Implementation of the Patient-Centered Medical Home in the Veterans Health Administration

Abstract

IMPORTANCE In 2010, the Veterans Health Administration (VHA) began implementing the patient-centered medical home (PCMH) model. The Patient Aligned Care Team (PACT) initiative aims to improve health outcomes through team-based care, improved access, and care management. To track progress and evaluate outcomes at all VHA primary care clinics, we developed and validated a method to assess PCMH implementation.OBJECTIVES To create an index that measures the extent of PCMH implementation, describe variation in implementation, and examine the association between the implementation index and key outcomes. DESIGN, SETTING, AND PARTICIPANTSWe conducted an observational study using data on more than 5.6 million veterans who received care at 913 VHA hospital-based and community-based primary care clinics and 5404 primary care staff from (1) VHA clinical and administrative databases, (2) a national patient survey administered to a weighted random sample of veterans who received outpatient care from June 1 to December 31, 2012, and(3) a survey of all VHA primary care staff in June 2012. Composite scores were constructed for 8 core domains of PACT: access, continuity, care coordination, comprehensiveness, self-management support, patient-centered care and communication, shared decision making, and team-based care.MAIN OUTCOMES AND MEASURES Patient satisfaction, rates of hospitalization and emergency department use, quality of care, and staff burnout.RESULTS Fifty-three items were included in the PACT Implementation Progress Index (Pi 2 ). Compared with the 87 clinics in the lowest decile of the Pi 2 , the 77 sites in the top decile exhibited significantly higher patient satisfaction (9.33 vs 7.53; P < .001), higher performance on 41 of 48 measures of clinical quality, lower staff burnout (Maslach Burnout Inventory emotional exhaustion subscale, 2.29 vs 2.80; P = .02), lower hospitalization rates for ambulatory care-sensitive conditions (4.42 vs 3.68 quarterly admissions for veterans 65 years or older per 1000 patients; P < .001), and lower emergency department use (188 vs 245 visits per 1000 patients; P < .001). CONCLUSIONS AND RELEVANCEThe extent of PCMH implementation, as measured by the Pi 2 , was highly associated with important outcomes for both patients and providers. This measure will be used to track the effectiveness of implementing PACT over time and to elucidate the correlates of desired health outcomes.

Teamlet Structure and Early Experiences of Medical Home Implementation for Veterans

“…1). Teamlets in Practice 1 (when fully staffed) conformed to the teamlet structure described in national PACT guidance, 11 where a panel of 1,200 patients was cared for by a PCP (or multiple part-time PCPs), a consistent RN care manager, LPN, and clerk. In contrast, in Practices 2 and 3, one or two clerks were assigned to registration desks in the front office, but the majority of clerks were centralized in appointment phone rooms and other non-patient care settings with little in-person interaction with Veterans.…”

A national evaluation of homeless and nonhomeless veterans’ experiences with primary care.

“…VHA has been at the forefront of primary care redesign efforts that could improve homeless persons’ experiences with care (Nelson et al, 2014; O’Toole et al, 2011; Rosland et al, 2013). In 2010, VHA began reorganizing primary care providers and staff into Patient-Aligned Care Teams (PACTs) in an effort to deliver efficient, well-coordinated, comprehensive, patient-centered care.…”

From programme theory to logic models for multispecialty community providers: a realist evidence synthesis

“…However, for remote electronic communication to be successful, face-to-face contact was also needed to build the relationships required. 100 Causal link 3:8 -multidisciplinary teams produce better demand management systems Three case studies in the UK 76 and the USA 66,102 provided evidence that MDTs could strengthen demand management systems and redistribute workload pressures across the care system. A multiple case study of five NHS vertical integration projects for paediatric/young persons' services 76 found that MDT working produced better gate-keeping and need-and/or risk-stratification.…”

“…GPs with access to advice and guidance from a consultant developed specialist expertise and could manage more complex cases without referring to secondary care, thus easing the workload there. 76 A study of the American Veterans Health Administration (VHA) 102 found that nurse visits in primary care were associated with a decreased risk of all-cause hospitalisation for veterans > 65 years of age. The Briot et al 66 case study of MHI in Utah 66 found evidence that MDT working redistributed workloads.…”