Study Evaluates Changes in VA Care since PACT Implementation
In 2010, VA became the largest healthcare system to implement the Patient-Centered Medical Home model of care–full implementation will continue through 2014. Referred to in VA as Patient-Aligned Care Teams (PACT), this initiative aims to improve VA healthcare by implementing team-based care for primary care patients. PACT staff are organized into "teamlets" that consist of one primary care provider, one RN care manager, one LPN or medical assistant, and one administrative clerk. PACT also includes funding for a full-time Health Promotion/Disease Prevention specialist at each facility to oversee screening and counseling programs related to healthy behaviors (e.g., smoking cessation.) PACT strives to improve access to care by: 1) offering advanced scheduling, i.e., increased same-day appointments; 2) increasing appointments via phone or by shared medical appointments (SMA); and 3) increasing Veterans' access to personal health data and providers via the Internet. This study evaluated interim changes in PACT-related care processes. Using VA data, investigators identified all Veterans assigned to a primary care provider (PCP) at all VA facilities from 4/09 to 9/12. They also used data from a national, facility-level survey (ACP Biopsy) that assessed the presence of 127 PACT components via "yes" or "no" items in 7 categories (e.g., patient-centered care and communication, use of technology, access and scheduling). The survey was completed by ambulatory care directors at 850 VA facilities in 10/09 (pre-PACT period) and by 846 facilities in 7/11 (interim-PACT period).
- VA achieved rapid progress in building a PACT infrastructure in the first 30 months of an extensive four-year implementation plan, and some interim changes in processes of care were observed: in-person PCP visit rates decreased slightly; healthcare via telephone and Internet increased dramatically (e.g., phone encounters increased 10-fold and patients using telehealth increased from 38,747 in 12/09 to 70,486 in 6/12); SMAs increased slightly; appointment access and continuity improved only slightly, but started at high levels; and post-hospitalization follow-up improved substantially but remains below goal (e.g., patients evaluated by primary care clinicians within 48 hrs of hospital discharge increased from 6% in 12/09 to 61% in 12/11).
- Facilities' average overall score on the ACP Biopsy survey increased from 69% "yes" in 10/09 to 80% "yes" in 7/11. The high score in the pre-PACT period reflects VA's previous investments in comprehensive electronic health records, population management tools, and other QI programs.
- ACP Biopsy scores were based on reports submitted by VA facilities and may be subject to reporting bias.
- Some measures were exhibiting change prior to the initiative, thus observed changes are not necessarily attributable solely to PACT.
Dr. Rosland is supported by an HSR&D Career Development Award. Drs. Rosland and Kerr are part of HSR&D's Center for Clinical Management Research, Ann Arbor; Drs. Nelson, Sun, Dolan, Maynard, and Bryson are part of HSR&D's Northwest Center for Outcomes Research in Older Adults, Seattle.
Rosland A, Nelson K, Sun H, Dolan E, Maynard C, Bryson C, Stark R, Shear J, Kerr E, Fihn S, and Schectman G. The Patient Centered Medical Home in the Veterans Health Administration. American Journal of Managed Care July 10, 2013;19(7):e263-72.