Evaluating Intensive Outpatient Primary Care VA Experience Steven

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Evaluating Intensive Outpatient Primary Care: VA Experience Steven M. Asch MD MPH Director, Center

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 utilization and costs. . 100% 90% 80% 70%

Same problem as everywhere: Concentration of utilization and costs. . 100% 90% 80% 70% 60% Bottom 90% Top 10% 50% 40% 30% 20% 10% 0% Percent of Total VA Patients Total VA Health Care Costs Source: Analysis of 2010 HERC Average Cost data

…But a different institutional context • Integrated system • Well developed Patient Centered Medical

…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)

How do we layer IOPC on top of PACT? Intensive Management PACT (Im. PACT)

How do we layer IOPC on top of PACT? Intensive Management PACT (Im. PACT) PACT + PACT

Core Elements of Im. PACT in Palo Alto • Multidisciplinary Team: NP, MD, SW,

Core Elements of Im. PACT in Palo Alto • Multidisciplinary Team: NP, MD, SW, Recreation Therapist, Clinical Coordinator • 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

Evaluation design • Automatic recruitment of high risk patients using CAN score/utilization • Randomized

Evaluation design • Automatic recruitment of high risk patients using CAN score/utilization • Randomized assignment to Im. PACT team • Outcomes • • Hospitalizations/ED use Satisfaction Patient activation Costs

Im. PACT patients’ satisfaction with VA improved P < 0. 01 P < 0.

Im. PACT patients’ satisfaction with VA improved P < 0. 01 P < 0. 05

Monthly costs declined… From Zulman DM. JAMA Int Med. 2017.

Monthly costs declined… From Zulman DM. JAMA Int Med. 2017.

…but about the same as controlsone! Regression to the mean From Zulman DM. JAMA

…but about the same as controlsone! Regression to the mean From Zulman DM. JAMA Int Med. 2017.

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

We spread the model to test it further PACT Intensive Management (PIM) Sites Milwaukee VAMC San Francisco VAMC and 2 CBOCs Cleveland VAMC and CBOC Salisbury VAMC Atlanta CBOC

Allowed more variation in program elements Site A Site B Site C Site D

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 Interdisciplinary care team X X X Social work X X X Mental health/addiction support X X Care coordination X X X Home visits X X X Assisted with medications X X X Health coaching X X X Replace PACT team Medic support X X

Again randomized QI evaluation, tested similar outcomes High risk for hosp (CAN score) +

Again randomized QI evaluation, tested similar outcomes High risk for hosp (CAN score) + hosp/ED visit <6 months PIM PACT N=1105 N=1102 Opt in N=691 Opt out of program N=414

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

Better trust, access, and coordination… (in a non statistically significant sort of way) Got needed services Ease in getting care PIM Easily accessible provider PACT Respect from provider Have a trusted provider Help with coordination of care 0% 10% 20% 30% 40% 50% 60% 70% Strongly Agree

Inpatient costs declined… 18 000 16 000 14 000 PIM Pre-Randomization 12 000 10

Inpatient costs declined… 18 000 16 000 14 000 PIM Pre-Randomization 12 000 10 000 PIM Post-Randomization 8 000 PACT Pre-Randomization 6 000 4 000 PACT Post. Randomization 2 000 Difference-in-Difference 0 -2 000 -2, 277 -4 000 ^Predicted means from regression models

…But outpatient costs went up 25 000 20 000 PIM Pre-Randomization 15 000 PIM

…But outpatient costs went up 25 000 20 000 PIM Pre-Randomization 15 000 PIM Post-Randomization PACT Pre-Randomization PACT Post-Randomization 10 000 Difference-in-Difference 5 000 2 638 0 * p<0. 01 ^Predicted means from regression models

In depth qualitative interviews and provider surveys • Providers appreciated the help • Patients

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.

Conclusions of 5 year effort thusfar • Layering intensive management on top of PCMH

Conclusions of 5 year effort thusfar • Layering intensive management on top of PCMH paid for itself* • Patient and provider satisfaction improved modestly • Might have drawn non. VA care to VA – analyses underway • We didn’t give up! • Modified program undergoing further testing • Refined selection criteria • Standardized elements- more focus on mental health and social factors *Translation- did not save money

Thank you… Donna Zulman Evelyn Chang Jean Yoon Susan Stockdale Gordon Schectman Lisa Rubenstein

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

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