Lisa Meredith is a Senior Behavioral Scientist at the RAND Corporation, Professor, Pardee RAND Graduate School, and Research Scientist at the VA Center for the Study of Healthcare Innovation, Implementation & Policy in Santa Monica, California. Gulrez Azhar is a Senior Fellow, Futures Health Scenarios at the Institute for Health Metrics and Evaluation, University of Washington and an Adjunct Policy Researcher at RAND. Evelyn Chang is a Primary Care Physician and Health Services Researcher at VA Greater Los Angeles Health System (VAGLAHS) and an Assistant Clinical Professor in Health Sciences at University of California in Los Angeles (UCLA). Adeyemi Okunogbe is a Health Systems Specialist at RTI International, Washington, DC. Alissa Simon is a Health Science Specialist at the VAGLAHS. Bing Han is a Senior Statistician at the RAND Corporation in Santa Monica, California. Lisa Rubenstein is Professor Emeritus at UCLA Geffen School of Medicine and UCLA Fielding School of Public Health, and Physician Policy Researcher at RAND. Correspondence:Lisa Meredith (lisa_meredith@rand.org)
Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
In the multivariable regression analyses, we found that the primary care staff, which reported being more likely to use intensive management teams to help care for high-risk patients at time 1, reported significantly higher satisfaction (0.63 points higher on a 5-point scale) and intention to stay (0.41 points higher) at VA primary care (both P < .05) at time 2, 18 months later (Table 2). These effect sizes are equivalent to nearly two-thirds and half of a standard deviation, respectively. Among our control variables, years practicing in the VA was significantly associated with a lower likelihood of intent to stay at the VA. Models account for 28% of the variation in satisfaction and 22% of the variation in retention. The Figure shows the adjusted means based on parameters from the regression models for job satisfaction and intent to stay at the VA as well as likelihood of using an intensive management team for high-risk patients. Job satisfaction is nearly 1 point higher among those who report being likely to draw on support from an intensive management team to care for high-risk patients compared with those who reported that they were unlikely to use such a team. The pattern for intent to stay at the VA, while less pronounced, is similar to that for satisfaction.
Discussion
Our findings are consistent with our hypothesis that augmenting primary care with high-risk patient intensive management assistance would improve primary care staff job satisfaction and retention. Findings also mirror recent qualitative studies, which have found that systemic approaches to augment primary care of high-risk patients are likely needed to maintain well-being.7,19 We found a positive relationship between the likelihood of using intensive management teams to help care for their high-risk patients and reported job satisfaction and intent to continue to work within VA primary care 18 months later. To our knowledge, this study is the first to examine the potential impact on PCPs and nurses of using intensive management teams to help care for high-risk patients.
Our study suggests that this approach has the potential to alleviate PCP and nurse stress by incorporating intensive management teams as an extension of the medical home. Even high-functioning medical homes may find it challenging to meet the needs of their high-risk patients.3,7,8 Time constraints and a structured clinic schedule may limit the ability of medical homes to balance the needs of the general panel vs the individual needs of high-risk patients who might benefit from intensive services. Limited knowledge and lack of training to address the broad array of problems faced by high-risk patients also makes care challenging.2
Intensive management services often include interdisciplinary and comprehensive assessments, care coordination, health care system navigation, and linkages to social and home care services.20 Medical homes may benefit from these services, especially resources to support care coordination and communication with specialists and social services in large medical neighborhoods.21 For example, including a social worker on the intensive patient care team can help primary care staff by focusing specialized resources on nonmedical issues, such as chronic homelessness, substance use disorders, food insecurity, access to transportation, and poverty.18
Limitations
This study is subject to some limitations, including those typical of surveys, such as reliance on self-reported data. The longitudinal sample we studied had response rates that varied by site, participation in the pilot program, and gender relative to those who did not respond to both surveys; selection bias is possible. While we use a longitudinal cohort, we cannot attribute causality; it is possible that more satisfied staff are more likely to use intensive management teams rather than the use of intensive management teams contributing to higher satisfaction. Although each study site includes at least 1 type of intensive management resource, we cannot ascertain which intensive management resource primary care staff accessed, if any. While our sample size for the longitudinal cohort responders was limited, focusing on our longitudinal cohort provides more valid and reliable estimates than does using 2 cross-sectional samples with all responders. In addition, our models do not completely explain variation in the outcomes (R2= 0.28 and 0.22), although we included major explanatory factors, such as team staffing and professional type; other unmeasured factors may explain our outcomes. Finally, our provider sample may not generalize to HCPs in non-VA settings.
Conclusions
Our study expands on the limited data regarding the primary care staff experience of caring for high-risk patients and the potential impact of using interdisciplinary assistance to help care for this population. A strength of this study is the longitudinal cohort design that allowed us to understand staff receptivity to having access to intensive management resources to help care for high-risk patients over time among the same group of primary care staff. Given that an economic analysis has determined that the addition of the pilot intensive management program has been cost neutral to the VA, the possibility of its benefit, as suggested by our study findings, would support further implementation and evaluation of intensive management teams as a resource for PCPs caring for high-risk patients.22
Understanding the mechanisms by which primary care staff benefit most from high-risk patient assistance, and how to optimize communication and coordination between primary care staff and intensive management teams for high-risk patients might further increase primary care satisfaction and retention.
