2012 National Meeting

3107 — Staff Perceptions of Barriers and Facilitators to Team-Based Care within the Patient-Aligned Care Team Initiative

Tuepker AJoos SKBowen JLNicolaidis CMAlperin MD, and Hickam DH, Portland VAMC;

Objectives:
Team-based care is a central tenet of the VA’s Patient-Aligned Care Team (PACT) initiative, but prior experience with this approach is limited. We conducted a needs assessment in the first year of implementing PACT at five community-based outpatient clinics and two facility-based primary care clinics.

Methods:
The VISN20 PACT Demonstration Laboratory conducted 19 focus groups with clinical staff over 10 months. Participants included 34 primary care providers (PCPs) and 106 other teamlet members.

Results:
We identified several barriers to an effective transition to team-based care. The volume of clinical work was perceived to be high, and lack of adequate staff was cited as a barrier to reorganizing this work. Although overall staffing had been increased in all clinics, most teamlets remained below the recommended staff ratio. Teamlet members frequently needed to cross cover for absent members of other teamlets. Frequent changes in work assignments and physical distance between team members were viewed as hindering clarity of communication, role renegotiation, and the development of panel management skills. Staff felt these barriers could be ameliorated with dedicated time for team building, as well as through redesign of clinic space. The 4-person PACT teamlet model can disrupt previously developed routines and protocols. Those staff most frequently pulled to cover multiple teamlets tended to emphasize the need for PACT to standardize procedures across the clinic, while PCPs tended to see PACT as functioning best when allowed to adapt to teamlet dynamics. Across locations, staff identified reasons why some flexibility in the model might help address their clinic’s unique staffing or space needs.

Implications:
Stability and consistency of work assignments may be as important as staffing ratios for implementing PACT. Existing approaches for providing coverage of absent staff members are viewed as disrupting attempts to implement team-based care. Use of clinic space is experienced as actively helping or hindering PACT.

Impacts:
Regardless of the staffing ratios obtainable given resource constraints, clinics implementing PACT will benefit from time dedicated to intentional team building, more consistent coverage strategies, optimized use of clinic space, and some autonomy at the clinic level to make decisions about work assignments.