Study Suggests VA PACT Implementation Increases Primary Care among Veterans with PTSD
Researchers have emphasized the need to study the patient-centered medical home (PCMH) model's impact on high-risk and vulnerable patient groups, including Veterans with PTSD who often have high levels of psychiatric and physical comorbidity and high rates of healthcare use. VA implemented a version of PCMH called Patient Aligned Care Teams (PACT) in 2010. This pre-post implementation study assessed the association between PACT and the use of health services among Veterans with PTSD. VA clinical and administrative data were obtained for the pre-PACT period (4/1/09 to 3/31/10) and the post-PACT period (6/1/11 to 5/31/12) on nearly 700,000 unique Veterans. Investigators examined outcomes that included hospitalizations, primary, specialty, and mental health visits, as well as emergency department (ED) and urgent care visits. Outcomes were adjusted for demographics, VA co-pay status, service-connected disability, diagnosis of substance use disorder, and comorbidities. Results were stratified by age to account for Medicare eligibility and examine how PACT associations may differ among Medicare-eligible Veterans.
- The period following PACT implementation was associated with lower rates of hospitalization and specialty care visits and a higher rate of primary care visits for Veterans with PTSD, indicating enhanced access to primary care.
- Adjusted results show a 9% decrease in hospitalizations, an 8% decrease in specialty care, and an 11% increase in primary care visits in the post-PACT period. No significant effects were found on mental health, ED, or urgent care visits.
- For Veterans younger than 65 years, findings mirrored the full sample, with significantly lower hospitalizations and specialty care visits and higher primary care visits in the post-PACT period. However, for Veterans older than 65 years, there were significant increases in both primary and specialty care visits, significant decreases in urgent care visits, and no significant decrease in hospitalizations.
- The pre-post study design limits the ability to infer causality.
- Veterans with PTSD were identified using ICD-9 codes rather than the PTSD checklist, which is a more reliable method for PTSD screening.
- Investigators did not measure the extent of PACT implementation at individual clinics, and thereby assumed a uniform level of implementation that is unlikely.
- The increased rate of primary care visits after PACT implementation holds promise to improve the quality of primary care over time – and further reduce mental and physical illness exacerbations that can lead to specialty care, hospitalizations, and ED and urgent care visits.
This study was funded by HSR&D. Dr. Mohr is part of HSR&D's Center for Healthcare Organization and Implementation Research, Boston; Dr. Maynard is part of HSR&D's Center for Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA.
Randall I, Mohr D, and Maynard C. VHA Patient-Centered Medical Home Associated with Lower Rate of Hospitalizations and Specialty Care among Veterans with Post-Traumatic Stress Disorder. Journal for Healthcare Quality. November 10, 2014;e-pub ahead of print.