Spotlight: Patient-Aligned Care Team (PACT) Research

July 2014

The Patient-Aligned Care Team (PACT) is a team-based model of care in which a group of healthcare professionals, led by a primary care provider, work collaboratively with the patient to provide all of the patient's healthcare, or to coordinate care with other qualified professionals as needed. The PACT is based on the patient-centered medical home (PCMH) model of care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety.

In 2010, as part of a comprehensive initiative to transform the delivery of care for our nation's Veterans, the VA healthcare system adopted the PACT model, which puts the Veteran's goals and needs at the center of the treatment decision-making process. The PACT model of care also encourages Veterans to play a more active role in managing their health and healthcare. Thus, PACT teams focus on:

• Partnerships with Veterans,
• Access to care using diverse methods,
• Coordinated care among team members, and
• Team-based care with Veterans as the center of their PACT.

Investigators with VA's Health Services Research & Development Service (HSR&D) have contributed to VA's adoption of PACT by conducting research that supports the appropriate, effective implementation of the care model. Issues being studied include methods of improving care coordination, how to automate point-of-care delivery, and point-of-care health literacy dissemination, among others. The following studies represent some of these research projects and publications.

Study Suggests Adoption of PACT Features is Significantly Associated with Lower Risk of Avoidable Hospitalization ¹

This study measured the baseline adoption of medical home features by VA primary care clinics prior to widespread PACT implementation to determine if these features were associated with lower risk and costs of potentially avoidable hospitalizations. Using VA data, investigators identified 2,853,030 Veterans who received care in 814 VA primary care clinics during FY09. Patient and clinic factors in the baseline year (FY09) were then used to predict patient outcomes in the follow-up year (FY10). The primary outcome measured in this study was potentially avoidable hospitalizations for ambulatory care sensitive conditions (ACSC), i.e., asthma, angina without procedure, pneumonia, dehydration, COPD, congestive heart failure, complications related to diabetes, hypertension, and urinary tract infection. In addition, the total number and costs of ACSC hospitalizations were measured for each Veteran during the 12-month follow-up period. The main independent variable—adoption of medical home features—came from a survey of all VA primary care clinics in 11/09. Findings show:

• Greater adoption of medical home features by VA primary care clinics was found to be significantly associated with lower risk of avoidable hospitalizations. Veterans in clinics with the highest medical home adoption had significantly lower ACSC rates (20 per 1,000) compared to Vetrans in clinics with the lowest (25 per 1,000) and medium (26 per 1,000) adoption of medical home features.
• If clinics were transformed from the mean level of medical home adoption to the maximum level, the reduction in hospitalization costs in an average-sized clinic with 3,500 Veterans could be as much as $83,000 annually.

Study Evaluates Changes in VA Care since PACT Implementation ²

In 2010, VA became the largest healthcare system to implement the Patient-Centered Medical Home model of care, referred to in VA as the Patient-Aligned Care Team (PACT), with full implementation continuing through 2014. This study evaluated interim changes in PACT-related care processes. Using VA data, investigators identified all Veterans assigned to a primary care provider (PCP) at all VA facilities from 4/09 to 9/12. They also used data from a national, facility-level survey (ACP Biopsy) that assessed the presence of 127 PACT components. The survey was completed by ambulatory care directors at 850 VA facilities in 10/09 (pre-PACT period) and by 846 facilities in 7/11 (interim-PACT period). Findings show:

• VA achieved rapid progress in building a PACT infrastructure in the first 30 months of an extensive four-year implementation plan, and some interim changes in processes of care were observed:
  • In-person PCP visit rates decreased slightly;
  • Healthcare via telephone and Internet increased dramatically (e.g., phone encounters increased 10-fold, and Veterans using telehealth increased from 38,747 in 12/09 to 70,486 in 6/12);
  • Appointment access and continuity improved only slightly, but started at high levels; and
  • Post-hospitalization follow-up improved substantially
  .

• PACT to Improve Health Care in People with Serious Mental Illness. Moving to a PACT model may have an impact on Veterans who have received the majority of their care in specialty settings, such as those with serious mental illness (SMI.) Set to conclude in 2018, investigators in this four-year study will partner with leadership at two medical centers to implement SMI-PACT, with the goal of improving healthcare and outcomes among people with SMI, while reducing unnecessary use of emergency and hospital services. Evidence-based quality improvement strategies will be used to reorganize processes of care. In a site-level controlled trial, this project will evaluate the effect (relative to usual care) of SMI-PACT implementation on: 1) providing appropriate preventive and medical treatments; 2) patient health-related quality of life and satisfaction with care; and 3) medical and mental health treatment utilization and costs.
  
  CREATE Initiative : Improving Quality and Safety through Better Communication in PACTs. The HSR&D funded Collaborative Research to Enhance and Advance Transformation and Excellence (CREATE) initiative is comprised of four studies that are looking at the development and implementation of point-of-care interventions designed to improve healthcare quality and safety in PACTs. The studies include:
  • Identifying and Delivering Point-of Care Information to Improve Care Coordination
  • Automated Point of-Care Surveillance of Outpatient Delays in Cancer Diagnosis
  • Automating Heart Failure Data for Patient Treatment Goals at the Point of Care
  • Point-of-care Health Literacy and Activation Information to Improve Diabetes Care

• Journal of General Internal Medicine : Special Supplement. The focus of this Supplement to the Journal of General Internal Medicine is on the initial implementation of PACT in VA. This open-access Supplement includes 19 peer-reviewed articles that reflect on lessons learned by researchers and their clinical and policy partners during early stages of the PACT implementation. The 19 published articles touch upon virtually all facets of medical homes including implementation strategies, performance measurement, care transitions, team development, mental health and pharmacy integration, quality improvement, and medical home neighborhood development.

References

1. Yoon J, Rose D, Canelo I, et al. Medical home features of VHA primary care clinics and avoidable hospitalizations. Journal of General Internal Medicine. September 2013;28(9):1188-1194.
2. Rosland A, Nelson K, Sun H, et al. The Patient Centered Medical Home in the Veterans Health Administration. American Journal of Managed Care July 10, 2013;19(7):e263-72.

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