Use of General Primary Care, Specialized Primary Care, and Other Veterans Affairs Services Among High-Risk Veterans | Psychiatry and Behavioral Health | JAMA Network Open | JAMA Network
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    Original Investigation
    Health Policy
    June 29, 2020

    Use of General Primary Care, Specialized Primary Care, and Other Veterans Affairs Services Among High-Risk Veterans

    Author Affiliations
    • 1Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, California
    • 2Division of General Internal Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California
    • 3Division of General Internal Medicine, David Geffen School of Medicine at UCLA (University of California at Los Angeles), Los Angeles
    • 4Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
    • 5Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
    • 6Seattle-Denver Health Services Research & Development Center of Innovation, VA Puget Sound Healthcare System, Seattle, Washington
    • 7General Internal Medicine Service, VA Puget Sound Healthcare System, Seattle, Washington
    • 8Department of Medicine, University of Washington, Seattle
    • 9Department of Health Services, University of Washington, Seattle
    • 10VA Pittsburgh Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania
    • 11Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
    • 12VA Greater Los Angeles Geriatric Research, Education and Clinical Center, Los Angeles, California
    • 13UCLA Multicampus Program in Geriatric Medicine and Gerontology, Los Angeles, California
    • 14VA Office of Clinical Systems Development & Evaluation, Washington, DC
    • 15Fielding School of Public Health, UCLA, Los Angeles, California
    • 16RAND Corporation, Santa Monica, California
    JAMA Netw Open. 2020;3(6):e208120. doi:10.1001/jamanetworkopen.2020.8120
    Key Points español 中文 (chinese)

    Question  Within the Veterans Health Administration, what is the role of general primary care, specialized primary care, mental health, and medical specialty services in caring for veterans at high risk for hospitalization?

    Findings  In this cross-sectional study, veterans at high risk for hospitalization had significantly more mental health encounters than primary care encounters and significantly more primary care encounters than medical specialty encounters. Most high-risk veterans (88%) were cared for in general primary care rather than in specialized primary care.

    Meaning  The findings suggest that health care system leaders should recognize the critical roles of general primary care and mental health for high-risk patients.


    Importance  Integrated health care systems increasingly focus on improving outcomes among patients at high risk for hospitalization. Examining patterns of where patients obtain care could give health care systems insight into how to develop approaches for high-risk patient care; however, such information is rarely described.

    Objective  To assess use of general and specialized primary care, medical specialty, and mental health services among patients at high risk of hospitalization in the Veterans Health Administration (VHA).

    Design, Setting, and Participants  This national, population-based, retrospective cross-sectional study included all veterans enrolled in any type of VHA primary care service as of September 30, 2015. Data analysis was performed from April 1, 2016, to January 1, 2019.

    Exposures  Risk of hospitalization and assignment to general vs specialized primary care.

    Main Outcome and Measures  High-risk veterans were defined as those who had the 5% highest risk of near-term hospitalization based on a validated risk prediction model; all others were considered low risk. Health care service use was measured by the number of encounters in general primary care, specialized primary care, medical specialty, mental health, emergency department, and add-on intensive management services (eg, telehealth and palliative care).

    Results  The study assessed 4 309 192 veterans (mean [SD] age, 62.6 [16.0] years; 93% male). Male veterans (93%; odds ratio [OR], 1.11; 95% CI, 1.10-1.13), unmarried veterans (63%; OR, 2.30; 95% CI, 2.32-2.35), those older than 45 years (94%; 45-65 years of age: OR, 3.49 [95% CI, 3.44-3.54]; 66-75 years of age: OR, 3.04 [95% CI, 3.00-3.09]; and >75 years of age: OR, 2.42 [95% CI, 2.38-2.46]), black veterans (23%; OR, 1.63; 95% CI, 1.61-1.64), and those with medical comorbidities (asthma or chronic obstructive pulmonary disease: 33%; OR, 4.03 [95% CI, 4.00-4.06]; schizophrenia: 4%; OR, 5.14 [95% CI, 5.05-5.22]; depression: 42%; OR, 3.10 [95% CI, 3.08-3.13]; and alcohol abuse: 20%; OR, 4.54 [95% CI, 4.50-4.59]) were more likely to be high risk (n = 351 012). Most (308 433 [88%]) high-risk veterans were assigned to general primary care; the remaining 12% (42 579 of 363 561) were assigned to specialized primary care (eg, women’s health and homelessness). High-risk patients assigned to general primary care had more frequent primary care visits (mean [SD], 6.9 [6.5] per year) than those assigned to specialized primary care (mean [SD], 6.3 [7.3] per year; P < .001). They also had more medical specialty care visits (mean [SD], 4.4 [5.9] vs 3.7 [5.4] per year; P < .001) and fewer mental health visits (mean [SD], 9.0 [21.6] vs 11.3 [23.9] per year; P < .001). Use of intensive supplementary outpatient services was low overall.

    Conclusions and Relevance  The findings suggest that, in integrated health care systems, approaches to support high-risk patient care should be embedded within general primary care and mental health care if they are to improve outcomes for high-risk patient populations.