Impact of Primary Care Intensive Management on High-Risk Veterans' Costs and Utilization

Abstract

Veterans Health Administration Primary Care Services.

Identifying Latent Subgroups of High-Risk Patients Using Risk Score Trajectories

“…39 The ability to categorize patients' trajectories of risk has potential implications for further research examining the effectiveness of intensive management interventions for patients at high risk of adverse outcomes, where most randomized trials have not shown significant benefits. For example, VA investigators conducted two randomized evaluations of an intensive, multidisciplinary, team-based approach for veterans with high hospitalization probability, as predicted by the CAN model, and showed no reduction in use of acute care or total healthcare 40,41 Future research should ascertain whether these programs exhibit variable effects on patients with different expected risk trajectories, characterized using baseline characteristics identified in this study. This study has several limitations.…”

“It’s Like Riding Out the Chaos”: Caring for Socially Complex Patients in an Ambulatory Intensive Care Unit (A-ICU)

“…Even if these programs do not reduce overall cost or utilization, they may still provide high value if they are cost neutral but enhance the quality of care delivered. 25 Health care teams caring for medically and socially complex patients endorse the importance of addressing patient-system mismatches, providing psychosocial supports in midst of patient's life chaos, and celebrating increased patient engagement with primary care. These principles should guide the evolution and design of future interventions to care for HNHC patients.…”

Using Predictive Analytics to Guide Patient Care and Research in a National Health System

“…The CAN score is being applied in a number of quality improvement projects and research studies with the goal of learning not only the effectiveness of intensive management for these patients but also the clinical processes needed to make use of CAN score information. 5,6 The CAN score illustrates how a health care system can harness electronic health record data to identify high-risk patients who may benefit from clinical interventions. Additional work is needed to fully characterize the heterogeneity of these patients' needs, and to determine the best methods for using the score to target patients in need of specific services.…”