The Patient Centered Medical Home at the VHA: The Patient Aligned Care Team (PACT) Karin Nelson, MD, MSHS Associate Director, National PACT evaluation Associate Professor, University of Washington, Department of Medicine Adjunct Associate Professor, Department of Health Services Staff Physician, VA Puget Sound Contact: Karin.Nelson@va.gov
Veterans Health Administration (VHA) Health Care System > 5 million primary care patients (95% empaneled) > 16 million primary care encounters annually 160 Medical centers, 802 community base outpatient clinics Features pre-PACT Capitated payment system Regional networks Salaried medical staff Universal EHR Performance & quality improvement system VETERANS HEALTH ADMINISTRATION 2
VHA Primary Care Practice Re-design Areas of focus Team based care Continuity & expanded access Care Coordination Patient centeredness Electronic tools Secure messaging Specialty care referral management & electronic consultation Population health tools (e.g., identification of high risk patients) Increased primary care support staff from 2.3 per FTE to 3.0 per FTE primary care provider >1,000 RN case managers hired since 2010 Training initiatives for PACT Rosland, Nelson, et al. AJMC , 2013 VETERANS HEALTH ADMINISTRATION 3
Other Team Members Integrated Behavioral Health Clinical Pharmacy Specialist Psychologist ± 3 panels ± 3 panels Social Worker ± 5 panels Social Work Care Manager ± 5 panels ± 2 panels Psychiatrist ± 10 panels Team: Assigned to 1 panel (±1200 patients) • Provider: 1 FTE • RN Care Manager: 1 FTE • Clinical Associate (LPN, Medical Assistant): 1 FTE • Clerk: 1 FTE Patient Caregiver 4
Key questions for national PACT evaluation • How to measure key features (e.g. team-based care) and implementation of PACT? • Does implementing PACT improve care? – Quality of care – Patient experience – Provider and clinical team experience • What are costs and savings associated with PACT? VETERANS HEALTH ADMINISTRATION
E VALUATION DATA FOR THE PACT N ATIONAL E VALUATION Corporate Data Warehouse (CDW) • Administrative and clinical data >11 million enrolled Veterans • Primary care management module • 2003 – present Patient surveys: SHEP Survey of Health Care Experiences • 2012 n = 75,101 Veterans CAHPS-PCMH module External Peer Review Program (EPRP), • External vendor chart review for clinical quality • Similar to HEDIS Primary care staff survey (n=5,405) VETERANS HEALTH ADMINISTRATION
C HALLENGES AND S OLUTIONS FOR THE N ATIONAL E VALUATION • No controls (implemented in over 900 clinics starting April 2010) Interrupted time series analyses Look for variation among sites in extent of implementation • For some key measures (e.g. burnout), no baseline Look for variation among sites in extent of implementation • Many key changes for PACT are team care processes Develop and field national survey • VHA already had in place many PCMH features Develop measure of PACT implementation VETERANS HEALTH ADMINISTRATION
PACT implementation progress index (PI 2 ) 8 Domains Source of Data # of Items Comprehensiveness 3 Self-management support Patient surveys 2 Patient-centered care & communication (CAHPS-PCMH) 6 Shared decision making 2 Access 11 Corporate Data Continuity Warehouse & 3 Patient surveys Coordination of care 8 Primary care Team-based care 18 personnel survey 53 Total VETERANS HEALTH ADMINISTRATION 8 Consumer Assessment of Health Plans (CAHPS)
JAMA Internal Medicine, 2014 Higher implementation clinics had higher patient satisfaction lower staff burnout higher proportion of Veterans meeting criteria on multiple measures of quality lower emergency room use VETERANS HEALTH ADMINISTRATION 9
JGIM , 2014 Staff and provider survey of primary care staff Primary care staff have high rates of burnout (~40%), comparable to other US data Features of PCMH associated with lower burnout • Participatory decision making on team • Adequate staffing VETERANS HEALTH ADMINISTRATION 10
Health Affairs , 2014 2003 – 12 trends in health care use +1.0% primary care visits -7.3% specialty mental health care -1.7% hospitalization for ACSC Potential costs avoided from 2010-2012 ~$600M Initial estimate of ROI as of FY12 was -$178M VETERANS HEALTH ADMINISTRATION 11
A CKNOWLEDGEMENTS • Stephan Fihn , Director, PACT Demonstration Laboratory Initiative • Paul Hebert, Christian Helfrich, Chuan-Fen Liu, Leslie Taylor, Edwin Wong, Greg Stewart, Joseph A. Simonetti, Susan Hernandez, Investigators • Idamay Curtis , Administrative Director • Philip Sylling, Chip Harvey, Sophie Lo, Haili Sun, Emily Dolan, Walter L. Clinton, Analysts • Alaina Mori, Gordon B. Wood, Support staff • Gordon Schectman, Primary Care Services • Richard Stark, Primary Care Operations Funding for the PACT Demonstration Laboratory Initiative is provided by the VA Office of Primary Care Services and Office of Primary Care Operations. The views expressed are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. VETERANS HEALTH ADMINISTRATION 12
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