The Patient-Centered Medical Home in the Veterans Health Administration

Background:

The Veterans Health Administration (VHA) is the largest integrated US health system to implement the patient-centered medical home. The Patient Aligned Care Team (PACT) initiative (implemented 2010-2014) aims to achieve teambased care, improved access, and care management for more than 5 million primary care patients nationwide.

Objectives:

To describe PACT and evaluate interim changes in PACT-related care processes.

Study Design:

Data from the VHA Corporate Data Warehouse were obtained from April 2009 (pre- PACT) to September 2012. All patients assigned to a primary care provider (PCP) at all VHA facilities were included.

Methods:

Nonparametric tests of trend across time points.

Results:

VHA increased primary care staff levels from April 2010 to December 2011 (2.3 to 3.0 staff per PCP full-time equivalent). In-person PCP visit rates slightly decreased from April 2009 to April 2012 (53 to 43 per 100 patients per calendar quarter; P <.01), while in-person nurse encounter rates remained steady. Large increases were seen in phone encounters (2.7 to 28.8 per 100 patients per quarter; P <.01), enhanced personal health record use (3% to 13% of patients enrolled), and electronic messaging to providers (0.01% to 2.3% of patients per quarter). Post hospitalization follow-up improved (6.6% to 61% of VA hospital discharges), but home telemonitoring (0.8% to 1.4% of patients) and group visits (0.2 to 0.65 per 100 patients per quarter; P <.01) grew slowly.

Conclusions:

Thirty months into PACT, primary care staff levels and phone and electronic encounters have greatly increased; other changes have been positive but slower.

Am J Manag Care. 2013;19(7):e263-e272The Veterans’ Health Administration (VHA) is the largest integrated health system to implement the patient-centered medical home (PCMH) to date. This initiative (implemented 2010-2014) aims to achieve team-based care, improved access, and care management for more than 5 million primary care patients nationwide. Interim changes in care processes include:

• Decreased rate of in-person primary care provider visits and increase in telephone and Internet care.

• No significant increase in shared medical appointments.

• Slight improvement in appointment access and continuity, which started at high levels.

• Improved but still suboptimal post hospitalization follow-up.

The patient-centered medical home (PCMH) model is being implemented by a growing number of health organizations, with the goal of providing more comprehensive, coordinated, and patient-centered care. The major primary care medical societies have endorsed the PCMH as the desired model for primary care.¹ Large health systems and primary care practice collaboratives are implementing the PCMH model, and the Centers for Medicare & Medicaid Services is funding PCMH demonstration and innovation projects in diverse clinical sites.^2-5 Nonetheless, published evaluations of PCMH initiatives to date have been limited to single-practice or smaller groups of practices, and often focus on limited clinical conditions.^3,6-11

In 2010, the Veterans Health Administration (VHA) became the largest integrated US health system to begin implementing the PCMH model at all primary care clinics throughout its nationwide system. The VHA delivers primary care to more than 5 million veterans in 16.4 million encounters annually—either at 160 large hospital-based primary care facilities, most of which are in urban areas, or 783 Community- Based Outpatient Clinics, many of which are in rural areas. Thus, VHA is facing the challenge of substantially redesigning major systems of care in an extremely large system across diverse clinical and community settings. In addition, veterans served by VHA typically have more chronic physical and mental illnesses, and are more socioeconomically vulnerable, than patients who receive care outside VHA.

Table 1

The VHA’s PCMH initiative, called Patient Aligned Care Teams (PACTs), builds upon foundations established in the 1990s, when VHA undertook a major transformation from loosely organized hospitals that provided mainly inpatient and specialty care into a regionally integrated system focused on outpatient primary care.¹² As part of that process, large numbers of primary care providers (PCPs) and nurses were hired by VHA, and several key elements of the PCMH model (as defined by the National Committee for Quality Assurance) were implemented, such as comprehensive electronic medical records and performance measurement and improvement programs (including programs addressing clinical outcome goals such as glycemic control and blood pressure control for patients with diabetes and cancer screening; ). Since that time, VHA has demonstrated better clinical quality of care and outcomes in many areas than have been reported in other parts of the healthcare sector, including Medicare.¹³

However, in the 2000s the level of primary care staffing and resources remained steady, despite steady increases in numbers of primary care patients.^14-16 In addition, VHA identified room for improvement in care continuity and coordination (eg, by decreasing the amount that VHA patients relied on providers not part of the Department of Veterans Affairs [VA] for acute care) and in patient-centeredness of care (eg, by providing care through telephone or electronic access when patients prefer it).¹⁷ Thus, the PACT initiative aims to enhance comprehensive and coordinated care, improve patient experience, and further improve health outcomes by increasing and reorganizing primary care staffing, and introducing several PCMH components that were not already in place.

The PACT initiative began in April 2010, and full implementation is anticipated to continue through 2014. Patient Aligned Care Teams also include a concurrent plan (and budget) for nationwide evaluation, including quantitative and qualitative data collection and analysis. In this study, we describe the design of PACT and the extent of structural changes made by facilities in response to the PACT plan to date. Then, we present an interim nationwide evaluation of observed changes in patient care processes related to PACT goals.

PACT DESIGN AND STRUCTURAL CHANGES TO DATE

Continuity Through Team-Based Care

To enhance continuity, staff are organized into teamlets that provide care to an assigned panel of about 1200 patients.¹⁸ A teamlet consists of 1 PCP, 1 registered nurse (RN) care manager, 1 licensed practical nurse (LPN) or medical assistant, and 1 administrative clerk. Teamlets are designed to optimize work flow by enabling each member to function at the top of their expertise. For example, PACT RNs are expected to manage care of patients with multiple chronic conditions through in-person and telephone encounters, and medical assistants are expected to provide preventive health screening. To facilitate communication and planning, teamlets are expected to hold regular huddles.¹⁹ The PACT clinical pharmacists assigned to a set of teamlets also manage patients with poorly controlled chronic illnesses through independent patient encounters.

Table 2

To establish the teamlet model, the VHA mandated that facilities provide 3.0 full-time equivalents (FTEs) of primary care support staff per full-time PCP by the end of 2011, with dedicated funding to facilities for this. From April 2010 to December 2011, primary care support staff increased from 10,501 FTEs to 13,742 FTEs (), corresponding to an increase from 2.3 FTEs to 3.0 FTEs support staff per PCP FTE nationwide. In addition, 76% of facilities reported holding daily teamlet huddles in July 2011 (up from 21% pre-PACT, Table 2).

Patient Access to Care

Patient Aligned Care Teams aim to improve patient access through 3 methods. First, facilities are instructed to enact advanced access scheduling,²⁰ including increased availability of same-day appointment slots. Second, facilities are asked to conduct more appointments via phone and by shared medical appointments. In response to this directive, 40% of facilities set aside hours during the clinical workday dedicated to scheduled phone visits by July 2011 (up from 14% pre-PACT; Table 2). It should also be noted that efforts were made to more accurately code and capture clinical encounters that occurred over the phone. Third, PACT aims to increase patient access to personal health data and providers via the Internet. This goal is accomplished through (1) an enhanced Internet-based personal health record (www.MyHealtheVet.gov), which allows patients to manage prescriptions and view test results and appointments; and (2) a secure messaging website, which allows patients to send electronic messages to their teamlet. To use either service, VA patients must complete an in-person registration and identity check. The PACT initiative directed each parent facility to add a personal health record/secure messaging coordinator, who encourages and facilitates patient and staff use of these technologies (Table 2).

Care Management and Coordination

The VHA hired 1271 primary care RN care managers between January 2010 and December 2011 (Table 2). The role of the RN care manager is envisioned to include chronic illness management, panel management of high-risk patients, and facilitation of patient care transitions. Among these responsibilities, post hospitalization follow-up was chosen as an early focus. Some RN care managers are assigned to telehealth monitoring of patients with chronic conditions. Telehealth consoles transmit patients’ health data (eg, blood glucose, blood pressure) from the patient’s home over a phone or Internet connection to the VA. Telehealth nurses at the patient’s home facility manage clinically relevant changes over the phone.

Also included in PACT is funding for a full-time health promotion/ disease prevention specialist at each facility to oversee screening and counseling programs related to healthy behaviors, such as healthy eating and tobacco cessation. Health Behavior Coordinators (typically clinical psychologists or social workers) at each facility support this program by training clinical staff in evidence based behavior change counseling techniques. Almost all facilities now have hired these 2 staff members (Table 2).²¹

Providing accessible and broad care for mental health conditions and coordinating that care with other aspects of primary care are essential to providing comprehensive primary care in the VHA, as approximately 15% of veterans have a mental illness or substance use disorder.²² The Primary Care-Mental Health Integration program, which began pre-PACT in 2007, provides primary care—based treatment of common mental health conditions (eg, depression) and risky health behaviors (eg, heavy alcohol use) by mental health clinicians partnering with and co-located with primary care staff. The Primary Care-Mental Health Integration program is already quite robust across the VHA, and its critical role in PACT is more fully described elsewhere.²¹

Patient Partnership

The PACT providers and clinical staff are being trained in patient-centered communication.²¹ By the end of 2011, facilitators were trained at all VHA facilities, and the 2012 PACT plan was to train 50% of the primary care teamlet staff. In addition, 36% of facilities followed the PACT plan to form patient advisory councils in July 2011, an increase from 18% in October 2009.

EVALUATION METHODSDesign and Sampling

Appendix A

We used data from VHA Corporate Data Warehouse databases derived from VHA operational systems. All measures except appointment wait times were calculated from data on the total number of active patients assigned to a PCP in the relevant month or quarter. All primary care patients at all VHA facilities nationally were included, regardless of the status of PACT implementation at the facility. Point measures were assessed on the last day of each month starting in December 2009. For measures compiled on a quarterly basis, data were available starting with the April through June 2009 quarter for some measures and the October through December 2009 quarter for others ().

We also used data from a national, facility-level survey based on the American College of Physicians (ACP) Medical Home Builder Practice Biopsy (ACP Biopsy). The ACP Biopsy assesses whether a practice has 127 PCMH components in place through yes/no items in 7 categories: patient-centered care and communication (ie, training in communication techniques and provision of self-management support); access and scheduling (ie, flexible and non—face-to-face scheduling); use of technology (ie, e-prescribing); care coordination and transitions; organization of practice (ie, electronic records and teamwork); population management (ie, patient registries); and quality improvement. The survey was completed by ambulatory care directors at 850 facilities (out of 862 eligible) in October 2009 (pre-PACT) and by 846 facilities in July 2011 (interim PACT).

Measurement

Appendix B

We assessed changes in key patient care processes including in-person and telephone encounter rates across teamlet members, continuity of care with the patient’s assigned PCP, appointment access, access to care through shared medical appointments and new technologies, and reach of RN care management. Details on measures are available in . To assess overall progress toward PCMH implementation, we compared the total percentage of yes responses in each ACP Biopsy category at both time points.

Statistical Analysis

We used nonparametric tests of trend for the ranks of measures across all quarters or months measured. All P values were based on 2-sided tests. Full quarterly and monthly data are available in Appendix A. The average age and comorbidity level (Deyo score)²³ of the primary care population remained stable throughout the study period, so encounter rates were not adjusted for these attributes.

RESULTS

Interim Changes in Patient Care Processes

Figure 1

Continuity Through Team-Based Care. The overall rate of primary care encounters (in person or by phone) per 100 patients increased from 85 in April through June 2009 (corresponding to a rate of 3.4 encounters per patient per year) to 101 in April through June 2012 (corresponding to 4.0 encounters per patient per year; P for trend = .01). However, in-person encounter rates declined slightly over this time period (). Among clinical staff, PCP visit rates declined slightly (53 to 43 visits per 100 patients per quarter; P for trend <.01), as did clinical pharmacist visits (2.6 to 2.4 visits; P < .01). Encounters with RNs and LPNs spiked each fall, but did not change significantly overall (P for trend RN = .39; P for trend LPN = .84). This pattern remained after encounters for flu shots were removed from the data.

Figure 2

As a measure of continuity, 80% of all PCP visits in October through December 2009 were with the patient’s assigned PCP (of 2,376,003 total PCP visits), which increased to 83% in April through June 2012 (2,570,618 total PCP visits) (P for trend = .01; ).

Patient Access to Care. Patient requests for same-day appointments were accommodated 67% of the time in December 2009 and 73% in June 2012 (P for trend <.01, Figure 2A). The proportion of patients seen within 7 days of their desired appointment date rose from 85% to 90% during the same time period (P for trend <.01).

Phone encounter rates, although a minority of overall encounters, increased more than 10-fold from April through June 2009 to April through June 2012, increasing for each clinical staff group (P for trend <0.01 for each, Figure 1B). In-person shared medical appointments increased from 0.24 to 0.65 (P <.01) per 100 patients per quarter over the same time period (Figure 1A).

The number of patients registered for the enhanced personal health record increased from 152,416 (3% of 4,759,668 primary care patients) in December 2009 to 694,206 (13% of 5,163,531 primary care patients) in June 2012 (P for trend <.01; Figure 2B). Total secure messages from patients to primary care staff increased from 9852 in 2010 to 289,519 in 2011. Patients using secure messaging (sending at least 1 message to their primary care team) increased from 0.07 per 1000 primary care patients in October through December 2009 to 22.8 per 1000 patients in April through June 2012 (P for trend <.01).

Care Management and Coordination. The number of patients using telehealth increased from 38,747 (0.8% of patients) in December 2009 to 70,486 (1.4% of patients) in June 2012 (P for trend <.01; Figure 2B). Patients evaluated by primary care clinicians within 48 hours of VHA hospital discharge increased from 6% of 46,195 discharges in December 2009 to 61% of 45,068 discharges in December 2011 (P for trend <.01).

Overall Progress Toward Implementation of PCMH Components. Facilities’ average overall score on the ACP Biopsy increased from 69% yes in October 2009 to 80% yes in July 2011. Pre-PACT, categories with the highest average scores were organization of practice (72%), population management (75%), and quality improvement (86%) (Figure 3). Categories with the lowest initial scores were also those with the greatest improvement by 2011: patient-centered care/communication (56% to 68%) and access/scheduling (66% to 76%).

DISCUSSION

Over the first 30 months of PCMH implementation, VHA made extensive nationwide structural changes in primary care staff levels and teamlet formation and capacity for telephone care, electronic access, care management, and healthy behavior promotion. The high scores noted on the ACP Biopsy pre-PACT reflect the investments made by VHA during the previous 15 years in comprehensive electronic health records, population management tools, and quality improvement programs. Larger increases on the ACP Biopsy related to patient-centered care, communication and access, and scheduling during the initial months of PACT correspond to the main components of the PACT initiative.

The VHA’s landmark investment in PCMH implementation and evaluation will provide unprecedented opportunities to augment existing data on PCMH outcomes and implementation. Published evaluations of PCMH interventions in adult populations to date are focused on specific chronic diseases^3,6,9 or limited to between 1 and 36 primary care practices within a larger system.^7,10,11 Two of the larger PCMH evaluations have focused on independent practices^3,10 without integrated administrative data.

Lessons Learned

At this point in PACT implementation, observed changes in patient care are mixed. In-person visits to PCPs have slightly decreased, while visits to nurses have stayed the same. However, phone encounters have increased dramatically, and patients’ use of electronic access to personal health information and providers is steadily growing. Other alternate visit modes such as shared medical appointments are just getting off the ground. One aspect of care management that was an early focus, post hospitalization follow-up has significantly improved but is reaching over 60% of those eligible. Appointment access and PCP continuity have improved only slightly, but started out at relatively high rates.

These data show that the pace of implementation of a large program, with many changes in patient care attempted at once, is slow. Those patient care processes showing substantial change started to change around 6 months after the April 2010 PACT start date. One particularly time-intensive aspect of PACT has been hiring and training clinical staff. For example, although VHA hired 1271 primary care RNs over 2 years, the RN vacancy rate was still 7% as of May 2012. In addition, systematic methods for delivering new care processes are still under development. For example, to assist with post hospitalization follow-up, primary care patient databases are currently being modified to notify the teamlet when a patient is discharged, and tool kits are being disseminated to help make the delivery and documentation of follow-up more consistent. The cyclic nature of planning, doing, and analyzing are common to previous PCMH interventions, but carrying out these rapid-cycle improvements across such a large system may mean that changes in PACT-related processes cyclically accelerate and slow down over the next few years.

National and health system context may have affected the adoption of PACT elements. For example, concurrent with the economic recession and an influx of new veterans from Gulf region conflicts, patients enrolled in VHA primary care increased from 4,817,273 at the start of PACT in April 2010 to 5,163,531 in June 2012. This corresponds to an average increase of 2164 patients (or 1.8 teamlet panels) per parent facility. Thus, although facilities were attempting to increase the number of primary care staff per patient panel and patient access to appointments, increasing numbers of patients made this challenging. In addition, some facilities may have prioritized timely access for new patients over continuity with the same PCP for those patients. Finally, many VHA PCPs are part-time clinicians or trainees, which may limit the continuity attainable with an individual PCP which may limit the continuity attainable with an individual PCP, particularly for urgent appointments.

The ability to present data from nearly the entire healthcare system is a strength of this study and enhances VHA’s ability to evaluate its PCMH program. However, this presentation also obscures variation in facility-level implementation of the PACT initiative. Reports from the field indicate that PACT rollout has not been uniform across facilities. Some sites are struggling to implement the basics of PACT, while others have fully functional PACT teamlets. Facility-level implementation is likely impacted by many local factors, including the supply of clinical staff, the presence of local clinician champions, previous primary care clinic organization, the demographics and health status of the local patients, and other pressing needs of the facility.

There are several limitations to these analyses. Although the ability to address a broad range of PCMH domains including staffing, processes of care, continuity, and access is a strength, we were unable in this study to examine individual PCMH domains in detail. The ACP Biopsy measures of implementation were based on reports submitted by the facilities and may be subject to reporting bias. All other measures were derived from data collected for patient care and administrative purposes. These data are routinely analyzed for accuracy, but are not validated by site visits or direct observations. Some of the data may have been influenced by more intensive data capture as PACT was implemented (in particular, phone encounter rates). Finally, some of the measures were exhibiting change prior to the initiative; thus, observed changes are not necessarily attributable solely to PACT. Because PACT has been rolled out in all VA clinics, there is no contemporaneous non-intervention control group.

Policy Implications

This report is the first step in a comprehensive assessment of the implementation and effects of the PACT initiative. The evaluation of the PACT initiative was planned and initiated concurrently with the planning and initiation of PACT itself. One strength of this approach is that realtime measures of PACT progress can be fed back to facilities. Future evaluation of the PACT initiative will examine any positive or unintended negative effects on patients’ clinical outcomes, as well as changes in unplanned care such as emergency department visits and ambulatory care—sensitive hospitalizations, and changes in costs. In particular, the apparent shifts we observed in utilization from face-to-face visits to care provided by telephone and secure messaging could potentially be cost saving but must be evaluated in relation to costs for other services as well as any potential differences in clinical outcomes and patient satisfaction. The VHA is also placing high emphasis on evaluating patient experiences²⁴ and primary care staff experiences through PCMH-specific, systemwide patient and staff surveys, complemented by qualitative interviews and observation at selected VHA facilities. With these comprehensive data, VHA will have the unique ability to compare PCMH outcomes across a variety of practice settings, including hospital-based versus community clinics and academically affiliated training sites versus non—academically affiliated clinics. In particular, VHA will examine variability across facilities in implementation of PCMH elements, and facilitators and barriers to implementation. The ability to examine data at multiple levels (ie, patient, individual teamlet, facility, regional) will make these analyses a rich source of information about a wide variety of factors influencing PCMH.

Although some of VHA’s experiences with PACT are unique to the VA system, overall experiences—including those with shifts to team-based care, attempts to improve patient access, and increased use of personal health record and telephone care&mdash;are highly relevant to other health systems. In VHA, PCMH is facilitated by an integrated electronic medical record system and centralized budgets not based on fee-for-service billing, which are also potential elements of developing Accountable Care Organizations.

In summary, VHA saw rapid progress in building PCMH infrastructure in the first 30 months of an extensive 4-year VHA PCMH implementation plan, and some interim changes in processes of patient care were observed. Currently, VHA is undertaking a comprehensive evaluation of the outcomes and implementation of its PCMH model, which will inform PCMH efforts nationwide. Acknowledgments

The authors are grateful to Elizabeth Yano, Fred Kirkland, Jennifer Burgess, and Sarah Conner for their assistance with this project.

*Drs Rosland and Nelson are co-first authors on this paper.

Author Affiliations: From VA Ann Arbor Center for Clinical Management Research (AR, EK), Ann Arbor, MI; Department of Internal Medicine (AR, EK), University of Michigan Medical School, Ann Arbor, MI; VA Puget Sound Healthcare System, Northwest HSR&D Center of Excellence (KN, HS, EDD, CM, CB), General Internal Medicine Service (KN, CB), Seattle, WA; Department of Medicine (KN, CB, SDF), School of Medicine, Department of Health Services (CM, SDF), School of Public Health, University of Washington, Seattle, WA; VHA Office of Patient Care Services (GS, RS); VHA Office of Primary Care Operations and Primary Care Services (JS), Washington DC.

Funding Source: Data for this report were developed by the national evaluation team at the Patient Aligned Care Team (PACT) Demonstration Lab Coordinating Center and the Veterans Health Administration (VHA) Office of Analytics and Business Intelligence. The VHA Office of Primary Care Operations is responsible for PACT implementation and the VHA Office of Patient Care Services is responsible for the PACT Demonstration Lab program. Ann-Marie Rosland is a VA Health Services Research and Development Service Career Development Awardee.

Author Disclosures: All authors report employment with the Veterans Health Administration. Dr Kerr also reports membership with the Patient Centered Outcomes Research Institute Health Systems Advisory Panel.

Authorship Information: Concept and design (AR, KN, EDD, RS, JS, EK, SDF, GS); acquisition of data (KN, EDD, RS, JS, SDF, GS); analysis and interpretation of data (AR, KN, HS, EDD, CM, CB, RS, JS, EK, SDF, GS); drafting of the manuscript (AR, KN, RS, JS, SDF, GS); critical revision of the manuscript for important intellectual content (AR, KN, EDD, CM, CB, RS, JS, EK, SDF, GS); statistical analysis (AR, KN, HS, EDD); provision of study materials or patients (KN); obtaining funding (EK, SDF); administrative, technical, or logistic support (EDD, CB, SDF); and supervision (KN, CM, SDF, GS).

Address correspondence to: Ann-Marie Rosland, MD, MS, 2215 Fuller Rd (152), Ann Arbor, MI 48105. E-mail arosland@umich.edu. 1. American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Osteopathic Association (AOA). Joint Principles of the Patient-centered Medical Home. http://www.acponline.org/advocacy/where_we_stand/medical_home/approve_jp.pdf. Published March 2007. Accessed June 5, 2013.

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