Journal of General Internal Medicine

, Volume 34, Issue 8, pp 1564–1570 | Cite as

High-Need Patients’ Goals and Goal Progress in a Veterans Affairs Intensive Outpatient Care Program

  • Kristie Y. Hsu
  • Cindie Slightam
  • Jonathan G. Shaw
  • Aaron Tierney
  • Debra L. Hummel
  • Mary K. Goldstein
  • Evelyn T. Chang
  • Derek Boothroyd
  • Donna M. ZulmanEmail author
Original Research



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.

Main Measures

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.


patient 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.

Prior Presentations

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.

Supplementary material

11606_2019_5010_MOESM1_ESM.docx (343 kb)
ESM 1 (DOCX 342 kb)


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Copyright information

© Society for General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2019

Authors and Affiliations

  • Kristie Y. Hsu
    • 1
  • Cindie Slightam
    • 2
  • Jonathan G. Shaw
    • 2
    • 3
  • Aaron Tierney
    • 2
    • 3
  • Debra L. Hummel
    • 4
  • Mary K. Goldstein
    • 5
    • 6
  • Evelyn T. Chang
    • 7
    • 8
  • Derek Boothroyd
    • 9
  • Donna M. Zulman
    • 2
    • 3
    Email author
  1. 1.School of MedicineStanford UniversityStanfordUSA
  2. 2.Center for Innovation to ImplementationVA Palo Alto Health Care SystemMenlo ParkUSA
  3. 3.Division of Primary Care and Population HealthStanford University School of MedicineStanfordUSA
  4. 4.Division of Primary CareStanford Health CareSanta ClaraUSA
  5. 5.Medical ServiceVA Palo Alto Health Care SystemPalo AltoUSA
  6. 6.Center for Primary Care and Outcomes ResearchStanford UniversityStanfordUSA
  7. 7.VA Center for the Study of Healthcare InnovationImplementation and Policy (CSHIIP)Los AngelesUSA
  8. 8.Department of MedicineUniversity of California at Los AngelesLos AngelesUSA
  9. 9.Quantitative Sciences UnitStanford University School of MedicineStanfordUSA

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