Evaluating Intensive Outpatient Primary Care: VA Experience Steven - - PowerPoint PPT Presentation

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evaluating intensive outpatient primary care va experience
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Evaluating Intensive Outpatient Primary Care: VA Experience Steven - - PowerPoint PPT Presentation

Aug 18, 2023 349 likes •556 views

Evaluating Intensive Outpatient Primary Care: VA Experience Steven M. Asch MD MPH Director, Center for Innovation to Implementation Professor and Vice Chief, Stanford Division of Primary Care Same problem as everywhere: Concentration of

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Evaluating Intensive Outpatient Primary Care: VA Experience

Steven M. Asch MD MPH Director, Center for Innovation to Implementation Professor and Vice Chief, Stanford Division of Primary Care

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Same problem as everywhere: Concentration of utilization and costs..

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Percent of Total VA Patients Total VA Health Care Costs Bottom 90% Top 10%

Source: Analysis of 2010 HERC Average Cost data

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…But a different institutional context

  • Integrated system
  • Well developed Patient Centered Medical Home
  • Patient Aligned Care Teams (PACT)
  • Geri PACT
  • Homeless PACT
  • Well developed programs for complex pts
  • Home Based Primary Care (HBPC)
  • Mental Health Intensive Case

Management (MHICM)

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How do we layer IOPC on top of PACT? PACT

Other Programs

Intensive Management PACT (ImPACT)

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Core Elements of ImPACT in Palo Alto

  • Multidisciplinary Team: NP, MD, SW, Rec therapy
  • Comprehensive intake; goal-concordant care
  • Frequent in-person/phone contact
  • After-hours access
  • Chronic condition case management
  • Coordination of primary and specialty care
  • Rapid response to health status deterioration
  • Support during transitions from hospital to home
  • Access to social and community resources
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Patient selection and evaluation design

  • Proactive recruitment of patients at top 10% risk of future

admission/cost

  • Randomized assignment to ImPACT team
  • Outcomes
  • Hospitalizations/ED use
  • Satisfaction
  • Patient activation
  • Costs
  • Qualitative interviews
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0% 20% 40% 60% 80% 100% General Satisfaction Communication Satisfaction Baseline Follow-Up P P < 0.01 P P < 0.05

ImPACT patients’ satisfaction with VA improved

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From Zulman DM. JAMA Int Med. 2017.

Monthly costs declined…

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From Zulman DM. JAMA Int Med. 2017.

  • ne!

…but about the same as controls- Regression to the mean

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We spread the model to test it further PACT Intensive Management (PIM) Sites

Atlanta CBOC Cleveland VAMC and CBOC Milwaukee VAMC Salisbury VAMC San Francisco VAMC and 2 CBOCs

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Allowed more variation in program elements

Site A Site B Site C Site D Site E Screened patients, triaged and assessed for services X X X X X Interdisciplinary care team X X X X X Social work X X X X X Mental health/addiction support X X X X Care coordination X X X X X Home visits X X X X X Assisted with medications X X X X X Health coaching X X X X X Replace PACT team X Medic support X

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Again randomized QI evaluation, tested similar

  • utcomes

High risk for hosp (CAN score) + hosp/ED visit <6 months

PIM

N=1105

Opt in

N=691

Opt out of program N=414

PACT N=1102

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Better trust, access, and coordination… (in a non statistically significant sort of way)

0% 10% 20% 30% 40% 50% 60% 70% Help with coordination of care Have a trusted provider Respect from provider Easily accessible provider Ease in getting care Got needed services PIM PACT

Strongly Agree

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Inpatient costs declined…

  • 2,277
  • 4,000
  • 2,000

2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000 18,000 PIM Pre-Randomization PIM Post-Randomization PACT Pre-Randomization PACT Post- Randomization Difference-in-Difference

^Predicted means from regression models

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…But outpatient costs went up

* p<0.01

2,638 5,000 10,000 15,000 20,000 25,000

PIM Pre-Randomization PIM Post-Randomization PACT Pre-Randomization PACT Post-Randomization Difference-in-Difference

^Predicted means from regression models

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In depth qualitative interviews and provider surveys

  • Providers appreciated the help
  • Patients loved single point of contact
  • Patients felt supported at specialist visits
  • Better end of life planning
  • Transitions from hospital to home easier.
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Conclusions of 5 year effort thusfar

  • Layering intensive management on top of PCMH paid for itself*
  • Might have drawn nonVA care to VA – analyses underway
  • Patient and provider satisfaction improved modestly
  • Regression to the mean serious challenge to pre-post studies
  • We didn’t give up! Lessons:
  • Refined selection criteria
  • Standardized - more focus on mental health and social factors
  • Modified program undergoing further testing

*Translation- did not save money

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Thank you…

Donna Zulman Evelyn Chang Jean Yoon Susan Stockdale Gordon Schectman Lisa Rubenstein Michael Ong David Atkins Frances Wu Debra Hummel Marian Katz Elvira Jimenez Mingming Wang Ava Wong Angel Park Brook Watts Jessica Eng Neha Pathak Parag Dalsania Andrew Lanto Shoutzu Lin Carrie Patton Belinda Black Jeff Jackson