Examining the Investment in Caring for High-Needs Patients

BACKGROUND:

Complex high-need patients are costly to healthcare systems and at high risk for adverse outcomes, including hospitalizations. Thus, many assumed they represented a good target for interventions that would reduce costs and improve outcomes. Since 2013, VA has invested more than $22 million in fostering and testing interventions within patient-centered medical homes at five demonstration sites to improve care for Veterans at highest risk for hospitalizations or death. In this commentary, VA authors involved in this project, known as the VA PACT Intensive Management program, reflect on lessons learned about improving care for this population.

Observations show that most high-risk patients are cared for in general primary care rather than in specialized primary care settings, and that half of primary care providers and nurses feel that caring for high-risk patients is the most stressful aspect of their job. In addition, a randomized quality improvement evaluation of VA intensive management teams (physician lead, social workers, nurses, psychologist, and in some instances, a peer support specialist) has demonstrated increased patient engagement, improved patient trust, and greater support to primary care teams. Intensive management teams tailored their intervention to patient and system needs by developing a range of services – from “low-touch” electronic consults (e.g., providing recommendations to primary care or referring to other VA or community resources) to providing “high-touch” case management. While VA did not observe cost reductions associated with these interventions, the improved outcomes came at no greater cost to the healthcare system than patient-centered medical homes.

SUMMARY:

VA’s complex high-need, high-cost demonstration was set up as a quality improvement project, which can provide information in a real-world setting, but rigorously studied as a randomized controlled trial. Important lessons learned have been used to inform future directions, including:

• Using a combination of population management and clinician judgment is valuable for identifying patients best suited for intensive management.
• The top reasons for preventable emergency department visits and hospitalizations include treatment nonadherence and lack of patient engagement, rather than uncoordinated care.
• Intensive management efforts should focus on assessment for – and treatment of – modifiable risk factors among moderately high-risk patients, such as social needs and caregiver issues.

As intensive management programs did not decrease costs any more than patient-centered medical homes, VA’s Office of Primary Care plans to incorporate those intensive management practices that are feasible into existing patient-centered medical homes. Such practices may include 1) using the “Whole Health” approach to understand patient goals, values, and preferences; 2) utilizing the entire multi-disciplinary team in the medical home to create a cohesive treatment plan for high-risk patients; and 3) using motivational interviewing to counsel high-risk patients.

AUTHOR/FUNDING INFORMATION:
Dr. Chang is part of HSR&D’s Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA. Dr. Asch is part of HSR&D’s Center for Innovation to Implementation (Ci2i) in Palo Alto, CA. Dr. Denietolis is Director of VA’s Office of Primary Care, and Dr. Atkins is Director of HSR&D in Washington, DC.

Chang E, Asch S, Eng J, Gutierrez F, Denietolis A, and Atkins D. What is the Return on Investment of Caring for Complex High-Need, High-Cost Patients? Journal of General Internal Medicine. September 10, 2021. Online ahead of print.