The Patient Centered Medical Home at the VHA: The Patient Aligned - - PowerPoint PPT Presentation

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The Patient Centered Medical Home at the VHA: The Patient Aligned - - PowerPoint PPT Presentation

May 04, 2023 249 likes •381 views

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

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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

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VETERANS HEALTH ADMINISTRATION

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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

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VETERANS HEALTH ADMINISTRATION

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

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Rosland, Nelson, et al. AJMC, 2013

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Other Team Members

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

Clinical Pharmacy Specialist ± 3 panels Social Work ± 2 panels Integrated Behavioral Health Psychologist ± 3 panels Social Worker ± 5 panels Care Manager ± 5 panels Psychiatrist ± 10 panels

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VETERANS HEALTH ADMINISTRATION

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?
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VETERANS HEALTH ADMINISTRATION

 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)

EVALUATION DATA FOR THE PACT NATIONAL EVALUATION

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VETERANS HEALTH ADMINISTRATION

  • 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

CHALLENGES AND SOLUTIONS FOR THE NATIONAL EVALUATION

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VETERANS HEALTH ADMINISTRATION

8 Domains Source of Data # of Items Comprehensiveness Patient surveys (CAHPS-PCMH) 3 Self-management support 2 Patient-centered care & communication 6 Shared decision making 2 Access Corporate Data Warehouse & Patient surveys 11 Continuity 3 Coordination of care 8 Team-based care Primary care personnel survey 18 Total 53

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PACT implementation progress index (PI2)

Consumer Assessment of Health Plans (CAHPS)

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VETERANS HEALTH ADMINISTRATION

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

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JAMA Internal Medicine, 2014

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VETERANS HEALTH ADMINISTRATION

 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

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JGIM, 2014

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VETERANS HEALTH ADMINISTRATION

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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

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VETERANS HEALTH ADMINISTRATION

  • 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

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ACKNOWLEDGEMENTS

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.