Care Assessment Need (CAN) Score and the Patient Care 

Assessment System (PCAS): Tools for Care Management

Stephan Fihn MD MPH

Tami Box PhD

Office of Informatics and Analytics

Veterans Health Administration

June 27, 2013
VETERANS HEALTH ADMINISTRATION

VA’s Health Care Delivery Model

 Personalized, Proactive and Patient-Driven

 Team Care

 Continuous Improvement

 Data-Driven, Evidence-Based

 Value

 Prevention / Population Health

⇒ Coordinated Care
VETERANS HEALTH ADMINISTRATION

Goal: Enhance Quality & Eliminate Unnecessary, 

Unplanned Care
VETERANS HEALTH ADMINISTRATION

Top 10 VHA Discharge Diagnoses 2008

• Affective psychoses

• Heart Failure

• Chronic ischemic heart disease 

• Respiratory symptoms/other chest sx

• Pneumonia

• Cardiac dysrhythmias

• Schizophrenic disorders

• Chronic bronchitis

• Alcohol dependence

• General symptoms

4 

(Maynard and Fihn, Internet Journal Epi 2010)
VETERANS HEALTH ADMINISTRATION

Broad range 

of clinical 

programs 

designed 

improve 

care for 

veterans 

with 

complex 

chronic 

illness

Home-based 

primary care

Casemanagement

Specialty 

clinics, e.g., 

heart failure

Telehealth

Palliative care

Knowledge of a patient’s risk of adverse event 

can help target services 

Providers can’t accurately 

predict Veterans at highest 

risk of deterioration

PACT RN Care Managers 

charged to coordinate care 

No systematic way to identify 

Veterans who might benefit 

most  predictive analytics 

using data from EHR 
VETERANS HEALTH ADMINISTRATION

• Patient characteristics

– Demographics – age, priority level

– Coexisting conditions – Deyo/Charlson score, HCCs

– Vital signs

– Utilization – inpatient and outpatient

– Pharmacy

– Lab values

• Outcomes occurring in subsequent yr. 

– Readmissions, deaths, either at 30, 60, 90 days & 1 yr

• Conjoint modeling admission and death using polytomous

(multinomial) logistic regression

Modeling Strategy 
VETERANS HEALTH ADMINISTRATION

Model Terms

1. Demographics Diabetes Recent Admission Bumetanide/ Torsemide

 Age (≥65) Liver disease BDOC (1-10 vs 0) Thiazides

 Sex Malnutrition No. providers (>3) CCB 

 Marital status Dementia 4. Vital Signs Digoxin

 Svc . Conn. ≥50% Functional disease Sys & Dias BP Furosemide

2. Chronic Illness Metastatic Cancer Heart rate (>85) Insulin

 Deyo-Charlson Trauma Resp. rate (≥20) Metolazone

 HCCs Psych disease BMI (<25) Metformin

 MI/UA/CABG PTSD 5. Pharmacy Nitrate-long acting

 Valvular dis. Depression Total # refills (>0 ) Opioids

 Resp. failure 3. Utilization ACEI/ARB NSAIDS

 HTN Outpt visits(>4) Alpha-blocker Lipid lowering drugs

 Stroke PC visits (>1) Nebulized drugs P-par-gamma-agonists 

 Renal Failure Cardiology visits Antiplatelet drugs K+ sparing diuretic 

 COPD Pulmonary visits Anti-depressants Oral steroids

 Atrial fib. Mental health visits Antipsychotics Warfarin

 ASPVD ER visits (>1 lst yr) Benzodiazepine 6. Interactions

Pneumonia Other visits (>3) Beta-blockers 18 interaction terms

 RRR ≤0.8 or RRR ≥1.5 (adm); RRR ≤0.8 or RRR≥1.5 (death); RRR ≤0.8 or RRR ≥1.5 (both)
VETERANS HEALTH ADMINISTRATION
VETERANS HEALTH ADMINISTRATION

Care Assessment Need (CAN) Score

• Reflects estimated probability of admission or 

death within a specified time period (90 days 

or 1 year)

• Expressed as a percentile, ranging from 0 

(lowest risk) to 99 (highest risk)

• Indicates how a given Veteran compares with 

other individuals in terms of likelihood of 

hospitalization or death

9 
VETERANS HEALTH ADMINISTRATION

Predicted and Observed Likelihood of Death/Admission 

4,505,501 primary care patients

10

C=0.87

C=0.83

C=0.81

C=0.85

C=0.81

C=0.79

Wang, et al. Med Care. 

2013;51:368-73. 
11

95th %ile – 39%

96th %ile – 42%

97th %ile -- 49%

98th %ile -- 57%

99th %ile -- 72%

Patients in highest percentile of risk 

have 62% probability of admission, 

30% probability of death, and 72% 

probability of either event
VETERANS HEALTH ADMINISTRATION

Comparison with other models

expected risk of death or 

unplanned readmission within 30d

Readmission model for 10,946 pts 

disch home from general medicine 

svcs at 6 AMCs. Hason, et al. JGIM 

Dec 2009 (epub ahead of print)

“LACE” model tested on 1M randomly 

selected pts discharged from Ontario 

hospitals 2004-08 (C statistic =0.6935). 

Walraven et al CMAJ March 2010 (epub 

ahead of print)

observed risk
VETERANS HEALTH ADMINISTRATION

Use of High Level Analytic Data for Population 

Management and Resource Planning

Dynamic 

Geospatial 

Mapping

1-yr likelihood 

of admission

1.86% - 5.93%

5.94% - 7.00%

7.01% - 7.97%

7.98% - 9.21%

9.22% - 16.99%

1-yr likelihood of admission or death

2.37% - 9.03%

9.04% - 10.01%

10.02% - 10.96%

10.97% - 12.18%

12.19% - 19.34%

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How to Access the CAN Score Report
VETERANS HEALTH ADMINISTRATION

Risk Data Updated Weekly

• About 1000 users monthly\ 

• Also reports can be developed using from 

Regional Data Warehouses
VETERANS HEALTH ADMINISTRATION

Marketing the CAN Score

• Available to all PCPs from EHR 

in Dec 2011 – “soft roll-out”

• Active roll-out in two VISNs

– VISN 4 – PC Collaborative

– VISN 17 – Live Broadcast 

(champion model)

• Broadcasts with live Q&A: 

primary care, nursing, VeHU

• Feedback to date – uniformly 

positive (some concerns about 

data overload)

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VETERANS HEALTH ADMINISTRATION

Marketing the CAN Score

• Encouraging Care Coordination

– all participants in the delivery of health services work cooperatively 

– facilitating access to care 

– right care in the right place at the right time

– shared responsibility

• Encouraging Care Management

– Linking patients with needed services, resources, and opportunities 

• Discouraging “misuse” of the score

– The score is not a performance measure to try to “improve”

– A high score does not indicate a pt is not receiving high quality of care

– A low score is not an indication to ignore a pt
VETERANS HEALTH ADMINISTRATION

Can CAN scores help? 

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After adjusting for age, sex, comorbidity, and mental 

health diagnoses, patients with CAN scores in the 

highest 10% who saw their assigned PCP for >60% of 

visits, were 10% less likely to die or be hospitalized than 

similar risk patients who did not see their PCP during 

the year before PACT implementation. Similar, but less 

pronounced association for high risk patients who saw 

their assigned PCP up to 60% of the time. 
VETERANS HEALTH ADMINISTRATION

High Number of Health Care 

Providers per Patient by CAN Score

19
VETERANS HEALTH ADMINISTRATION

High Number of Different Drugs per Patient by 

CAN Score
VETERANS HEALTH ADMINISTRATION

Mental Health Diagnoses according 

to CAN Score

21
VETERANS HEALTH ADMINISTRATION

Bed Days - Per Patient, Average
VETERANS HEALTH ADMINISTRATION

Few Patients with High Scores Referred to 

Coordination Programs: Telehealth, HBPC, 

Palliative Care, and Hospice

Palliative Care

Score ≥ 95 --1,353 of 241,917 total patients (0.6%)

Hospice

Score ≥ 95 -- 569 of 241,917 total patients (0.2%)
VETERANS HEALTH ADMINISTRATION

Total Patientss and Percentage with CAN 

Score ≥95 by Geographic Area
VETERANS HEALTH A

How might a care manager or 

provider use the tool?

Scan list of pts weekly to identify those who may be 

at high risk

Call high risk patients to check in: are questions 

answered? are medications taken as prescribed?

Confirm that high risk pts have visits coming up soon

Ensure that high risk patients are on appropriate 

medical therapy

Review resources already in use, such as telehealth 

DMoI

r s NISTRpAeTIcOialt N y care
VETERANS HEALTH ADMINISTRATION

Feedback – 6-19-13 

“Attached is the PP created for local executive leadership, to gain their buy-in and 

support, which we have fully received. I am beginning to educate frontline staff 

on this structured framework so they can better understand the importance of 

risk stratification. This education allows them to begin connecting the dots of 

the different settings, how they impact the continuum of care, and how we can 

better serve our Veterans together, especially those suffering from chronic 

diseases. So far I have received positive feedback from frontline staff and 

leadership. Our Home Telehealth program has begun utilizing the CANS to ‘pull’ 

their Veterans into the program, rather than waiting for Veterans to be ‘pushed’ 

into the program. The PACT teams utilize the CANS for specifically for patient 

selection for shared medical appointments. Several PACT teams also crossreference the CANS with the DataMart database for patient selection of chronic 

disease management protocols. 

26
VETERANS HEALTH ADMINISTRATION

...continued

We plan to implement the CANS in Specialty Clinic and Case Management 

over the next year. We are currently developing and expanding these two 

areas to center our care around Veterans actively suffering from chronic 

diseases by establishing a partnership to assist and guide Veterans with selfmanagement. Case Managers are currently developing inclusion and 

exclusion criteria for their newly developed case management programs, and 

will include the CANS as a criteria point to consider when 

consulted. Specialty Clinic will utilize CANS for patient selection in shared 

medical appointments and chronic disease management protocol, similar to 

PACT. .... The CANS is the missing link, as we previously had no method to 

stratify the patient panel, to identify those high-utilizers, high-cost 

Veterans. Now with the CANS we can better serve our Veterans suffering 

from chronic diseases in a more efficient, ideal method. 

Nurse Manager, Specialty & Case Management

27
VETERANS HEALTH ADMINISTRATION

Problems/ Limitations

• Processing requirements  recoding production 

process, enhancement of analytic environment

• Model performance monitoring/degradation 

recalibration, updating

• Plateau in use and uncertainty about how being used 

 PCAS, evaluation

• Generic issues with development and deployment of 

predictive models

28
VETERANS HEALTH ADMINISTRATION

Patient Care Assessment System (PCAS)

• Integration of key data from 

multiple sources

• Summary of patient risk 

factors

• Task Lists and notifications

• Multiple VAMCs & 

Community info

• Ability to create a care plan 

and write it back to CPRS as 

a standardized note
VETERANS HEALTH ADMINISTRATION

Stephen Anderson MS Betsy Lancaster MS

Tami Box Shawn Loftus

Chris Bryson, MD MPH Elliot Lowy PhD

Dean Delventhal Charles Maynard PhD

Stephan Fihn MD MPH Mary McDonell MS

Kathleen Frisbee PhC Chris Nielson MD

Brian Gillespie Clare Reda PhD

Toni King Haili Sun PhD

Fred Kirkland Li Wang MS

Steve Krysiak

Project Team

30
PATIENT CARE ASSESSMENT SYSTEM

A tool to identify, manage, and coordinate patient care.

Tamara L. Box, PhD

Office of Analytics and 

Business Intelligence,

VHA OFFICE OF INFORMATICS 

AND ANALYTICS
COORDINATE

6.5 Million Patients

High Risk Patients

IDENTIFY

MANAGE
Patient-Aligned Care Teams

• VHA Patient Care Services

• Initiative to support 

VHA’s Universal Health 

Care Services Plan to:

– Increase access

– Improve coordination and 

communication

– Enable better continuity of care
Patient-Aligned Care Teams

• Patient-centered care managed by primary care 

providers

• Clinical and non-clinical staff

• Patient have more active role
High Risk Patient Identification
OUR MISSION

The Patient Care Assessment System is a 

web-based application 

to provide 

Patient Aligned Care Teams (PACT) 

with 

tools to 

identify, manage, and coordinate care

for their paneled patients. 

Special emphasis is given to high risk patients. 
PCAS 

VISTA

CDW

CAN OTHERS

ADMIN

Patient Care Assessment System (PCAS)
Highly Desired Functionality

• Integration of key data from 

multiple sources

• Summary of patient risk 

factors

• Task Lists and notifications

• Multiple VAMCs & 

Community info

• Ability to create a care plan 

and write it back to CPRS as 

a standardized note
CAN PCAS

PRIMARY 

AUDIENCE 

PACT PROVIDERS PACT RN CARE 

MANAGERS

ROLE CAN Scores 

Key risk data

Dashboard format

CAN Scores

Key risk data

PACT Team 

Management 

Patient and Team 

Notifications

Clinical data

Care planning

Tools for Identifying and Coordinating Care
Quick Poll

If you are involved in the VA Patient Aligned Care 

Teams, what do you feel is the most challenging aspect 

of patient care?

A. Nothing – it’s a breeze!

B. With very large panels, understanding where to 

focus daily care/effort.

C. Knowing what services are available for my patients.

D. Coordinating care and care tasks for patients as a 

team. 
Patient Care Assessment System
Patient Care Assessment System
Patient Care Assessment System Help

Risk Characteristics

Patient Demographics

Team Information

Discharges

Encounters

Diagnosis List

Clinical Data

Medications

Consults

Tasks/Notifications

Username / Clinic Location [ROLE]
Help

RISK INDICATORS

CAN Scores (all models; 0-99) 

CAN Score Graph Over Time

Clinical Priority (0-10) 

Manual High Risk Flag

Risk Type

Patient Care Assessment System Username / Clinic Location [ROLE]

• Statistical High Risk

• High Intensity Medical 

Management 

• Suicide Risk

• Homeless 

• Frequent ER User

• Polypharmacy

• Frequent PCP Visits

• Frequent Admissions

• Medication NonAdherence (MUET)

• OID/OIF/OND High Risk
Patient Care Assessment System Username / Clinic Location [ROLE] Help

KEY CLINICAL & COST RISK FACTORS

(past 12 mos) 

Number of ER Visits

Number of Discharges

DSS Cost

National BDOC

Fee Cost

VERA Classifications

Polypharmacy

Pain Scale
Patient Care Assessment System Help

CARE & CASE MANAGEMENT

High-Level Primary Care Management

Primary Care RN Case Manager

Primary Care MSW Case Manager

Other Case Manager Activity

Username / Clinic Location [ROLE]
Help

TEAM MANAGEMENT

All PCMM Team Members – any location

Expanded Team Members

Home/Community Providers

Patient Care Assessment System Username / Clinic Location [ROLE]
Patient Care Assessment System Username / Clinic Location [ROLE] Help

Diagnosis List

10 Most Recent (last 24 months)

Major Category Diagnosis Diagnosis Date

DIAGNOSIS LIST

10 Most Recent (last 24 months)
Patient Care Assessment System Username / Clinic Location [ROLE] Help

CLINICAL DATA

Immunizations (last 2 years)

Lab Values (with extended filter capability)

Community Labs
Patient Care Assessment System Help

ENCOUNTERS

Date

Provider Name

Type

Facility

Clinic Name

Stop Code

Diagnosis

Username / Clinic Location [ROLE]

Encounters

10 Most Recent

Scheduled 

Date

Encounter 

With 

Encounter

Type

Facility Clinic

Name

Primary

Stop Code

Diagnosis
Help

TASKS & NOTIFICATIONS

Team & patient-related 

Scheduling

Reminders

Priorities

Historical Tracking

Patient Care Assessment System Username / Clinic Location [ROLE]
Patient Care Assessment System Username / Clinic Location [ROLE] Help

CONSULT TRACKING

Full Panel Overview 

Search/filter – date range, patient, status

Per-Patient Consult Report

Per-Consult Details
Patient Care Assessment System Help

CARE PLANNING

Situation/Background

Learning Preferences

Assessment/Goals 

Planning/Implementing

Evaluation & Monitoring/Plan Update

PACT Interdisciplinary Care Plan Note

PACT RN Care Manager Note

Username / Clinic Location [ROLE]
Patient Care Assessment System Help

ASSESSMENT & GOALS

Case Management Report

Problem Identification

Functional Status Assessments

Username / Clinic Location [ROLE]
PLANNING & IMPLEMENTING

VA Case Management Services

Home/Community Services

Patient Care Assessment System Username / Clinic Location [ROLE] Help
Patient Care Assessment System Help

PACT Interdisciplinary Care Plan Note

Dynamically created

Include specific Care Plan sections if changed

Include any option patient information

Username / Clinic Location [ROLE]
Patient Care Assessment System Username / Clinic Location [ROLE] Help

QUERY FUNCTIONALITY

Appointment Range

Risk Types

Risk Categories

Care Plan Evaluation
Patient Care Assessment System Help

Nationally-Standardized Reports

Clinic Overall Summary

Case Management

Upcoming PC Appointments

Intensive Care Management

Functional Status Trends

Open Consults

MY REPORTS

Standardized Ad Hoc #1

Standardized Ad Hoc #2

Username / Clinic Location [ROLE]
PCAS Functionality and Release Schedule

RELEASE

highly desired 

FUNCTIONALITY

implementation

GOAL

1.0

ONGOING 

Pilot

Site

review 

initiated 

09. 

2012. 

• Infrastructure 

• PACT Team management

• Administrative access 

management module

• Panel overview

• Consults

• Patient demographics & 

contacts

• Risk characteristics 

(including CAN)

IDENTIFY 

1. National

awareness of 

PCAS

2. Manage PACT 

teams 

3. Identify highest 

risk patients

4. Track consults
PCAS Functionality and Release Schedule

RELEASE

highly desired 

FUNCTIONALITY

implementation

GOAL

2.0* 

To pilot 

07.2013 

• Outpatient encounters

• Discharge summaries 

• Care management tasks 

and notifications

• Query functionality

MANAGE

Adoption for tasks 

and notifications
PCAS Functionality and Release Schedule

RELEASE

highly desired 

FUNCTIONALITY

implementation

GOAL

3.0 • Medications

• Problem lists

• Additional clinical and 

vitals data

• Legal documents

MANAGE

Establish routine 

tasks for patient 

management to 

facilitate 

implementation of 

care planning
RELEASE

highly desired 

FUNCTIONALITY

implementation

GOAL

4.0 • CARE PLANNING

Service (VA and 

community-based) 

administration

COORDINATE

Adoption of care 

planning

5.0 • CARE PLAN NOTES

Advanced reports and 

query

• Additional community 

integration (where 

possible)

COORDINATE

Full use of PCAS 

for PACT care plan 

documentation

PCAS Functionality and Release Schedule
Ongoing Evaluation

• Implementation 

• Standards of care

• High risk ambulatory 

patient evaluation

• Primary Care Services

• Office of Nursing Services
Ongoing Evaluation

PILOT SITE EVALUATION SUPPORT

• Implementation 

• Standards of care

• High risk ambulatory 

patient evaluation

• Team-Based Care vs

Episodic Care

• Workflow Patterns

• Bugs/Issues/Suggestions! 
TEAM

• Steve Krysiak

• Sophie Lo

• Indra Gupta

• Dean Delventhal

• SP Thakur

• Fred Kirkland

• Shawn Loftus

• Elliot Lowy, PhD

• Charles Maynard, PhD

• Haili Sun, PhD

• Li Wang, MS

• PACT Nurse and Provider 

Members of 

Requirements Team

• Stephen Anderson, MS

• Tamara Box, PhD

• Chris Bryson, MD MPH

• Stephan Fihn, MD MPH

• Kathleen Frisbee

• Betsy Lancaster, MS

• Toni King

• Mary McDonell, MS

• Chris Nielson, MD
THANK YOU

Tamara L. Box, PhD (Tami)

Tamara.Box@va.gov