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Solimeo SL, Center for Comprehensive Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System; Ono SS, Center to Improve Veteran Involvement in Care (CIVIC); Stewart K, Center for Comprehensive Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System; Lampman M, Center for Comprehensive Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System; Rosenthal G, Center for Comprehensive Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System; Stewart GL, Center for Comprehensive Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System;
Objectives:
To describe team and organizational barriers preventing full utilization of Administrative Associates in VA PACTs.
Methods:
Qualitative interviews (individual and group) and observational data (field notes from site visits and training events) were collected from core and extended team members of 22 PACTs over an 18-month period. Data were managed in a qualitative software package (MAXQDA v.11) where they were coded by two trained analysts using an 80% agreement benchmark. Codes pertaining to Administrative Associate (aka clerk) role, implementation processes and barriers, leadership, facility, and teamwork were independently reviewed and synthesized into themes, with attention to differences between clerks and clinical staff perspectives. Themes were refined through constant comparison techniques to identify factors limiting full integration of administrative staff in PACTs.
Results:
Clerks view themselves as providing patient-centered care by individually tailoring care coordination and scheduling to meet patient's needs; serving as informal patient advocates; and functioning as the public face of the clinic. We identified four primary factors, across multiple perspectives, which appear to limit recognition of clerks' contributions to patient care, including: (1) the location of clerks' workspaces with regard to teammates; (2) leadership cultures which regard clerks as interchangeable across PACTs and clinics; (3) organizational culture which defines clerks as "support staff" or "gatekeepers"; and (4) leadership and organizational cultures which give higher prioritization to the needs and staffing of clinically trained PACT members.
Implications:
Clerks are Veterans' first point of contact and provide patient-centered care, but support of their role within PACT is limited by organizational and cultural barriers: Clerks are thus visible to Veterans but literally and figuratively nearly invisible to VA leaders and their PACT teammates. Broader adherence to PACT staffing models and role-specific PACT training could enhance delivery of patient-centered care.
Impacts:
The experience of VA primary care staff implementing the patient centered medical home model through PACT can inform national and international health care policy and quality. Our focus on examining how Administrative Associates provide Veterans with patient-centered care extends previous PACT research that has examined the work of clinically trained staff.
