In 2009, the VA Office of Rural Health (ORH) funded the "Veteran-Centered Medical Home" pilot project to implement a Patient Centered Medical Home (PCMH) at all VA Community Based Outpatient Clinics (CBOCs) in Vermont and Maine and one CBOC in northern New Hampshire. The pilot project endeavored to increase Veteran access to comprehensive healthcare, improve care coordination, enhance health information technology utilization, and improve care continuity through office system improvements. This ORH-funded pilot project provided a real-world laboratory to evaluate PCMH implementation, which became even more relevant as VA made the decision to roll out nationally the Patient Aligned Care Teams (PACT), based on the medical home model.
We conducted a process evaluation of PCMH implementation in rural CBOCs to better understand the complexities of practice transformation. We addressed the following research questions: (1) Did participating staff consider the PCMH implementation a success; (2) What facilitators and barriers to implementation were encountered; and (3) In what ways did staff perceive PCMH implementation to have impacted dual care processes?
We conducted in-depth staff and provider interviews at nine CBOCs. Staff members at any CBOC that participated in the "Veteran-Centered Medical Home" pilot project were eligible to participate. The majority of the clinics (6/9) are classified by the VA as rural. The majority (50.4% - 99.5%) of patients seen by the clinics reside in rural or highly rural areas. All interviews were conducted in an individual format. We used a semi-structured interview guide comprised of primarily open-ended questions which explored conceptual dimensions of the PCMH (e.g., treatment team structure and functioning, care coordination, access to care), perceived facilitators/barriers to implementation, and perceived changes since implementation of the PCMH. Sampling was purposive with respondents representing a variety of CBOC staff members (e.g. physicians, nurses, case managers, support staff) to ensure the richest possible data pool. Interviews were audio-taped and transcribed verbatim. Data analysis was conducted using ATLAS.ti v6.0 and used an inductive process based on Grounded Theory. Data were analyzed using an iterative, constant comparison process of textual review, code development and refinement. In addition to the interview, participants were invited to complete the "Survey of Organizational Attributes for Primary Care" (SOAPC) which measures internal resources of primary care practices for change (e.g.: decision-making approaches, relationships among staff and practice leadership, communication strategies, perceived stress).
A total of 46 staff completed interviews (13 Male, 33 Female). Of these, 39 (85%) also completed the SOAPC. The sample represented an experienced group with 45% having 10 or more years of VA experience (Median=9 years, Range=less than 1 to 30 years). The average interview time was 22 minutes and ranged from 10 to 41 minutes. Textual review and refinement resulted in 92 unique codes. Overall, respondents expressed that PCMH implementation was a work in progress and there was a common stated impression that "we were already doing this". Despite the assertion that they had always provided patient-centered care, respondents also acknowledged that certain PCMH practice innovations (i.e., case managers) facilitated the provision of quality care. Additionally, some felt that the active emphasis on patient-centered care and support from VA leadership gave them the freedom to develop and test innovative ideas for improving access to care.
Respondents identified a variety of interpersonal facilitators of intentional practice change. Small clinic sizes, years of staff shared experiences, and feeling anchored within close-knit rural communities were commonly emphasized as making patient-centered care successful. SOAPC scores showed respondents perceived good communication and a participatory approach to working in the practices. Strong local leadership was identified as a key element, especially within the more remote clinics. An expressed sense of disconnection from the main facility was coupled with the idea that rural clinics are, by necessity, self-reliant and operate on a "we take care of our own" philosophy. A commitment to "the mission" and a desire to care for the Veteran was often cited as advancing targeted clinic changes, even when faced with limited resources.
Barriers to implementation included interpersonal factors, and process and structural issues. As care teams realigned tasks were redistributed, responsibilities were shifted and role confusion sometimes led to frustration and discord. Processes for providing care in rural clinics routinely include staff assuming collateral duties. Significant uncertainty was expressed about staff ability to assume more work. SOAPC scores were indicative of mild stress in the practices. Some respondents, recalling past VA care initiatives, questioned whether the necessary staffing resources and patterns would be available to fully implement a medical home model. A need for an explicit direction, adequate preparation, and clarity of vision were seen as the pivotal components needed to be in place prior to beginning implementation. Many respondents articulated a desire for on-going program assessment to detect what is working and make corrections as needed.
Dual care is common in rural areas and generally described by respondents as challenging. Specific improvements in dual care processes were attributed to the addition of case managers. Smoother discharges from local hospitals and opportunities to foster relationships with community providers and resources were specific examples. Substantive questions were raised about the role of the VA provider within a medical home when a non-VA clinician provides the majority of a Veteran's care.
This process evaluation showed that the needs, experiences and expectations of CBOC staff, especially those located in rural or remote areas, may be different than that of teams at the Medical Center. Identifying a strong local "champion" would support implementation efforts. Definition of roles and processes must occur from the outset and opportunities for on-going clarification must be provided. On-going support from the VAMC must be made evident in order to sustain staff efforts and cultivate locally occurring innovations. As VA embraces a medical home model, further refinement of expectations and guidelines for VA providers in dual care situations should be explored.
None at this time.