What are the key elements for implementing intensive primary care? A multisite Veterans Health Administration case study

Publication date: Available online 6 November 2017Source: HealthcareAuthor(s): Evelyn T. Chang, Pushpa V. Raja, Susan E. Stockdale, Marian L. Katz, Donna M. Zulman, Jessica A. Eng, Kathy H. Hedrick, Jeffrey L. Jackson, Neha Pathak, Brook Watts, Carrie Patton, Gordon Schectman, Steven M. AschAbstractMany integrated health systems and accountable care organizations have turned to intensive primary care programs to improve quality of care and reduce costs for high-need high-cost patients. How best to implement such programs remains an active area of discussion. In 2014, the Veterans Health Administration (VHA) implemented five distinct intensive primary care programs as part of a demonstration project that targeted Veterans at the highest risk for hospitalization. We found that programs evolved over time, eventually converging on the implementation of the following elements: 1) an interdisciplinary care team, 2) chronic disease management, 3) comprehensive patient assessment and evaluation, 4) care and case management, 5) transitional care support, 6) preventive home visits, 7) pharmaceutical services, 8) chronic disease self-management, 9) caregiver support services, 10) health coaching, and 11) advanced care planning. The teams also found that including social workers and mental health providers on the interdisciplinary teams was critical to effectively address psychosocial needs of these complex patients. Having a central implementation coordinator facilitated the convergence...
Source: Healthcare - Category: Middle East Health Source Type: research