Patient Aligned Care Team (PACT) Intensive Management (PIM) Project
Phase: NA
Conditions: Primary Health Care, Health Care Costs
Sponsor: Veteran Affairs Office of Patient Care Services

 
Patient Aligned Care Team (PACT) Intensive Management (PIM) Project 
Protocol 
Modified 1-29-2020 
 
Contents 
Background ................................................................................................................................................... 2 
Summary of outcome measures ................................................................................................................... 2 
Primary and Secondary Outcome Measures Procedures ............................................................................. 4 
Sample selection and recruitment ............................................................................................................ 4 
Demonstration Site Selection: .............................................................................................................. 4 
Inclusion criteria:................................................................................................................................... 4 
Exclusion criteria: .................................................................................................................................. 5 
Sample ................................................................................................................................................... 5 
Interventions ............................................................................................................................................. 6 
Measurements .......................................................................................................................................... 6 
Analysis ..................................................................................................................................................... 6 
Other Outcome Measures ............................................................................................................................ 7 
Functional Status, Quality of life, Symptom Burden ................................................................................. 7 
Implementation Outcome/challenges ...................................................................................................... 7 
Sample selection/ recruitment ............................................................................................................. 7 
Instrument Development ...................................................................................................................... 8 
Procedures ............................................................................................................................................ 8 
Analysis ................................................................................................................................................. 8 
Primary Care Staff Job Satisfaction and Intention to Stay at the VA. ....................................................... 8 
Sample ................................................................................................................................................... 8 
Method ................................................................................................................................................. 8 
Analysis ................................................................................................................................................. 9 
 

 
 
 
 
 
Background 
In 2013, VHA Primary Care Services submitted a request for proposal (RFP) seeking VA Medical 
Center (VAMC) participation in a national PACT Intensive Management (PIM) initiative. The 
specific objectives of the initiative were to 1) reduce preventable hospitalizations and 
emergency care in persons having complex medical and social needs and who are identified as 
being at highest risk for unplanned visits, hospitalization, and death, 2) optimize high-risk 
patient functional status, and 3) maintain high-risk patients in their homes and communities to 
the greatest extent possible.  Through the RFP, five VAMCs were selected to receive funding for 
up to $750,000 per year to support demonstration projects to innovate strategies to manage 
high-risk Veterans in a rigorously evaluated quality improvement project. Through this 
initiative, the PIM teams at each of the demonstration sites became subject matter experts and 
valuable advocates for high-risk patients’ individual and system-level needs. 
Summary of outcome measures 
Primary Outcome Measure:  
1. VA health care cost  
Total costs of VA care, including inpatient, outpatient, pharmacy and fee-basis services. 
Secondary Outcome Measures: 
2. Healthcare Utilization  
VA central repository administrative data will be analyzed to calculate utilization of 
hospital, emergency and outpatient primary and specialty care. This information will be 
electronically abstracted through the VA central repository administrative data center. 
 
3. Medicare utilization and cost  
Medicare claims data was used to capture utilization and costs for services reimbursed 
by Medicare. The Master Beneficiary Summary File was used to ascertain patients’ 
Medicare enrollment status. 

Other Pre-Specified Outcome Measures: 
4. Engagement  
The investigators will look at patient PIM enrollment data by utilizing central repository 
administrative data. The data will be electronically abstracted through the VA central repository 
administrative data center. 
5. Functional status  
Patient report of their physical, social, and mental functional status is routinely collected as part 
of their medical visit. The data will be abstracted through the VA central repository 
administrative data. 
6. Quality of Life Status  
Patient assessment of their quality of life collected as part of their medical care. This 
information will be electronically abstracted through the VA central repository administrative 
data center. 
7. Symptom Burden  
Patient assessment of mental health and physical health symptom burden is routinely collected 
as part of their care and documented in their medical record. This data will be electronically 
abstracted through the VA central repository administrative data center. 
8. Implementation Outcome/ challenges  
Information about implementation barriers and facilitators, feasibility, and sustainability will be 
obtained through two waves of key stakeholder interviews, including demonstration site staff 
and facility leaders 
9. Primary Care Staff Job Satisfaction and Intention to Stay at the VA  
The investigators will survey Primary Care Providers (PCPs) (physicians, MDs/DOs; nurse 
practitioners, NPs; physician assistants, PAs) and nurses (registered nurses, RNs; 
licensed practical nurses, LPNs; licensed vocational nurses-LVNs) at the five healthcare 
systems that have a PIM team. They will use both online using RedCap and paper-and-
pen versions of the survey to increase response rate. The investigators will survey 
Primary Care staff at baseline and one year later. The first survey was fielded December 
2014 - May 2015 and again from October 2016 - January 2017). Primary Care Staff Job 
Satisfaction is measured by a single item "Overall, I am satisfied with my job," rated on a 
5-point Likert agreement scale. 
 

10. Primary Care Staff Intention to Stay at the VA 
 
The investigators will survey Primary Care Providers (PCPs) (physicians, MDs/DOs; nurse 
practitioners, NPs; physician assistants, PAs) and nurses (registered nurses, RNs; 
licensed practical nurses, LPNs; licensed vocational nurses-LVNs) at the five healthcare 
systems that have a PIM team.  They will use both online using RedCap and paper-and-
pen versions of the survey to increase response rate. The investigators will survey 
Primary Care staff at baseline and one year later. The first survey was fielded December 
2014 - May 2015 and again from October 2016 - January 2017). Intention to Stay at the 
VA is measured by a single item "I intend to continue working in PC at the VA for the 
next two years," rated on a 5-point Likert agreement scale. 
 
Primary and Secondary Outcome Measures Procedures 
 
Sample selection and recruitment 
Demonstration Site Selection: Five sites will be selected in a competitive process by reviewers 
and funders from the VHA Office of Primary Care Services. Selection criteria include sites that: 
1) have geographically diverse teams, spanning both rural and urban settings; 2) have teams 
that include a mental health provider; and 3) provide services that can increase Veteran access 
to healthcare, including home visits and telehealth. 
Inclusion criteria: The evaluation team will collaborate with demonstration sites over six 
months to define and identify the high-risk Veteran population using the CAN score (Wang et 
al.) The CAN score is computed weekly for each VHA patient based on multiple electronic data 
elements (i.e., clinical diagnoses, laboratory data, vital signs, previous inpatient and outpatient 
utilization over the preceding year) and predicts risk of hospitalization in the subsequent 90 
days. The patient lists will include those on the top 10th percentile of the CAN score and that 
had at least one ED visit or hospitalization in the VHA over the prior 6 months. All patients will 
have an assigned primary care medical homes in general Primary Care, Women’s Health, 
Geriatrics, or Infectious Disease (mostly caring for patients with Human Immunodeficiency 
Virus, HIV). The Infectious Disease medical home will be included as a tracer for assessing 
specialty medical homes, to provide formative information on differences from primary care 
medical homes.  
Table 1. Exclusion Criteria 
Exclusion Criteria 
• A clinical encounter with specialty primary care teams with comprehensive resources 
other than those identified in inclusion criteria (i.e., Post-Deployment, Renal, Spinal 

Cord Injury, Homeless PACT, Home-Based Primary Care team), in the previous two 
months 
• Outpatient encounters in Mental Health Intensive Care Management programs (VHA-
adapted Assertive Community Treatment program), palliative care, and hospice in the 
previous two months  
• Nursing home in the previous two months 
• Care Assessment Need Score (CAN) (Wang et al.) < 90th percentile 
• Inpatient admission to a residential substance abuse treatment program in the 
previous two months 
• Death 
 
 
Exclusion criteria: Patients will be excluded if they are managed by an intensive primary care 
team or have received intensive outpatient services in the past two months, such as homeless 
primary care services, primary care for home-bound patients, intensive outpatient mental 
health services. Patients residing in a VHA nursing home facility or residential substance abuse 
treatment program in the previous two months will also be excluded. Full exclusion criteria are 
listed in Table 1.  
Sample: The evaluation team will randomly identify a sample of high-risk Veterans from among 
patients assigned to a primary care medical home at a demonstration site. Half of these 
patients will be randomly allocated to the innovation group and sent to the demonstration 
teams for recruitment consideration, and the other half will be allocated to usual care in the VA 
patient-centered medical home. The investigators will stratify by gender to ensure 
representation of 10% women in both the innovation group and the usual care group to inform 
future policy. Demonstration teams will receive lists of high-risk patients from the evaluation 
team through a secure workspace behind VHA firewall.  Demonstration patients on this list are 
considered innovation patients (intent-to-treat), if they receive services from the 
demonstration teams. Demonstration teams will be blinded to the list of usual care patients in 
the comparison group as part of the quality improvement design. 
Local healthcare providers will be permitted to refer a limited number of Veterans to the 
intensive primary care programs (up to 10% of the program capacity). To allow usual care 
patients the opportunity to participate as a demonstration patient, after 12 months, high-risk 
Veterans in the usual care group will not be excluded from being randomly selected for an 
invitation to participate in the intensive management innovation. 
Based on a univariate comparison, a sample size of 526 patients per evaluation arm (1052 total) 
will provide 90% power to detect a small effect (Cohen’s d = 0.2) in ED visits or hospitalizations 
with a two-sided significance level of 0.05. The investigators estimate that at least 200 patients 
will have the opportunity to be invited to the intensive management program at each 
demonstration site over a one-year period, which will provide a sufficient sample size of 1000 
patients in the innovation and 1000 in the comparison arm. Sites control the frequency and 

quantity of high-risk patients identified to them each month, based on clinical and resource 
considerations. PIM teams are expected, however, to receive at least 200 names over 12 
months, rather than all 200 at the beginning.   
Interventions 
Selected demonstration sites will span a variety of high-risk patient care approaches, such as a 
patient-centered medical home for high-risk Veterans, collaborative care model for high-risk 
patients, and care transitions program. Each site will propose a site-specific intervention.  All 
proposed interventions will use population management models and determined their own 
approaches to stratifying patients and determining eligibility for and intensity of services. The 
types of services offered by each team will depend on program staff, local resources, and 
facility and program priorities. Each site will also develop its own criteria for when to 
discontinue services for patients.  
Measurements 
Patient demographics, chronic conditions and other health conditions (Yoon, Scott, Phibbs, & 
Wagner, 2011), comorbidity score (Charlson), VHA outpatient/inpatient utilization, measures of 
prescription drug use and mortality will be obtained through the VHA Corporate Data 
Warehouse. For costs, VHA inpatient and outpatient utilization records will be linked to 
Managerial Cost Accounting (MCA) cost data to obtain the costs of outpatient and inpatient 
care.  Pharmacy utilization and costs will be obtained from MCA Pharmacy files, and VHA-
sponsored care is obtained from Fee Basis files. Implementation costs will be determined 
through micro-costing methods from site reports. Because these are administrative data, these 
are collected from each participant regardless if they were not offered services or if they were 
discontinued from the intervention.  
Analysis 
The investigators will conduct an intent-to-treat analysis based on patients’ allocated group.  
The investigators plan to compare unadjusted mean utilization counts and costs for different 
categories of inpatient care and outpatient care and total care.  The investigators will estimate 
the impact of PIM using regression models to obtain the differences-in-differences estimate of 
the change from the 12-month pre-intervention period to 12-month and 24-month post-
intervention period attributable to PIM above and beyond any time trends that occurred in 
both groups.  Our regression models will predict utilization of outpatient encounters and 
inpatients stays in count data models (Poisson and negative binomial regression models) 
including a time-varying measure of risk using the Charlson Index and patient fixed effects to 
account for factors fixed over time.  Regression models of costs include the same predictors as 
the utilization models and will be conducted using ordinary least squares (OLS); sensitivity 
analyses will be conducted using generalized linear models (GLM) with a log link and Poisson 
distribution.  Mortality will be compared between treatment groups with a log-rank test for 
equality of survivor functions.   

In other sensitivity analyses, the investigators plan to conduct regression models with patient 
random effects and covariates for patients’ age, gender, race/ethnicity, marital status, means 
test, service connection, homelessness, Charlson Index, and site.  The investigators will also 
measure the treatment effect on the treated by conducting regression analysis using 
instrumental variables to examine whether more PIM encounters were related to cost and 
utilization impacts by using randomization to PIM as an instrument for number of PIM 
encounters.  Instrumental Variable models will use the two-staged least squares estimator.   
Other Outcome Measures 
Functional Status, Quality of life, Symptom Burden 
Standardized assessments of symptom burden (mental health and physical health), quality of 
life, and functional status (physical, social, and mental) will be based on patient-reported 
outcomes measurement information system (PROMIS) global items. These measures will be 
obtained only on the innovation patients and entered into the electronic medical record using a 
standardized assessment template available only to the demonstration staff. Some 
standardized assessments are available on the entire sample as part of VHA medical records 
(i.e., pain score, Patient Health Questionnaire (PHQ)-2 for depression) and performance 
measures. 
Implementation Outcome/challenges  
Sample selection/ recruitment 
The investigators will interview PIM staff about implementation challenges and lessons. The 
investigators will use PIM staffing lists from the demonstration sites to compile the sampling 
frame. The investigators will include in the sampling frame the team leaders, team members, 
and program coordinators. The investigators will select all PIM team leads and program 
coordinators (if the site has a coordinator), and randomly select 1 of each job title/role from the 
PIM team members. Team members who refuse or are ineligible will be replaced by randomly 
selecting another person in the same job title/role, until one completed interview is obtained 
for each job title/role for each site. Team members will include RNs, NPs, MDs, social workers, 
psychologists, and intermediate care technicians. The investigators will invite 35 potential 
respondents by email, and follow up by telephone and using instant messaging for those who 
do not respond to the initial email.  
With approval from site and program leadership, stakeholders will be sent an email describing 
the interviews and inviting them to participate. If stakeholders do not respond to the invitation 
email within 2-3 business days, the investigators will follow up by either phone, instant 
message, or additional emails. Methods of communication will be determined by available 
contact information and perceived individual stakeholder preferences. The investigators will 
make 3 follow-up contact attempts. 

Instrument Development 
Two qualitative team members drew on the Consolidated Framework for Implementation 
Research (CFIR) and chronic care model to develop the interview guides. The interviews are 
designed to take approximately 30 minutes, except the program lead interviews which are 
approximately 60 minutes. Interview guides will be refined through piloting and consultation 
with PIM and evaluation team clinicians. 
Procedures 
Interviews will be conducted by telephone.  The investigators will analyze the transcripts of 
these interviews thematically, guided by the Consolidated Framework for Implementation 
Research and the Chronic Care Model. 
Analysis 
All interviews will be audio recorded. Audio recordings of the interviews will be transcribed in 
full. Summaries will be created from the transcripts, or directly from the audio recordings, using 
standardized templates based on the interview guides, with additional sections included for 
recording good quotes, emergent themes, and analyst observations. The summarized data will 
then be organized into Excel matrices to facilitate within and across site comparisons.  
The substantive findings from these comparisons will be disseminated to the evaluation team, 
the PIM sites, and to VA central office via Powerpoint presentations and written reports, 
providing a richly detailed record of stakeholders’ perceptions of the PIM pilot project and PIM 
program activities and providing timely and specific formative feedback that will be used to 
shape and improve PIM. 
Primary Care Staff Job Satisfaction and Intention to Stay at the VA.  
Sample 
The investigators will survey all Primary Care Providers (PCPs) (physicians, MDs/DOs; nurse 
practitioners, NPs; physician assistants, PAs) and nurses (registered nurses, RNs; licensed 
practical nurses, LPNs; licensed vocational nurses-LVNs) at the five healthcare systems that 
have a PIM team.  
Method 
The investigators will use both online using RedCap and paper-and-pen versions of the survey 
to increase response rate. The investigators will survey Primary Care staff at baseline and one 
year later.  The first survey will be fielded December 2014 - May 2015 and again from October 
2016 - January 2017).  

 Analysis 
Longitudinal cohort of staff who responds to both Wave 1 and Wave 2. The investigators will 
use ordinary least squares regression analysis to examine associations between the 
independent variable measured at wave 1 and outcome variables measured at wave 2 
controlling for wave 1 outcomes among staff who completed both waves. The investigators will 
focus on Job Satisfaction and Intention to Stay at VA as dependent variables. The investigator 
will adjust for provider-level covariates (type of staff, location, type of primary care team, 
gender, length of time at VA) and clustering of respondents within clinics assuming a random 
effect using robust standard errors. The investigators will use sample weighting for 
nonresponse based on provider characteristics in both waves and conduct multiple imputations 
for item-level missing data; 
Difference-in-differences between Wave 1 and Wave 2: will treat Wave 1 and Wave 2 as two 
independent samples and use difference-in-difference regression analysis to assess differences 
in outcome variables between Wave 1 and Wave 2 among PIM and usual care. The 
investigators will focus on primary care staff experience (e.g., stress, satisfaction with help 
received) working with high-risk patients as dependent variables. The investigators will adjust 
for covariates (type of staff, location, type of primary care team, gender, length of time at VA). 
The investigators will use sample weighting for nonresponse based on provider characteristics 
in both waves. 
 
 
Wang, L., Porter, B., Maynard, C., Evans, G., Bryson, C., Sun, H., . . . Fihn, S. D. (2013). Predicting risk of 
hospitalization or death among patients receiving primary care in the Veterans Health 
Administration. Med Care, 51(4), 368-373. doi:10.1097/MLR.0b013e31827da95a 
Yoon, J., Scott, J. Y., Phibbs, C. S., & Wagner, T. H. (2011). Recent trends in Veterans Affairs chronic 
condition spending. Popul Health Manag, 14(6), 293-298. doi:10.1089/pop.2010.0079