- Eight Organizational Target Areas for Improving Access to Primary Care
This study sought to identify priorities for improving healthcare organization management of patient access to primary care based on prior evidence and a stakeholder panel. Findings showed that optimal access to primary care for enrolled patient populations requires active ongoing management of at least eight diverse target areas (two organizational structure targets, four process improvements, and two outcomes): 1) Clearly identified group practice management structure; 2) Interdisciplinary primary care site leadership; 3) Patient telephone access to ensure patient safety, scheduling, and coordination; 4) Contingency staffing (planned minimal excess staffing to cover routine absences); 5) Nurse management of demand through care coordination; 6) Proactive demand management by optimizing provider visit schedules; 7) Quality of patients’ experiences of access; and 8) Provider and staff morale in relationship to supply-demand mismatch (e.g., provider vacancies, panels exceeding recommended size).
Date: February 1, 2020
- JGIM Supplement Features VA Research on Care Coordination Both within VA and with Non-VA Healthcare Providers
In March 2018, a state-of-the-art (SOTA) conference on care coordination was jointly planned by VA HSR&D and the Offices of Primary Care, Community Care, Nursing Services, and Care Management and Social Work. The SOTA was organized into three workgroups: 1) measures and models of care coordination; 2) care coordination within the VA system; and 3) care coordination between VA and non-VA providers for care paid for by VA. SOTA participants included VA and non-VA health services researchers, clinicians, and policymakers. Funded by HSR&D, this JGIM Supplement presents recommendations from the SOTA, as well as original research papers on care coordination strategies within VA and between VA and non-VA providers.
Date: May 1, 2019
- Effect of Intensive Primary Care on Patient Experience Outcomes
To address the gap in evidence about patient experiences with intensive primary care, study investigators conducted a survey of Veterans in a five-site randomized trial of intensive primary care in the VA healthcare system. Findings showed that augmenting VA’s patient-centered medical home with intensive primary care had a modestly positive influence on high-risk patients’ experiences with care coordination and provider relationships – but did not have a significant impact on most patient-reported access and satisfaction measures. Veterans randomized to PIM (PACT-Intensive Management) were more likely than those in PACT to report that they were asked about their health goals (73% vs. 68%) and about barriers to taking care of their health (60% vs. 55%). Veterans randomized to PIM also were more likely than those in PACT to strongly agree that they could trust their VA healthcare provider (61% vs. 53%) and were more likely to report 10 out of 10 on satisfaction with primary care (37% vs. 32%). Findings suggest that augmenting a medical home with an intensive management program may help fulfill the promise of primary care, with the potential for long-term consequences such as changes in health behaviors and clinical outcomes.
Date: May 1, 2019
- Receipt of Opioid Prescriptions from Both VA and Medicare Associated with Greater Likelihood of Overdose Death
This study assessed the association between dual receipt of opioid prescriptions from VA and Medicare Part D and prescription opioid overdose death among Veterans enrolled in both VA and Part D. Findings showed that receipt of opioid prescriptions from both VA and Part D was associated with 2-3 times greater odds of overdose death than among Veterans receiving opioids from VA or Part D only. Dual users also had a higher cumulative opioid dose over 180 days and average daily opioid dose. Dual enrollees are a vulnerable group of Veterans, emphasizing the importance of care coordination across providers and healthcare systems to increase the safety of opioid prescribing within and outside VA.
Date: March 12, 2019
- Pharmacotherapy for Opioid Use Disorder Highly Variable across VA Residential Substance Abuse Treatment Programs
Pharmacotherapy, including methadone, buprenorphine, and naltrexone, is both efficacious and cost-effective for treating opioid use disorder (OUD), however it is infrequently prescribed in VA. Investigators in this study sought to describe barriers to and facilitators of pharmacotherapy provided to a national cohort of VA patients with OUD in VA residential substance use disorder (SUD) treatment programs in FY2012. Findings showed that implementation of pharmacotherapy for OUD is highly variable across VA residential SUD treatment programs. Across all 97 treatment programs, the average rate of receipt of pharmacotherapy for OUD in FY2012 was 21% and ranged from 0% to 67%. There were 11 programs where 0% of patients received pharmacotherapy for OUD. Barriers included program or provider philosophy against pharmacotherapy and a lack of care coordination with non-residential treatment settings. Facilitators included education for staff and patients and having a prescriber on staff. Intensive educational programs, such as academic detailing, and policy changes such as mandating buprenorphine waiver training for VA providers, may help improve receipt of pharmacotherapy for OUD.
Date: November 1, 2018
- High-Risk Veterans with Access to Primary Care Intensive Management Receive Increased Outpatient Care without Increased Cost
Intensive Management (IM) models aim to proactively reduce complex patients’ deteriorations in health and resultant high-cost hospitalizations through interdisciplinary teams, care coordination, and support for care transitions. This study evaluated the impact of outpatient primary care IM programs on health care utilization and cost at five VA medical centers. Findings showed that Veterans receiving IM care had higher utilization of outpatient care without an increase in total costs (including costs of the IM program) or differences in mortality over a 12-month period. Veterans in IM care had greater use of outpatient services such as mental health/substance abuse care, home care, and palliative/hospice care both in person and by telephone. Increased outpatient costs were attributed to higher use of these services. Veterans in IM care had a statistically significant reduction in nursing home days and non-significant trends toward lower mean inpatient costs, number of inpatient stays, and number of hospital days. IM programs appeared to improve access to necessary outpatient services and improve engagement in care.
Date: June 19, 2018
- Online Toolkit to Improve Primary Care Coordination within VA and with Community Providers
The Coordination Toolkit and Coaching (CTAC) project aims to improve patients’ experience of care coordination, while also developing better methods for bringing research evidence on care coordination into routine care. In this article, investigators describe CTAC’s first phase, which involved selecting tools for an online care coordination toolkit and developing a VA Intranet site to support the tools. The final Care Coordination Toolkit, available on the VA Intranet at https://vaww.visn10.portal.va.gov/sites/Toolkits/toolkit/Pages/Home.aspx, provides access to 18 tools that remained after the selection process noted above, as well as detailed information about tools’ expected benefits, and the resources required for tool implementation. The 18 tools cover 5 topics: 1) managing referrals to specialty care, 2) medication management, 3) patient after-visit summary, 4) patient activation materials, and 5) provider contact information for patients. The CTAC project is expected to improve care coordination in VA primary care clinics and provide readily-applicable methods for spreading improvements throughout VA. In addition, the project will inform VA policymakers regarding what other implementation strategies, including the use of distance coaching, might influence the use of toolkits within healthcare delivery systems.
Date: May 23, 2018
- Evaluating Care Coordination Program for Pregnant Veterans
The VA Maternity Care Coordinator Telephone Care Program (MCC-TCP) was created to support MCCs and includes outlines to guide up to eight calls with Veterans on topics such as VA maternity care benefits, chronic health problems, substance use cessation, and depression and suicide screening. Investigators evaluated the program and assessed its feasibility, as well as facilitators and barriers to its implementation in 11 VA facilities. Findings showed that the VA Maternity Care Coordinator Telephone Care Program was successfully implemented and was perceived by the maternity care coordinators as valuable in meeting the care coordination needs of pregnant Veterans. MCC-TCP implementation barriers included limited information and communication technology tools to support the program – and lack of coordinator time for delivering telephone care. Consistent with prior research, pregnant women Veterans using VA maternity care had a high need for care coordination services due to their substantial burden of physical and mental health problems: 41% had pre-pregnancy chronic physical problem(s); 34% had mental health problem(s), particularly depression (28%) and PTSD/anxiety (21%); and 18% actively or recently smoked. Given the substantial and growing maternity care coordination needs among pregnant Veterans, especially those with chronic medical and mental illness, further investments in programs such as the Maternity Care Coordinator Telephone Care Program should be prioritized.
Date: May 23, 2018
- Phone Communication and Care Coordination Associated with Access to Needed Care as Reported by Women Veterans
This study used a survey of women Veterans to examine associations between key care team functions and patient-rated access to needed care (routine and urgent). Findings showed that overall, 74% of study participants reported usually or always being able to see a provider for routine care, and 68% for urgent care. In addition, 62% of patients gave high ratings of care coordination, and 76% gave high ratings of in-person communication. Among women Veterans who called their provider with a healthcare question, 63% usually or always got an answer as soon as needed. Phone communication was strongly associated with better ratings of access to routine and urgent care (absolute increases of 25% and 33%, respectively). Care coordination was also associated with better ratings of access to routine and urgent care (absolute increases of 8% and 13%). Associations with in-person communication were not statistically significant. Results suggest that approaches to improving access that increase reliance on non-VA providers may prove counter-productive if they compromise the team's ability to coordinate care, or diminish their role as a primary point of contact for patients.
Date: March 1, 2018
- Intensive Outpatient Care for High-Need Patients Does Not Reduce Acute Care Use or Costs Compared to Standard VA Care
This study evaluated the effectiveness of augmenting VA’s Patient-Aligned Care Teams (PACTs) with an Intensive Management program (ImPACT). In February 2013, the Palo Alto VAMC launched an ImPACT multidisciplinary team that addressed healthcare needs and quality of life through comprehensive patient assessments, intensive outpatient case management, care coordination, and social and recreational services. Findings showed that intensive outpatient care for high-need patients did not reduce acute care utilization or costs compared with standard VA care, although there were positive effects on healthcare experiences among Veterans who participated in ImPACT. During the first 16 months of the intervention period, the average number of primary care visits was 22 for ImPACT patients vs. 7 for PACT patients. However, after accounting for the cost of ImPACT encounters, the average baseline and follow-up person-level monthly costs declined at similar rates among ImPACT patients (21.0%) and PACT patients (20.7%). Implementing intensive outpatient programs in VA may offer high-need Veterans more comprehensive services. However, in settings with high-functioning PACTs, these programs may not prevent hospitalizations or achieve substantial cost savings.
Date: December 27, 2016
- Evaluating Patient-Mediated Health Information Exchange
In 2013, VA’s Office of Rural Health and the Department of Health and Human Services (Office of the National Coordinator) partnered to promote the use of My HealtheVet’s Blue Button capability to facilitate the transfer of Veterans’ health information to non-VA providers to improve care coordination for Veterans living in rural settings who use both VA and non-VA care (dual users). This partnership resulted in the Veteran-Initiated Electronic Care Coordination pilot study, which sought to: 1) train rural-dwelling dual-use Veterans to use Blue Button capabilities to share their health information with non-VA providers, and 2) evaluate whether or not the availability of VA information during community clinical encounters impacted the care they received. Findings from this study showed that with brief training, Veterans were able to generate their Continuity of Care Document (CCD) in My HealtheVet, share it with non-VA providers, and benefit from improved communication about medications and reduced laboratory duplication. After training, 78% of Veterans reported that the CCD would help them be more involved in their healthcare, and 86% planned to share it regularly with non-VA providers. The majority of non-VA providers (97%) were confident in the accuracy of the information, and 96% wanted to continue to receive the CCD. Moreover, 50% of non-VA providers reported that they did not order a laboratory test or other procedure because of CCD information.
Date: October 11, 2016
- More than Half of Privately Insured Veterans Younger than 65 Years of Age Access both VA and Non-VA Healthcare
This study sought to quantify use of VA and non-VA care among working-age Veterans with private insurance by linking VA data to private health insurance plan (PHIP) data. Findings showed that more than half (54%) of Veterans younger than 65 who were enrolled in both VA and private health insurance plans accessed both healthcare systems; 39% used non-VA healthcare only, while 5% used VA healthcare only. Dual system users had the lowest percentage of Veterans under age 40 (15%) and the highest percentage of Veterans over age 50 (71%), while VA-only users had the highest percentage of Veterans under age 40 (22%) and the lowest percentage of Veterans over age 50 (61%). Dual system users also had the highest proportion of Veterans residing in rural settings (61%). VA reliance was 33% for outpatient care, 14% for inpatient care, and 40% for pharmacy. Findings suggest that care coordination efforts for Veterans across age groups should include privately insured Veterans under age 65 in order to ensure safe and coordinated care.
Date: September 1, 2016
- Impact of Medical Home Features on Use of VA Healthcare and Total Costs of Care
This study evaluated changes in the adoption of different components of the PACT model in all VA primary care clinics and the relationship to patients’ use of acute and non-acute care, as well as total costs after two years. Findings showed that VA clinics reported large improvements in the adoption of all medical home components from FY09 to FY11. Improvements under the components ‘organization of practice’ and ‘care coordination and transitions in care’ appear to have impacted VA outpatient care (fewer primary care visits and more specialty care/fewer ED visits, respectively), but reductions in acute care were largely absent. Moreover, none of the changes in medical home components was significantly related to telephone visits, ACSC hospitalizations, or total health care costs. During the study period, the mean number of primary care visits decreased by 17%, while ED visits rose by 7%, and telephone visits rose by 85%.
Date: March 1, 2015
- Increasing Number of Women Veterans Use VA Maternity Benefits
This study examined the number and cost of inpatient deliveries in VA over a five-year period – from FY2008 to FY2012. Findings showed that the volume of women Veterans using VA maternity benefits increased by 44% – from 12.4 to 17.8 deliveries per 1,000 women Veterans. Also, the number of deliveries increased during each year – from 1,442 delivery claims in FY2008 to 2,730 in FY2012. A majority of women using VA maternity benefits were age 30 and older, resided in urban areas, and had a service-connected disability. Also, 42% were OEF/OIF/OND Veterans. Over the five-year study period, VA paid more than $46 million in delivery claims to community providers for deliveries of women Veterans ($4,993 per Veteran). The rate of C-section delivery was 34%, which is similar to the national average of 32%. Given the sizeable increase in delivery rates, the authors suggest that VA increase its capacity for pregnant Veterans and ensure care coordination systems are in place to address the needs of pregnant Veterans with service-connected disabilities. Coordinating community-based maternity care with ongoing VA care is critical because many women Veterans have complex medical and mental health conditions that may increase their risk of adverse pregnancy outcomes.
Date: January 1, 2014
- Study Assesses VA/Alzheimer’s Association Care Coordination Program for Informal Caregivers of Veterans with Dementia
A new initiative targeting caregivers of Veterans with dementia is “Partners in Dementia Care” (PDC) — a care-coordination program delivered via a partnership between VA and Alzheimer’s Association chapters. This study assessed the effectiveness of the PDC program. Findings showed that the PDC program is a promising model that improves linkages between VA healthcare services and community services for informal caregivers of Veterans with dementia. Compared to comparison caregivers, those who participated in the PDC program had significant improvement in outcomes representing unmet needs, all three types of caregiver strains, depression, and support resources. Most improvements were evident after six months, with more limited improvements from months 6 – 12. However, improvements after the first six months were maintained during the entire study. Some outcomes improved for all caregivers, while others improved for caregivers with more initial difficulties – or those who were caring for Veterans with more severe impairments.
Date: August 1, 2013
- Prediction Model Using VA Data May Help Identify Primary Care Patients at Increased Risk for Hospitalization or Death
In an attempt to identify high-risk patients, investigators in this study developed statistical models using health information from VA’s clinical and administrative databases to predict the risk of hospitalization or death among all Veterans who were assigned to a primary care provider as of 10/1/10. Findings showed that prediction models using electronic clinical data accurately identified Veterans receiving VA primary care who were at increased risk of hospitalization or death. Of the top 5% of Veterans in terms of predicted risk, 51% were hospitalized or died within the following year. Predictors of death were quite different from predictors of hospitalization. In general, clinical and demographic characteristics (i.e., increasing age, metastatic cancer) were most predictive of death, while recent use of health services was most predictive of hospitalization. The authors suggest that in clinical settings, these values can be used to identify high-risk patients who might benefit from care coordination and special management programs, such as intensive case management, telehealth, home care, specialized clinics, and palliative care.
Date: April 1, 2013
- Adoption of PACT Features is Significantly Associated with Lower Risk of Avoidable Hospitalization
The primary outcome measured in this study was potentially avoidable hospitalizations for ambulatory care sensitive conditions (ACSC) that included: asthma, angina without procedure, pneumonia, dehydration, COPD, congestive heart failure, complications related to diabetes, hypertension, perforated appendix, and urinary tract infection. In addition, the total number and costs of ACSC hospitalizations were measured for each Veteran during a 12-month follow-up period. Findings showed that greater adoption of medical home features by VA primary care clinics was found to be significantly associated with lower risk of avoidable hospitalizations. Veterans in clinics with the highest medical home adoption had significantly lower ACSC rates (20 per 1,000) compared to Veterans in clinics with the lowest (25 per 1,000) and medium (26 per 1,000) adoption of medical home features. If clinics were transformed from the mean level of medical home adoption to the maximum level, the reduction in hospitalization costs in an average-sized clinic with 3,500 Veterans could be as much as $83,000 annually. Two PACT features were independently related to lower risk of ACSC hospitalization: access and scheduling, and care coordination/transitions in care. For example, Veterans in clinics with the highest scores on access and scheduling had 17% lower odds of having an ACSC admission compared to the lowest scoring clinics.
Date: March 26, 2013
- JGIM Special Supplement Highlights Access to VA Healthcare
The JGIM Supplement includes both the white papers commissioned as background for the September 2010 state-of-the-art (SOTA) conference on “Improving Access to VA Care” and manuscripts submitted in response to a post-SOTA solicitation for original research and reviews pertaining to improving access to VA care. Articles focus on a myriad of topics related to improving access to care for Veterans, including: eHealth technologies (e.g., Care Coordination Home Telehealth program, and My HealtheVet personal electronic health record); measuring the impact of access on healthcare utilization, quality, and outcomes; and redefining access for 21st century healthcare.
Date: November 1, 2011
- Medicare-Eligible Veterans’ Reliance on VA Primary and Specialty Care Decreased Significantly from 2001 through 2004
This study assessed longitudinal changes in patterns of cross-system healthcare use in VA and Medicare among Medicare-eligible Veterans who had used VA primary care in FY00. Findings showed that during the study period (FY01-FY04), 39% of all primary and specialty care visits occurred within VA, with almost three times more specialty care visits than primary care visits each year. However, a majority of specialty care and nearly half of all primary care for Medicare-eligible Veterans was provided outside VA over this time period. Reliance on both VA primary and specialty care decreased substantially over the study period but the decrease was greatest in specialty care. By FY04, only 20% of Medicare-eligible Veterans were completely reliant on Medicare for primary care (i.e., had 90% or more of their primary care visits with a Medicare provider) but 47% were completely reliant on Medicare for specialty care. Among Medicare-eligible Veterans, use of Medicare primary care increased among patients who were older, had a greater burden of illness, were served by a VA community-based outpatient clinic, or lived farther from a VA facility. Patient reductions in reliance on VA primary and specialty care suggest increasingly fragmented care and more difficult care coordination. Increasing use of non-VA services may complicate implementation of the PACT model, but also may emphasize new opportunities for care coordination initiatives within PACT.
Date: June 16, 2011
- Telephone-based Care Coordination Intervention Complements Care for Veterans with Dementia and Supports their Caregivers
This article provides a detailed description of a telephone-based care coordination intervention – Partners in Dementia Care (PDC) – developed for Veterans with dementia and their family caregivers across all stages of the disease. Findings show that, overall, the PDC intervention addresses the diverse needs of Veterans with dementia and their caregivers, including non-medical care issues such as understanding VA benefits, accessing community resources, and addressing caregiver strain. The authors also note that the PDC intervention incorporates several unique features that distinguish it from most other services and programs for dementia caregiving, such as the delivery of the intervention through formal partnerships between VAMCs and local Alzheimer’s Association Chapters, the inclusion of family caregivers, and the breadth of issues addressed for both Veterans and their caregivers. The consumer-directed philosophy of the program enabled Care Coordinators to serve a large number of families in a cost-efficient way, since Veterans and families were taking action on their own with support and guidance from both VA and Alzheimer’s Association care coordinators.
Date: January 17, 2011
- Long-Term Impact of Home Telehealth on Preventable Hospitalizations for Veterans with Diabetes
This study assessed the longitudinal effect of a VA Care Coordination Home Telehealth (CCHT) program on preventable hospitalizations for Veterans with diabetes. Findings showed a statistically significant reduction in preventable hospitalizations for Veterans enrolled in the CCHT program during the initial 18 months of follow-up compared to Veterans in the control group, even after adjusting for potential socio-demographic and clinical risk factors. However, the program did not demonstrate a significant impact after the initial 18 months, which may largely be due to the fact that the control group had more deaths than the CCHT group during those 18 months, likely resulting in the control group’s decreased use of preventable hospitalizations during the remainder of the study period. Over the entire four-year study period, the CCHT group had a lower death rate and longer survival time than the control group, while the control group had much higher frequency in all diabetes-related ambulatory care sensitive conditions such as lower-extremity amputations, uncontrolled diabetes, and bacterial pneumonia.
Date: October 1, 2009
- Providing Better Care for Vulnerable Elders in the Primary Care Setting
Investigators identify three key processes of care needed to achieve better outcomes for vulnerable elder patients: communication, developing a personal care plan for each patient, and care coordination. They also describe two delivery models of primary care: co-management (e.g., primary care clinician shares patient responsibility with another clinician or care team with additional expertise in caring for vulnerable elders), and augmented primary care (e.g., enhanced decision support for clinicians, such as computerized clinical reminders).
Date: December 1, 2008