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Tuepker A, Reyes ME, Newell S, Gonzalez-Prat MC, Skaperdas E, Kansagara D, Nicolaidis C. Veterans’ Experiences with Early Implementation of the VA’s Patient Aligned Care Team (PACT) Initiative. Poster session presented at: AcademyHealth Annual Research Meeting; 2015 Jun 15; Minneapolis, MN.
Abstract: Research Objective: Since 2010 the Veterans Health Administration (VHA) has been implementing a patient-centered medical home model of primary care, called the Patient Aligned Care Team (PACT) Initiative. Key elements of PACT include pro-active population management facilitated by a team-based approach to care, with each patient empanelled with a Primary Care Provider (PCP), Nurse Care Manager (NCM), Clinical Associate and Administrative Associate. As part of a mixed-methods evaluation of the PACT transition, we investigated veterans' recent primary care experiences, with a focus on identifying changes most noticed by patients. We also sought to understand patient priorities around care experiences within the particular context of a primary care clinic serving a veteran population.
Study Design: Retrospective, qualitative study using data from coded transcripts of semi-structured interviews with VA patients (veterans), purposively sampled for diversity in age, race, sex, and other characteristics, who had recently received care at one of 8 participating VA primary care clinics and who either had a designated chronic health condition or had been recently hospitalized. Our analysis employed a hybrid directed-inductive approach to identifying thematic results.
Population Studied: 32 veterans (7 women, 25 men) were interviewed (out of 259 screened, 145 invited to participate). Participants were racially diverse (20 White, 6 Black/African American, 3 Alaskan Native/American Indian, 3 other), with limited Hispanic/Latino representation (2 participants). The age range was 43-88 (median 65). All participants had a chronic health condition, and 14 had more than one such condition; 7 had been recently hospitalized.
Principal Findings: No strong thematic differences were found related to patient characteristics. Most participants were highly satisfied with their primary care, and the majority perceived either no change or some improvement in the quality of care since the PACT initiative began. The most frequently perceived changes were more staff, better organized care, improved communication outside of visits, and shorter wait times from arrival until being seen. When asked about team care, most participants emphasized primary-specialty care interactions; few described having strong relationships with primary care team members other than the PCP, and some expressed concern related to the perception of the NCM as a gatekeeper. "Listening," "knowing my history," and "genuinely caring" were strongly endorsed components of quality care which took on additional nuanced meanings related to veteran identity and awareness of veteran care needs.
Conclusions: Patient definitions of the healthcare "team" emphasize roles other than those affected by the PACT transformation; however, patients noticed positive changes in care made possible by team-based primary care. PACT's envisioned role of the NCM as a key provider of patient education and counselling remains largely unrealized; this may be due in part to inadequate staffing as well as patient expectations. For a veteran population, attention to "caring for the whole person" may be especially resonant.
Implications for Policy or Practice: Continued attention to PACT staffing is needed to realize the model's potential for improving patients' experience of care. Development of new measures of primary-specialty care continuity and whole-person care could better reflect patients' priorities and help VHA to continue to develop patient-centered care.