PIM 2.0: Patient Aligned Care Team (PACT) Intensive Management (PIM) Project

"Purpose: Implement a Patient Aligned Care Team (PACT) model that identifies and proactively manages Veterans at the highest risk for hospital admission and death while they are still in the ambulatory care setting.~Goal:~* Reduce emergency department and urgent care utilization, hospitalization, and mortality in complex, high risk patients~* Improve Veteran and staff satisfaction~Objectives:~* Maintain the patient in the home setting as much as possible~* Secure appropriate home environment to facilitate health and well-being~* Utilize comprehensive team-based care~* Engage appropriate VHA programs to provide interdisciplinary, coordinated, and timely management of complex medical issues"