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

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)

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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.