Primary Care Intensive Management for High-Risk VA Patients Did Not Improve Long-term (12-24 Month) Outcomes or Costs
Healthcare systems have implemented interventions for patients at the highest risk for adverse outcomes, in hopes of reducing costs and improving outcomes. Previous randomized controlled trials of intensive management programs to improve care for patients with complex needs have not demonstrated decreased acute care use or costs in their first 6-12 months. This randomized trial tested whether primary care intensive management (PIM) teams could decrease acute care use, such as emergency department visits and hospitalizations, among high-risk Veterans during the second year of PIM implementation. Patients were “high-risk” if they were in the top 10% of patients at highest risk for hospitalization using a VA risk prediction algorithm based on several factors (i.e., prior outpatient use, demographics, comorbidities). Veterans were randomly assigned to the intervention group (1,902 patients) or to usual primary care (1,882 patients). Veterans in the intervention group were offered PIM services and, based on need and interest, received intensive management via PIM teams, led by primary care physicians and generally consisting of nurses, social workers, psychologists, and, in some instances, peer specialists. PIM teams performed comprehensive assessments, preventative home visits, transitional care management, medication management, care coordination, health coaching, patient and caregiver education, case management for social needs, and advance care planning. Usual care consisted of primary care delivered via VA’s Patient-Aligned Care Teams (PACT). Primary outcomes were outpatient use, inpatient use, hospital length of stay, and VA healthcare costs for the 12 months prior to and the 13-24 months following randomization. Investigators also examined non-VA use and costs, as provided by VA via community care.
- Offering an intensive case management program in addition to routine primary care services for high-risk patients increased outpatient use (e.g., primary care, mental health, home visits, case management, telehealth) during the 2nd year of implementation. But it did not significantly decrease inpatient use or healthcare costs, even when taking VA-covered community care costs into account.
- There were also no significant differences in VA healthcare use or costs for Veterans older than 65 years old or Veterans who were more frail and functionally impaired.
- Findings suggest approaches targeting VA patients based solely on high risk of hospitalization are unlikely to reduce acute care use or total costs beyond that provided by a well-functioning patient-centered medical home with additional support services.
- Expectations that the benefits of intensive management might increase over time were not supported by longer follow-up.
Drs. Chang, Stockdale, Jimenez and Ms. Chu are part of HSR&D’s Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP). Drs. Yoon and Esmaeili are with HSR&D’s Health Economics Resource Center (HERC). Drs. Zulman and Asch are with HSR&D’s Center for Innovation to Implementation (Ci2i), and Dr. Atkins is Director of HSR&D in Washington, DC.
Chang E, Yoon J, Esmaeili A, Zulman D, Ong M, Stockdale S, Jimenez E, Chu K, Atkins D, Denietolis A, and Asch S on behalf of the PACT Intensive Management (PIM) Demonstration Sites, PIM National Evaluation Center, and the PIM Executive Committee. Outcomes of a Randomized Quality Improvement Trial for High-Risk Veterans in Year Two. Health Services Research. June 18, 2021; online ahead of print.