Evelyn T Chang1, Donna M Zulman2, Steven M Asch3, Susan E Stockdale4, Jean Yoon5, Michael K Ong6, Martin Lee7, Alissa Simon8, David Atkins9, Gordon Schectman10, Susan R Kirsh11, Lisa V Rubenstein12. 1. VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, United States; Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States; Department of Medicine, Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States. Electronic address: Evelyn.Chang@va.gov. 2. VA Center for Innovation to Implementation (Ci2i), Menlo Park, CA, United States; Division of General Medical Disciplines, Stanford University School of Medicine, Stanford, CA, United States. Electronic address: Donna.Zulman@va.gov. 3. VA Center for Innovation to Implementation (Ci2i), Menlo Park, CA, United States; Division of General Medical Disciplines, Stanford University School of Medicine, Stanford, CA, United States. Electronic address: Steven.Asch@va.gov. 4. VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, United States. Electronic address: Susan.Stockdale@va.gov. 5. VA Center for Innovation to Implementation (Ci2i), Menlo Park, CA, United States; VA Health Economics Resource Center, Menlo Park, CA, United States. Electronic address: Jean.Yoon@va.gov. 6. VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, United States; Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States; Department of Medicine, Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States. Electronic address: Michael.Ong2@va.gov. 7. VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, United States; Fielding School of Public Health, University of California at Los Angeles, Los Angeles, CA, United States. Electronic address: Martin.Lee@va.gov. 8. VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, United States. Electronic address: Alissa.Simon@va.gov. 9. VA Office of Health Services Research and Development, Washington, DC, United States. Electronic address: David.Atkins@va.gov. 10. VA Office of Primary Care, Washington, DC, United States. Electronic address: Gordon.Schectman@va.gov. 11. VA Office of Primary Care, Washington, DC, United States; Case Western Reserve University School of Medicine, Cleveland, OH, United States. Electronic address: Susan.Kirsh@va.gov. 12. VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, United States; Department of Medicine, Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States; Fielding School of Public Health, University of California at Los Angeles, Los Angeles, CA, United States; RAND, Santa Monica, CA, United States. Electronic address: Lisa.Rubenstein@va.gov.
Abstract
BACKGROUND: Patient-centered medical homes have made great strides providing comprehensive care for patients with chronic conditions, but may not provide sufficient support for patients at highest risk for acute care use. To address this, the Veterans Health Administration (VHA) initiated a five-site demonstration project to evaluate the effectiveness of augmenting the VA's Patient Aligned Care Team (PACT) medical home with PACT Intensive Management (PIM) teams for Veterans at highest risk for hospitalization. METHODS/ DESIGN: Researchers partnered with VHA leadership to design a mixed-methods prospective multi-site evaluation that met leadership's desire for a rigorous evaluation conducted as quality improvement rather than research. We conducted a randomized QI evaluation and assigned high-risk patients to participate in PIM and compared them with high-risk Veterans receiving usual care through PACT. The summative evaluation examines whether PIM: 1) decreases VHA emergency department and hospital use; 2) increases satisfaction with VHA care; 3) decreases provider burnout; and 4) generates positive returns on investment. The formative evaluation aims to support improved care for high-risk patients at demonstration sites and to inform future initiatives for high-risk patients. The evaluation was reviewed by representatives from the VHA Office of Research and Development and the Office of Research Oversight and met criteria for quality improvement. DISCUSSION: VHA aims to function as a learning organization by rapidly implementing and rigorously testing QI innovations prior to final program or policy development. We observed challenges and opportunities in designing an evaluation consistent with QI standards and operations priorities, while also maintaining scientific rigor. TRIAL REGISTRATION: This trial was retrospectively registered at ClinicalTrials.gov on April 3, 2017: NCT03100526. Protocol v1, FY14-17.
RCT Entities:
BACKGROUND:Patient-centered medical homes have made great strides providing comprehensive care for patients with chronic conditions, but may not provide sufficient support for patients at highest risk for acute care use. To address this, the Veterans Health Administration (VHA) initiated a five-site demonstration project to evaluate the effectiveness of augmenting the VA's Patient Aligned Care Team (PACT) medical home with PACT Intensive Management (PIM) teams for Veterans at highest risk for hospitalization. METHODS/ DESIGN: Researchers partnered with VHA leadership to design a mixed-methods prospective multi-site evaluation that met leadership's desire for a rigorous evaluation conducted as quality improvement rather than research. We conducted a randomized QI evaluation and assigned high-risk patients to participate in PIM and compared them with high-risk Veterans receiving usual care through PACT. The summative evaluation examines whether PIM: 1) decreases VHA emergency department and hospital use; 2) increases satisfaction with VHA care; 3) decreases provider burnout; and 4) generates positive returns on investment. The formative evaluation aims to support improved care for high-risk patients at demonstration sites and to inform future initiatives for high-risk patients. The evaluation was reviewed by representatives from the VHA Office of Research and Development and the Office of Research Oversight and met criteria for quality improvement. DISCUSSION: VHA aims to function as a learning organization by rapidly implementing and rigorously testing QI innovations prior to final program or policy development. We observed challenges and opportunities in designing an evaluation consistent with QI standards and operations priorities, while also maintaining scientific rigor. TRIAL REGISTRATION: This trial was retrospectively registered at ClinicalTrials.gov on April 3, 2017: NCT03100526. Protocol v1, FY14-17.
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