1025 — Frontline Challenges to Delivering Primary Care
Farmer MM, Rose DE, Rubenstein LV, Canelo I, and Taylor SL, COE Sepulveda; Schectman G, VA Office of Patient Care Services; Stark R, VA Primary Care Operations; Yano EM, COE Sepulveda;
VA has launched a nationwide effort to implement Patient Aligned Care Teams (PACTs); a primary care (PC) based transformation towards patient-centered medical homes. In anticipation of the inherent challenges to redesigning PC delivery in such fundamental ways, the VA Office of Patient Care Services and HSR&D researchers partnered to assess the challenges frontline PC managers were already facing in delivering PC to our nation’s Veterans.
We designed and fielded a National VA Primary Care Survey in 2008-09 to all VA PC Directors at VAMCs and large CBOCs (92% response rate, n = 229). We asked frontline directors about their PC management challenges in access, preventive care, chronic disease care, selected medical conditions, mental health/PC coordination, clinical informatics, and special populations. We rank ordered those reported as moderately to extremely challenging.
The top VA PC challenges nationwide were anchored in clinical informatics: top challenges included the volume of clinical reminders (80%), volume of CPRS alerts (75%), and time/effort to input notes (60%) as moderately to extremely challenging. Over 70% reported chronic non-malignant pain requiring opiate therapy as especially challenging in PC. Coordination of care between VA and non-VA providers (57%), and caring for seriously mentally ill Veterans (52%) and patients with substance abuse problems (52%) were also particularly challenging. Providing access to PC teams via telephone was challenging to 46% of directors. Results did not vary significantly by facility type or urban/rural location.
Even before VA launched PACT implementation, PC directors were faced with substantial challenges, some of which may pose barriers to key initiatives that rely on CPRS-based informatics tools to enhance patient care and provider communication (e.g., reminders, alerts, note completion). The complexity of VA PC patients, including management of chronic pain and care for mental health/substance abuse conditions, will continue to complicate PC delivery, and may invoke special challenges during organizational change. While not an explicit focus of initial PACT changes, coordination of Veterans’ care with community providers may be an important target for subsequent policy and practice changes.
PACT implementation will need to continually address the complex challenges that field-based PC leadership had not solved prior to VA’s transformational initiatives.