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The Patient Aligned Care Team (PACT) is a team-based model of care—based on the Patient Centered Medical Home model—in which a team of VA primary care providers and staff works collaboratively with the patient to provide access to appropriate care for Veterans and coordinate care with other providers, as needed. PACT Intensive Management (PIM) targets Veterans at highest risk for hospital admission and death in primary care, including those with complex chronic conditions. To best help this vulnerable patient population, PIM includes comprehensive needs assessment, coordination of specialty care, chronic condition management, home visits, provision of mental health and social services, rapid response to deteriorations in health, and facilitation of transitions after high-acuity events.
The Effects of Intensive Outpatient Management Programs on Medication-Related Outcomes for High-Risk Patients Partnered Evaluation QUERI initiative is currently studying whether PIM – or programs using interdisciplinary teams to provide intensive services that augment PACT – can lead to increased adherence and improved management of medications. Improving medication management can potentially lead to improved chronic condition management, better health status, and lower costs over the long term. The Intensive Outpatient Management QUERI is working in partnership with VA Primary Care (PC) and Pharmacy Benefits Management Services (PBM) to support operations’ priorities of improving care and medication management of high-risk patients.
The CAN score looks at factors such as demographics, co-existing conditions, vital signs, utilization of services, pharmacy visits, and lab results to determine if the patient is high risk. The score shows the probability of hospital readmission or death within a specific time period, such as 90 days or one year.
In 2013, following the development of the Care Assessment Need (CAN) Score to track all VA patients’ risk for future hospitalizations and death, Patient Care Services began a national PIM initiative focusing on patients at the highest risk for hospitalizations. A critical part of this initiative included testing PIM through pilot programs around the country. Thus, a partnership began between VA Primary Care, HSR&D, the five PIM sites (Atlanta, GA; Cleveland, OH; Milwaukee, WI; Salisbury, CT; and San Francisco, CA), and the PIM National Evaluation Center – an interdisciplinary group of VA health services researchers – to support the development of PIM programs and to evaluate the programs through a randomized quality improvement trial. This partnership ensured that PC priorities were reflected in outcomes targeted by the programs, and that programs were implemented in a way that could be rigorously evaluated.
The PIM initiative was supported by a national advisory committee comprised of VA operations leaders :
- Patient Care Services has 10 service areas/programs dedicated to providing patient-centered care that is personal and proactive.
- Geriatrics and Extended Care (GEC) works to optimize the health and wellbeing of Veterans (of any age) with chronic conditions or life-limiting illness.
- Homeless PACT (H-PACT) coordinates “medical home” care specifically tailored to the needs of homeless Veterans.
- VA Telehealth Services uses health informatics, disease management, and telehealth technologies to improve access to care for Veterans.
- Community Care strives to optimize community care for all Veterans who need it.
- Specialty Care Services range from dermatology to critical care.
- Mental Health works to provide Veterans with high-quality, evidence-based mental health care.
- Women Veterans Health Care provides programmatic and strategic support to implement positive changes in the provision of care for all women Veterans.
- Office of Analytics and Business Intelligence works to improve the quality of VA data, so as to provide the right information to the right people at the right time.
This committee provided important feedback on the potential integration of PIM programs with other VA programs for high-risk patients. In the advisory committee’s review of one-year PIM outcomes – and given their awareness of medication management as a common problem for high-risk patients – the committee highlighted the potential impact of PIM on medication outcomes. This led to the development of the Intensive Outpatient Management QUERI in 2018, along with a new partnership with Pharmacy Benefits Management Services to evaluate PIM’s impact on specific medication management-related outcomes, including drug adherence. With its extensive knowledge of pharmacy quality and safety issues, PBM is uniquely situated to understand the range of prescribing challenges for high-risk patients and the role of pharmacists in helping to manage their prescriptions.
Through its partnerships, the Intensive Outpatient Management QUERI incorporates input from operations partners into its study aims, development of its evaluation plan, guidance around measurement and qualitative analysis issues, and, eventually, will collaborate on policy implications from this work. These partnerships help to ensure that lessons learned from this QUERI Partnered Evaluation can lead to sustainable improvements in care for Veterans at high risk.
For more information about Intensive Outpatient Management QUERI, please contact Jean Yoon, PhD, MHS, at Jean.Yoon@va.gov .