Factors affecting implementation of Patient‐Centered Medical Homes (PCMH) for Older Adults in the Veterans Health Administration (VHA) using the Consolidated Framework for Implementation Research (CFIR) Jennifer L. Sullivan, PhD Academyhealth June 25, 2018 1
Acknowledgements Evaluation Team: Partners: Marlena H. Shin, JD, MPH Office of Geriatrics and Extended Omonyêlé Adjognon, ScM Care (GEC) Melissa Steffen, BS, MPH Orna Intrator, PhD, GEC Data Jennifer Moye, PhD, ABPP Analysis Center Kenneth Shay, DDS, MS Samantha L. Solimeo, PhD Funding: Helena Greener ‐ Temkin, PhD HSR&D QUERI PEI ‐ 15 ‐ 468 Kimberly Harvey, MSc Amy Rosen, PhD 2
Background • Patient ‐ Centered Medical Homes (PCMH) • Coordinated, accessible, team ‐ based care • Better clinical quality and lower cost • May reduce over utilization of health care services • Challenges for care provision for older adults • Providing care coordination • Scheduling longer appointments 3
Background • Development of innovative Geriatric Patient ‐ Aligned Care Team (GeriPACT) model in VHA • Team composition • Panel size • Advanced geriatrics training • Opportunity to look at potential benefits of GeriPACT model 4 Shay and Schectman (2010) Sullivan et. al. (2018)
Objective • To assess factors affecting implementation of GeriPACT in VHA 5
Conceptual Model • Consolidated Framework of Implementation Research (CFIR) • Characteristics of Individuals • Intervention Characteristics • Inner Setting • Outer Setting • Process of Implementation 6 Damschroder et. al. (2009)
Methods ‐ Site Selection • 8 sites strongly aligned with the GeriPACT Operations Handbook • Sites varied on • Patient Aligned Care Team (PACT) Access • Team functioning 7
Methods ‐ Sample Key informants included: • GeriPACT physician leaders • GeriPACT team members • Other staff working with GeriPACT • Referring providers • Executive and middle managers 8
Methods ‐ Data Collection • 2 ‐ day in ‐ person site visits (11/2016 ‐ 2/2017) • 2 site visitors • Interview guide based on CFIR constructs • Interviews recorded and transcribed 9
Methods ‐ Data Analysis • Deductive coding based on CFIR constructs • CFIR construct summaries reviewed for each site • Site data reduced by: • creating construct summaries • supporting evidence and ratings into a matrix by site • Cross site summary created and ratings compared 10
Results ‐ Site Characteristics Variable A B C D E F G H Location South South East West Midwest West South Midwest # GeriPACT Teams 4 1 1 1 1 1 5 7 Max panel size 280 ‐ 800 900 750 320 750 497 ‐ 800 550 708 11
Results – Sample (N=134) Role Percent GeriPACT Core Team GeriPACT Providers 22% GeriPACT Social Workers 9% GeriPACT Pharmacists 7% GeriPACT Clinical Care Associate 6% GeriPACT Administrative Associate 6% GeriPACT Extended Team GeriPACT Mental Health Providers 7% GeriPACT Dieticians 4% Staff outside of GeriPACT (e.g. referrals) 17% Leaders Service ‐ line and Executive Leaders 22% 12
Results ‐ Positive CFIR Influences • Knowledge and Beliefs • Relative Advantage • Culture • Learning Climate • Champions/Opinion Leaders/Implementation Leaders 13
Knowledge and Beliefs “Some of the unique services that we're able to provide through GeriPACT interactions between the clinicians, social workers, and pharmacy include better management of social needs of the patient, additional supports in the home, and support for polypharmacy" 14
Knowledge and Beliefs Committed to caring for older Veterans • Knew patients well • • Valued focus on collaborative care 15
Relative Advantage “In comparison to PACT, GeriPACT is a special team devoted to the frail or elderly population that have geriatric syndromes, that are better served by an interdisciplinary team than from a standalone provider" 16
Relative Advantage In comparison to PACT, staff reported: Higher levels of rapport with Veterans • • Additional available resources Social worker • • Pharmacist Staff trained in geriatrics • 17
Culture "The values that VHA has are at the heart of everything that we do. In our clinic, we definitely are here to serve veterans, show compassion….we’re advocates for our patients" 18
Culture Fit with VHA’s mission • • Fit with commitment to interdisciplinary team ‐ based approach 19
Learning Climate “We work well together….we get along. If we don’t agree with something, we discuss and then everyone has input and we come out with a solution." 20
Learning Climate • Positive learning environment • Leaders willing to listen to staff • Open discussions • Staff felt comfortable giving input • Team members felt providers respected them 21
Champions/Opinion Leaders/ Implementation Leaders “It took staff buy ‐ in and support from our leaders. For example, our Nurse Manager is really good at escorting and encouraging , being on top of things, and making sure things are working…she rolls up her sleeves and gets in and helps out. She's always open for talking if there's an issue." 22
Champions/Opinion Leaders/ Implementation Leaders • Many types of advocates • Leaders (Medical Directors and/or Service Line Leads) • Enthusiastic and committed front ‐ line team members 23
Negative CFIR Influence: Relative Priority “Staff got split and spread…it's not best…it's competing priorities so depending on who the administrator is, the short ‐ term goals, the medical center priorities, geriatrics is not always…the resources aren't always there. In fact, we have experienced a resource reduction." 24
Relative Priority Many programs competing for resources • Priority on pressing needs • • Performance and productivity metrics were less applicable 25
Conclusion • Variation in GeriPACT model implementation • Successful GeriPACTs: • fit within their organizational setting • have teams dedicated to the model and Veterans • Implementation limited by relative priority of GeriPACT implementation • More research focused on how these variations may affect patient outcomes 26
Thank you! For more information, contact: jennifer.sullivan@va.gov @jlsullivan10 27
References CFIR Wiki Page: http://cfirwiki.net/wiki/index.php?title=Main_Page Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation science. 2009 Dec;4(1):50. Shay K, Schectman G. Primary Care for Older Veterans. Generations. 2010 Jul 1; 34 (2):35 ‐ 42. Sullivan, JL, Eisenstein, R., Price, T., Solimeo, S., Shay, K. Implementation of the Geriatric Patient ‐ Aligned Care Team Model in the Veterans Health Administration J Am Board Fam Med 2018 31 (3): 456 ‐ 465. 28
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