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Effectiveness of VA Primary care firm systems: Preliminary findings
Yano EM, Wang MM, Rubenstein LV. Effectiveness of VA Primary care firm systems: Preliminary findings. Paper presented at: VA HSR&D National Meeting; 1999 Feb 24; Washington, DC.
Objectives: As a healthcare delivery model, firm systems have been associated with improved prevention, continuity and coordination. By 1996, many VA facilities had launched firm 'like' primary care delivery models, with little information about the relative effectiveness of the variations being used. We assessed the relative performance of VA firm systems in contrast with non-firms in terms of preventive and chronic disease care and patients' satisfaction with continuity and coordination. Methods: In 1996, a national VA expert panel operationally defined a VA firm system through a modified Delphi process that examined the relative importance and contribution to the suggested effects of firms of each of 30 proposed features. Survey items based on these features were incorporated into a 50-item organizational survey, pilot tested and fielded in June 1996 among all VAMCs nationwide. A VAMC was classified as having a firm system if they had 1+ interdisciplinary primary care teams with patients indefinitely assigned to a primary care provider who was responsible for care from clinic-to-ward. We used these survey results (100% response rate) to evaluate the performance associated with VA firm systems using baseline chart-based data from the VHA External Peer Review Program and 1996 VHA National Customer Feedback Center patient satisfaction data. We compared performance associated with firms vs. non-firms and among alternate firm system specifications using the Kruskal-Wallis test. Results: Overall, 35 (21.9%) VAMCs had firm systems. Compared to non-firms, VA firms served fewer patients (p < .05), but achieved higher proportions of patients who reported having a primary care provider (76.4% vs. 71.3%, p < .05). Preventive practices were higher in firms vs. non-firms (Prevention Index .79 vs. .74, p < .05), with specific benefits in alcohol counseling and colon-cancer screening (p < .05). The Chronic Disease Index scores were also higher among firms (.87 vs. .82, p < .05), with higher performance of sensation exams and foot pulse checks among diabetics, and exercise counseling among hypertensives and obese patients (each p < .05). On average, patients reported slightly fewer problems with continuity (.24+/-.12 vs. .28+/-.10, p = .08). VA firms were more likely to have specialty referral and notification policies (p < .01). The subset of firms with randomized patients and providers and the larger set of firms without inpatient-outpatient continuity had few performance benefits in contrast. Conclusions: VA healthcare facilities adopting firm systems as their primary care delivery model have higher proportions of patients who report having a primary care provider, provide more preventive care, and higher quality of care for selected chronic conditions. Patients were only marginally more satisfied with their continuity of care. More research is needed to understand the key ingredients of effective delivery models to support the continued growth and development of VA primary care delivery systems, including the adoption of managed care practices, especially as they relate to interdisciplinary teams of providers. Impact: This work will support the planning and design of VA primary care delivery systems that are associated with higher facility performance.