Lead/Presenter: S. Nicole Hastings, COIN - Durham
All Authors: Hastings SN (Durham VA Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Duke University School of Medicine), Smith VA (Durham VA Center of Innovation ADAPT, Duke University School of Medicine) Lindquist J (Durham VA Center of Innovation ADAPT) Stanwyck C (Durham VA Center of Innovation ADAPT) Perfect C (Duke University School of Medicine) Seidenfeld J (Durham VA Center of Innovation ADAPT, Duke University School of Medicine) Van Houtven CH (Durham VA Center of Innovation ADAPT, Duke University School of Medicine)
Objectives:
Geriatric Patient Aligned Care Teams, or GeriPACTs, provide comprehensive primary care combined with specialty expertise for older Veterans with a goal of promoting independence and quality of life. To guide VHA’s optimal investment in GeriPACTs, it is essential to understand how GeriPACT differs from VA’s traditional primary care medical home (PACT). Therefore, in this study we examine how key quality of care (QOC) and quality of life (QOL) measures differ when a patient moves from usual care, in PACT, to GeriPACT.
Methods:
In this prospective cohort study, we used matching to guide enrollment of GeriPACT-PACT dyads across 57 VA medical centers. Matching variables were derived from EHR data in the pre-exposure period. They included a rich set of factors known to drive entry into GeriPACT (e.g. age, dementia diagnoses, prior utilization). QOC measures included rates of completed advance directives, falls screening, incontinence screening, and functional status assessment within 18 months of the first GeriPACT or PACT visit during the exposure period. QOC outcomes were assessed using logistic regression adjusted for control variables drawn from EHR data in the pre-exposure period, and from a baseline survey conducted at the time of enrollment. The QOL measure was home time, defined as days not in an emergency department, hospital, or nursing home over pre-exposure, exposure, and 18-month post-exposure periods. Home time was assessed using a negative binomial model adjusted for patient-level clustering to account for repeated measures and similar control variables.
Results:
We enrolled 275 dyads in near real-time, with a median time of 7 days between enrolling a GeriPACT patient and a matched PACT patient. Standardized mean differences were < 0.2 among nearly all baseline variables, indicating excellent balance in characteristics such as age (mean age 81 GeriPACT and 79 PACT), race (12.4% Black race in both groups), medical complexity (mean Care Assessment Need scores 49.4 GeriPACT and 53.1 PACT), and frailty (mean Jen Frailty Index 4.0 GeriPACT and 3.9 PACT). In adjusted models for the QOC measures, GeriPACT was associated with higher odds of completed assessment for falls (Odds Ratio (OR) 2.86; 1.6-5), incontinence (OR 2.7; 1.7-4.4), and function (OR 4.12; 2.4-7.1) and modestly associated with higher odds of completed advance directive (OR 2.1; 0.96-4.6). In adjusted models for the QOL measure, there were no differences in rate of home time among GeriPACT vs PACT patients in the pre-exposure (Rate Ratio (RR) 1.17; 0.7-1.9), exposure (RR 1.04; 0.7-1.6), or post-exposure (RR 0.99; 0.6-1.6) time periods.
Implications:
Using matching to guide enrollment and construct a high-quality comparison group was a successful approach to prospectively evaluate the effects of a program when randomization was not feasible. In this study older Veterans who transitioned care to a specialized geriatrics primary care clinic experienced improved QOC metrics, but no improvements in the QOL measure of home time.
Impacts:
Further investment in GeriPACTs can be expected to improve QOC for older adults. Evaluation of patient-reported outcomes and a longer time horizon are needed to fully understand how well GeriPACTs are helping Veterans achieve greater independence and quality of life.