“We’ve Not Gotten Even Close to What We Want to Do”: a Qualitative Study of Early Patient-Centered Medical Home Implementation

Abstract

BACKGROUND:The Veterans Health Administration (VA) Patient Aligned Care Team (PACT) initiative is designed to deliver a medical home model of care associated with better patient outcomes, but success will depend in part on the model's acceptability and sustainability among clinic employees. OBJECTIVE: We sought to identify key themes in the experience of primary care providers, nurse care managers, clerical and clinical associates, and clinic administrators implementing PACT, with the aim of informing recommendations for continued development of the model and its components. DESIGN: Observational qualitative study; data collection from 2010 to 2013, using role-stratified and team focus groups and semi-structured interviews. PARTICIPANTS: 241 of 337 (72 %) identified primary care clinic employees in PACT team or administrative roles, from 15 VA clinics in Oregon and Washington. APPROACH: Data coded and analyzed using conventional content analysis techniques. KEY RESULTS: Overall, participants were enthusiastic about the PACT concept, but felt necessary resources for success were not yet in place. Well-functioning teams were perceived as key to successful implementation. Development of such teams depended on adequate staffing, training, and dedicated time for team development. Changes within the broader VA system were also seen as necessary, including devolving greater control to the clinic level and improving system alignment with the PACT model. PACT advocates from among clinic and institutional level leadership were identified as a final key ingredient for success. These themes were consistent despite differences in clinic settings and characteristics. CONCLUSIONS: PACT implementation faced significant challenges in its early years. Realizing PACT's transformative potential will require acting on the needs identified by clinic workers in this study: ensuring adequate staffing in all team roles, devoting resources to in-depth training for all employees in communication and other skills needed to maximize team success, and aligning the broader VA hospital system with PACT's decentralized, team-based approach.KEY WORDS: primary care redesign; patient-centered medical home; team-based care; Veterans; health services research; qualitative research.

Dedicated to the Mission: Strategies US Department of Veterans Affairs Home‐Based Primary Care Teams Apply to Keep Veterans at Home

“…Participants felt their dedication to keeping veterans at home and their accountability to their veterans exceeded what exists in traditional, in‐person clinical care in models such as PACT in the VA. The interdisciplinary nature of the teams led to development of close‐knit, longitudinal relationships with the veterans, whereas primary care clinical environments like PACT have experienced challenges with staffing, team development, and training . Past VA research has also shown that reduced continuity of PCPs decreased odds of excellent communication with patients .…”

“…The interdisciplinary nature of the teams led to development of close-knit, longitudinal relationships with the veterans, whereas primary care clinical environments like PACT have experienced challenges with staffing, team development, and training. 27 Past VA research has also shown that reduced continuity of PCPs decreased odds of excellent communication with patients. 28 Thus, the strong continuity of care HBPC provides, combined with effective communication, seems to be a significant factor contributing to high-quality care.…”

“…The Central VA Institutional Review Board approved the study (VA CIRB No. [14][15][16][17][18][19][20][21][22][23][24][25][26][27][28].…”

Who is responsible for what tasks within primary care: Perceived task allocation among primary care providers and interdisciplinary team members

“…[11][12][13][14] Prior studies have indicated that lack of understanding of roles within PCMH models is an important source of confusion and dissatisfaction among PCPs and staff. [15][16][17] Yet the degree to which staff and PCPs agree regarding allocation or sharing of specific primary care tasks is not known.…”

Staff Perspectives on Primary Care Teams as De Facto “Hubs” for Care Coordination in VA: a Qualitative Study

“…14,15 Effective care coordination, however, requires appropriate resources. 16 In the VA, inadequate staffing and time constraints are well-documented challenges of PACT implementation, [17][18][19][20] often associated with higher staff burnout 18 and lower scores on PACT implementation metrics. 19 Competing care delivery priorities and lack of communication from leadership about PACT performance metrics are additional challenges.…”