Health Services Research & Development

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Commentary

Since 2010, Patient Aligned Care Team (PACT) implementation in the Veterans Health Administration (VHA) has focused on improving care coordination and transitions of care for Veterans. PACT is VHA's patient-centered medical home model of primary care and is based on principles of personalized, proactive, patient-centered, team-based health care. PACT is a partnership between the Veteran and the health care team—a partnership that places the Veteran at the center of a care team that also includes family members, caregivers, and health care professionals. PACT emphasizes prevention, health promotion, and patient self-management. PACT staff work with the Veteran to identify personalized health care goals, provide basic health care services and education, develop a care plan, and coordinate care. When more specialized services are needed, PACT coordinates with other members of the patient's care team, which may include discipline-specific, specialty, or non-VA team members. Together, the entire PACT is focused on helping the Veteran meet his/her health care goals while improving the patient experience, as well as ensuring the clinical quality, safety, and efficiency of care.

Care coordination and seamless transitions of care are core PACT change concepts, and together with care management, they make up the second of three foundational "pillars" of the PACT model. A variety of actions occur on a regular basis within PACTs to support this pillar, including daily team huddles, monthly treatment planning meetings to discuss complex/high risk clinical patient needs, notification of admission and involvement in discharge planning, and follow-up contact with patients within two business days following hospital discharge. In addition, PACTs work to identify high risk or chronically-ill patients on a proactive basis by using patient registries. PACT team members also identify and monitor incomplete referrals/consults, and have in place a process for ensuring that Veterans receive timely notification of test results. Furthermore, at each regularly scheduled provider visit, PACT team members ask Veterans about non-VA providers and non-VA care while educating Veterans about the importance of sharing medical records from non-VA providers.

To ensure smooth, safe, and effective transitions of care, Veterans and their family caregivers should receive and understand their transition record and care plan as well as be encouraged to participate in the development of it. The care plan must be appropriate to the patient's health literacy. Additionally, many VA PACTs have implemented clinic after-visit summaries and/or printed care plans to enhance the Veteran's participation in their health care and to support care coordination. All these activities are designed with the overarching goal of improving transitions of care by coordinating inpatient and outpatient care, primary and specialty care, and finally VA and non-VA care.

National PACT metrics available on the Primary Care Almanac and the Primary Care Operations PACT Dashboard support data-driven PACT teams and continuous improvement. These metrics demonstrate that PACT has improved care coordination for Veterans. Approximately 65 percent of Veterans requesting a same day primary care appointment with their personal provider are accommodated, and 78 percent of Veterans are able to see their own primary care provider for any appointment on the date they desire. Veteran access to primary care during extended hours (non-business hours) has increased 75 percent since January 2013. Post-discharge follow up is also important to reducing readmissions. Now, over 72 percent of all Veterans discharged from VHA are contacted within two days to ensure they are following discharge instructions and doing well.

An important benefit of health information technology (HIT) is to ensure that pertinent patient health information is readily available to all members of the health care team, especially during critical transitions of care. A variety of clinical care processes use HIT to enhance patient care coordination. First, secure messaging offers Veterans easy, asynchronous communication with the PACT and connects them to their team between visits. Second, Blue Button technology allows Veterans to download portions of their medical record for sharing with non-VA health care providers. And finally, Veterans who are located far from VA medical centers may now use a variety of technologies to bridge that distance, including E-consults, CVT consultation, and SCAN-ECHOs.

The Patient Care Assessment System (PCAS), a VHA Web-based application for care management tracking, also promises to greatly enhance care coordination. PCAS integrates key data from multiple sources while allowing manual entry of information such as non-VA providers and contact numbers. It is designed to link to the Care Assessment Needs (CAN) score and to support a summary of patient risk factors, task lists, and notifications. Future plans include the ability to create a care plan that is sent to CPRS as a standardized note.

Care coordination within VHA is supported by a robust electronic health record (EHR) system that enhances health information sharing. The EHR provides support for key functions of care coordination, including referral tracking, consultants' recommendations, care management activities, medication management and reconciliation, patient preferences, and more. Both VHA and non-VA health care systems are enhancing their EHRs to comply with meaningful use certification, which includes, among many other requirements, clinical information reconciliation (medications, allergies, and problems) and the ability to automatically generate a transitions of care/referral summary document. These innovations will further support care coordination through enhanced information flow between VHA and non-VHA health care systems.

Improving care coordination and transitions of care for Veterans is an important and primary focus of PACT. PACT policy, metrics, and practical implementation strategies are aligned to promote care coordination. As PACT evolves, continued identification and spread of best practices will further enhance coordination of care and smooth transitions between PACT and inpatient care, specialty care, and non-VA care.