Pieces of PACT: Realist Evaluation of Primary Care Clinics’ Experiences Implementing the Patient Aligned Care Team Initiative

Tuepker A, Raymaker D, Skaperdas E, Newell S, Reyes ME, van Dyck S, Bender R, Totten A, Nicolaidis C, Kansagara D. Pieces of PACT: Realist Evaluation of Primary Care Clinics’ Experiences Implementing the Patient Aligned Care Team Initiative. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 10; Philadelphia, PA.

Objectives: Since 2010 VA has been implementing a patient-centered medical home model called the Patient Aligned Care Team (PACT) Initiative. Our aim was to develop insights into dynamics that facilitated or hindered individual PACT-implementing clinics achieving positive perceived clinic culture change, improved employee work experience, and improved patient satisfaction. Methods: Realist evaluation of nine VA primary care clinics within the VA Portland Health Care system, using primarily qualitative data collected 2010-2013, which included transcripts of 42 clinic employee focus groups and 42 semi-structured interviews, as well as key informant clinic summaries generated from direct observation of clinic and management meetings. Data on clinic characteristics such as staffing turnover and clinic growth were obtained from administrative records. Our analysis used a team-based, iterative method of data reduction to develop individual clinic templates and narratives that were then compared against each other to identify implementation dynamics. Results: Structural barriers to PACT implementation resulting from the external context of the larger VA healthcare system were shared across clinics; these included a lack of feedback and communication mechanisms between separate services and within program hierarchies. Six key contextual factors - manageable growth, stable staffing, facilitative space, efficacy-generating leadership, teambuilding, and sustainable activity/prioritized goals - were identified in different constellations across clinics. Clinics with more of these contextual factors in place more often had achieved a perceived shift in the clinic culture, decreased burnout among employees, and/or improved patient satisfaction, while those lacking most or all of these factors less often achieved these outcomes. Contextual factors do not operate independently but influence one another; in particular, efficacy-generating leadership at the clinic level was observed to impact all other key factors except manageable growth. Implications: Understanding a clinic's unique characteristics and responses to a national initiative can assist not only in identifying "next steps" at clinic and facility levels, it can yield useful insights into implementation dynamics at work across sites. Realist evaluation is feasible for evaluating multi-site, complex health care delivery interventions like PACT. Impacts: As VA's implementation of PACT continues, system-wide efforts should concentrate on addressing system-wide constraints, such as barriers to communication and feedback across services.