Dataset Information

Effects of Intensive Primary Care on High-Need Patient Experiences: Survey Findings from a Veterans Affairs Randomized Quality Improvement Trial.

ABSTRACT:

Background

Intensive primary care programs aim to coordinate care for patients with medical, behavioral, and social complexity, but little is known about their impact on patient experience when implemented in a medical home.

Objective

Determine how augmenting the VA's medical home (Patient Aligned Care Team, PACT) with a PACT-Intensive Management (PIM) program influences patient experiences with care coordination, access, provider relationships, and satisfaction.

Design

Cross-sectional analysis of patient survey data from a five-site randomized quality improvement study.

Participants

Two thousand five hundred sixty-six Veterans with hospitalization risk scores ≥ 90th percentile and recent acute care.

Intervention

PIM offered patients intensive care coordination, including home visits, accompaniment to specialists, acute care follow-up, and case management from a team staffed by primary care providers, social workers, psychologists, nurses, and/or other support staff.

Main measures

Patient-reported experiences with care coordination (e.g., health goal assessment, test and appointment follow-up, Patient Assessment of Chronic Illness Care (PACIC)), access to healthcare services, provider relationships, and satisfaction.

Key results

Seven hundred fifty-nine PIM and 768 PACT patients responded to the survey (response rate 60%). Patients randomized to PIM were more likely than those in PACT to report that they were asked about their health goals (AOR = 1.26; P = 0.046) and that they have a VA provider whom they trust (AOR = 1.35; P = 0.005). PIM patients also had higher mean (SD) PACIC scores compared with PACT patients (2.91 (1.31) vs. 2.75 (1.25), respectively; P = 0.022) and were more likely to report 10 out of 10 on satisfaction with primary care (AOR = 1.25; P = 0.048). However, other effects on coordination, access, and satisfaction did not achieve statistical significance.

Conclusions

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.

SUBMITTER: Zulman DM

PROVIDER: S-EPMC6542922 | biostudies-literature | 2019 May

REPOSITORIES: biostudies-literature

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Publications

Effects of Intensive Primary Care on High-Need Patient Experiences: Survey Findings from a Veterans Affairs Randomized Quality Improvement Trial.

Zulman Donna M DM Chang Evelyn T ET Wong Ava A Yoon Jean J Stockdale Susan E SE Ong Michael K MK Rubenstein Lisa V LV Asch Steven M SM

Journal of general internal medicine 20190501 Suppl 1

<h4>Background</h4>Intensive primary care programs aim to coordinate care for patients with medical, behavioral, and social complexity, but little is known about their impact on patient experience when implemented in a medical home.<h4>Objective</h4>Determine how augmenting the VA's medical home (Patient Aligned Care Team, PACT) with a PACT-Intensive Management (PIM) program influences patient experiences with care coordination, access, provider relationships, and satisfaction.<h4>Design</h4>Cro ...[more]

PMID: 31098977

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Project description:BackgroundHealthcare systems nationwide are implementing intensive outpatient care programs to optimize care for high-need patients; however, little is known about these patients' personal goals and factors associated with goal progress.ObjectiveTo describe high-need patients' goals, and to identify factors associated with their goal progress DESIGN: Retrospective cohort study PARTICIPANTS: A total of 113 high-need patients participated in a single-site Veterans Affairs intensive outpatient care program.Main measuresTwo independent reviewers examined patients' goals recorded in the electronic health record, categorized each goal into one of three domains (medical, behavioral, or social), and determined whether patients attained goal progress during program participation. Logistic regression was used to determine factors associated with goal progress.ResultsThe majority (n = 72, 64%) of the 113 patients attained goal progress. Among the 100 (88%) patients with at least one identified goal, 58 set goal(s) in the medical domain; 60 in the behavioral domain; and 52 in the social domain. Within each respective domain, 41 (71%) attained medical goal progress; 34 (57%) attained behavioral goal progress; and 32 (62%) attained social goal progress. Patients with mental health condition(s) (aOR 0.3; 95% CI 0.1-0.9; p = 0.03) and those living alone (aOR 0.4; 95% CI 0.1-1.0; p = 0.05) were less likely to attain goal progress. Those with mental health condition(s) and those who were living alone were least likely to attain goal progress (interaction aOR 0.1 compared to those with neither characteristic; 95% CI 0.0-0.7; p = 0.02).ConclusionsAmong high-need patients participating in an intensive outpatient care program, patient goals were fairly evenly distributed across medical, behavioral, and social domains. Notably, individuals living alone with mental health conditions were least likely to attain progress. Future care coordination interventions might incorporate strategies to address this gap, e.g., broader integration of behavioral and social service components.

Project description:Background & aimsThe coronavirus disease-2019 pandemic profoundly disrupted preventative health care services including cancer screening. As the largest provider of cirrhosis care in the United States, the Department of Veterans Affairs (VA) National Gastroenterology and Hepatology Program aimed to assess factors associated with hepatocellular carcinoma (HCC) stage at diagnosis, treatment, and survival.MethodsVeterans with a new diagnosis of HCC in 2021 were identified from electronic health records (N = 2306). Structured medical record extraction was performed by expert reviewers in a 10% random subsample of Veterans with new HCC diagnoses. Factors associated with stage at diagnosis, receipt of treatment, and survival were assessed using multivariable models.ResultsAmong 199 patients with confirmed HCC, the average age was 71 years and most (72%) had underlying cirrhosis. More than half (54%) were at an early stage (T1 or T2) at diagnosis. Less-advanced liver disease, number of imaging tests adequate for HCC screening, HCC diagnosis in the VA, and receipt of VA primary care were associated significantly with early stage diagnosis. HCC-directed treatments were administered to 145 (73%) patients after a median of 37 days (interquartile range, 19-54 d) from diagnosis, including 70 (35%) patients who received potentially curative treatments. Factors associated with potentially curative (vs no) treatments included HCC screening, early stage at diagnosis, and better performance status. Having fewer comorbidities and better performance status were associated significantly with noncurative (vs no) treatment. Early stage diagnosis, diagnosis in the VA system, and receipt of curative treatment were associated significantly with survival.ConclusionsThese results highlight the importance of HCC screening and engagement in care for HCC diagnosis, treatment, and survival while demonstrating the feasibility of developing a national quality improvement agenda for HCC screening, diagnosis, and treatment.

Project description:Insomnia is a widespread issue among United States adults and rates of insomnia among veterans are even higher than the general population. Prior research examining primary care provider (PCP) perspectives on insomnia treatment found that: sleep hygiene and pharmacotherapy are the primary treatments offered; PCPs tend to focus on perceived causes of insomnia rather than the insomnia itself; and neither patients nor providers are satisfied with insomnia treatment options. Although insomnia complaints are typically first reported to primary care providers, little research has focused on perspectives regarding insomnia treatment among PCPs working in the largest integrated health care system in the United States-the Veterans Affairs (VA) health care system. This study was conducted to examine VA PCP perceptions of the availability of insomnia treatments, identify specific strategies offered by PCPs, and examine perceptions regarding the importance of treating insomnia and the role of comorbid conditions.A survey was conducted within the VA health care system. Primary care providers completed surveys electronically.A high percentage of veterans (modal response = 20% to 39%) seen in VA primary care settings report an insomnia complaint to their provider. Almost half of respondents do not consistently document insomnia in the medical record (46% endorsed "sometimes," "rarely," or "never"). PCPs routinely advise sleep hygiene recommendations for insomnia (ie, avoid stimulants before bedtime [84.3%], and keep the bedroom environment quiet and dark and comfortable [68.6%]) and many are uncertain if cognitive behavioral therapy for insomnia is available at their facility (43.1%).Findings point to the need for systems-level changes within health care systems, including the adoption of evidence-based clinical practice standards for insomnia and PCP education about the processes that maintain insomnia.A commentary on this article appears in this issue on page 937.

Project description:ImportanceMany veterans enrolled in the Veterans Affairs (VA) health care system have access to non-VA care through insurance and VA-purchased community care. Prior comparisons of VA and non-VA hospital outcomes have been limited to subpopulations.ObjectiveTo compare outcomes for 6 acute conditions in VA and non-VA hospitals for younger and older veterans using VA and all-payer discharge data.Design, setting, and participantsThis cohort study used a repeated cross-sectional analysis of hospitalization records for acute myocardial infarction (AMI), coronary artery bypass graft (CABG), gastrointestinal (GI) hemorrhage, heart failure (HF), pneumonia, and stroke. Participants included VA enrollees from 11 states at VA and non-VA hospitals from 2012 to 2017. Analysis was conducted from July 1, 2022, to October 18, 2023.ExposuresTreatment in VA or non-VA hospital.Main outcome and measuresThirty-day mortality, 30-day readmission, length of stay (LOS), and costs. Average treatment outcomes of VA hospitals were estimated using inverse probability weighted regression adjustment to account for selection into hospitals. Models were stratified by veterans' age (aged less than 65 years and aged 65 years and older).ResultsThere was a total of 593 578 hospitalizations and 414 861 patients with mean (SD) age 75 (12) years, 405 602 males (98%), 442 297 hospitalizations of non-Hispanic White individuals (75%) and 73 155 hospitalizations of non-Hispanic Black individuals (12%) overall. VA hospitalizations had a lower probability of 30-day mortality for HF (age ≥65 years, -0.02 [95% CI, -0.03 to -0.01]) and stroke (age <65 years, -0.03 [95% CI, -0.05 to -0.02]; age ≥65 years, -0.05 [95% CI, -0.07 to -0.03]). VA hospitalizations had a lower probability of 30-day readmission for CABG (age <65 years, -0.04 [95% CI, -0.06 to -0.01]; age ≥65 years, -0.05 [95% CI, -0.07 to -0.02]), GI hemorrhage (age <65 years, -0.04 [95% CI, -0.06 to -0.03]), HF (age <65 years, -0.05 [95% CI, -0.07 to -0.03]), pneumonia (age <65 years, -0.04 [95% CI, -0.06 to -0.03]; age ≥65 years, -0.03 [95% CI, -0.04 to -0.02]), and stroke (age <65 years, -0.11 [95% CI, -0.13 to -0.09]; age ≥65 years, -0.13 [95% CI, -0.16 to -0.10]) but higher probability of readmission for AMI (age <65 years, 0.04 [95% CI, 0.01 to 0.06]). VA hospitalizations had a longer mean LOS and higher costs for all conditions, except AMI and stroke in younger patients.Conclusions and relevanceIn this cohort study of veterans, VA hospitalizations had lower mortality for HF and stroke and lower readmissions, longer LOS, and higher costs for most conditions compared with non-VA hospitalizations with differences by condition and age group. There were tradeoffs between better outcomes and higher resource use in VA hospitals for some conditions.

Dataset Information

Effects of Intensive Primary Care on High-Need Patient Experiences: Survey Findings from a Veterans Affairs Randomized Quality Improvement Trial.

Background

Objective

Design

Participants

Intervention

Main measures

Key results

Conclusions

Publications

Effects of Intensive Primary Care on High-Need Patient Experiences: Survey Findings from a Veterans Affairs Randomized Quality Improvement Trial.

Similar Datasets

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