palo Alto.

METHODS:
We partnered with the implementation team of VA Palo Alto's ImPACT program to conduct a Hybrid Type 1 evaluation of the program's feasibility, implementation, and effectiveness. Patients were eligible for ImPACT if their VA health care costs or risk for hospitalization (based on the Care Assessment Needs Score) were in the top 5% for the facility, they were outpatients for over half of the eligibility period, and they were not enrolled in another VA intensive management program (e.g., MHICM, HBPC) or palliative care. Among 583 eligible patients, 150 randomly selected individuals were invited to enroll in ImPACT; the remaining ImPACT-eligible patients received standard PACT care and served as a control group. An implementation evaluation was conducted at 9 months and involved semi-structured interviews (n = 15) with ImPACT and PACT team members and facility leadership. The Consolidated Framework for Implementation Research was used to evaluate implementation facilitators and barriers, using standard content analysis methods for coding and synthesizing textual data. An evaluation of the program's effectiveness was conducted after the program had been in place for 17 months. We evaluated changes in total health care costs (including intervention costs), hospital admissions, and emergency department visits among ImPACT and PACT patients, excluding those who died or moved away before the intervention began (n=38), across a 16-month baseline and 17-month follow-up period. We performed an intention-to-treat analysis within a difference-in-differences framework. In secondary analyses, we estimated the effect of the intervention on patients who actively participated in ImPACT using randomization as an instrument for participation. We also conducted stratified analyses to examine the influence of age, comorbid mental health and medical conditions, and baseline risk for hospitalization. We assessed changes in satisfaction with VA care using ImPACT patients' responses to the Patient Satisfaction Questionnaire at baseline and 6 months after enrollment.

FINDINGS/RESULTS:
Two-thirds of invited patients (n=101) enrolled in ImPACT, 87% of whom remained actively engaged at 9 months. Patients who engaged in ImPACT (69%), had a mean (SD) of 10 (4) chronic conditions; 65% had a mental health diagnosis and 22% had a history of homelessness. Implementation was influenced most notably by three CFIR domains. First, the Inner Setting (i.e., the organizational environment), mostly enabled implementation through a culture of innovation, good networks and communication, and positive tension for change. Second, Characteristics of Individuals, including clinical and interpersonal expertise, also enabled implementation. Finally, Intervention Characteristics, enabled implementation (e.g., through adaptability) and impeded implementation (e.g., through complexity, which generated confusion). In the quantitative evaluation, after accounting for program costs, adjusted monthly healthcare expenditures decreased similarly for ImPACT compared to PACT patients (D-in-D (SE) -$101 ($623)). There were no differences in acute care utilization patterns between ImPACT and PACT patients. Greater, but non-statistically significant, cost reductions were observed for ImPACT patients who were under age 65, those with a recent hospitalization, and individuals with heart failure, diabetes, or chronic lung disease. ImPACT patients reported increases in satisfaction with VA care (p < 0.05) and communication (p < 0.05) (56% response rate).

IMPACT:
Findings suggest that the ImPACT intervention improved patient satisfaction and experience, and provided intensive primary care services and care coordination without significantly increasing costs. Study findings are directly informing the VA's Office of Primary Care PACT-Intensive Management Demonstration Project, specifically by guiding patient selection criteria and PIM team interventions. Findings have also informed the development of new recommendations in the PACT Roadmap for High Risk Patients.

PUBLICATIONS:

Journal Articles

  1. Wu FM, Slightam CA, Wong AC, Asch SM, Zulman DM. Intensive Outpatient Program Effects on High-need Patients' Access, Continuity, Coordination, and Engagement. Medical care. 2018 Jan 1; 56(1):19-24.
  2. Hummel DL, Hill C, Shaw JG, Slightam C, Zulman DM. Nurse practitioner-led intensive outpatient team: Effects on end-of-life care. The journal for nurse practitioners : JNP. 2017 Mar 14; 13(5):e245-e248.
  3. Zulman DM, Pal Chee C, Ezeji-Okoye SC, Shaw JG, Holmes TH, Kahn JS, Asch SM. Effect of an Intensive Outpatient Program to Augment Primary Care for High-Need Veterans Affairs Patients: A Randomized Clinical Trial. JAMA internal medicine. 2017 Feb 1; 177(2):166-175.
  4. Breland JY, Asch SM, Slightam C, Wong A, Zulman DM. Key ingredients for implementing intensive outpatient programs within patient-centered medical homes: A literature review and qualitative analysis. Healthcare (Amsterdam, Netherlands). 2016 Mar 1; 4(1):22-9.
  5. Gidwani R, Zulman D. Association Between Acute Medical Exacerbations and Consuming or Producing Web-Based Health Information: Analysis From Pew Survey Data. Journal of medical Internet research. 2015 Jun 23; 17(6):e145.
  6. Hunter G, Yoon J, Blonigen DM, Asch SM, Zulman DM. Health Care Utilization Patterns Among High-Cost VA Patients With Mental Health Conditions. Psychiatric services (Washington, D.C.). 2015 Sep 1; 66(9):952-8.
  7. Zulman DM, Pal Chee C, Wagner TH, Yoon J, Cohen DM, Holmes TH, Ritchie C, Asch SM. Multimorbidity and healthcare utilisation among high-cost patients in the US Veterans Affairs Health Care System. BMJ open. 2015 Apr 16; 5(4):e007771.
  8. Breland JY, Greenbaum MA, Zulman DM, Rosen CS. The effect of medical comorbidities on male and female Veterans' use of psychotherapy for PTSD. Medical care. 2015 Apr 1; 53(4 Suppl 1):S120-7.
  9. Zulman DM, Jenchura EC, Cohen DM, Lewis ET, Houston TK, Asch SM. How Can eHealth Technology Address Challenges Related to Multimorbidity? Perspectives from Patients with Multiple Chronic Conditions. Journal of general internal medicine. 2015 Aug 1; 30(8):1063-70.
  10. Zulman DM, Ezeji-Okoye SC, Shaw JG, Hummel DL, Holloway KS, Smither SF, Breland JY, Chardos JF, Kirsh S, Kahn JS, Asch SM. Partnered research in healthcare delivery redesign for high-need, high-cost patients: development and feasibility of an Intensive Management Patient-Aligned Care Team (ImPACT). Journal of general internal medicine. 2014 Dec 1; 29 Suppl 4:861-9.
  11. Breland JY, Chee CP, Zulman DM. Racial Differences in Chronic Conditions and Sociodemographic Characteristics Among High-Utilizing Veterans. Journal of racial and ethnic health disparities. 2015 Jun 1; 2(2):167-75.
Conference Presentations

  1. Zulman DM, Chee CP, Ezeji-Okoye SC, Shaw JG, Kahn JS, Asch SM. Randomized controlled evaluation of an Intensive Management Patient Aligned Care Team (ImPACT) for high-need, high-cost Veterans Affairs patients. Presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 10; Philadelphia, PA.
  2. Zulman DM, Ezeji-Okoye SC, Shaw JG, Kahn JS, Asch SM. Randomized controlled evaluation of an Intensive Management Patient Aligned Care Team (ImPACT) for high-need, high-cost Veterans Affairs patients. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2015 Apr 24; Toronto, Canada.
  3. Zulman DM, Shaw JG, Brandt K, Lewis ET, Asch SM. “They are interrelated, one feeds off the other”: A taxonomy of disease interactions derived from patients with multiple chronic conditions. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2015 Apr 24; Toronto, Canada.
  4. Breland JY, Asch SM, Slightam C, Zulman DM. Who should we hire? Key ingredients for implementing intensive management programs within patient-centered medical homes. Poster session presented at: National Institutes of Health / AcademyHealth Conference on the Science of Dissemination and Implementation; 2014 Dec 8; Bethesda, MD.
  5. Zulman DM, Ezeji-Okoye SC, Shaw JG, Hummel DL, Holloway KS, Smither SF, Breland JY, Chardos JF, Kirsh S, Kahn JS, Asch SM. Partnered research in healthcare delivery redesign for high-need, high-cost patients: development and feasibility of an Intensive Management Patient-Aligned Care Team (ImPACT). Poster session presented at: National Institutes of Health / AcademyHealth Conference on the Science of Dissemination and Implementation; 2014 Dec 8; Bethesda, MD.
  6. Zulman DM. Measuring the Impact of Complex Care Interventions. Presented at: California HealthCare Foundation Northern California Complex Care Workshop; 2014 Jul 30; Oakland, CA.


DRA: Health Systems
DRE: Treatment - Observational
Keywords: Care Coordination, Cost-Effectiveness, Effectiveness, Implementation, Utilization
MeSH Terms: none