title: Effect of an Intensive Outpatient Program to Augment Primary Care for High-Need Veterans Affairs Patients: A Randomized Clinical Trial.
abstract: Many organizations are adopting intensive outpatient care programs for high-need patients, yet little is known about their effectiveness in integrated systems with established patient-centered medical homes.
  
  
  
  To evaluate how augmenting the Veterans Affairs (VA) medical home (Patient Aligned Care Teams [PACT]) with an Intensive Management program (ImPACT) influences high-need patients' costs, health care utilization, and experience.
  
  
  
  Randomized clinical trial at a single VA facility. Among 583 eligible high-need outpatients whose health care costs or hospitalization risk were in the top 5% for the facility, 150 were randomly selected for ImPACT; the remaining 433 received standard PACT care.
  
  
  
  The ImPACT multidisciplinary team addressed health care needs and quality of life through comprehensive patient assessments, intensive case management, care coordination, and social and recreational services.
  
  
  
  Primary difference-in-difference analyses examined changes in health care costs and acute and extended care utilization over a 16-month baseline and 17-month follow-up period. Secondary analyses estimated the intervention's effect on ImPACT participants (using randomization as an instrument) and for patients with key sociodemographic and clinical characteristics. ImPACT participants' satisfaction and activation levels were assessed using responses to quality improvement surveys administered at baseline and 6 months.
  
  
  
  Of 140 patients assigned to ImPACT, 96 (69%) engaged in the program (mean [SD] age, 68.3 [14.2] years; 89 [93%] male; mean [SD] number of chronic conditions, 10 [4]; 62 [65%] had a mental health diagnosis; 21 [22%] had a history of homelessness). After accounting for program costs, adjusted person-level monthly health care expenditures decreased similarly for ImPACT and PACT patients (difference-in-difference [SE] -$101 [$623]), as did acute and extended care utilization rates. Among respondents to the ImPACT follow-up survey (n = 54 [56% response rate]), 52 (96%) reported that they would recommend the program to others, and pre-post analyses revealed modest increases in satisfaction with VA care (mean [SD] increased from 2.90 [0.72] to 3.16 [0.60]; P = .04) and communication (mean [SD] increased from 2.99 [0.74] to 3.18 [0.60]; P = .03).
  
  
  
  Intensive outpatient care for high-need patients did not reduce acute care utilization or costs compared with standard VA care, although there were positive effects on experience among patients who participated. Implementing intensive outpatient care programs in integrated settings with well-established medical homes may not prevent hospitalizations or achieve substantial cost savings.
  
  
  
  clinicaltrials.gov Identifier: NCT02932228.
authors.affiliation: Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California2Division of General Medical Disciplines, Stanford University, Stanford, California3Medical Services, VA Palo Alto Health Care System, Palo Alto, California.
authors.forename: Donna M
authors.initials: DM
authors.lastname: Zulman
authors.affiliation: Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California4Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California.
authors.forename: Christine
authors.initials: C
authors.lastname: Pal Chee
authors.affiliation: Medical Services, VA Palo Alto Health Care System, Palo Alto, California5Chief of Staff Office, VA Palo Alto Health Care System, Palo Alto, California.
authors.forename: Stephen C
authors.initials: SC
authors.lastname: Ezeji-Okoye
authors.affiliation: Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California2Division of General Medical Disciplines, Stanford University, Stanford, California.
authors.forename: Jonathan G
authors.initials: JG
authors.lastname: Shaw
authors.affiliation: Stanford University Human Immune Monitoring Center, Institute for Immunity Transplantation and Infection, Stanford University, Stanford, California.
authors.forename: Tyson H
authors.initials: TH
authors.lastname: Holmes
authors.affiliation: Division of General Medical Disciplines, Stanford University, Stanford, California3Medical Services, VA Palo Alto Health Care System, Palo Alto, California.
authors.forename: James S
authors.initials: JS
authors.lastname: Kahn
authors.affiliation: Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California2Division of General Medical Disciplines, Stanford University, Stanford, California3Medical Services, VA Palo Alto Health Care System, Palo Alto, California.
authors.forename: Steven M
authors.initials: SM
authors.lastname: Asch
mesh_terms: D000328:Adult; D000368:Aged; D000553:Ambulatory Care / Q000191:economics / Q000458:organization & administration*; D017046:Cost Savings; D005260:Female; D006301:Health Services Needs and Demand; D006302:Health Services Research; D006801:Humans; D008297:Male; D008875:Middle Aged; D010348:Patient Care Team / Q000458:organization & administration*; D017060:Patient Satisfaction; D018802:Patient-Centered Care / Q000191:economics / Q000458:organization & administration*; D011320:Primary Health Care / Q000191:economics / Q000458:organization & administration*; D015397:Program Evaluation; D058996:Quality Improvement; D014481:United States; D014493:United States Department of Veterans Affairs; D014728:Veterans