Study Examines Factors Affecting Readiness for Implementation of VA's Patient-Aligned Care Team Model
In the face of growing concerns over the quality and viability of the current system of primary care, the Patient-Centered Medical Home (PCMH) has emerged as a promising alternative care-delivery model. In 2010, VA launched one of the largest PCMH initiatives to date — the Patient-Aligned Care Team (PACT) model — with the goal of transforming primary care clinics across more than 850 hospital-based medical centers and community-based outpatient clinics (CBOCs) by the end of 2014. The focus of early PACT implementation was on training pilot teams from each facility, funding additional staff, leveraging existing space and technology resources, and redesigning existing processes. This study sought to describe the impact of readiness for implementation on the efforts of 32 pilot teams to make changes to improve access to healthcare for Veterans — and to identify successful strategies to overcome barriers to change. Investigators conducted site visits and interviews with implementation teams that included administrators, primary care providers, and staff from 56 primary care clinics located at 10 VAMCs and 45 CBOCs across six states. In addition, internal organizational documents were reviewed. All data collection took place between 4/10 and 12/11.
- Key factors related to readiness for implementation (or lack thereof) had an impact on which interventions pilot teams could put into place, as well as viability and sustainability of access gains:
- o Leadership Engagement. Lack of leadership engagement/support posed a barrier to open access, however, strategies to engage/educate administrators led to successful interventions to improve access.
- o Staffing Resources. Lack of personnel to staff PACT teams was a barrier to improving access; at sites where funds were made available to hire new staff or where teams were able to re-configure existing staff, access interventions were more often implemented.
- o Access to Information and Knowledge. Having experienced staff who could generate reports from the electronic medical record was a major facilitator of access interventions.
- Pilot teams used a number of effective strategies for improving access, i.e., extending time between appointments for some Veterans; reorganizing clinic schedules in order to provide a mix of face-to-face, telephone, and same-day appointments; and contacting Veterans after an ED visit to determine appropriate follow-up care.
- The authors note that wide variations in interventions to improve access occurred across sites, which has important implications for efforts to measure the impact of enhanced access on patient outcomes, costs, and other systems level indicators of the PACT model's success.
- Face-to-face interactions with early adopters were limited to initial site visits and observations at Learning Collaboratives.
- Follow-up interviews were typically conducted with just one person. The extent to which this person knew the consistency with which changes were implemented may be limited.
The VISN 4 Center for Evaluation of PACT (CEPACT) is funded through the VHA Office of Primary Care. All authors are part of CEPACT; Drs. True, Shea, Asch, and Werner (CEPACT Director) are also part of HSR&D's Center for Health Equity Research and Promotion, Philadelphia.
True G, Butler A, Lamparska B, Lempa M, Shea J, Asch D, and Werner R. Open Access in the Patient-Centered Medical Home: Lessons from the Veterans Health Administration. Journal of General Internal Medicine November 29, 2012;e-pub ahead of print.