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. 2021 May 23;37(1):40–48. doi: 10.1007/s11606-021-06884-5

Association of Team-Based Care and Continuity of Care with Hospitalizations for Veterans with Comorbid Mental and Physical Health Conditions

Hayley D Germack 1,2,✉, Lucinda Leung 3,4, Xinhua Zhao 2, Hongwei Zhang 2, Grant R Martsolf 1,5
PMCID: PMC8739416  PMID: 34027614

Abstract

Background

Integrating mental health in primary care settings is associated with improved screening and detection of mental illness. In 2010, the Veterans Health Administration launched a patient-centered medical home (PCMH) model nationally across all clinical sites that integrated mental health into primary care—the Patient Aligned Care Team (PACT) initiative. Team-based delivery of continuous primary and mental health care, as found in effective collaborative care models, is thought to be crucial to managing veterans with mental health disorders. The association between clinic implementation of specific aspects of PACT and clinical outcomes of veterans with mental health disorders remains unknown.

Objective

To examine the association between clinic implementation of team-based care and continuity of care and subsequent hospitalizations among veterans with mental health disorders.

Design

Retrospective cohort study.

Patients

A total of 1,444,942 veterans with comorbid mental health disorders and physical health conditions receiving primary care in 831 VA PACT clinics in fiscal year (FY) 2015.

Main Measures

We examined the clinic-level implementation of team-based care and continuity of care in the clinic where veterans received their primary care. Our primary outcome was any hospitalization in the VA or fee-based service in FY2016. We examined the impact of clinic-level implementation of team-based care and continuity of care on having a hospitalization, adjusting for patient demographic, clinical characteristics, and facility characteristics.

Key Results

Veterans receiving care in clinics with the greatest versus lowest quartile of implementation of team-based care had lower rates of hospitalization (8.8% vs. 12.3%; adjusted OR = 0.92, 95% CI 0.85–0.99, p < 0.035). There was not a statistically significant association between clinic-level implementation of continuity of care and hospitalization.

Conclusions

Veterans receiving care in clinics with greater implementation of team-based care had statistically significant lower rates of hospitalization.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11606-021-06884-5.

KEY WORDS: mental health, veterans, hospitalization, comorbid conditions, primary care

INTRODUCTION

People with mental health conditions are at risk for poor physical health outcomes including premature mortality and hospitalization for ambulatory care sensitive conditions (ACSCs).1 In fact, people with serious mental illness (SMI; i.e., major depression, bipolar disorder, schizophrenia, and posttraumatic stress disorder [PTSD])2 have mortality rates two to three times higher than the general US population, largely due to cardiovascular disease.3,4 Mental health conditions are persistent and debilitating, affecting every aspect of life, including effective self-management of chronic medical conditions.5 Collaborative care models featuring integrated mental health in primary care settings can improve screening and detection of mental health conditions6–8 and improve chronic comorbid physical health conditions in people with mental health conditions.9,10 These models are especially important for the care of those with mental health conditions and comorbid physical health conditions because of the unique challenges these individuals encounter.11 Further, team-based care models specifically (i.e., provision of comprehensive health services by at least two health professionals who work collaboratively with the patient, and a key feature of collaborative care models) have been associated with improved physical health outcomes including chronic disease management in people with mental health conditions.12–15 Team-based care and the associated enhanced continuity of care (i.e., a sustained relationship between patients and their provider) are hallmarks to collaborative care.16

Central to a collaborative and team-based care approach involving nurse care managers, social workers, and pharmacists is continuity of care.17 The Veterans Health Administration (VHA) is an ideal venue for studying the relationship between team-based care and continuity of care and health outcomes for people with mental health conditions for several reasons. For one, it is a major health-care delivery system with 9 million enrolled veterans receiving primary care at more than 1000 clinics.18 Second, in 2010, it launched a patient-centered medical home (PCMH) model nationally across all clinical sites through the Patient Aligned Care Team (PACT) initiative.19 The goal of PACT is to use teams and non-face-to-face care to provide continuous, accessible, comprehensive access to primary care patients across the country while decreasing unnecessary emergency department (ED) use and costly hospitalizations.19,20 Lastly, a high proportion of veterans using VHA services have mental health conditions.21 PACT provides staffing and resources to primary care providers including care managers and integrated mental health specialists to jointly treat low-to-moderately severe mental health conditions in primary care.22

Given PACT’s expansion of mental health services in primary care, research has examined the impact of PACT on health outcomes for veterans with mental health disorders. Researchers examining health service use before and after PACT implementation have identified mixed outcomes among veterans with mental illness. One study identified increases in ACSC hospitalizations among younger veterans with mental illness and decreases in ACSC hospitalization among older veterans with mental illness after the implementation of PACT.23 Among veterans specifically with PTSD, PACT implementation has been associated with a 8.6% decrease in hospitalizations.24

However, there has been great variation in the adoption of all PACT components across VA outpatient clinics.25,26 Clinics have implemented different components of PACT to varying degrees.27,28 Although greater implementation of the PACT overall has been associated with a decrease in ACSC hospitalizations25 and, specifically, greater implementation in the component of continuity of care has been associated with fewer hospitalizations,29 little is known about the impact of specific PACT components on health outcomes among veterans with mental health conditions. In this study, we examine the relationship between two components of PACT implementation—team-based care and continuity of care—and acute care hospitalization among veterans with mental health conditions.

METHODS

Data Sources and Study Population

This retrospective cohort study is the result of VA evaluation efforts that are part of ongoing quality improvement at the VHA and are not considered research activity. Thus, this study, which follows STROBE guidelines, is not subject to institutional review board review or waiver. The primary data sources were originally obtained to examine the impact of PACT implementation using evidence-based quality improvement.30,31 We additionally linked the national patient-level data for fiscal years (FYs) 2015 and 2016 (October 1, 2014, to September 30, 2016) from the VA Corporate Data Warehouse (CDW), including inpatient, outpatient, and fee-based services files, to extract patient demographics, diagnosis codes, and hospitalizations.

Eligible veterans were VA primary care users (i.e., veterans who had at least one visit in FY15) who were alive and 18 years or older in the study year of FY16 (n = 5,816,348). To understand the impact of PACT implementation on veterans with mental health disorders and comorbid physical health conditions, the sample was restricted to veterans with baseline (FY15) diagnostic data including a mental health condition (major depressive disorder, psychosis/schizophrenia, bipolar disorder, anxiety, and posttraumatic stress disorder [PTSD]; ICD-9 codes in the Appendix) and a comorbid physical health condition (Alzheimer’s disease or related dementia; diabetes; hypertension; chronic heart failure; coronary artery disease; chronic pain; chronic and acute renal failure; liver disease; chronic hepatitis; chronic arthritis; cardiac arrhythmia; clotting disorder; anemia; peripheral vascular disease; chronic pulmonary disease; cerebrovascular disease; thyroid disorder; myoneural disorder; malignant tumor; malignant neoplasms; weight loss; and fluid or electrolyte disorders; ICD-9 codes in the Appendix) who had at least one visit to a clinic in FY15 (n = 1,542,699). We excluded patients who received hospice or palliative care in FY15 and/or FY16 (n = 24,114) or received care at a clinic missing a PACT implementation Progress Index (Pi2) and sub-domain scores in FY15 (n = 73,843). We identified 1,444,942 veterans from 831 VA facilities included in the analysis (Fig. 1).

Figure 1.

Figure 1

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Derivation of analytic cohort.

Measures

Main Outcomes

Our main outcome was a hospitalization from any cause during FY16. Hospitalizations were identified from the Acute Care (e.g., Hospitals) of VA Medical SAS datasets (MedSAS) and fee-basis source using the Fee Purpose of Visit (FPOV) variable (i.e., a unique variable not found in the traditional VA inpatient and outpatient datasets).

Main Predictor

Our main predictors were clinic implementation of team-based care and continuity of care, defined as clinic performance on two domains of the Pi2, a validated method to assess PCMH implementation, which has been described previously.23,32 The team-based care domain was calculated using clinic-level standardized mean scores on 18 items from the PACT Primary Care Personnel Survey from FY2012 to FY2014. Examples of survey questions used to create the team-based care measure included clinician responses to “Primary care provider relies on registered nurse care manager for tasks including gathering patient preventive services, responding to prescription refills” and “Time spent in team huddles.”25 Variables were standardized using national means.

The continuity of care domain was calculated using clinic-level standardized mean scores on one response from the CAHPS-PCMH survey (specifically, “How long have you been going to this provider” with five responses ranging from less than 6 months to 5 years or more) and two responses from administrative data (the proportion of total primary care encounters that are with the assigned primary care provider and the mean number of assigned primary care providers per patient).29 Variables were standardized using national means.

For ease of interpretation, for those two main predictors, we separately grouped the clinics into quartiles based on their “continuity of care” and “team-based case” subscale implementation and compared patients from clinics in the upper and lower quartiles of implementation. Specifically, we calculated the mean facility-level response for each individual variable. In order to combine variable responses and include sites with missing data, we standardized the responses by subtracting the national level mean from the facility mean and dividing by the standard deviation (SD) for all facilities. We calculated domain scores for each site by taking the average of these standardized responses.

Covariates

Our study controlled for patient characteristics potentially affecting acute care utilization that were measured in the baseline year (FY2015) including age, gender, race/ethnicity, driving distance from the home address to the assigned primary care clinic, and homelessness.1,23,33–35 Patient comorbidity was measured using the Gagne Comorbidity Score36 and separate indicators for serious mental illness and drug or alcohol use disorders. In addition to the patient characteristics, we adjusted for several clinic-level characteristics measured in the baseline year that could influence acute care utilization. Clinic type was characterized as hospital-based (i.e., VA Medical Center-based) and community-based. Clinic rurality was defined based on the residence of the majority of the patients attending the clinic using Rural Urban Commuting Area (RUCA) codes.37 The clinic’s Census region was defined as Midwest, Northeast, South, or West by mapping the county code of the facility to the 2014 and 2015 Area Health Resource Files.

Analysis

We described the patient characteristics, comorbidities, and facility-level characteristics overall and by the lower and upper quartiles of clinic implementation of team-based care and continuity of care. We used the chi-square test for categorical variables and Wilcoxon rank-sum test for continuous variables to compare baseline characteristics.

To examine the association between clinic implementation of team-based care and continuity of care and the rate of acute care hospitalizations, we firstly described the rate of acute care hospitalizations by quartiles of the two predictors and compared the group difference using chi-square test. We then used random-effect logistic regression models with robust standard errors clustered at the facility level to account for grouping of patients within the same facility.38 We ran models in three steps: (1) univariate analyses first; (2) multivariable analyses adjusting for patient-level covariates, including age, gender, race/ethnicity, Gagne Comorbidity Score, driving distance from the home address to the assigned primary care clinic, having a diagnosis of serious mental illness, drug use disorder, alcohol use disorder, and homelessness; and (3) the multivariable analyses adjusting for patient-level covariates and the clinic characteristic of clinic type, rural location, and census region. To account for missing data in covariates (gender for 19 patients, race for 4.4%, rural 0.9%, census region 0.1%, and driving distance 0.3%, a total of 5.4% patients with any missing data), we used multiple imputation by chained equations (MICE) across 5 multiply imputed datasets.39

In sensitivity analyses, we examined the outcomes of psychiatric hospitalizations and acute care hospitalizations using VA data only (as the fee-basis data did not have diagnoses to classify hospitalizations as psychiatric or acute). Analyses were performed using SAS version 9.4 (SAS Institute Inc., Cary, NC) and STATA 14 (College Station, TX).

RESULTS

Table 1 displays the characteristics of the 1,444,942 veterans with comorbid mental illness and physical health conditions receiving care in PACT in FY15, overall and by clinic-level implementation of team-based care and continuity of care. Most veterans were non-Hispanic White (64.9%) men (88%) under the age of 65 (59.4%). The most common physical health comorbidities were chronic pain (80.1%), hypertension (56.8%), chronic arthritis (48.7%), diabetes (27.7%), and chronic pulmonary disease (17.9%). The most common mental health comorbidities were major depressive disorder (66%), posttraumatic stress disorder (44.5%), and anxiety (34.9%). 13.7% had a comorbid alcohol abuse diagnosis and 13% had a comorbid drug abuse diagnosis. Compared to veterans receiving care in the bottom quartile of team-based care, those receiving care in the top quartile were slightly older (58.2 years versus 57.6 years; p < 0.001), a bigger proportion were male (90.4% vs. 88%; p < 0.001), a greater proportion were less racially diverse (66.8% vs. 60.6% non-Hispanic White; p < 0.001), and a greater proportion were married (55.4% vs. 46.5%; p < 0.001). Veterans receiving care in clinics with the highest level of team-based care were less likely to be homeless (3.3% vs. 7.4%; p < 0.001), and healthier with a larger proportion of veterans falling into the bottom 33% of the Gagne comorbidity score (35.1% vs. 21.8%; p < 0.001). These differences were similar between veterans receiving care in clinics in the top and bottom quartiles of continuity of care.

Table 1.

Characteristics of Veterans Overall and by Clinic Implementation of Team-Based Care and Continuity of Care (N = 1,444,942)

Characteristics Stratified by implementation of team-based care Stratified by implementation of continuity of care
All clinics Lowest quartile Highest quartile P value Lowest quartile Highest quartile P value
N = 1,444,942 N = 360,917 N = 219,649 N = 304,130 N = 206,967
Age, years (mean, SD) 57.6 (15.1) 57.6 (15.1) 58.2 (15.2) < .0001 57.6 (14.9) 59.3 (15.1) < .0001
Age (n, %)
18 to 44 303,886 (21) 75,634 (21) 45,290 (20.6) < .0001 63,122 (20.8) 37,580 (18.2) < .0001
45 to 54 221,424 (15.3) 56,164 (15.6) 31,705 (14.4) 46,740 (15.4) 28,437 (13.7)
55 to 64 333,289 (23.1) 85,925 (23.8) 47,237 (21.5) 71,355 (23.5) 45,330 (21.9)
65 to 74 453,981 (31.4) 110,222 (30.5) 74,161 (33.8) 96,655 (31.8) 72,382 (35)
75 to 84 90,290 (6.2) 21,938 (6.1) 14,836 (6.8) 18,177 (6) 15,362 (7.4)
85+ 42,072 (2.9) 11,034 (3.1) 6420 (2.9) 8081 (2.7) 7876 (3.8)
Sex (n, %)*
Female 161,817 (11.2) 43,203 (12) 21,138 (9.6) < .0001 35,103 (11.5) 18,325 (8.9) < .0001
Male 1,283,106 (88.8) 317,710 (88) 198,509 (90.4) 269,020 (88.5) 188,641 (91.1)
Race/ethnicity (n, %)*
Non-Hispanic White 937,238 (64.9) 218,860 (60.6) 146,638 (66.8) < .0001 200,865 (66) 150,619 (72.8) < .0001
Non-Hispanic Black 268,221 (18.6) 82,907 (23) 27,153 (12.4) 48,053 (15.8) 28,397 (13.7)
Hispanic 118,220 (8.2) 28,155 (7.8) 26,477 (12.1) 27,314 (9) 12,861 (6.2)
Non-Hispanic other 57,844 (4) 14,087 (3.9) 9672 (4.4) 13,648 (4.5) 6609 (3.2)
Marital status (n, %)*
Never married, single, common-law 204,497 (14.2) 61,826 (17.1) 25,410 (11.6) < .0001 43,191 (14.2) 27,836 (13.4) < .0001
Married 727,588 (50.4) 167,851 (46.5) 121,775 (55.4) 151,082 (49.7) 108,279 (52.3)
Divorced, separated, or widowed 494,188 (34.2) 126,730 (35.1) 69,172 (31.5) 105,898 (34.8) 68,284 (33)
Homeless (n, %) 85,581 (5.9) 26,548 (7.4) 7321 (3.3) < .0001 20,962 (6.9) 9309 (4.5) < .0001
Gagne Comorbidity Score (mean, SD) 0.6 (0.2) 0.7 (0.2) 0.6 (0.2) < .0001 0.7 (0.2) 0.6 (0.2) < .0001
Gagne Comorbidity score category (n, %)
Bottom 33% of Gagne scores 315,157 (21.8) 78,610 (21.8) 77,179 (35.1) < .0001 64,778 (21.3) 63,582 (30.7) < .0001
Middle 33% of Gagne scores 727,504 (50.3) 142,956 (39.6) 110,997 (50.5) 135,493 (44.6) 102,562 (49.6)
Upper 33% of Gagne scores 402,281 (27.8) 139,351 (38.6) 31,473 (14.3) 103,859 (34.1) 40,823 (19.7)
Average distance traveled to clinic, miles (mean, SD)* 15.4 (14.7) 13.5 (14.2) 15.9 (15.5) < .0001 15.6 (15.7) 14.8 (13.8) < .0001
Mental health disorders
Major depressive disorder 954,683 (66.1) 237,644 (65.8) 144,289 (65.7) 0.231 200,118 (65.8) 134,574 (65) < .0001
Posttraumatic stress disorder (PTSD) 642,862 (44.5) 163,727 (45.4) 99,653 (45.4) 0.9702 141,845 (46.6) 88,308 (42.7) < .0001
Anxiety 503,761 (34.9) 120,077 (33.3) 77,025 (35.1) < .0001 103,634 (34.1) 72,573 (35.1) < .0001
Psychosis/schizophrenia 172,769 (12) 44,921 (12.4) 22,553 (10.3) < .0001 37,516 (12.3) 21,785 (10.5) < .0001
Bipolar disorder 111,413 (7.7) 28,363 (7.9) 14,988 (6.8) < .0001 23,904 (7.9) 15,075 (7.3) < .0001
Mental health diagnosis and alcohol abuse 198,215 (13.7) 55,223 (15.3) 25,370 (11.6) < .0001 42,534 (14) 26,318 (12.7) < .0001
Mental health diagnosis and drug abuse 187,328 (13) 52,682 (14.6) 22,442 (10.2) < .0001 40,335 (13.3) 23,969 (11.6) < .0001
Selected physical health comorbidities with prevalence of 10%+
Chronic pain 1,157,895 (80.1) 288,419 (79.9) 171,766 (78.2) < .0001 244,908 (80.5) 159,142 (76.9) < .0001
Chronic arthritis 704,192 (48.7) 174,187 (48.3) 102,953 (46.9) < .0001 147,109 (48.4) 95,211 (46.0) < .0001
Hypertension 820,073 (56.8) 200,487 (55.5) 127,049 (57.8) < .0001 171,093 (56.3) 119,841 (57.9) < .0001
Chronic pulmonary disease 258,951 (17.9) 62,364 (17.3) 38,734 (17.6) 0.0005 55,458 (18.2) 38,389 (18.5) 0.0045
Diabetes 400,661 (27.7) 96,344 (26.7) 63,146 (28.7) < .0001 84,224 (27.7) 58,866 (28.4) < .0001
Coronary artery disease 219,495 (15.2) 50,844 (14.1) 34,572 (15.7) < .0001 45,698 (15.0) 35,687 (17.2) < .0001
Thyroid disorders 144,511 (10.0) 34,768 (9.6) 22,541 (10.3) < .0001 31,528 (10.4) 21,483 (10.4) 0.8784
Cardiac arrhythmias 143,060 (9.9) 36,199 (10.0) 20,175 (9.2) < .0001 31,942 (10.5) 21,344 (10.3) 0.0291
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*Missing data: sex for 19 veterans (0.001%); race/ethnicity for 63,419 veterans (4.4%); marital status for 18,669 veterans (1.3%); and driving distance for 4304 veterans (0.3%)

Table 2 displays the characteristics of the 831 PACT clinics providing care to the veterans in our sample overall and by clinic-level implementation of team-based care and continuity of care. Most clinics were community-based outpatient centers (80.4%) located in the South (34.8%) with no primary care mental health integration (56.1%). Forty-one percent were located in rural areas. Compared to clinics in the bottom quartile of team-based care implementation, a much greater proportion of those in the top quartile were community-based as opposed to hospital-based (96.2% vs. 78.7%; p < 0.001) and less likely to be located in the South (40.4% vs. 58%; p = 0.0181). Differences were similar between clinics in the bottom and top quartiles of continuity of care.

Table 2.

Characteristics of PACT Clinics, Overall and by Clinic Implementation of Team-Based Care and Continuity of Care, N = 831

Clinic characteristics Stratified by implementation of team-based care Stratified by implementation of continuity of care
All clinics Lowest quartile Highest quartile P value Lowest quartile Highest quartile P value
N = 831 N = 207 N = 208 N = 207 N = 208
Rural location (n, %)* 341 (41) 70 (33.8) 102 (49) 0.001 107 (51.7) 103 (49.5) 0.3488
Clinic type (n, %)
Community-based 668 (80.4) 163 (78.7) 200 (96.2) <.0001 164 (79.2) 198 (95.2) < .0001
Hospital-based 163 (19.6) 44 (21.3) 8 (3.8) 43 (20.8) 10 (4.8)
Census region (n, %)* 0.0181 < .0001
Midwest 218 (26.2) 51 (24.6) 54 (26) 52 (25.1) 66 (31.7)
Northeast 156 (18.8) 49 (23.7) 31 (14.9) 16 (7.7) 67 (32.2)
South 289 (34.8) 58 (28) 84 (40.4) 83 (40.1) 53 (25.5)
West 166 (20) 48 (23.2) 38 (18.3) 54 (26.1) 22 (10.6)
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*Missing data: census region for 12,712 veterans (0.88%) from 38 clinics, and rural location for 1462 veterans (0.1%) from 2 clinics

Figure 2 displays unadjusted veteran hospitalization rates by quartiles of team-based care and continuity of care. Veterans consistently had lower hospitalization rates when they received care in clinics with greater implementation of team-based care and continuity of care (p < 0.001). 9.5% and 8.8% of veterans receiving care in clinics in the highest implementation of continuity of care and team-based care, respectively, were hospitalized. Comparatively, 11.6% and 12.3% of veterans receiving care in clinics with the lowest implementation of continuity of care and team-based care, respectively, were hospitalized.

Figure 2.

Figure 2

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Veteran hospitalization rates, by quartiles of team-based care and continuity of care.

Table 3 displays the odds of hospitalization for veterans receiving care in PACT by clinic-level implementation of team-based care and continuity of care, with the lowest quartile of implementation being the reference category. In the univariate model, veterans receiving care in clinics with the highest quartile of team-based care and continuity of care had lower odds of hospitalization compared to lowest implementation (OR = 0.69, p < 0.001; OR = 0.80; p = 0.001). After controlling for patient and facility characteristics, veterans receiving care in clinics with the highest quartile of team-based care and continuity of care had lower odds of hospitalization (OR = 0.88, p = 0.01; OR = 0.90, p = 0.01, respectively). After controlling for patient and facility-level characteristics, only the relationship between implementation of the highest quartile of team-based care and hospitalization remained significant (OR = 0.92; p = 0.035).

Table 3.

Relationship Between Implementation of Team-Based Care and Continuity of Care Implementation and Hospitalization (N = 1,444,942 patients)

Team-based care Continuity of care
OR (95% CI) P value OR (95% CI) P value
Model 1: univariate model
Lowest quartile Reference
2nd quartile 0.94 (0.85, 1.04) 0.24 0.98 (0.88, 1.10) 0.81
3rd quartile 0.87 (0.78, 0.97) 0.01 0.96 (0.86, 1.08) 0.50
Highest quartile 0.69 (0.60, 0.79) < 0.001 0.80 (0.69, 0.91) 0.001
Model 2: multivariable model adjusted for patient-level covariates*
Lowest quartile Reference
2nd quartile 1.01 (0.95, 1.08) 0.74 1.01 (0.94, 1.08) 0.81
3rd quartile 0.96 (0.90, 1.03) 0.24 1.02 (0.95, 1.10) 0.555
Highest quartile 0.88 (0.80, 0.97) 0.01 0.90 (0.84, 0.97) 0.01
Model 3: multivariable model adjusted for patient and facility-level covariates†
Lowest quartile Reference
2nd quartile 0.99 (0.93, 1.05) 0.71 1.00 (0.95, 1.06) 0.93
3rd quartile 0.94 (0.89, 0.999) 0.05 1.02 (0.96, 1.08) 0.57
Highest quartile 0.92 (0.85, 0.99) 0.035 1.01 (0.94, 1.08) 0.89
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*Model 2: multivariable analyses adjusting for patient-level covariates, including age, gender, race/ethnicity, Gagne Comorbidity Score, driving distance from the home address to the assigned primary care clinic, having a diagnosis of serious mental illness, drug use disorder, alcohol use disorder, homelessness

†Model 3: multivariable analyses adjusting for patient-level covariates in model 2 above and additionally adjusted the clinic characteristic of clinic type, rural location, and census region

The Appendix contains the results of our sensitivity analysis, in which we examined the outcomes of psychiatric hospitalization and acute care hospitalization using VA data only. In the fully controlled models, we did not identify a significant relationship between clinic-level implementation of team-based care and continuity of care and psychiatric and acute care hospitalizations.

DISCUSSION

In this retrospective cohort study of 1,444,942 veterans with comorbid mental and physical health conditions receiving primary care at 831 clinics in FY15, we observed that clinic implementation of team-based care was significantly associated with the veteran’s odds of acute care hospitalization. Veterans receiving care in clinics with the higher levels of team-based care implementation had lower odds of hospitalization. We did not observe a significant relationship between acute care hospitalization and clinic implementation of continuity of care. It appears that team-based care impacts both the physical and mental health of the veteran as acute care hospitalizations included both physical and mental health hospitalizations.

Our findings about decreased odds of hospitalization being associated with greater implementation of team-based care among veterans with mental health disorders align with and add to the existing literature. The implementation of the overall PACT model has been associated with decreases in hospitalizations among veterans with PTSD40 and decreases in ambulatory care sensitive condition–related hospitalizations in older veterans with mental illness.23 It has also been associated with improved quality of primary care for Veterans with mental illness.41 Contrary to our study, which did not detect an association between hospitalizations and continuity of care, two other studies found that among veterans receiving care in PACT, continuity of care was associated with fewer hospitalizations and ACSC hospitalizations29 and a lower likelihood of admission in the subsequent year.42 However, neither of these studies focused on veterans with mental health disorders and one defined continuity of care as the proportion of visits made to the assigned primary care provider,42 whereas we used a more comprehensive measure including visits with the assigned provider, time engaged with the provider, and mean number of assigned primary care providers.

Our finding about lower odds of hospitalization among veterans with comorbid mental and physical health conditions receiving care in clinics with greater implementation of team-based care contradicts a previous study, in which researchers found no association between team-based care and hospitalization in the general population.29 This suggests that perhaps veterans with mental health disorders disproportionately benefit from practices with greater implementation of team-based care. This has important implications for the design of PACT services specifically for veterans with mental health disorders. The SMI-PACT model, for example, builds upon the traditional VA PACT model by tailoring and intensifying physical health management and psychiatric care integration for patients with SMI through decreased panel size to allow for longer visits and proactive phone panel management.43 There is currently a hybrid implementation-effectiveness study underway to examine the impact of SMI-PACT on provision of preventive and medical treatment, health-related quality of life, satisfaction with care, and medical and mental health treatment utilization and costs among veterans with SMI.43

There were several limitations identified in this study. First, our results are based on observational, cross-sectional associations and therefore may not reflect causal connections. It is possible that other unobserved confounders including other clinic investments correlated with team-based care may explain the association between clinic implementation of team-based care and acute care utilization. Secondly, we relied on the accuracy of the diagnosis codes used. Coding accuracy may suffer due to the limited precision of codes to describe conditions in detail. Thirdly, our findings did not incorporate services paid for by Medicare or private insurers, which accounts for a non-negligible proportion of veterans.44 This may lead to underestimates of acute care utilization. Further, our findings are not necessarily generalizable to broad patient populations because the veteran population is, on average, older than the general population and heavily male, and has higher rates of mental illness and comorbidities.45 Additionally, the findings from this study are relevant to systems that have attempted to institute team-based care. It is possible that partially implemented team-based care is more effective than none at all. Moreover, this study was conducted in a system that is relatively resource-rich in comparison with other systems that may not have access to services including social work, nutrition, pharmacy, and mental health. Finally, the estimates of team-based care’s and continuity of care’s effects are likely conservative because we are estimating the effect of a veteran receiving care in a high-implementation clinic compared with a low-implementation clinic and not the presence or absence of team-based care or care continuity. Despite these limitations, this study has several strengths including the large sample size and the ability to use VA’s extensive CDW data. We also considered and adjusted for multiple variables with significant clinical impact. Additionally, a strength of our study is that we captured both internal VA and external fee-basis data. Future research should characterize veterans’ acute care use using both VA and non-VA facilities to better characterize health-care utilization patterns.

CONCLUSION

This study contributes to our understanding of how clinic organizational factors influence acute care use for veterans with mental health disorders and comorbid chronic physical health conditions. The lower odds of hospitalization among veterans receiving care with higher implementation of team-based care suggests that this important aspect of the patient-centered medical home may be particularly impactful on this vulnerable group of veterans. Specifically, tailoring PACT to the needs of veterans with mental health disorders, through increased attention to team-based care, could improve outcomes for this vulnerable population.

Supplementary Information

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(DOCX 43 kb)

Acknowledgements

Contributors: Ann-Marie Rosland, MD; Ranak Trivedi, PhD; Erin Jaske, MPH MA

Funding

Veterans Affairs Pittsburgh Healthcare System Center for Health Equity Research and Promotion Competitive Pilot Project Program

Compliance with Ethical Standards

Conflict of Interest

Authors HDG, LL, XZ, HZ, and GRM have no conflicts of interst to report.

Footnotes

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