1124 — Can VHA Improve Primary Care for High-Risk, High-Need Patients? Lessons Learned During Early Implementation of PACT Intensive Management Programs

Stockdale SE, HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy; Katz ML, HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy; Raja P, VA Greater Los Angeles Healthcare System; Chang E, VA Greater Los Angeles Healthcare System; Collier C, Ashville, NC VAMC; Zulman D, Palo Alto VAMC; Kirsh S, VACO, Primary Care Services; Rubenstein LV, HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy;

Objectives:
Despite promising outcomes for VHA's Patient Aligned Care Teams (PACT), challenges remain in configuring primary care resources for prevention of deteriorations in health among the complex, chronically ill patients who account for most hospitalization and emergency department use in VA. In 2013, Primary Care Services funded a five-site demonstration program and National Evaluation Center (NEC) to implement and evaluate PACT Intensive Management (PIM) for patients at highest risk for hospitalization. We describe implementation barriers and facilitators during early implementation.

Methods:
We collected information from the sites through 38 stakeholder interviews and PIM administrative reports spanning 18 months from funding through early care delivery experiences. Guided by the Consolidated Framework for Implementation Research and the Chronic Care Model, we conducted content analysis of the resulting qualitative data.

Results:
Comprised of interdisciplinary teams, 4 of the 5 PIM programs were designed to augment PACT, while 1 assumed primary care responsibility from the local PACT for a small panel. Pre-implementation challenges included lengthy hiring processes and inexperience implementing intensive care management programs. Early implementation barriers included defining team member roles/responsibilities, establishing procedures for workload credit, and understanding home visit regulations. Patient-related challenges included targeting appropriate patients, enrolling/engaging patients, and conducting comprehensive assessments. Cross-site sharing through weekly calls, implementation mentoring/support from NEC staff, IT and other logistical support from PCS, local leadership engagement, and team training mitigated many of the pre-implementation barriers. Strategies to address patient-related challenges included obtaining "buy-in" and warm hand-offs from PACTs and meeting patients at scheduled appointments or during hospitalization.

Implications:
Implementation of PACT intensive management programs was facilitated by early outreach to establish relationships with PACT providers, support from local interdisciplinary leadership to secure resources and address barriers to hiring staff, and collaboration with other local programs/services. Future evaluation results may suggest how existing resources can be harnessed to implement PIMs more widely.

Impacts:
Primary care settings face challenges in delivering the needed intensity of care for the very ill. Given the context-dependent nature of design and implementation, understanding barriers and facilitators will be important for wider VHA implementation of programs addressing this population.