Can Using an Intensive Management Program Improve Primary Care Staff Experiences With Caring for High-Risk Patients?

Patients with complex medical and psychosocial needs are at the highest risk for fragmented care and adverse health outcomes.^1,2 Although these high-risk patients make up only about 5% of the US patient population, they can account for as much as half of total health care costs.¹ High-risk patients are complicated to treat because most have multiple chronic medical conditions, and many have a wide variety of psychological and social needs. Thus, physician, physician assistant, and nurse practitioner primary care providers (PCPs), and nurses (registered nurses, licensed vocational nurses, and licensed practical nurses) must address the complexity of the human condition in conjunction with health problems.²

Background

Caring for high-risk patients within a tight clinic schedule geared to the provision of comprehensive care to large panels of less complex patients can be a source of stress for PCPs and nurses.^3-5 These conditions may lead to reduced well-being among primary care team members and to potential turnover.⁶ Furthermore, primary care staff may feel uncomfortable or lack the ability to address nonmedical concerns because of “person-specific factors that interfere with the delivery of usual care and decision making for whatever condition the patient has.”^7,8 Having additional support for complex patients, such as intensive outpatient management teams, may be protective both by reducing health care provider (HCP) stress and improving patient outcomes.^3,4

Caring for high-risk patients is challenging.^9-11 High-risk patient care may require additional, often unpaid, work hoursand may be discouraging because these patients can be difficult to engage in care.^7,12 Furthermore, high-risk patient care is challenging for primary care teams, since these complex patients may fall through the cracks and experience potentially preventable hospitalization or even death. Avoiding these negative consequences typically requires substantial time for the primary care team to engage and counsel the patient, family, and caregiver, through more frequent visits and additional communication. Furthermore, the primary care team typically must coordinate with other HCPs and resources—as many as 16 in a single year and as much as 12 for a single patient over an 80-day period.^13,14 Not surprisingly, primary care teams identify help with care coordination as a critical need that may be addressed with intensive management support.

Primary care at the US Department of Veterans Affairs (VA) Veterans Health Administration (VHA) provides care for a large proportion of high-risk patients.¹⁵ Accordingly, VHA provides a variety of intensive management options for equipping primary care teams with expanded resources for caring for high-risk patients, including those offered in a few sites by a pilot intensive management program.¹⁶ As part of the pilot’s evaluation, we studied the work experiences of PCPs and nurses, some of whom had experienced the pilot program and some of whom only had access to typical VHA intensive management resources, such as telehealth and specialty medical homes (referred to in the VA as patient aligned care teams, or PACT), eg, for women patients, for patients who are homeless, or for older adults.¹⁷ Surveys assessed whether HCPs who indicated they were likely to seek help from PACT intensive management (PIM) teams to care for high-risk patients had higher job satisfaction and intention to stay at VHA compared with those who were not likely to seek help.

While substantial research on high-risk patients’ intensive management needs has focused on patient-level outcomes of interventions for meeting those needs,little research has examined links between primary care team access to intensive management resources and experiences, such as job satisfaction and job retention.¹⁸ In the work presented here, our objectives were to (1) assess the likelihood that a PCP or nurse intent to manage high-risk patients by seeking care coordination help from or transferring care to an intensive management team; and (2) evaluate the relationship between PCP or nurse intentions regarding using intensive management help for high-risk patients and their job satisfaction and likelihood of leaving VA primary care. We hypothesized that the accessibility of intensive management resources and PCP and nurse receptivity to accessing those resources may affect job-related experiences.

Methods

This study was conducted as part of the evaluation of a VA pilot project to provide general primary care teams with intensive management support from interdisciplinary teams for high-risk patients in 5 VHA systems in 5 states (Ohio, Georgia, North Carolina, Wisconsin, and California).⁶ We sampled primary care staff at 39 primary care clinics within those systems, all of whom had access to VA intensive management resources. These included telehealth, health coaches, integrated mental health providers, and specialty PACTs for specific populations (eg, those who are women, elderly, homeless, HIV-positive, or who have serious mental illness). Of the 39 primary care clinics that participated in the survey, 8 also participated in the pilot program offering an intensive management team to support general primary care in their care of high-risk patients.