PIM 2.0: Patient Aligned Care Team (PACT) Intensive Management (PIM) Project
试验速览
- 阶段
- 不适用
- 状态
- 已完成
- 发起方
- 入组人数
- 599
- 试验地点
- 1
- 主要终点
- VA health care cost
研究概览
简要总结
Purpose: Implement a Patient Aligned Care Team (PACT) model that identifies and proactively manages Veterans at the highest risk for hospital admission and death while the patient is still in the ambulatory care setting.
Goal:
- Reduce emergency department and urgent care utilization, hospitalization, and mortality in complex, high risk patients
- Improve Veteran and staff satisfaction
Objectives:
- Maintain the patient in the home setting as much as possible
- Secure appropriate home environment to facilitate health and well-being
- Utilize comprehensive team-based care
- Engage appropriate Veteran Health Administration (VHA) programs to provide interdisciplinary, coordinated, and timely management of complex medical issues
研究设计
- 研究类型
- Interventional
- 分配方式
- Non Randomized
- 干预模型
- Parallel
- 主要目的
- Health Services Research
- 盲法
- None
入排标准
- 年龄范围
- 18 Years 至 —（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •Refered for intensive management
排除标准
- 未提供
研究组 & 干预措施
Intervention--PACT Intensive Management
The intervention is the PACT Intensive Management Program (PIM) provides a standardized menu of services, ranging from chart review assessment or in-home assessment, to a time limited intensive care management intervention. The following PIM features are standardized across the PIM demonstration sites:
A) Chart review assessment template in the EMR; B) Comprehensive assessment template of unmet needs and modifiable risk factors in EMR; C) Transitions in care process (eligibility criteria, clinical protocols); D) Diagnostic home visits process (eligibility criteria, clinical protocols); E) Core risk stratification/Triage process; F) Discharge criteria and note template in EMR; G) Standardized interdisciplinary team (IDT) meeting note procedure and template in EMR.
干预措施: PACT Intensive Management (Behavioral)
Usual care
High-Risk patients receiving care in PACT.
结局指标
主要结局
VA health care cost
时间窗: 2 years (two 1-year points)
Total costs of VA care, including inpatient, outpatient, pharmacy and fee-basis services.
次要结局
- Healthcare Utilization(2 years (two 1-year points))
- Total Medicare Cost(2 years (two 1-year points))
- Total Medicare Utilization(2 years (two 1-year points))