Supplementary Online Content

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1 Supplementry Online Content Zulmn DM, Pl Chee C, Ezeji-Okoye SC, et l. Effect of n intensive outptient progrm to ugment primry cre for high-need Veterns Affirs ptients: rndomized clinicl tril. JAMA Intern Med. Published online December 27, doi: /jminternmed etble 1. Chrcteristics of vs. PACT ptients, Engged vs. Non-Engged ptients, nd ptients who responded to the bseline vs. bseline nd follow-up surveys etble 2. Chronic condition dignoses mong vs. PACT ptients, nd Engged vs. Non-Engged ptients efigure 1. Kpln-Meier survivl curves for ptients in nd PACT etble 3. Estimted progrm effects on person-level monthly utiliztion rtes (men, stndrd error) mong intention-to-tret ptients in vs. PACT efigure 2. Estimted monthly person-level totl costs mong intention-to-tret ptients in vs. PACT, during bseline (10/11-1/13) nd follow-up (2/13-6/14) periods etble 4. Estimted progrm effects on monthly person-level costs (men, stndrd error) mong intention-to-tret ptients in vs. PACT etble 5. Estimted progrm effects on monthly person-level costs (men, stndrd error) mong ptients who engged in (tretment on the treted, estimted using rndomiztion s n instrument for prticiption) This supplementry mteril hs been provided by the uthors to give reders dditionl informtion bout their work.

2 etble 1: Chrcteristics of vs. PACT ptients, Engged vs. Non Engged ptients, nd ptients who responded to the bseline vs. bseline nd follow up surveys Bseline + (n = 140) PACT (n = 405) Engged (n = 96) Non Engged (n = 44) Bseline Survey Only (n = 36) Follow up Survey (n = 54) n (%) n (%) P vlue b n (%) n (%) P vlue b n (%) n (%) P vlue b Age, men (SD) 66.4 (14.0) 65.7 (13.0) (14.2) 62.1 (12.6) (13.4) 67.5 (13.3) 0.24 <30 1 (1) 3 (1) 0 (0) 1 (2) 0 (0) 0 (0) (9) 27 (7) 8 (8) 4 (9) 1 (3) 5 (9) (36) 182 (45) 31 (32) 20 (45) 8 (22) 19 (35) (30) 98 (24) 28 (29) 14 (32) 14 (39) 15 (28) (24) 95 (24) 29 (30) 5 (11) 13 (36) 15 (27) Mle Sex 130 (93) 365 (90) (93) 41 (93) (92) 51 (94) 0.61 Geogrphicl Indictor Urbn 125 (89) 372 (92) 90 (94) 35 (80) 31 (86) 52 (96) Rurl 11 (8) 29 (7) 4 (4) 7 (16) 4 (11) 1 (2) Unknown 4 (3) 4 (1) 2 (2) 2 (5) 1 (3) 1 (2) Rce/Ethnicity White, Non Hispnic 79 (56) 240 (59) 58 (60) 21 (48) 23 (64) 30 (56) Blck, Non Hispnic 20 (14) 68 (17) 14 (15) 6 (14) 7 (19) 6 (11) Hispnic 9 (6) 27 (7) 4 (4) 5 (11) 0 (0) 3 (5) Other 32 (23) 70 (17) 20 (21) 12 (27) 6 (16) 15 (28) Chronic Conditions, men (SD) 10.2 (3.5) 10.5 (3.4) (3.5) 10.2 (3.5) (3.7) 9.8 (3.7) (13) 46 (11) 12 (13) 6 (14) 5 (14) 8 (15) (29) 115 (28) 27 (28) 13 (30) 9 (25) 16 (29) (36) 130 (32) 35 (36) 15 (34) 12 (33) 20 (37) 13 or more 32 (23) 114 (28) 22 (23) 10 (23) 10 (28) 10 (18) Non VA Helth Insurnce (Any) c 74 (53) 224 (55) 0.62 c 57 (59) 17 (39) 0.02 c 24(67) 29(54) 0.22 c Medicre nd/or Med Advntge 69 (49) 205 (51) 54 (56) 15 (34) 22(61) 29(54) Mjor Medicl c 12 (9) 38 (9) 10 (10) 2 (5) 4(11) 5(9) Medicid 4 (3) 10 (2) 3 (3) 1 (2) 1(3) 0(0) All Other 3 (2) 11 (3) 3 (3) 0 (0) 1(3) 2(4) Homelessness (ICD ) 35 (25) 104 (26) (22) 14 (32) (28) 10 (18) 0.30 CAN Score, men (SD) d 95 (6) 94 (6) (6) 94 (6) (5) 94 (6) 0.60 Acute Med/Surg Hosps, men (SD) 1.2 (1.4) 1.2 (1.4) (1.4) 1.1 (1.3) (2) 1.3 (1) 0.01 Emergency Dept Visits, men (SD) 3.4 (3.3) 3.3 (3.3) (3.5) 3.1 (2.9) (3) 3.5 (3) 0.83 Unless otherwise indicted b P vlues reflect t tests for continuous vribles (Age, Chronic Condition Number, CAN Score, Acute Medicl/Surgicl Hospitliztions, Emergency Deprtment Visits) nd chisqure tests for dichotomous/ctegoricl vribles (Sex, Geogrphicl Indictor, Rce/Ethnicity, Homelessness). c Insurnce Sttus ctegories re not mutully exclusive. P vlue reflects chi squre test for the proportion of ptients who hve ny form of helth insurnce outside of VA coverge. Mjor Medicl Insurnce ctegory Includes HMO, PPO, Chmpus, nd Indemnity. d Cre Assessment Need Score (Wng, et l., Medicl Cre, 2013)

3 etble 2: Chronic condition dignoses mong vs. PACT ptients, nd Engged vs. Non Engged ptients (n=140) PACT (n=405) Engged (n=96) Not Engged (n=44) n (%) n (%) P Vlue n (%) n (%) P Vlue Cncer Cncer (solid/heme cncers, melnom) 29 (21) 112 (28) (21) 9 (20) 0.96 Crdiovsculr Hypertension 100 (71) 288 (71) (73) 30 (68) 0.57 Coronry Artery Disese 51 (36) 114 (28) (38) 15 (34) 0.70 Hert Filure 34 (24) 87 (21) (26) 9 (20) 0.47 Arrhythmi/Conduction Disorder 46 (33) 150 (37) (35) 12 (27) 0.34 Cerebrovsculr Disese 18 (13) 55 (14) (11) 7 (16) 0.47 Vsculr Disese 41 (29) 117 (29) (33) 9 (20) 0.12 Endocrine/Metbolic/Nutritionl Dibetes Mellitus 47 (34) 152 (38) (35) 13 (30) 0.50 Lipid Disorders 89 (64) 243 (60) (65) 27 (61) 0.71 Overweight/Obesity 35 (25) 116 (29) (26) 10 (23) 0.67 Thyroid Disorders 17 (12) 57 (14) (11) 6 (14) 0.71 Gstrointestinl Esophgel/Gst/Duod Disorders 63 (45) 178 (44) (46) 19 (43) 0.77 Liver Disese or Heptitis C 30 (21) 107 (26) (17) 14 (32) 0.04 Mentl Helth Any Mentl Helth Condition 95 (68) 280 (69) (65) 33 (75) 0.22 Depression 68 (49) 195 (48) (49) 21 (48) 0.89 PTSD 32 (23) 115 (28) (23) 10 (23) 0.98 Anxiety Disorders 20 (14) 86 (21) (14) 7 (16) 0.71 Bipolr Disorders 12 (9) 25 (6) (8) 4 (9) 0.88 Personlity Disorders 12 (9) 38 (9) (6) 6 (14) 0.15 Schizophreni 11 (8) 24 (6) (5) 6 (14) 0.09 Psychotic Disorders Other 9 (6) 39 (10) (6) 3 (7) 0.90 Alcohol Use Disorders 30 (21) 103 (25) (17) 14 (32) 0.04 Drug Use Disorders 41 (29) 102 (25) (25) 17 (39) 0.10 Musculoskeletl Spine Disorders 65 (46) 187 (46) (45) 22 (50) 0.57 Joint Disorders 80 (57) 237 (59) (60) 22 (50) 0.25 Musculoskeletl Conditions Other 73 (52) 188 (46) (53) 22 (50) 0.73 Neurologic Trumtic Brin Injury 10 (7) 25 (6) (7) 3 (7) 0.92 Dementi 13 (9) 17 (4) (8) 5 (11) 0.57 Spinl Cord Injury or Prlysis 5 (4) 16 (4) (2) 3 (7) 0.16 Peripherl Nerve Disorders 25 (18) 78 (19) (18) 8 (18) 0.95 Nervous System Sx/Disorders Other 57 (41) 180 (44) (39) 20 (45) 0.44 Renl/Urinry Renl Filure or Nephropthy 40 (29) 101 (25) (29) 12 (27) 0.82 Kidney/Ureter/Urinry Conditions 48 (34) 174 (43) (38) 12 (27) 0.24 Respirtory Chronic Obstructive Pulmonry Disese 34 (24) 76 (19) (25) 10 (23) 0.77 Asthm 9 (6) 34 (8) (6) 3 (7) 0.90 Respirtory Conditions Other 82 (59) 248 (61) (59) 25 (57) 0.78 Hemtologic/Immunologic Anemi 36 (26) 114 (28) (29) 8 (18) 0.17 Thrombocytopeni 6 (4) 30 (7) (4) 2 (5) 0.92 Cogultion nd Hem Disorders 5 (4) 20 (5) (3) 2 (5) 0.67 Hemtologic/Imm Conditions Other 10 (7) 38 (9) (8) 2 (5) 0.42 P vlues reflect chi squre tests

4 efigure 1: Kpln Meier survivl curves for ptients in nd PACT Proportion Surviving Kpln-Meier Survivl Curves Months Since PACT Usul Cre

5 etble 3. Estimted progrm effects on person level monthly utiliztion rtes (men, stndrd error) mong intention to tret ptients in vs. PACT Monthly Utiliztion Utiliztion Mesure D in D Stndrd Error Acute Med/Surg Admissions (0.010) Acute Med/Surg Dys (0.079) Acute MH Admissions (0.005) Acute MH Dys (0.079) Extended Med Admissions (0.003) Extended Med Dys (0.290) Extended MH Admissions (0.002) Extended MH Dys (0.251) ED Visits (0.017) Primry Cre Visits (0.094) Specilty Cre Visits (0.080) MH Outptient Visits (0.100) etble 3 presents estimted progrm effects on person level monthly utiliztion rtes. These effects represent difference indifferences (D in D) mong ll ptients in the intention to tret popultion, which correspond to the chnge in monthly utiliztion mong ptients in, minus the chnge in monthly utiliztion for ptients in PACT. A negtive progrm effect corresponds to lrger decline in utiliztion over the study period mong ptients in, compred to ptients in PACT. Chnges in monthly costs were estimted using liner regression, controlling for ptient fixed effects. MH: Mentl Helth; Acute Med/Surg: medicine/surgery hospitl wrd; Acute MH: cute psychitric hospitl wrd; Extended Med: inptient rehbilittion, extended cre, hospice; Extended MH: inptient mentl helth/ptsd, substnce use rehbilittion, domiciliry, domiciliry/foundtion of recovery; ED: Emergency Deprtment.

6 efigure 2. Estimted monthly person level totl costs mong intention to tret ptients in vs. PACT, during bseline (10/11 1/13) nd follow up (2/13 6/14) periods Implementtion End of Enrollment PACT Totl costs include ll inptient/outptient/fee bsis costs including costs ssocited with encounters

7 etble 4. Estimted progrm effects on monthly person level costs (men, stndrd error) mong intention to tret ptients in vs. PACT Inptient Costs Outptient Costs n Totl Inptient Acute Acute Extended Extended ED Primry Fee Bsis Encounter Costs b (All) Med/Surg MH Med MH Visits Cre Specilty MH Costs Costs All ptients ** (623) (587) (370) (156) (387) (107) (11) (14) (28) (35) (97) (12) Age under (1014) (911) (574) (288) (586) (229) (19) (21) (39) (65) (75) (18) Age 65 nd older (773) (765) (496) (151) (519) (39) (13) (17) (41) (33) (164) (15) HF/DM/COPD (775) (766) (516) (184) (478) (56) (16) (18) (39) (41) (149) (15) MH dignosis (725) (713) (422) (226) (484) (155) (15) (17) (33) (50) (137) (15) No MH dignosis ** (1,202) (1,038) (741) (5) (636) (21) (16) (21) (54) (21) (69) (18) Hospitliztion in ** mo pre enrollment (1336) (1220) (882) (397) (559) (241) (22) (23) (56) (62) (92) (23) High cost t bseline (828) (808) (506) (230) (550) (160) (14) (17) (38) (47) (142) (14) High risk t bseline ** (674) (600) (447) (195) (321) (89) (14) (16) (31) (37) (64) (14) Eligibility: High risk & hosp 6 mo pre enrollment (1364) (1258) (956) (449) (537) (191) (25) (25) (54) (65) (104) (24) ** p<0.05 HF/DM/COPD: Hert Filure, Dibetes, or Chronic Obstructive Pulmonry Disese; ED: Emergency Deprtment; MH: Mentl Helth; Acute Med/Surg: medicine/surgery hospitl wrd; Acute MH: cute psychitric hospitl wrd; Extended Med: inptient rehbilittion, extended cre, hospice; Extended MH: inptient mentl helth/ptsd, substnce use rehbilittion, domiciliry, domiciliry/foundtion of recovery. Estimted progrm effects represent difference in differences mong ll ptients in the intention to tret popultion, which correspond to the chnge in monthly costs mong ptients in, minus the chnge in costs for ptients in PACT. A negtive progrm effect corresponds to lrger decline in costs over the study period mong ptients in, compred to ptients in PACT. Chnges in monthly costs were estimted using liner regression, controlling for ptient fixed effects. If ptients died or moved wy, their costs were set to 0 nd missing, respectively, for subsequent months. b Totl costs include ll inptient/outptient/fee bsis costs including costs ssocited with encounters (in fr right column)

8 etble 5. Estimted progrm effects on monthly person level costs (men, stndrd error) mong ptients who engged in (tretment on the treted, estimted using rndomiztion s n instrument for prticiption) Inptient Costs Outptient Costs Impct Totl Costs b Inptient (All) Acute Med/Surg Acute MH Extended MED Extended MH ED Visits Primry Cre Outptient Specilty Outptient MH Fee Bsis Costs Encounter Costs All ptients ** (842) (870) (481) (217) (506) (178) (14) (17) (37) (51) (155) (14) Age under (1402) (1491) (932) (452) (891) (371) (30) (33) (66) (91) (114) (26) Age 65 nd older ** (1175) (1012) (714) (199) (818) (63) (14) (20) (56) (37) (188) (17) HF/DM/COPD , (1029) (867) (674) (258) (712) (64) (22) (27) (58) (58) (187) (18) MH dignosis (929) (1145) (695) (355) (624) (211) (21) (23) (46) (68) (196) (16) No MH dignosis ** (1508) (1505) (870) (5) (848) (26) (21) (30) (67) (25) (107) (14) Hospitliztion in mo pre enrollment (1870) (1555) (1187) (432) (680) (366) (33) (25) (78) (72) (117) (24) High cost t bseline (1160) (1122) (796) (340) (884) (249) (20) (25) (52) (64) (231) (14) High risk t bseline ** (1051) (855) (692) (292) (446) (148) (20) (24) (38) (48) (81) (18) Eligibility: High risk & hosp 6 mo pre enrollment (1652) (1804) (1297) (630) (712) (253) (37) (33) (63) (97) (152) (26) ** p<0.05 HF/DM/COPD: Hert Filure, Dibetes, or Chronic Obstructive Pulmonry Disese; ED: Emergency Deprtment; MH: Mentl Helth; Acute Med/Surg: medicine/surgery hospitl wrd; Acute MH: cute psychitric hospitl wrd; Extended Med: inptient rehbilittion, extended cre, hospice; Extended MH: inptient mentl helth/ptsd, substnce use rehbilittion, domiciliry, domiciliry/foundtion of recovery. Estimted progrm effects represent difference in differences for ptients who engged in, which correspond to the chnge in monthly costs mong ptients in, minus the chnge in costs for ptients in PACT. A negtive progrm effect corresponds to lrger decline in costs over the study period mong ptients in, compred to ptients in PACT. Chnges in monthly costs were estimted using liner regression, controlling for ptient fixed effects. If ptients died or moved wy, their costs were set to 0 nd missing, respectively, for subsequent months. b Includes ll inptient/outptient/fee bsis costs including costs ssocited with encounters (in fr right column) etble 5 reports results from secondry nlyses in which we estimted the effect of the intervention on ptients who ctively engged in (defined priori s completing n intke nd t lest three dditionl encounters) using rndomiztion s n instrument for prticiption. These nlyses re in contrst to the intention to tret nlyses presented in etble 4, where we estimted the effect of being rndomized to receive. As expected, we estimte effects tht re modestly lrger thn those from the intention to tret nlyses.