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| Name | Class |
|---|---|
| VA Office of Research and Development | FED |
| VA Palo Alto Health Care System | FED |
| US Department of Veterans Affairs | FED |
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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:
Objectives:
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Intervention--PACT Intensive Management | Experimental | 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. |
|
| Usual care | No Intervention | High-Risk patients receiving care in PACT. |
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| PACT Intensive Management | Behavioral | 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:
Objectives:
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| 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) |
| 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) |
| Measure | Description | Time Frame |
|---|---|---|
| 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) |
Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Evelyn Chang, MD | VAGLAHS- WLA | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| VAGLAHS | Los Angeles | California | 90073 | United States |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 39075268 | Derived | Chang ET, Huynh A, Yoo C, Yoon J, Zulman DM, Ong MK, Klein M, Eng J, Roy S, Stockdale SE, Jimenez EE, Denietolis A, Needleman J, Asch SM; PACT Intensive Management (PIM) Demonstration Sites, PIM National Evaluation Center, and PIM Executive Committee. Impact of Referring High-Risk Patients to Intensive Outpatient Primary Care Services: A Propensity Score-Matched Analysis. J Gen Intern Med. 2025 Feb;40(3):637-646. doi: 10.1007/s11606-024-08923-3. Epub 2024 Jul 29. |
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| Type | Includes Protocol | Includes SAP | Includes ICF | Document Label | Document Date | Document Uploaded Date | Document File Name |
|---|---|---|---|---|---|---|---|
| Prot | Yes | No | No | Study Protocol | Jul 8, 2020 | Jul 8, 2020 | Prot_000.pdf |
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| 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) |
| 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) | 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) | 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) | 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:
| 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. | 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. | 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. | 2 years (two 1-year points) |
| Cognitive Status | The Blessed-Short and/or the Mini-Cog where the lower the score the more impairment. | 2 years (two 1-year points) |
| Pain level | Pain in past 24 hours on scale of 0 = no pain, to 10 = worst pain imaginable. | 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. | 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. | 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. | 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. | 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 | 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 | 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 | 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 | 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 | 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 | 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?
| 2 years (two 1-year points) |
| Patient Satisfaction- overall provider | is the best provider possible, what number would you use to rate this provider?
| 2 years (two 1-year points) |