Study Overview
Objective. To determine the effect of an intensive out-patient program for high-need patients in a Veterans Affairs patient-centered medical home.
Design. Randomized controlled trial.
Setting and participants. The study was conducted at a single VA health care facility. Participants were 583 patients whose health care costs were in the top 5% for the facility during a 9-month eligibility period or whose risk for 1-year hospitalization risk as determined by the Care Assessment Need risk prediction algorithm [1] was in the top 5% for the facility. Patients were excluded if they were enrolled in mental health intensive case management program, home-based primary program or palliative care program, or if they were in an inpatient setting for more than half of the eligibility period. 150 patients were randomly assigned to the intensive outpatient group and the rest were assigned to receive standard VA-based primary care, which uses the patient-centered medical home model [2].
Intervention. The intensive outpatient care group received care from a multidisciplinary team comprising a nurse practitioner, physician, social worker, and recreational therapist. The enhanced care included comprehensive patient assessment, identification and tracking of patients’ health-related goals and priorities, assessment of physical function, cognitive function, social support, medical adherence and level of patient activation, and care management for medical and social needs. Frequent contacts using telephone lines and in-person visits as needed, weekly team discussions of high-acuity patients, and coordination of care with VA and non-VA clinicians also occurred. Additionally, the program offered interventions to support patients’ and caregivers’ quality of life, such as recreation therapy.
Main outcome measures . The main outcome measures were health care costs and utilization. Total health care costs included inpatient, outpatient, and fee-basis care provided outside the VA. Utilization measures included hospitalization frequency, hospital length of stay, and number of outpatient and emergency room visits. The study team examined cost and utilization patterns during the 16 months prior to initiation of the program (baseline period) and the 17 months after initiation of the program (follow-up period). The study also evaluated patient care experience in the intensive care group via survey at baseline and at 6 months after enrollment. The survey included items from the Patient Satisfaction questionnaire, the Patient Activation Measures tool, and questions about satisfaction with the intensive care program and the likelihood to recommend the program to others.
Main results. Of the 150 patients assigned to the intervention, 140 patients were included in the analysis after excluding those who were ineligible or died before the intervention began; there were 405 in the usual care group. Among the 140 patients, 96 engaged in the program and 60 completed the follow-up survey. The average patient age was 66 years and over 90% were male, with the majority living in an urban area. The average number of chronic conditions was approximately 10, and about two-thirds had a mental health diagnosis. In the follow-up period, patients in the intensive outpatient care group had a higher number of outpatient primary care visits (average of 21.8 visits [SD 17.4]) compared with the usual care group (average of 7.4 visits [SD 7.5]). The number of acute medical or surgical hospitalizations in the follow-up period was similar between the 2 groups, as was the number of emergency room visits. There were also no significant differences on other inpatient or outpatient health care utilization measures. The intensive outpatient care program was not associated with reduced costs of care when compared with usual care. For measurements on patient experience, the majority of patients who completed the survey (92%) indicated that they would recommend the program to others and 70% indicated that they were extremely satisfied with the program’s medical care.
Conclusions. Intensive outpatient care for high-need patients in this VA setting was not associated with a decrease in acute health care utilization or reduced costs. Patients in the intensive outpatient care program indicated that they were satisfied with the program and would recommend the program to others.
Commentary
Management of high-risk, high-cost patients continues to be a challenge for the health care system. High-users account for a disproportionate amount of health care costs. It would seem reasonable that attending to these patients’ complex needs by providing lower-cost supplemental primary care services early would reduce the need for more expensive care (eg, hospitalization) down-stream.
In this study, researchers examined the impact of an intensive outpatient care program targeting high-need veterans on health care utilization and costs. Although patients liked the program, the results demonstrated no reduction in either acute care utilization, including inpatient hospitalization or emergency room visits, or costs. The findings are consistent with a number of prior studies that have demonstrated limited impact of care coordination programs on cost and utilization [3] albeit demonstrating impact on other clinically relevant outcomes, including patient experience.
The study authors proposed a few factors that may have contributed to this finding. One was that a longer follow-up period may be needed to demonstrate improved outcomes. Another was that there may be a mismatch between the patients’ needs and the services offered by the program. In addition, the intensive out-patient services may have uncovered unmet needs that led to appropriate care, which could increase costs. The role of these factors might be examined using process measures, or with ongoing collection of administrative data, perhaps in a future study.
In interpreting this study, it is important to point out certain differences between this study and the typical randomized clinical trial. In this study, patients were not enrolled in a clinical trial at the time of the intensive outpatient care program—it was considered a quality improvement initiative at the time when the program was started. Thus, the study subjects may be different from the subjects likely to be included in a randomized clinical trial, where subjects must agree to participate in research in order to be part of the study. The patients in this study therefore likely resemble the patient population in a clinical setting rather than in a research study setting.
The other difference is that in addition to examining the impact of the intervention, the study tests the targeting strategy of the intervention—in this case, targeting patients with high need using algorithms already embedded in the VA. This strategy contrasts with a number of outpatient collaborative care interventions [4,5] that target specific medical conditions. While targeting high-utilizers makes sense from an economic point of view, such a group may be more diverse and have more diverse needs than a study population with a condition-specific profile, eg, patients with chronic disease and depression [4]. Two thirds of the study population had a mental health diagnosis, but the team did not include specific mental health personnel or care protocols for mental health management.
Because of its design as a quality improvement project, the study suffers from a number of shortcomings that may threaten its internal validity, namely, the low follow-up rate, the lack of a comparison group for some outcomes, and perhaps, less assurance that participants were treated equally except for the study intervention.
Applications for Clinical Practice
The study adds to the current literature on interventions for improving care and reducing costs for patients with high health care needs. As health care costs continue to escalate, implementing strategies to improve efficiency continues to be a priority. The intensive outpatient care program may not be the solution for curbing costs for the study population at this time; perhaps follow-up studies that assess its impact on other relevant clinical outcomes with longer follow-up may tell a different story.
—William W. Hung, MD, MPH