Patient Aligned Care Team (PACT) Intensive Management (PIM) Project

Veteran Affairs Office of Patient Care Services

Status: Completed

Conditions: Health Care Costs; Primary Health Care

Treatments: Behavioral: PACT Intensive Management

Study type: Interventional

Funder types: Other U.S. Federal agency; Other

Identifiers

NCT03100526

PIM Evaluation

Details and patient eligibility

About

Purpose: Implement a Patient Aligned Care Team (PACT) model that identifies and proactively manages Veterans at the highest risk for hospital admission and death while the patient is still in the ambulatory care setting.

Goal:

• Reduce emergency department and urgent care utilization, hospitalization, and mortality in complex, high risk patients
• Improve Veteran and staff satisfaction

Objectives:

• Maintain the patient in the home setting as much as possible
• Secure appropriate home environment to facilitate health and well-being
• Utilize comprehensive team-based care
• Engage appropriate Veteran Health Administration (VHA) programs to provide interdisciplinary, coordinated, and timely management of complex medical issues

Enrollment: 2,210 patients

Sex: All

Ages: 18+ years old

Volunteers: No Healthy Volunteers

Inclusion criteria

• selected for intensive management

Exclusion criteria

• enrolled in other intensive case management at VA

Trial design

Primary purpose: Health Services Research

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: None (Open label)

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2,210 participants in 2 patient groups

Intervention--PACT Intensive Management

Experimental group

Description:

The intervention is the PACT Intensive Management Program (PIM) which provides intensive interdisciplinary care planning, care coordination, patient self-management support, and tailored goal setting based on patient needs and preferences, and additional care management services.

Treatment:

Behavioral: PACT Intensive Management

Usual care

No Intervention group

Description:

High-Risk patients receiving care in PACT.