Impact of Primary Care Intensive Management on High-Risk Veterans' Costs and Utilization: A Randomized Quality Improvement Trial.

Background: Primary care models that offer comprehensive, accessible care to all patients may provide insufficient resources to meet the needs of patients with complex conditions who have the greatest risk for hospitalization.

Objective: To assess whether augmenting usual primary care with team-based intensive management lowers utilization and costs for high-risk patients.

Design: Randomized quality improvement trial.

An operations-partnered evaluation of care redesign for high-risk patients in the Veterans Health Administration (VHA): Study protocol for the PACT Intensive Management (PIM) randomized quality improvement evaluation.

Background: Patient-centered medical homes have made great strides providing comprehensive care for patients with chronic conditions, but may not provide sufficient support for patients at highest risk for acute care use. To address this, the Veterans Health Administration (VHA) initiated a five-site demonstration project to evaluate the effectiveness of augmenting the VA's Patient Aligned Care Team (PACT) medical home with PACT Intensive Management (PIM) teams for Veterans at highest risk for hospitalization.

Methods/design: Researchers partnered with VHA leadership to design a mixed-methods prospective multi-site evaluation that met leadership's desire for a rigorous evaluation conducted as quality improvement rather than research.

What are the key elements for implementing intensive primary care? A multisite Veterans Health Administration case study.

Many integrated health systems and accountable care organizations have turned to intensive primary care programs to improve quality of care and reduce costs for high-need high-cost patients. How best to implement such programs remains an active area of discussion. In 2014, the Veterans Health Administration (VHA) implemented five distinct intensive primary care programs as part of a demonstration project that targeted Veterans at the highest risk for hospitalization.

The Association of Team-Specific Workload and Staffing with Odds of Burnout Among VA Primary Care Team Members.

Background: Work-related burnout is common in primary care and is associated with worse patient safety, patient satisfaction, and employee mental health. Workload, staffing stability, and team completeness may be drivers of burnout. However, few studies have assessed these associations at the team level, and fewer still include members of the team beyond physicians.

Patient-Centered Medical Home Implementation and Burnout Among VA Primary Care Employees.

Burnout is widespread throughout primary care and is associated with negative consequences for providers and patients. The relationship between the patient-centered medical home model and burnout remains unclear. Using survey data from 8135 and 7510 VA primary care employees in 2012 and 2013, respectively, we assessed whether clinic-level medical home implementation was independently associated with burnout prevalence and estimated whether burnout changed among this workforce from 2012 to 2013.

Association of medical home team-based care functions and perceived improvements in patient-centered care at VHA primary care clinics.

Introduction: Team-based care is central to the patient-centered medical home (PCMH), but most PCMH evaluations measure team structure exclusively. We assessed team-based care in terms of team structure, process and effectiveness, and the association with improvements in teams׳ abilities to deliver patient-centered care.

Material And Methods: We fielded a cross-sectional survey among 913 VA primary care clinics implementing a PCMH model in 2012.

Elements of the patient-centered medical home associated with health outcomes among veterans: the role of primary care continuity, expanded access, and care coordination.

Care continuity, access, and coordination are important features of the patient-centered medical home model and have been emphasized in the Veterans Health Administration patient-centered medical home implementation, called the Patient Aligned Care Team. Data from more than 4.3 million Veterans were used to assess the relationship between these attributes of Patient Aligned Care Team and Veterans Health Administration hospitalization and mortality.

Implementation of the patient-centered medical home in the Veterans Health Administration: associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department use.

Importance: In 2010, the Veterans Health Administration (VHA) began implementing the patient-centered medical home (PCMH) model. The Patient Aligned Care Team (PACT) initiative aims to improve health outcomes through team-based care, improved access, and care management. To track progress and evaluate outcomes at all VHA primary care clinics, we developed and validated a method to assess PCMH implementation.

Elements of team-based care in a patient-centered medical home are associated with lower burnout among VA primary care employees.

Background: A high proportion of the US primary care workforce reports burnout, which is associated with negative consequences for clinicians and patients. Many protective factors from burnout are characteristics of patient-centered medical home (PCMH) models, though even positive organizational transformation is often stressful. The existing literature on the effects of PCMH on burnout is limited, with most findings based on small-scale demonstration projects with data collected only among physicians, and the results are mixed.

Challenges facing primary care practices aiming to implement patient-centered medical homes.

Background: While the potential of patient-centered medical homes (PCMH) is promising, little is known empirically about the frontline challenges that primary care (PC) leaders face before making the decision to implement PCMH, let alone in making it a reality.

Objective: Prior to the design and implementation of the Veterans Health Administration's (VA) national PCMH model--Patient Aligned Care Teams (PACT)--we identified the top challenges faced by PC directors and examined the organizational and area level factors that influenced those challenges.

Design And Participants: A national cross-sectional key informant organizational survey was fielded to the census of PC directors at VA medical centers and large community-based outpatient clinics (final sample n = 229 sites).

Relational continuity or rapid accessibility in primary care?: A mixed-methods study of veteran preferences.

Objective: To examine preferences for relational continuity and rapid accessibility for telephone care.

Methods: A mixed-methods sequential explanatory design was utilized. Structured telephone interviews were conducted with 448 Veterans receiving primary care from Veterans Affairs facilities, who rated the importance of relational continuity and rapid accessibility.

The patient-centered medical home in the Veterans Health Administration.

Background: The Veterans Health Administration (VHA) is the largest integrated US health system to implement the patient-centered medical home. The Patient Aligned Care Team (PACT) initiative (implemented 2010-2014) aims to achieve team based care, improved access, and care management for more than 5 million primary care patients nationwide.

Objectives: To describe PACT and evaluate interim changes in PACT-related care processes.

Improving the quality of telephone-delivered health care: a national quality improvement transformation initiative.

Background: Many Veterans Affairs (VA) primary care (PC) patients prefer telephone-delivered care to other health care delivery modalities.

Objective: To evaluate PC patients' telephone experiences and outcomes before and after a national telephone transformation quality improvement (QI) collaborative.

Methods: Cross-sectional surveys were conducted pre- and post-collaborative.

Medical Home Features of VHA Primary Care Clinics and Avoidable Hospitalizations.

Background: As the Veterans Health Administration (VHA) reorganizes providers into the patient-centered medical home, questions remain whether this model of care can demonstrate improved patient outcomes and cost savings.

Objective: We measured adoption of medical home features by VHA primary care clinics prior to widespread implementation of the patient-centered medical home and examined if they were associated with lower risk and costs of potentially avoidable hospitalizations.

Design: Secondary patient data was linked to clinic administrative and survey data.

Understanding health care communication preferences of veteran primary care users.

Objective: To assess veterans' health communication preferences (in-person, telephone, or electronic) for primary care needs and the impact of computer use on preferences.

Methods: Structured patient interviews (n=448). Bivariate analyses examined preferences for primary care by 'infrequent' vs.

Improving outpatient diabetes care.

More than 20% of patients in the Veterans Health Administration (VHA) have diabetes; therefore, disseminating "best practices" in outpatient diabetes care is paramount. The authors' goal was to identify such practices and the factors associated with their development. First, a national VHA diabetes registry with 2008 data identified clinical performance based on the percentage of patients with an A1c >9%.

Optimizing primary care telephone access and patient satisfaction.

Telephone medicine is often preferred by patients to meet primary care needs and may be associated with high patient satisfaction. This article presents findings about incoming patient calls to primary care for medically based reasons during office hours and reports factors independently associated with telephone encounter satisfaction, considering patient characteristics, call reasons, and staff responsiveness, for a national cohort of primary care users. Interviews were conducted with patients from 18 nationwide primary care clinics during the fall of 2009.

Relationship of scheduling interval to missed and cancelled clinic appointments.

Background: The interval between when a clinical appointment is created and when it occurs may affect the rate of missed and cancelled appointments, affecting access and loss to follow-up, key component of quality.

Methods: We examined this relationship in various clinic types across Veterans Health Administration clinics nationwide.

Results: As the interval increased, the missed appointment rate increased from 12.

Reinventing Veterans Health Administration: focus on primary care.

Can we improve access in primary care without compromising the quality of care? The purpose of this article is to demonstrate how timely access to primary care can be achieved without compromising the quality of the care being delivered.

Reinventing Veterans Health Administration: focus on primary care.

Can we improve access in primary care without compromising the quality of care? The purpose of this article is to demonstrate how timely access to primary care can be achieved without compromising the quality of the care being delivered. The Veterans Health Administration (VHA) is an integrated healthcare system that has implemented change to improve primary care access to the veterans it serves, while not only maintaining but also actually improving the quality of care. Many healthcare executives are struggling with achieving desirable access to care and continuity of care.

Prolonging the return visit interval in primary care.

Purpose: Extending the scheduled return visit interval has been suggested as one means to improve clinic access to the provider. However, prolonging the return visit interval may affect quality of care if prevention measures and chronic disease management receive less attention as clinic visits become less frequent. The purpose of this study was to determine whether a comprehensive education program could encourage providers to lengthen their return visit interval without compromising performance on key quality indicators.