Patient Aligned Care Team (PACT) Performance in Urban and Rural VHA Primary Care Clinics: A Mixed Methods Study

Abstract

Purpose To assess differences in Patient Aligned Care Team (PACT) performance between rural and urban primary care clinics within the Veterans Health Administration (VHA). Methods An Explanatory Sequential Mixed Methods design was conducted using VHA administrative data to assess performance of a national sample of 891 VHA primary care clinics. Generalized Estimating Equations with repeated measures were used to estimate associations between rurality and process‐oriented endpoints including: chronic disease management through telehealth; use of telephone visits, group visits or secured messaging; same‐day access; continuity with primary care provider; and postdischarge follow‐up. Qualitative data collected during on‐site visits with 5 clinics were used to provide insights into PACT processes from the perspectives of staff in rural and urban clinics. Findings After adjusting for patient‐ and practice‐level characteristics, clinics located in large rural or small/isolated rural areas demonstrated difficulty enhancing access through use of telephone visits, group visits, or secured messaging and completing postdischarge follow‐up calls, compared to urban clinics. Qualitative analysis indicated that staff from both rural and urban clinics reported similar barriers implementing these PACT processes. Both patient and staff behaviors and preferences impact implementation of these processes. Distance to care and access to high‐speed Internet were also reported as barriers. Conclusions This study contributes to the understanding of PACT performance in rural settings by highlighting ways contextual and behavioral factors relate to performance. Increasing implementation of patient‐centered medical home (PCMH) models, such as PACT, will require additional attention to the complex relationships between the practice and surrounding context.

Rural and urban differences in the implementation of Virtual Integrated Patient‐Aligned Care Teams

“…The Veterans Health Administration (VHA) has been a leader in delivering health services through interactive clinical telemedicine and the patient-centered medical home model (Patient Aligned Care Teams-PACT) prior to the COVID-19 pandemic. 1,2 Yet, many veterans, especially rural veterans, face challenges accessing primary care services due to extensive wait times for appointments, shortages of available, qualified health care providers, and long drive distances to facilities. [3][4][5][6] In response to these barriers, the VHA initiated a pilot program called the Virtual Integrated Patient-Aligned Care Teams (V-IMPACT) to increase access to primary care services through delivery of teleprimary care in a team-based environment and with the use of PACT principles--coordinated, collaborative, comprehensive, interdisciplinary care.…”

“…The Veterans Health Administration (VHA) has been a leader in delivering health services through interactive clinical telemedicine and the patient‐centered medical home model (Patient Aligned Care Teams‐PACT) prior to the COVID‐19 pandemic 1,2 . Yet, many veterans, especially rural veterans, face challenges accessing primary care services due to extensive wait times for appointments, shortages of available, qualified health care providers, and long drive distances to facilities 3–6 …”