Study Shows Impact of Evidence-based Quality Improvement Strategy on VA Patient-Aligned Care Team Implementation

BACKGROUND:
In 2010, VA began implementing the patient-centered medical home model of care via the Patient-Aligned Care Team (PACT) in more than 700 primary care sites. This was expected to result in better access to face-to-face care, more non-face-to-face care, better care coordination, and better mental healthcare access in primary care for Veterans. However, there was wide variability among practices in readiness and capacity to implement PACT features. Evidence-based quality improvement (EBQI) methods, which incorporate many elements of Lean and similar approaches, may facilitate practice redesign for more effective implementation of the PACT model. This longitudinal study assessed changes in VA healthcare utilization and costs for Veterans (n=136,856) from six practices in three different medical centers using an EBQI approach to implement PACT and 28 comparison practices over a five-year period (FY2009 to FY2013). Each EBQI practice established a primary care-based interdisciplinary quality council, with Veteran representation and a data savvy facilitator, to develop and implement quality improvement innovation projects. Study variables included the number of outpatient encounters, inpatient stays, and prescription fills, and the cost of care provided directly by VA in each study year.

FINDINGS:

• After PACT implementation, the overall use of primary care, specialty care, and mental health/substance abuse care decreased, while the use of telephone care increased.
• Decreased outpatient care use occurred more rapidly for VA practices that employed an EBQI approach to PACT implementation, including outpatient visits for primary care, specialty care, and mental health and substance abuse care that appeared to augment the effects of PACT.
• EBQI practice was significantly associated with a 15% reduction in primary care encounters over the study period. For specialty care, there was a 17% decrease in encounters associated with EBQI overall, but the rate of decrease slowed each year after the implementation of PACT.
• There was no significant effect of EBQI status on emergency department visits, all-cause hospitalizations, or prescription drugs.
• Total VA healthcare costs per patient decreased by 5% each year across all practices, but there was no effect of EBQI practice on costs.
• There also was no separate effect of EBQI on patient death rates.

LIMITATIONS:

• VA practices initiating EBQI were selected by local leadership.
• There may have been unmeasured characteristics of VA practices that led to successful uptake.

IMPLICATIONS:
EBQI is a promising implementation strategy that could be used to promote the scale-up and spread of best practices in VHA and beyond.

AUTHOR/FUNDING INFORMATION:
Drs. Yoon and Chow are part of HSR&D's Health Economics Resource Center (HERC) in Menlo Park, CA. Dr. Rubenstein is part of HSR&D's Center for Healthcare Innovation, Implementation and Policy (CSHIIP) in Los Angeles, CA.

Yoon J, Chow A, and Rubenstein L. Impact of Medical Home Implementation through Evidence-Based Quality Improvement on Utilization and Costs. Medical Care. February 2016;54(2):118-125.