High-Need Patients’ Goals and Goal Progress in a Veterans Affairs Intensive Outpatient Care Program
Healthcare systems nationwide are implementing intensive outpatient care programs to optimize care for high-need patients; however, little is known about these patients’ personal goals and factors associated with goal progress.
To describe high-need patients’ goals, and to identify factors associated with their goal progress
Retrospective cohort study
A total of 113 high-need patients participated in a single-site Veterans Affairs intensive outpatient care program.
Two independent reviewers examined patients’ goals recorded in the electronic health record, categorized each goal into one of three domains (medical, behavioral, or social), and determined whether patients attained goal progress during program participation. Logistic regression was used to determine factors associated with goal progress.
The majority (n = 72, 64%) of the 113 patients attained goal progress. Among the 100 (88%) patients with at least one identified goal, 58 set goal(s) in the medical domain; 60 in the behavioral domain; and 52 in the social domain. Within each respective domain, 41 (71%) attained medical goal progress; 34 (57%) attained behavioral goal progress; and 32 (62%) attained social goal progress. Patients with mental health condition(s) (aOR 0.3; 95% CI 0.1–0.9; p = 0.03) and those living alone (aOR 0.4; 95% CI 0.1–1.0; p = 0.05) were less likely to attain goal progress. Those with mental health condition(s) and those who were living alone were least likely to attain goal progress (interaction aOR 0.1 compared to those with neither characteristic; 95% CI 0.0-0.7; p = 0.02).
Among high-need patients participating in an intensive outpatient care program, patient goals were fairly evenly distributed across medical, behavioral, and social domains. Notably, individuals living alone with mental health conditions were least likely to attain progress. Future care coordination interventions might incorporate strategies to address this gap, e.g., broader integration of behavioral and social service components.
KEY WORDSpatient goal patient-centered medical home primary care redesign Veterans
The authors would like to acknowledge Josephine Jacobs, PhD, Ms. Georgezetta Rogers, and Ms. Kathryn Holloway, for their meaningful contributions to this study. Views expressed are those of the authors and not necessarily those of the Department of Veterans Affairs.
This work was previously presented on January 20, 2018, at the SGIM California-Hawaii regional meeting, on April 13, 2018, at the national SGIM meeting as an oral presentation, and on June 25, 2018, at the Academy Health Annual Research Meeting.
Ms. Hsu was supported by a MedScholars grant from Stanford University School of Medicine. Dr. Zulman is supported by VA HSR&D Career Development Award (CDA 12-173). The ImPACT program was developed and evaluated with support from the VA Office of Specialty Care Transformation (Specialty/Surgical Care Neighborhood Team Based Model Pilot Program) and by VA HSR&D (PPO 13-117).
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they do not have a conflict of interest.
- 1.Zulman DM, Pal Chee C, Ezeji-Okoye SC, Shaw JG, Holmes TH, Kahn JS, et al. Effect of an Intensive Outpatient Program to Augment Primary Care for High-Need Veterans Affairs Patients: A Randomized Clinical Trial. JAMA Intern Med. 2017;177(2):166–75. https://doi.org/10.1001/jamainternmed.2016.8021.CrossRefPubMedGoogle Scholar
- 2.Boult C, Reider L, Leff B, Frick KD, Boyd CM, Wolff JL, et al. The effect of guided care teams on the use of health services: results from a cluster-randomized controlled trial. Arch Intern Med. 2011;171(5):460–6. https://doi.org/10.1001/archinternmed.2010.540.CrossRefPubMedPubMedCentralGoogle Scholar
- 5.Stremikis K, Connors C, Hoo E. Intensive Outpatient Care Program: A Care Model for the Medically Complex Piloted by Employers. 2017.Google Scholar
- 6.Long P, Abrams M, Milstein A, Anderson G, Apton KL, Dahlberg ML, Whicher D. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. NAM Special Publication; 2017.Google Scholar
- 7.Blaum C, Tinetti M, Rich MW, Hoy L, Hoy S, Esterson J, et al. A Research Agenda to Support Patient Priorities Care for Adults with Multiple Chronic Conditions. Patient-Centered Outcomes Research Institute New York University School of Medicine Yale University School of Medicine; 2017.Google Scholar
- 17.Hulen E, Ervin A, Schue A, Evans-Young G, Saha S, Yelin EH, et al. Patient goals in rheumatoid arthritis care: A systematic review and qualitative synthesis. Musculoskeletal Care. 2016. https://doi.org/10.1002/msc.1173.
- 18.Chang ET, Raja PV, Stockdale SE, Katz ML, Zulman DM, Eng JA, et al., eds. What are the key elements for implementing intensive primary care? A multisite Veterans Health Administration case study. Healthcare: Elsevier; 2017.Google Scholar
- 20.Wu FM, Slightam CA, Wong AC, Asch SM, Zulman DM. Intensive Outpatient Program Effects on High-need Patients’ Access, Continuity, Coordination, and Engagement. Med Care. 2017. https://doi.org/10.1097/MLR.0000000000000833.
- 23.The Radical Redesign of Health Care. Partnering with Veterans for their Greatest Health and Well-Being. U.S. Department of Veterans Affairs; 2017:22-4.Google Scholar
- 25.California Healthcare Foundation CQC. Complex Care Management Toolkit. 2012 [01/24/19]. Available from: http://www.calquality.org/storage/documents/cqc_complexcaremanagement_toolkit_final.pdf.
- 28.Edwards ST, Peterson K, Chan B, Anderson J, Helfand M. Effectiveness of Intensive Primary Care Interventions: A Systematic Review. J Gen Intern Med. 2017. https://doi.org/10.1007/s11606-017-4174-z.
- 40.Bachrach D, Anthony S, Detty A, Manatt P, Phillips L. State strategies for integrating physical and behavioral health services in a changing Medicaid environment. The Commonwealth Fund; 2014.Google Scholar