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Partnered Research in Healthcare Delivery Redesign for High-Need, High-Cost Patients: Development and Feasibility of an Intensive Management Patient-Aligned Care Team (ImPACT)

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ABSTRACT

OBJECTIVES

We employed a partnered research healthcare delivery redesign process to improve care for high-need, high-cost (HNHC) patients within the Veterans Affairs (VA) healthcare system.

METHODS

Health services researchers partnered with VA national and Palo Alto facility leadership and clinicians to: 1) analyze characteristics and utilization patterns of HNHC patients, 2) synthesize evidence about intensive management programs for HNHC patients, 3) conduct needs-assessment interviews with HNHC patients (n = 17) across medical, access, social, and mental health domains, 4) survey providers (n = 8) about care challenges for HNHC patients, and 5) design, implement, and evaluate a pilot Intensive Management Patient-Aligned Care Team (ImPACT) for a random sample of 150 patients.

RESULTS

HNHC patients accounted for over half (52 %) of VA facility patient costs. Most (94 %) had three or more chronic conditions, and 60 % had a mental health diagnosis. Formative data analyses and qualitative assessments revealed a need for intensive case management, care coordination, transitions navigation, and social support and services. The ImPACT multidisciplinary team developed care processes to meet these needs, including direct access to team members (including after-hours), chronic disease management protocols, case management, and rapid interventions in response to health changes or acute service use. Two-thirds of invited patients (n = 101) enrolled in ImPACT, 87 % of whom remained actively engaged at 9 months. ImPACT is now serving as a model for a national VA intensive management demonstration project.

CONCLUSIONS

Partnered research that incorporated population data analysis, evidence synthesis, and stakeholder needs assessments led to the successful redesign and implementation of services for HNHC patients. The rigorous design process and evaluation facilitated dissemination of the intervention within the VA healthcare system.

IMPACT STATEMENT

Employing partnered research to redesign care for high-need, high-cost patients may expedite development and dissemination of high-value, cost-saving interventions.

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Acknowledgements

Contributors

Authors would like to acknowledge Drs. Ian Tong and James Hallenbeck, Ms. Kalkidan Asrat, Ms. Lien Nguyen, and Ms. Jessica Radmilovic for their contributions to ImPACT’s design and implementation; Drs. Alan Glaseroff and Ann Lindsay from Stanford Coordinated Care for serving as clinical advisors to the ImPACT program; Danielle Cohen, Valerie Meausoone, and Cindie Slightam for data management and program evaluation support; and Ava Wong and Cindie Slightam for assistance with manuscript preparation. VA Palo Alto data acquisition and analysis was supported by Robert Chang, Robert King, Chi Pham, Lakshmi Ananth, and the Veterans Affairs Women’s Health Evaluation Initiative. Views expressed are those of the authors and not necessarily those of the Department of Veterans Affairs.

Funders

ImPACT program development and implementation was supported by the VA Office of Specialty Care Transformation (Specialty/Surgical Care Neighborhood Team Based Model Pilot Program). ImPACT program evaluation was supported by VA HSR&D (PPO 13-117). Dr. Zulman is supported by a VA HSR&D Career Development Award (CDA 12-173). Dr. Shaw is supported in part by VA Office of Academic Affairs and HSR&D funds. Dr. Breland is supported by the VA Office of Affiliations and VA HSR&D Service in conjunction with a VA HSR&D Advanced Fellowship Program.

Prior Presentations

None.

Conflicts of Interest

The authors report no conflicts of interest.

Author information

Authors and Affiliations

  1. Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road, MPD-152, Menlo Park, CA, 94025, USA

    Donna M. Zulman M.D., M.S., Jonathan G. Shaw M.D., M.S., Jessica Y. Breland M.S., Ph.D. & Steven M. Asch M.D., M.P.H.

  2. Division of General Medical Disciplines, Stanford University, Stanford, CA, USA

    Donna M. Zulman M.D., M.S., Jonathan G. Shaw M.D., M.S., John F. Chardos M.D., James S. Kahn M.D. & Steven M. Asch M.D., M.P.H.

  3. Medical Services, VA Palo Alto Health Care System, Palo Alto, CA, USA

    Donna M. Zulman M.D., M.S., Stephen C. Ezeji-Okoye M.D., Jonathan G. Shaw M.D., M.S., John F. Chardos M.D., James S. Kahn M.D. & Steven M. Asch M.D., M.P.H.

  4. Chief of Staff Office, VA Palo Alto Health Care System, Palo Alto, CA, USA

    Stephen C. Ezeji-Okoye M.D. & John F. Chardos M.D.

  5. Nursing Service, VA Palo Alto Health Care System, Palo Alto, CA, USA

    Debra L. Hummel M.S.N., A.R.N.P-.C.

  6. Recreation Therapy Service, VA Palo Alto Health Care System, Palo Alto, CA, USA

    Katie S. Holloway M.S., C.T.R.S.

  7. Social Work Service, VA Palo Alto Health Care System, Palo Alto, CA, USA

    Sasha F. Smither M.S.W., L.C.S.W.

  8. Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA

    Jessica Y. Breland M.S., Ph.D.

  9. Office of Specialty Care and Specialty Care Transformation, Washington, DC, USA

    Susan Kirsh M.D., M.P.H.

  10. Case Western Reserve School of Medicine, Cleveland, OH, USA

    Susan Kirsh M.D., M.P.H.

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  1. Donna M. Zulman M.D., M.S.
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  3. Jonathan G. Shaw M.D., M.S.
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  4. Debra L. Hummel M.S.N., A.R.N.P-.C.
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  5. Katie S. Holloway M.S., C.T.R.S.
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  6. Sasha F. Smither M.S.W., L.C.S.W.
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  7. Jessica Y. Breland M.S., Ph.D.
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  8. John F. Chardos M.D.
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  10. James S. Kahn M.D.
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  11. Steven M. Asch M.D., M.P.H.
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Corresponding author

Correspondence to Donna M. Zulman M.D., M.S..

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Zulman, D.M., Ezeji-Okoye, S.C., Shaw, J.G. et al. Partnered Research in Healthcare Delivery Redesign for High-Need, High-Cost Patients: Development and Feasibility of an Intensive Management Patient-Aligned Care Team (ImPACT). J GEN INTERN MED 29 (Suppl 4), 861–869 (2014). https://doi.org/10.1007/s11606-014-3022-7

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