Improving Care for Complex, High-Risk Patients in Primary Care

Va Greater Los Angeles Healthcare System, Los Angeles CA

Investigators

Linked publications & trials

Abstract

The top 5% of Veterans at the highest risk for hospitalizations account for almost 50% of VHA healthcare costs, have significant multimorbidity, and are at high risk for poor health outcomes. In the VHA, most (88%) high-risk patients are managed by general primary care teams (i.e., Patient-Aligned Care Teams; PACTs). Few PACTs, however, have implemented evidence-based practices (EBPs) known to address the most common issues among high-risk Veterans. Some evidence indicates that usual implementation strategies, such as dissemination of toolkits and training are not effective for improving uptake of EBPs. The most effective implementation strategies to achieve evidence-based care for high-risk patients, however, are unknown. The overall impact goal of the high-RIsk VETerans (RIVET) QUERI Program is to improve VHA primary care capacity to provide comprehensive, evidence-based care for complex, high-risk Veterans. We will test 2 implementation strategies to implement two EBPs: 1) Comprehensive Assessment and Care Planning (CACP), and 2) Phone-Based Health Coaching for Medication Adherence (HCMA). CACP is based on the Comprehensive Geriatric Assessment and guides teams in systematically addressing patients? cognitive, functional, and social needs through a comprehensive care plan. HCMA addresses common challenges to medication adherence using a patient-centered approach through virtual encounters. Both comprehensive assessments and health coaching have demonstrated efficacy in randomized, controlled trials and have been implemented by two of our national partners in geriatrics and Whole Health teams. However, both EBPs have had low uptake in primary care. Implementing these practices in primary care has the potential to improve quality of care for the large majority of high-risk Veterans. To improve implementation of EBPs in primary care we will compare two strategies: Evidence-Based Quality Improvement-Individual Consultation (EBQI-IC) and EBQI-Learning Collaborative (EBQI-LC) (Aim 1). EBQI has been successfully used to implement complex evidence-based practices in primary care, such as the PACT model and primary care-mental health integration. EBQI core components include engaging VISN- and facility-level multidisciplinary stakeholders in evidence-based agenda setting and fostering structured front-line innovation directed towards agenda goals. Some EBQI initiatives have focused on using EBQI core components in combination with individual site-level consultation, while others have leveraged group facilitation through learning collaboratives. These two approaches have not been directly compared, leaving implementers without guidance on how best to implement EBQI. We will test how EBQI delivered using individual site consultation (EBQI-IC) or delivered within groups of sites functioning as a learning collaborative (EBQI-LC) will increase EBP uptake and sustainment. We will conduct a mixed methods type 3 hybrid effectiveness-implementation design to test the effectiveness of EBQI-IC and EBQI-LC versus usual care (national tool dissemination and training efforts) in at least 14 sites in 2 VISNs using a Concurrent Stepped Wedge design (Aim 2). Our primary outcome is proportion of eligible high-risk patients that receive each EBP. We will use the Practical, Robust Implementation and Sustainability Model (PRISM) framework to compare and evaluate Reach, Effectiveness, Adoption, Implementation, and costs. We will then assess the Maintenance/sustainment and spread of both EBPs in primary care across 3 VISNs after the active 18-month implementation period (Aim 3). The RIVET QUERI Program is designed to improve the capacity of PACTs to implement EBPs for high-risk patients beyond the two EBPs proposed as part of this program, improving patient care experiences and quality metrics. It will also provide the evidence needed to choose the most effective and efficient implementation strategies to improve future delivery of evidence-based care to high-risk Veterans.