Intensive Outpatient Care for High-Need Patients Does Not Reduce Acute Care Use or Costs Compared to Standard VA Care

BACKGROUND:
Many healthcare organizations are adopting intensive outpatient care programs for high-need patients (i.e., those in the top 5% of their facility in terms of healthcare costs), yet little is known about their effectiveness in integrated systems with patient-centered medical homes. Thus, this study evaluated the effectiveness of augmenting VA's Patient-Aligned Care Teams (PACTs) with an Intensive Management program (ImPACT). In February 2013, the Palo Alto VAMC launched an ImPACT multidisciplinary team that addressed healthcare needs and quality of life through comprehensive patient assessments, intensive outpatient case management, care coordination, and social and recreational services. Investigators in this study identified 583 Veterans who were high-need outpatients and whose healthcare costs or hospitalization risk were in the top 5% at this VAMC: 150 were randomly selected for ImPACT, while 433 received standard PACT care. Investigators then examined total costs of VA care (inpatient, outpatient, and fee-basis) and healthcare use among ImPACT and PACT patients during a 16-month baseline period (10/11-1/13) and 17-month follow-up period (2/13-6/14). ImPACT participants' satisfaction and activation levels were assessed via survey.

FINDINGS:

• Intensive outpatient care for high-need patients did not reduce acute care utilization or costs compared with standard VA care, although there were positive effects on healthcare experiences among Veterans who participated in ImPACT.
• During the first 16 months of the intervention period, the average number of primary care visits was 22 for ImPACT patients vs. 7 for PACT patients. However, after accounting for the cost of ImPACT encounters, the average baseline and follow-up person-level monthly costs declined at similar rates among ImPACT patients (21.0%) and PACT patients (20.7%).
• Among ImPACT patients who responded to the follow-up survey (n=54, 56% response rate), 96% reported that they would recommend the program to others. A majority of Veterans also reported being "extremely satisfied" with the program's medical care (70%), social work (76%), and recreation therapy and community services (78%).

IMPLICATIONS:

• Implementing intensive outpatient programs in VA may offer high-need Veterans more comprehensive services. However, in settings with high-functioning PACTs, these programs may not prevent hospitalizations or achieve substantial cost savings.

LIMITATIONS:

• Because of unanticipated delays in program initiation, some patients left the facility or died before the ImPACT program began, reducing statistical power.
• The assessment of patients' experiences was based on a quality improvement survey of ImPACT patients (with no comparison group and a 63% response rate), and could be biased if follow-up survey completion was correlated with positive or negative experience.

AUTHOR/FUNDING INFORMATION:
This study was partly funded by HSR&D (PPO 13-117), and Dr. Zulman was supported by an HSR&D Career Development Award. Drs. Zulman, Chee, and Asch are part of HSR&D's Center for Innovation to Implementation (Ci2i) in Palo Alto, CA.

Zulman D, Chee C, Ezeji-Okoye S, et al. Effect of an Intensive Outpatient Program to Augment Primary Care for High-Need Veterans Affairs Patients. JAMA Internal Medicine. December 27, 2016;e-pub ahead of print.