Evaluation of Intensive Management Patient Aligned Care Team

Inclusion Criteria:

   - Patient receives care from one of 14 primary care providers (MDs, NPs) who have at
   least three half-days of clinic per week

   - Total VA healthcare costs in the top 5% for VA Palo Alto facility during the 9-month
   eligibility phase (10/1/11-6/30/12) AND/OR

   - Risk for one-year hospitalization in November 2012 in the top 5% (using the VA's Care
   Assessment Need risk-prediction algorithm)

Exclusion Criteria:

   - Enrollment in VA's mental health intensive case management program, home-based primary
   care, or palliative care programs

   - Recipient of inpatient care for over half of the 9-month eligibility phase
   (10/1/11-6/30/12).

   - Total VA healthcare costs in the lowest cost decile in the 9-month eligibility phase
   (10/1/11-6/30/12)

   - Risk for one-year hospitalization in November 2012 in the lowest risk quartile (using
   the VA's Care Assessment Need risk-prediction algorithm).