Partnered Research in Healthcare Delivery Redesign for High-Need, High-Cost Patients: Development and Feasibility of an Intensive Management Patient-Aligned Care Team (ImPACT)

Disruptive Models in Primary Care: Caring for High-Needs, High-Cost Populations

“…These services may be superimposed on, or incorporated into, standard officebased primary care practices, as has been proposed in the patient-centered medical home model. 25 Figure 1 Stratification of health risk within a population. Patients with Bsevere health risk^represent the 5-20% of the primary care population with the highest needs and costs.…”

Partner or Perish: VA Health Services and the Emerging Bi-Directional Paradigm

“…3 Second, successful partnered research involves shared resources (e.g., data, provider networks, personnel) that enable regional or national roll-out studies and flexibility for investigators to work on the policy-relevant issues. Examples of current initiatives involving shared data or provider networks include the VHA's medical home models 4,5 and the suicide predictive analytic projects. 6,7 In addition, optimal partnerships achieve clinical or policy impacts, ideally felt from the national or regional levels, through new policies as well as at the frontline provider levels through care improvement.…”

The Impact of Intensive Case Management on Hospice Utilization

“…The ImPACT program was implemented for Veterans receiving care at VA Palo Alto. The patient criteria was designed to identify high-risk, high-need ambulatory care patients that were 1) >18 years of age, 2) their primary care provider is one of 14 ImPACT-affiliated PACT providers with 3 or more half-days of clinic per week, 3) encounters were predominantly outpatient during the eligibility period and 4) their total healthcare costs were in the top 5% during a 9-month eligibility phase (10/1/2011-6/20-2012) or if their risk for one-year hospitalization was in the top 5% based on a Care Assessment Need (CAN) score of 95 or greater (Zulman et al, 2014). The CAN score is the percentile risk of a hospitalization within one year and ranges from 0 indicating low risk to 99, the highest risk of hospitalization (Wang et al, 2013).…”

“…More than three-quarters of the VA population have more than three chronic conditions and almost fifty percent have more than five chronic conditions (Zulman et al, 2013). The most prevalent chronic illnesses include hypertension, ischemic heart disease, diabetes, chronic renal failure, low back pain, depression, post-traumatic stress disorder, alcohol, and substance abuse (Yoon et al, 2011;Zulman et al, 2014).…”

“…improvement project is a quantitative retrospective study examining hospice referral for individuals enrolled in the ImPACT program who died between 2/2013-1/2015. It is a secondary analysis of a larger study of a quality improvement evaluation that took place at the Veteran's Administration (VA) facility in Palo Alto, California from 2/1/2013-6/30/2014(Zulman et al, 2014). The purpose of the capstone project is to examine if patients enrolled in a multi-disciplinary intensive case management (ImPACT) program alter the patient's end-oflife path or setting of death.…”