Clinical trial NCT04521816: PIM 2.0: Patient Aligned Care Team (PACT) Intensive Management (PIM) Project
Official title: PIM 2.0: Patient Aligned Care Team (PACT) Intensive Management (PIM) Project
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Primary Health Care
Health Care Costs
Keywords: High-Risk Patients, Complex patients
Lead sponsor: Veteran Affairs Office of Patient Care Services
Sponsor class: FED
Collaborators: name: VA Office of Research and Development
name: VA Palo Alto Health Care System
name: US Department of Veterans Affairs
First posted: 2020-08-21
Enrollment: 599
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: NON_RANDOMIZED
Intervention model: PARALLEL
Primary purpose: HEALTH_SERVICES_RESEARCH

Brief summary: 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


Eligibility criteria: Inclusion Criteria:

* Refered for intensive management

Exclusion Criteria:

* None

Primary outcomes:
measure: VA health care cost
timeFrame: 2 years (two 1-year points)
Secondary outcomes:
measure: Healthcare Utilization
timeFrame: 2 years (two 1-year points)
measure: Total Medicare Cost
timeFrame: 2 years (two 1-year points)
measure: Total Medicare Utilization
timeFrame: 2 years (two 1-year points)
Other outcomes:
measure: Functional status- General
timeFrame: 2 years (two 1-year points)
measure: Functional Status- Social
timeFrame: 2 years (two 1-year points)
measure: Functional status- ADLS
timeFrame: 2 years (two 1-year points)
measure: Functional status- IDLS
timeFrame: 2 years (two 1-year points)
measure: Patient Quality of Life Status
timeFrame: 2 years (two 1-year points)
measure: Patient Symptom Burden
timeFrame: 2 years (two 1-year points)
measure: Anxiety
timeFrame: 2 years (two 1-year points)
measure: Substance Abuse
timeFrame: 2 years (two 1-year points)
measure: Cognitive Status
timeFrame: 2 years (two 1-year points)
measure: Pain level
timeFrame: 2 years (two 1-year points)
measure: Shortness of Breath
timeFrame: 2 years (two 1-year points)
measure: Problems with constipation
timeFrame: 2 years (two 1-year points)
measure: Sleep Problems
timeFrame: 2 years (two 1-year points)
measure: Level of Fatigue
timeFrame: 2 years (two 1-year points)
measure: Risk of Falls
timeFrame: 2 years (two 1-year points)
measure: Patient Satisfaction-Trust
timeFrame: 2 years (two 1-year points)
measure: Patient Satisfaction- Care Coordination
timeFrame: 2 years (two 1-year points)
measure: Patient Satisfaction- Access
timeFrame: 2 years (two 1-year points)
measure: Patient Satisfaction- Goals
timeFrame: 2 years (two 1-year points)
measure: Patient Satisfaction- Help with Barriers
timeFrame: 2 years (two 1-year points)
measure: Patient Satisfaction- overall facility
timeFrame: 2 years (two 1-year points)
measure: Patient Satisfaction- overall provider
timeFrame: 2 years (two 1-year points)
Locations:
city: Los Angeles
country: United States
facility: VAGLAHS
state: California
Study officials:
affiliation: VAGLAHS- WLA
name: Evelyn Chang, MD
role: PRINCIPAL_INVESTIGATOR
References: