Veterans with Post-Traumatic Stress Disorder in the Patient Centered Medical Home: Assessing utilization patterns and identifying key medical home elements
Randall, Ian Anthony
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University of Washington Abstract Veterans with Post-Traumatic Stress Disorder in the Patient Centered Medical Home: Assessing utilization patterns and identifying key medical home elements Ian A. Randall Chair of the Supervisory Committee: Christopher Johnson, PhD The Veterans Health Administration (VHA) started implementing a patient-centered medical home (PCMH) model—named Patient Aligned Care Teams (PACT)—across the nation in 2010. The PACT initiative focused on seven foundational principles: 1) creating patient-driven services, 2) offering team-based care, 3) increasing care efficiency, 4) providing comprehensive care including access to specialists, 5) developing longitudinal patient relationships, 6) improving communication, and 7) developing coordinate care. Key features of the PACT model hold promise to improve primary care and reduce avoidable utilization of resource-intensive services for vulnerable and high-need patient subpopulations. At the VHA, one such group is Veterans with Post-Traumatic Stress Disorder (PTSD), a condition with high prevalence among Veterans that is associated with combat trauma. To date, we are unaware of existing research that provides a comprehensive assessment of the effect of PTSD on utilization patterns across a range of utilization outcomes, utilizes a control group, or explores individual associations between PACT elements and utilization outcomes. This dissertation research seeks to address these knowledge gaps by addressing the following research questions: 1) What is the association between whether a Veteran with PTSD received care in the pre- or post-PACT period, and the quarterly utilization rates for key health services? 2) What is the effect of receiving care in a high-PACT implementation clinic on utilization patterns, compared to receiving care in a low-PACT implementation clinic? 3) What is the association between PACT elements and clinic-level utilization rates for hospitalizations and ED encounters for all eight PACT elements developed in the PI2: 1) Access, 2) Continuity, 3) Care Coordination, 4) Comprehensiveness, 5) Self-Management Support, 6) Patient-Centered Care and Communication, 7) Shared Decision Making, and 8) Delegation, Staffing and Team Functioning. Results from Chapter 2 indicate that Veterans receiving care in the post-PACT period experienced significantly lower utilization rates of hospitalizations and specialty care, and higher primary care rates. Results from Chapter 3 research indicate that Veterans that received care in VHA clinics with high levels of PACT implementation experienced decreased utilization rates for hospitalizations, specialty mental health, urgent care and emergency department (ED) utilization, compared to a low-level of PACT implementation. We did not find an increase in primary care rates in Chapter 3, and effect sizes for changes in utilization and mental health visits were modest. In Chapter 4, we found that high levels of Access, Comprehensive Care and Self-Management Support were associated with significantly lower ED utilization rates. We did not find any significant associations between PACT elements and hospitalization rates. This dissertation research provides ample evidence that PACT is driving changes in utilization patterns and reducing downstream utilization of resource-intensive health services. There is also some evidence that PACT is intensifying primary care, or potentially improving primary care, which is causing the subsequent decline in hospitalizations, and specialty, urgent and emergent care. Finally, this research sheds light on three PACT elements that were associated with decreases in ED utilization-- Access, Comprehensive Care and Self-Management Support—offering evidence to health systems and policymakers about high-impact interventions within the PCMH model.
- Health services