BACKGROUND/RATIONALE:
A Geriatric Patient Aligned Care Team (GeriPACT) is a "Special Population PACT" designed to provide comprehensive primary care combined with specialty expertise for complex geriatric and high-risk Veterans. GeriPACT integrates and coordinates traditional ambulatory health care services with a variety of community-based services to optimize independence, quality of life, and quality of care for Veterans who are particularly vulnerable due to multiple interacting cognitive, functional, psychosocial, and medical challenges in the setting of advanced age. Currently, there is a lack of essential information about how GeriPACT differs from traditional PACT care in terms of clinical processes and patient experience of care, specifically what types of patients may benefit the most from this limited resource. PACT is fully implemented throughout VHA, therefore the question of highest impact is how quality and experience of care differ when a patient moves from usual care, in PACT, to GeriPACT.

OBJECTIVE(S):
The main objective of this study is to understand the impact of GeriPACT on patient experience and key quality of care clinical process measures that may be contributing to observed cost differences. In addition, we plan to evaluate three important sub-populations of interest, patients with cognitive impairment, functional disability, and multiple chronic conditions (MCCs), as we anticipate differences in care and improvements in outcomes may be largest in these groups. Using targeted recruiting strategies to increase homogeneity between GeriPACT and PACT patients, along with coarsened matching methods to derive a balanced sample, we will examine between-person changes between GeriPACT and PACT patients. Additionally, by combining data from a patient-reported survey and comprehensive VA electronic medical records (Corporate Data Warehouse and Computerized Patient Record System) we will minimize sources of bias that plague many comparative effectiveness studies. This prospective, matched comparative effectiveness study will (1) examine the quality of care among Veterans who transfer care to GeriPACT, compared to similar patients in traditional PACTs; (2) examine patient experience of care among Veterans who transfer care to GeriPACT, compared to similar patients in traditional PACTs; and, (3) examine whether the relationship between GeriPACT exposure and outcomes differs based on cognitive status, functional disability, or MCC.

METHODS:
This study will be a prospective, matched cohort design with an 18-month outcomes observation period. We will enroll 550 matched patients (225 in the GeriPACT arm and 225 in the PACT arm). Participants will be Veterans selected from VA Medical Centers nationally that offer established GeriPACTs.
In order to optimize homogeneity of the cohorts, we will apply sampling restrictions at both the patient and facility level. We focus on patients with at least 2 visits to GeriPACT and match on important pre-exposure health and utilization characteristics. In this way we are able to compare similar patients who either 1) transferred care to GeriPACT; or 2) continued to receive usual care in PACT.
To be included in the study, potentially eligible subjects from the matching pool must meet all inclusion / exclusion criteria, assessed via medical chart review and phone screening.
We will conduct computer-assisted telephone interviews (CATIs) at baseline and at 3 subsequent time points (6, 12, 18 months).
The primary outcome, days at home, is measured from administrative data over the full 18 month outcomes window. The 18 month time horizon allows for the clinical gains in days at home from GeriPACT to accrue before we would expect an impact on utilization. The frail elderly quality indicators are measured by chart review at 12 months because guidelines stipulate annual assessment. We measure the other outcomes longitudinally over 6 month intervals for 18 months because we expect them to be sensitive both in the short and the longer-term to the GeriPACT model of care.

FINDINGS/RESULTS:
No findings to date.

IMPACT:
This study will help determine how quality and experience of care differ when a veteran patient moves from usual care, in PACT, to GeriPACT. The study will also help decision-makers to guide appropriate resources towards GeriPACT, and inform decisions about the type of patients who will benefit most from GeriPACT care.

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External Links for this Project

NIH Reporter

Grant Number: I01HX002039-01A2
Link: https://reporter.nih.gov/project-details/9286441

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PUBLICATIONS:

Journal Articles

1. Smith VA, Van Houtven CH, Lindquist JH, Hastings SN. Evaluation of a geriatrics primary care model using prospective matching to guide enrollment. BMC medical research methodology. 2021 Aug 16; 21(1):167. [view]
2. Shepherd-Banigan M, Smith VA, Stechuchak KM, Van Houtven CH. Informal Caregiver Support Policies Change Use of Vocational Assistance Services for Individuals With Disabilities. Medical care research and review : MCRR. 2022 Apr 1; 79(2):218-232. [view]
3. Boucher NA, Zullig LL, Shepherd-Banigan M, Decosimo KP, Dadolf J, Choate A, Mahanna EP, Sperber NR, Wang V, Allen KA, Hastings SN, Van Houtven CH. Replicating an effective VA program to train and support family caregivers: a hybrid type III effectiveness-implementation design. BMC health services research. 2021 May 6; 21(1):430. [view]
4. Allen KD, Woolson S, Hoenig HM, Bongiorni D, Byrd J, Caves K, Hall KS, Heiderscheit B, Hodges NJ, Huffman KM, Morey MC, Ramasunder S, Severson H, Van Houtven C, Abbate LM, Coffman CJ. Stepped Exercise Program for Patients With Knee Osteoarthritis : A Randomized Controlled Trial. Annals of internal medicine. 2021 Mar 1; 174(3):298-307. [view]

DRA: Aging, Older Veterans' Health and Care
DRE: TRL - Applied/Translational, Treatment - Observational
Keywords: Comparative Effectiveness, Medication Management, Models of Care, Outcomes - Patient, Practice Patterns/Trends
MeSH Terms: none