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VHA: Designing Tomorrow's Veteran-Centered Model of Care

During the 1990s, the Veterans Health Administration (VHA) underwent a major transformation, balancing inpatient care with outpatient services, ensuring Veterans had access to standardized benefits, and improving population health. Since those years, VHA has continued to make many incremental improvements. Faced with enormous changes within health care, future financial constraints on government, and evolving Veteran expectations, VHA must move beyond problem-based disease care to patient-centered health care, based on relationships between the patient, his or her family, and the health care team. This new system must also be safe, of high quality, and efficient.

Today, VHA is embarking on our next major transformation, one that places the Veteran and his or her family at the center. This means focusing holistically on optimizing health and not just the treatment of disease; designing the delivery system around the needs of our Veterans and not around a medical model; and being responsive to the desires of our patients rather than designed for our convenience.

A Vision for Continuing to Deliver 'The Best Care Anywhere'

Veterans have told us that they want a system that they can trust to reliably provide all necessary services to restore health and functionality, but that is well coordinated and conveniently available—both in terms of being timely and close to home. They want a relationship with a personal clinician, some choice in their options for care, and above all else, they want to be treated with respect and dignity. Yes, VHA has made enormous improvements over the last couple of decades; but if we are to continue to deliver "The Best Care Anywhere," we must be bold in our vision of the future.¹

Patient Aligned Care Teams (PACT) will be the patient-centered medical home for enrolled Veterans—the hub that helps patients develop and meet personal health goals, coordinates services and hand-offs, and ensures that patients have access to the right care, at the right time, in the right place, and by the right provider. We know that systems that have implemented similar models, particularly for patients with chronic disease, have been able to improve outcomes while reducing costs.² While they did not call it PACT or medical home, VISN 23 implemented similar changes six years ago. Over the next five years, their admissions for ambulatory sensitive conditions fell 14 percent while the rest of the country increased 5 percent. But PACT will not succeed without new strategies to fully engage Veterans in the management of their own health.

The VHA system must develop processes to better help patients manage their chronic conditions. Telehealth, secure messaging, and mobile communication strategies can better link clinicians and patients through a web of support. Deployment of new technologies, such as the PTSD applet for the iPhone, will help improve the lives of VHA patients. The applet allows Veterans to track PTSD symptom severity and offers resources to those in need. Additional applications are being developed as part of VHA's iPad-based "clinic in a hand," which will be piloted next year.

From Medical Home to a Patient-Centered Community

To ensure seamlessness, VHA must design the rest of the health care neighborhood around that medical home. Specialty services must be available in real-time, and be designed to better serve the needs of patients and primary care clinicians. Several innovative ways of providing better subspecialty support for patients and primary care teams are currently being piloted. The first, Specialty Care Access Networks (SCAN), modeled after the University of New Mexico's ECHO project, provides virtual specialty consultation for non-urgent issues, which improves access and enhances the ability of primary care teams to manage complex conditions, especially for those patients living in rural areas. Second, eConsult pilots provide specialty help to primary care clinicians without requiring a patient visit. These pilots are modeled after innovative work done by the Mayo Clinic, which estimated that 30 percent of their consults could be done with a virtual visit. Finally, specialists are providing just-in-time support to primary care clinicians through phone consults.

VHA must also design care around the specific needs of patients instead of organ systems. Bohmer and Lawrence suggested we should be designing "clinical production" around the unique needs of patient cohorts in ways that improve integration, predictability, and reliability.³ Oncology services are often arranged this way. We know that most patients with cancer need certain services over the course of their illness. Interdisciplinary teams have clinic together and coordinate services through a common treatment plan. Why not build similar care models for other unique patient populations?

Duke University cardiologists have developed such a program for patients with advanced congestive heart failure.⁴ Highly integrated with primary care, these multidisciplinary teams have improved clinical outcomes and reduced costs by more than $8,000 per patient-year. They have successfully incorporated registries, protocols, and telehealth into their model.

I can see a very different VA health care system 10 years from now, one that is truly designed around the Veteran. Places that excel at patient-centered care, such as Griffin Hospital in Connecticut, engage patients in ways that we find hard to imagine. In the ICU at Griffin, there are no visiting hours. Even the family dog is welcome. Families stay overnight in a 'hotel room" immediately adjacent the patient's ICU bed. Common family rooms and kitchenettes bring families together to support one another. They are invited to be present during invasive procedures and even at codes. The hospital's approach reflects a fundamental belief about the primacy of the patient. For the past 10 years, Griffin Hospital has been on Fortune Magazine's list of Top 100 Employers of Choice. Although many may wonder if VHA can make this journey, or even if we should, I am confident that in the future we will fulfill Lincoln's promise to America's Veterans in powerful new ways.

References

1. Longman, P. 2007. Best Care Anywhere: Why VA Healthcare is Better Than Yours. Sausalito: Polipoint Press.
2. Grumbach, K. et al. The Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence on Quality, Access, and Costs from Recent Prospective Evaluation Studies, UCSF Center For Excellence in Primary Care, August 2009.
3. Bohmer, R.M.J. and D.M. Lawrence, "Care Platforms: A Basic Building Block for Care Delivery," Health Affairs 2008; 27(5):1336-40.
4. Whellan D.J. et al. "The Benefits of Implementing a Heart Failure Disease Management Program," Archives of Internal Medicine 2001; 61:2223-8.