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As part of its mission to provide Veterans with the best possible healthcare, VA has adopted a patient-centered care model called the Patient Aligned Care Team, or (PACT). The PACT model involves a team of healthcare professionals—led by a primary care provider—who work collaboratively with patients.
The studies funded under this CREATE seek to address gaps or missed opportunities for high-risk primary care populations (i.e., patients who might be at risk for adverse health outcomes resulting from communication and coordination breakdowns in the outpatient setting.) Projects within this CREATE foster adoption of best practices by engaging primary care staff in the development and implementation of point-of-care interventions designed to improve healthcare quality and safety. The interventions are expected to provide tools to the PACT team and/or patients that facilitate the utilization of evidence derived from routine health care interactions, thus advancing clinical outcome improvements in the learning health care system. This approach is consistent with VA's vision of providing high-quality patient-centered care.
Patient Safety & Electronic Health Record by Hardeep Singh, MD (4:05)
Partner Offices
Each CREATE works closely with operational partners throughout the VA System. The partners associated with this CREATE are:
VA Primary Care Program Office
"We are looking forward with great anticipation to the fruits of these research efforts. Proposed investigations to develop processes that minimize cancer diagnosis delay are particularly relevant to the PACT (patient aligned care team) mission. This CREATE has the potential to simultaneously promote proactive personalized patient-centered care and optimize patient safety and healthcare quality. We expect this funded research will be very relevant and applicable to VHA clinical care, and the findings will have the potential for broad dissemination and implementation." -
Gordon Schectman, M.D., Chief Consultant, Primary Care Services, VA Primary Care Program Office.
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VISN 12: Great Lakes VA Healthcare System
"The products of this work will enhance our VISN's care coordination in PACT and ultimately improve the quality of care provided to all Veterans. I am particularly enthusiastic about the partnership with Dr. Gordon Schectman, Acting Chief Consultant of Primary Care in the VA Primary Care Program Office, as this will facilitate nationwide implementation of findings from this project. I strongly believe that this work will enhance the effectiveness of the investments made in the PACT program and align with current VHA strategic goals. The projects leverage personalized care planning and enhanced coordination based on proactive disease identification. I am greatly interested in the results in the high impact disease populations proposed."
- Jeffrey Murawsky, M.D., Former Director VISN 12.
This CREATE initiative includes four funded projects:
Identifying and Delivering Point-of Care Information to Improve Care Coordination
This project uses the Productivity Measurement and Enhancement System (ProMES) to systematically identify organizational objectives and develop clear, accountable measures of coordination, which in turn help identify care coordination needs in PACT settings. ProMES is a performance measure development method based on more than 30 years of work in motivation, feedback, participation in decision-making, and goal-setting. Based on the measures developed using ProMES, study participants receive feedback on how well they are meeting goals identified by front-line staff as being important in care coordination; improvement over time is then tracked on the ProMES-developed measures of coordination.
(PIs: Laura A. Petersen, M.D., M.P.H. and Sylvia J. Hysong, Ph.D.)
Point-of-care Health Literacy and Activation Information to Improve Diabetes Care
Diabetes mellitus is a highly prevalent chronic condition, affecting one in five Veterans who use the Veterans Affairs (VA) healthcare system. Self-management skills are critical for controlling diabetes and reducing its cardiovascular side effects. This project evaluates:
The process of implementing a collaborative, goal-setting intervention (i.e. Empowering Patients in Chronic Care, or EPIC) that is personalized to patient activation and health literacy levels into routine PACT care, and
The effectiveness of the intervention relative to usual care.
(PI: LeChauncy D. Woodard, M.D., M.P.H.)
Automated Point of-Care Surveillance of Outpatient Delays in Cancer Diagnosis
This study evaluates the accuracy of a "real-time" automated surveillance system to identify Veterans at risk for missed or delayed diagnosis of common cancers. Key aspects of the study include: identifying and transmitting data on potentially missed abnormal test results in near "real time;" allowing PACT team members to review specific patient data to confirm whether follow-up actions need to be initiated; and enhancing timeliness of care by identifying patients who are lost to follow-up, and bringing them back into the VA healthcare system for further diagnostic evaluation.
(PI: Hardeep Singh, M.D., M.P.H.)
Automating Heart Failure Data for Patient Treatment Goals at the Point of Care.
Investigators build from prior work developing automated data extraction systems to develop a process that uses automation to identify and deliver patient-specific data regarding guideline-concordant treatment for congestive heart failure (CHF) to PACT providers. The project's key goals are to: provide a communication aid to the PACT team about beta-blocker titration for Veterans with CHF; determine optimal attributes of the communication aid in partnership with PACT teams; and improve provider delivery of guideline-concordant care and decrease patient readmissions and mortality.
(PI: Jennifer Garvin, Ph.D., M.B.A., R.H.I.A.)
