An interventional study of PACT Intensive Management in Primary Health Care and Health Care Costs, sponsored by Veteran Affairs Office of Patient Care Services. Completed at 1 site in United States. Open to participants aged 18 Years and older. Per ClinicalTrials.gov, last updated 2020-08-21.
Sponsored by Veteran Affairs Office of Patient Care Services · Not applicable, Interventional, and Health services research
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:
Objectives:
Veteran Affairs Office of Patient Care Services is the lead sponsor of 3 studies on the registry; none are open to participants now.
Counted across the registry records on this site, refreshed daily.
Exclusion Criteria:
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
High-Risk patients receiving care in PACT.
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
Also known as: PIM
VA health care cost
Total costs of VA care, including inpatient, outpatient, pharmacy and fee-basis services.
Time frame: 2 years (two 1-year points)
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
Time frame: 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.
Time frame: 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.
Time frame: 2 years (two 1-year points)
Functional status- General
Patient report of their physical, social, and mental functional status is routinely collected as part of their medical visit as health factor data. The data will be abstracted through the VA central repository administrative data. The variables used to measure functional status are the following: •In general, please rate how well you carry out your usual social activities and roles. (This includes activities at home, at work and in your community, and responsibilities as a parent, child, spouse, employee, friend, etc.) (Excellent, Very good, Good, Fair, Poor)
Time frame: 2 years (two 1-year points)
Functional Status- Social
Patient report of their physical, social, and mental functional status is routinely collected as part of their medical visit as health factor data. The data will be abstracted through the VA central repository administrative data. The variables used to measure functional status are the following: •In general, how would you rate your satisfaction with your social activities and relationships? (Excellent, Very good, Good, Fair, Poor)
Time frame: 2 years (two 1-year points)
Functional status- ADLS
Patient report of their physical, social, and mental functional status is routinely collected as part of their medical visit as health factor data. The data will be abstracted through the VA central repository administrative data. The variables used to measure functional status are the following: •Administer Katz Index of Independence in Activities of Daily Living (Independence=1 point; dependence = 0 points for each of the six item pairs)
Time frame: 2 years (two 1-year points)
Functional status- IDLS
Patient report of their physical, social, and mental functional status is routinely collected as part of their medical visit as health factor data. The data will be abstracted through the VA central repository administrative data. The variables used to measure functional status are the following: •Administer the Lawton Instrumental Activities of Daily Living (IADL) Scale (score 0-8)
Time frame: 2 years (two 1-year points)
Patient Quality of Life Status
Patient assessment of their quality of life collected as part of their medical care as a health factor. This information will be electronically abstracted through the VA central repository administrative data center. The variables used to assess a patient's quality of life are the following: * Patient's self-rating of quality of life in general: Excellent, Very Good, Good, Fair, Poor * Patient's self-rating of mental health, including mood and ability to think: Excellent, Very Good, Good, Fair, Poor
Time frame: 2 years (two 1-year points)
Patient Symptom Burden
Patient assessment of symptom burden is routinely collected as part of their care and documented in their medical record and will be electronically abstracted through the VA central repository administrative data center. Mental Health and physical burdens are abstracted from the medical record utilizing ICD-9 and ICD-10 code. It will be assessed as yes/no if present.
Time frame: 2 years (two 1-year points)
Anxiety
Generalized Anxiety Disorder 2-item (GAD-2): (Not at all; several days; More than half the days, nearly every day). The higher the score the higher the anxiety.
Time frame: 2 years (two 1-year points)
Substance Abuse
The 3-item AUDIT-C scored on a scale of 0-12; Drugs: How many times in the past year, have you used an illegal drug or used a prescription medication for nonmedical reasons? (Yes/No, Number of times). The greater the score the worse the substance abuse status.
Time frame: 2 years (two 1-year points)
Cognitive Status
The Blessed-Short and/or the Mini-Cog where the lower the score the more impairment.
Time frame: 2 years (two 1-year points)
Pain level
Pain in past 24 hours on scale of 0 = no pain, to 10 = worst pain imaginable.
Time frame: 2 years (two 1-year points)
Shortness of Breath
Shortness of breath in past 24 hours on a scale of 0, no shortness of breath, to 10, worst imaginable.
Time frame: 2 years (two 1-year points)
Problems with constipation
Constipation in past 24 hours on a scale from 0, no constipation, to 10, worst imaginable.
Time frame: 2 years (two 1-year points)
Sleep Problems
Sleep problems in past 24 hours on a scale from 0, no sleep problems, to 10, worst imaginable.
Time frame: 2 years (two 1-year points)
Level of Fatigue
Fatigue in past 24 hours on a scale from 0, no fatigue, to 10, worst imaginable.
Time frame: 2 years (two 1-year points)
Risk of Falls
Falls (Patient reports no falls in past 12 months;Patient reports no problems with walking or balance; Patient reports problems with walking or balance; Patients reports falls in past 12 months
Time frame: 2 years (two 1-year points)
Patient Satisfaction-Trust
I have a VA healthcare provider who I can trust. 1: Very dissatisfied 2: Dissatisfied 3: Somewhat dissatisfied 4: Somewhat satisfied 5: Satisfied 6: Very satisfied
Time frame: 2 years (two 1-year points)
Patient Satisfaction- Care Coordination
I have a VA healthcare provider who helps coordinate my care from different doctors and services. 1: Very dissatisfied 2: Dissatisfied 3: Somewhat dissatisfied 4: Somewhat satisfied 5: Satisfied 6: Very satisfied
Time frame: 2 years (two 1-year points)
Patient Satisfaction- Access
I got the service I needed. 1: Very dissatisfied 2: Dissatisfied 3: Somewhat dissatisfied 4: Somewhat satisfied 5: Satisfied 6: Very satisfied
Time frame: 2 years (two 1-year points)
Patient Satisfaction- Goals
In the last 6 months, did someone at the VA talk with you about specific goals for your health. 1: Very dissatisfied 2: Dissatisfied 3: Somewhat dissatisfied 4: Somewhat satisfied 5: Satisfied 6: Very satisfied
Time frame: 2 years (two 1-year points)
Patient Satisfaction- Help with Barriers
In the last 6 months, did someone at the VA ask you if there are things that make it hard for you to take care of your health. 1: Very dissatisfied 2: Dissatisfied 3: Somewhat dissatisfied 4: Somewhat satisfied 5: Satisfied 6: Very satisfied
Time frame: 2 years (two 1-year points)
Patient Satisfaction- overall facility
Overall, how satisfied are you with the health care you have received at your VA facility? 1. Very dissatisfied 2. Dissatisfied 3. Somewhat dissatisfied 4. Somewhat satisfied 5. Satisfied 6. Very satisfied
Time frame: 2 years (two 1-year points)
Patient Satisfaction- overall provider
is the best provider possible, what number would you use to rate this provider? 1. Very dissatisfied 2. Dissatisfied 3. Somewhat dissatisfied 4. Somewhat satisfied 5. Satisfied 6. Very satisfied
Time frame: 2 years (two 1-year points)
Documents are hosted by the registry — open the source record to download them.
Plan to share: No
This study is completed, as verified in Aug 2020. You cannot join it, but the record below documents what was studied.
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Veteran Affairs Office of Patient Care Services