The Partnered Evidence Based Policy Resource Center: Building The VA Learning Healthcare System June 27, 2017 Steven D. Pizer, PhD Boston University PEPReC Chief Economist Email: Steven.Pizer@va.gov VETERANS HEALTH ADMINISTRATION
PE PEPR PReC eC What is PEPReC? The Partnered Evidence-based Policy Partnered Evidence-based Policy Resource Center Resource Center • A new HSR&D/QUERI resource center to – Provide timely, rigorous data analysis – Support development of high-priority policy, planning, and management initiatives – Plan quantitative program evaluations with randomized designs • Core Mission 1: Collaborate with VA operations partners to – Accurately forecast the demand for VA care – Develop and validate performance metrics – Make sound decisions about major new investments • Core Mission 2: Design and implement randomized program evaluations – Veteran-directed home and community based services – Opioid risk stratification and management – Suicide risk stratification and intervention VETERANS HEALTH ADMINISTRATION 2
PE PEPR PReC eC Three Steps to a Partnered Evidence-based Policy Learning Healthcare System Resource Center • Step 1: Solicit nominations of promising practices from operations partners – We will piggyback on existing solicitation for systematic reviews – Consult with nominators to refine and focus nominations – Prioritize with advisory panels • Step 2: Develop selected topics through rapid operations projects – Operations partners have lots of urgent questions; some can be addressed quickly – Identify breakdowns, refine policies, develop metrics, measure costs and benefits – Larger themes connect rapid projects over time and may build to larger initiatives • Step 3: Expand key initiatives for randomized program evaluation – Randomization generates rigorous evaluation results and helps prevent gaming – Randomized quantitative evaluation can be combined with qualitative and implementation research for full, mixed methods approach VETERANS HEALTH ADMINISTRATION 3
PEPR PEPReC eC Current Operations Projects Partnered Evidence-based Policy Resource Center • Electronic Medical Record Interoperability National Evaluation • National Evidence-based Budgeting Initiative • VA Community Care Policy and Systems Development VETERANS HEALTH ADMINISTRATION 4
PEPR PEPReC eC Electronic Medical Record Interoperability National Evaluation Partnered Evidence-based Policy Resource Center • Partner: Office of Informatics and Information Governance • Accomplished: • Measured positive relationship between DOD data sharing and patient satisfaction with provider’s knowledge of patient’s history • Economic analysis consultation for clinical ontology development • Ongoing: • Measure effects of data sharing on • Follow-up to positive screening • Duplicate imaging • Psychiatric medication continuity VETERANS HEALTH ADMINISTRATION 5
PEPR PEPReC eC National Evidence-based Budgeting Initiative Partnered Evidence-based Policy Resource Center • Partners: Office of Finance and Office of Policy and Planning • Accomplished : • Measured relationships between capacity change and new patient waiting time • Briefed CFO, PDUSH on capacity/waiting times framework • Prepared Draft Policy Memo relating budget options to estimated access consequences • Completed Draft Policy Memo on impact of ACA repeal on VA • Distributed Policy Briefs on lessons from fee-for-service and risk-contracting in Medicare • Provided economic consultation to OMB-VA working group • Provided economic consultation to Enrollee Health Care Projection Model update • Ongoing: • Refine budget options modeling and Policy Memo • Update ACA repeal impact Policy Memo as legislation develops • Develop bundled payments Policy Brief with Office of Community Care VETERANS HEALTH ADMINISTRATION 6
PEPR PEPReC eC VA Community Care Policy and Systems Development Partnered Evidence-based Policy Resource Center • Partner: Office of Community Care • Accomplished: • Assisted development of RFA and evaluation of SDR proposals • Preliminary analysis of community care access and utilization data • Convened kick-off meeting for opioid disorder treatment P4P contract • Ongoing: • VA cost analysis to benchmark P4P contract • Develop P4P contract performance standards • Support SDR project teams • Refine access metrics for community care • Evaluate effects of health info exchange on duplicate imaging VETERANS HEALTH ADMINISTRATION 7
PEPR PEPReC eC Randomized Program Evaluations (RPE) Partnered Evidence-based Policy Resource Center • Each RPE is a collaboration between PEPReC, operations and a research partner - Operations focuses on the development of the intervention/program - PEPReC focuses on randomized study design and administrative outcomes - Research partners focus on the implementation science of the intervention • Stratification Tool for Opioid Risk Management • Veteran-directed Home and Community Based Services • Suicide Risk Stratification and Intervention VETERANS HEALTH ADMINISTRATION 8
PEPR PEPReC eC RPE: Stratification Tool for Opioid Risk Management Partnered Evidence-based Policy Resource Center • Operations Partner: Office Of Mental Health Operations • Research Partner: CHERP (Pittsburgh) • The Stratification Tool for Opioid Risk Mitigation (STORM) estimates risk of adverse behavioral outcomes, overdoses and accidents for patients who received VA opioid prescriptions or who have an opioid use disorder • Facilities are randomized to 1 of 4 states: • STORM plus mandated local process for review and management • Very high risk patients with monitoring • Very high risk patients with monitoring and action planning • High & very high risk with monitoring • High & very high risk with monitoring and action planning • Outcomes: suicide-related events, overdoses, and accidents • Forthcoming national policy will mandate use of STORM under randomized design to comply with Comprehensive Addiction Recovery Act (CARA 2016) VETERANS HEALTH ADMINISTRATION 9
PEPR PEPReC eC RPE: Veteran-Directed Home & Community Based Services Partnered Evidence-based Policy Resource Center • Operations Partner: Office of Geriatrics & Extended Care Services • Research Partner: LTSS COIN (Providence) and Durham VA • VD-HCBS gives Veterans at risk for institutional placement the ability to hire their own workers to provide services in their homes • Potential to reduce health care costs by delaying institutional placement and hospital admissions • Has been implemented in 62 VAMCs since 2008 to over 2,000 Veterans • GEC has agreed to randomize staggered implementation in about 90 sites over 2017-2019 • Outcomes: hospitalization, nursing home use, emergency department admission, days at home, costs • PEPReC collaborating with J-PAL and research partners to refine planned analyses of administrative data and preparing to randomize the first set of VAMCs to VD-HCBS VETERANS HEALTH ADMINISTRATION 10
PEPR PEPReC eC RPE: Suicide Risk Stratification & Intervention Partnered Evidence-based Policy Resource Center • Operations Partner: Office of Mental Health Operations • Research Partner: CeMHOR (North Little Rock) • Dashboard based on validated predictive model that estimates and ranks risk for suicide • Model predicts increases in rates of up to 30-40 fold for the first three months after cases are identified and 16 fold over one year for the 0.1% at the highest predicted risk • In FY18-19, 30 sites will be randomized to receive centralized support for sending caring communications to patients in the top 0.1% of risk • Outcomes: suicide attempts and VHA hospitalizations (any and frequency) • Pending budget to enroll enough sites for adequate statistical power, PEPReC will work with partners to refine the randomization plan and planned administrative analyses VETERANS HEALTH ADMINISTRATION 11
PEPR PEPReC eC Partnership Challenges Partnered Evidence-based Policy Resource Center • Maintaining focus on long-term policy questions with shifting budgets and political landscape - VA community care scenarios for budget - Shifting schedules, priorities and budgets for EMR development (e.g., Cerner) • Aligning resources to synchronize interventions and evaluations - Hiring of staff for VDHC - Uncertain timing of national policy release mandating STORM • Adhering to rigorous study designs - Maintaining randomization in RPEs - Facility variation in implementation of programs VETERANS HEALTH ADMINISTRATION 12
PEPR PEPReC eC Future Opportunities Partnered Evidence-based Policy Resource Center • Office of Informatics and Information Governance - Evaluate interoperability with DOD - Incorporate cost-utility data into clinical decision support • Office of Finance/Office of Policy and Planning - Modeling of budget options and consequences - Estimating potential efficiency gains - Cost comparison with TRICARE • VA National Center on Homelessness Among Veterans - Program cost-benefit assessments - Randomized evaluation feasibility assessment • New randomized program evaluations VETERANS HEALTH ADMINISTRATION 13
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