PIM 2.0: Patient Aligned Care Team (PACT) Intensive Management (PIM) Project (PIM2)

V

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

NCT04521816
PIM #2

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

599 patients

Sex

All

Ages

18+ years old

Volunteers

No Healthy Volunteers

Inclusion criteria

  • Refered for intensive management

Exclusion criteria

  • None

Trial design

Primary purpose

Health Services Research

Allocation

Non-Randomized

Interventional model

Parallel Assignment

Masking

None (Open label)

599 participants in 2 patient groups

Intervention--PACT Intensive Management
Experimental group
Description:
The intervention is the PACT Intensive Management Program (PIM) provides a standardized menu of services, ranging from chart review assessment or in-home assessment, to a time limited intensive care management intervention. The following PIM features are standardized across the PIM demonstration sites: A) Chart review assessment template in the EMR; B) Comprehensive assessment template of unmet needs and modifiable risk factors in EMR; C) Transitions in care process (eligibility criteria, clinical protocols); D) Diagnostic home visits process (eligibility criteria, clinical protocols); E) Core risk stratification/Triage process; F) Discharge criteria and note template in EMR; G) Standardized interdisciplinary team (IDT) meeting note procedure and template in EMR.
Treatment:
Behavioral: PACT Intensive Management
Usual care
No Intervention group
Description:
High-Risk patients receiving care in PACT.

Trial documents
1

Trial contacts and locations

1

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Data sourced from clinicaltrials.gov

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