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.

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)
• 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)
• Administer Katz Index of Independence in Activities of Daily Living (Independence=1 point; dependence = 0 points for each of the six item pairs)
• Administer the Lawton Instrumental Activities of Daily Living (IADL) Scale (score 0-8)

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

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.

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.

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.

The Blessed-Short and/or the Mini-Cog where the lower the score the more impairment.

Pain in past 24 hours on scale of 0 = no pain, to 10 = worst pain imaginable.

Shortness of breath in past 24 hours on a scale of 0, no shortness of breath, to 10, worst imaginable.

Constipation in past 24 hours on a scale from 0, no constipation, to 10, worst imaginable.

Sleep problems in past 24 hours on a scale from 0, no sleep problems, to 10, worst imaginable.

Fatigue in past 24 hours on a scale from 0, no fatigue, to 10, worst imaginable.

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

Implementation barriers and facilitators, feasibility, and sustainability will be obtained through stakeholder interviews of patients, staff and facility leaders. PIM Staff topics include program goals, patient enrollment, engagement strategies, patient decision making; target population, gaps in care, care coordination, readiness, resource adequacy, and sustainability. PIM program leader topics include lessons learned, impact and sustainability, and implementation process. Patient topics include experience in program, engagement in care and suggestions for improvement. PACT teamlet topics include exposure to PIM, the impact on workload, the services PIM provides, feasibility of providing PIM services, impact and sustainability of PACT on working with PIM team. Facility leaders topics include PIM program goals, specialty service programs, target population, and services for high-risk patients, PACT functioning, PIM affects patients on services, and facility.

We 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. We will use both online using RedCap and paper-and-pen versions of the survey to increase response rate. We will survey Primary Care staff at baseline and one year later. 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. (Strongly disagree, Disagree, Neither agree nor disagree, Agree, Strongly agree). The higher the score the higher the satisfaction.

• Overall, I am satisfied with my job. (Strongly disagree, Disagree, Neither agree nor disagree, Agree, Strongly agree). The higher the score the higher the satisfaction.

We 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. We will use both online using RedCap and paper-and-pen versions of the survey to increase response rate. We will survey Primary Care staff at baseline and one year later. 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. (Strongly disagree, Disagree, Neither agree nor disagree, Agree, Strongly agree). The higher the score the higher the satisfaction.