PIM 2.0: Patient Aligned Care Team (PACT) Intensive Management (PIM) Project

Study Overview
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Brief Summary
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Purpose: Implement a Patient Aligned Care Team (PACT) model that identifies and proactively manages Veterans at the highest risk for hospital admission and death while the patient is still in the ambulatory care setting. Goal: Reduce emergency department and urgent care utilization, hospitalization, and mortality in complex, high risk patients Improve Veteran and staff satisfaction Objectives: Maintain the patient in the home setting as much as possible Secure appropriate home environment to facilitate health and well-being Utilize comprehensive team-based care Engage appropriate Veteran Health Administration (VHA) programs to provide interdisciplinary, coordinated, and timely management of complex medical issues

Official Title
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PIM 2.0: Patient Aligned Care Team (PACT) Intensive Management (PIM) Project

Conditions
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Primary Health Care, Health Care Costs

Intervention / Treatment
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* Behavioral: PACT Intensive Management


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Refered for intensive management Exclusion Criteria: None

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Intervention--PACT Intensive Management<br>The intervention is the PACT Intensive Management Program (PIM) provides a standardized menu of services, ranging from chart review assessment or in-home assessment, to a time limited intensive care management intervention. The following PIM features are standardized across the PIM demonstration sites: A) Chart review assessment template in the EMR; B) Comprehensive assessment template of unmet needs and modifiable risk factors in EMR; C) Transitions in care process (eligibility criteria, clinical protocols); D) Diagnostic home visits process (eligibility criteria, clinical protocols); E) Core risk stratification/Triage process; F) Discharge criteria and note template in EMR; G) Standardized interdisciplinary team (IDT) meeting note procedure and template in EMR. | Behavioral: PACT Intensive Management<br>* Purpose: Implement a Patient Aligned Care Team (PACT) model that identifies and proactively manages Veterans at the highest risk for hospital admission and death while they are still in the ambulatory care setting. Goal: Reduce emergency department and urgent care utilization, hospitalization, and mortality in complex, high risk patients Improve Veteran and staff satisfaction Objectives: Maintain the patient in the home setting as much as possible Secure appropriate home environment to facilitate health and well-being Utilize comprehensive team-based care Engage appropriate VHA programs to provide interdisciplinary, coordinated, and timely management of complex medical issues<br>* Other names: PIM;|
| No Intervention: Usual care<br>High-Risk patients receiving care in PACT. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| VA health care cost | Total costs of VA care, including inpatient, outpatient, pharmacy and fee-basis services. | 2 years (two 1-year points) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| 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 | 2 years (two 1-year points) | 
| Total Medicare Cost | Data will be extracted from VHA's Corporate Data Warehouse to capture patient Medicare cost. Medicare claims data to measure total patient inpatient and outpatient cost for services reimbursed by Medicare. Inpatient cost will be measured as cost for total acute hospitalizations, and subcategories: medical, surgical, psychiatric, rehabilitation, hospice and ambulatory care-sensitive conditions. Outpatient cost will be measured as the cost for combined visits in VHA and elsewhere reimbursed by Medicare in 9 categories: primary care, specialty care, mental health, surgical, home health, nursing home, diagnostic, rehabilitation and ED. | 2 years (two 1-year points) | 
| Total Medicare Utilization | Data will be extracted from VHA's Corporate Data Warehouse to capture patient utilization. Medicare claims data to measure total patient inpatient and outpatient utilization for services reimbursed by Medicare. Inpatient utilization will be measured as counts of total acute hospitalizations, and subcategories: medical, surgical, psychiatric, rehabilitation, hospice and ambulatory care-sensitive conditions. Outpatient utilization will be measured as the number of combined visits in VHA and elsewhere reimbursed by Medicare in 9 categories: primary care, specialty care, mental health, surgical, home health, nursing home, diagnostic, rehabilitation and ED. | 2 years (two 1-year points) | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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High-Risk Patients, Complex patients