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PACT ( PATIENT ALIGNED CARE TEAMS) VHA’S NEW APPROACH TO PRIMARYCARE
Vinodini Krishnan M.D FACP CMO, Primary Care and Community Medicine James H Quillen VAMC Mountain Home
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Disclosure statement of Financial Interest
I, Vinodini Krishnan DO NOT have a financial interest/ arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of the presentation
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Acknowledgement VHA PC Program Office
Gordon Schectman M.D: Acting Chief Consultant, PC Richard Stark M.D: Director PC Clinic Operations All the presenters at the various PACT learning sessions
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“ The good physician treats the disease, the great physician treats the patient who has the disease”
Sir William Osler
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Patient-Centered Care
VA is changing the way health care is delivered by shifting from a problem-based health care system, to one that is patient-centered and healing Key Components Personalized Health Planning Whole Person; Integrative Strategies Behavior Change and Skill Building That Works Created for VHA Overview Version 1.6/13/2011
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Patient Aligned Care Team
Replaces episodic care based on illness and patient complaints with coordinated care and a long term healing relationship Takes collective responsibility for patient care Is responsible for providing all the patient’s health care needs Arranges for appropriate care with other specialties Would use either this slide or the previous one, not both to introduce the idea of PACT and what it does. THE PRIMARY CARE TEAM
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Future of VA Health Care
Past VA Present Future “What can I fix?” “How can we help what is wrong with you?” “How can we help you live the life you want to live?” Physician Clinical Team Veteran, Family and Health Care Team Case-Based Paper Medical Record Disease-Based Electronic Medical Record Whole-Person Electronic Health Record “We’ll address your immediate concern.” “You have a risky problem, please follow this plan to improve by your next visit.” “We can design your personalized health plan to meet your goals.” Tracy will like this!
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The Patient’s View of Primary Care
Access I can get care when and how I need it Relationship over time I have a Team who knows me as a person Comprehensive services My Team takes care of the bulk of my health needs Coordination My Team coordinates any care I need in the health system Added the word health
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Patient Aligned Care Team
Access Offer same day appointments Increase shared medical appointments Increase non- appointment care Care Management & Coordination Focus on high-risk pts: Identify Manage Coordinate Improve care for: Prevention Chronic disease Improve transitions between PCMH and: Inpatient Specialty Broader Team Practice Redesign Redesign team: Roles Tasks Enhance: Communication Teamwork Improve Processes: Visit work Non-visit work Patient Centeredness: Mindset and Tools Improvement: Systems Redesign, VA TAMMCS Resources: Technology, Staff, Space, Community
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Patient Other Team Members
Teamlet: assigned to 1 panel (±1200 patients) Provider: 1 FTE RN Care Mgr: 1 FTE Clinical Associate (LPN, MA, or Health Tech): 1 FTE Clerk: 1 FTE Patient Other Team Members Clinical Pharmacy Specialist: ± 3 panels Clinical Pharmacy anticoagulation: ± 5 panels Social Work: ± 2 panels Nutrition: ± 5 panels Case Managers Trainees Integrated Behavioral Health Psychologist ± 3 panels Social Worker ± 5 panels Care Manager ± 5 panels Psychiatrist ± 10 panels For each parent facility HPDP Program Manager: 1 FTE Health Behavior Coordinator: 1 FTE My HealtheVet Coordinator: 1 FTE Panel size adjusted (modeled) for rooms and staffing per PCMM Handbook Monitored via Primary Care Staffing and Room Utilization Data report in VSSC * The Patient’s Primary Care Team
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“Ways In” a practice OLD New Visits Phone Visits
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Changes in Primary Care
Past PACT (Patient Aligned Care Team) The patient has one provider The patient has a team Care delivered only by provider Care delivered by team members Focus on visits Focus on overall health Most care delivered by visits New care delivery routes and tools Virtual visits uncommon Phone, telehealth visits, secure messaging common Continuity inconsistent Continuity consistent High risk patients get routine care Identify and manage high risk patients Hospitalizations common Hospitalizations less frequent Care not well coordinated Care coordinated throughout the system Prevention not stressed Prevention and health promotion essential Added PACT acronym spelled out.
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Huddles and Team Meetings
Every Day 10 Minutes All Teamlet Members and Teamlet Social Worker Identify Priorities for the Day Communicate, Clarify, Assign Tie Up Loose Ends from Prior Day
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Huddles and Team Meetings
Once a Week One Hour Teamlet, Social Worker and Others as Related to Agenda Agenda Multidisciplinary team meetings to help manage complex health care problems of veterans
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Access: Traditional Saturated schedules
Triage and rework often with high intensity resource Multiple appointment types Needs for “urgent”, “routine” and intermediate not met Capacity: Overbook and “over there” Continuity: Fine if you wait Come to work and schedule is full every day. Response: overbook, deflect. Deflection increases demand for the PCP. 11/10/2018
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Open Access PACT Continuity: Every patient sees their own provider/team member Capacity: Future schedule is truly open Backlog has been eliminated Increase non-appointment care Increase shared medical appointments Right team member engaged with right patient’s needs Right needs addressed by right tool (phone) “Do Today’s Work Today” Need to overcome fears: 1. Need to get rid of backlog Demand appears insatiable. Need to measure. Need to get rid of backlog Panel size is a fear. If panel is bigger than the doctor, then need to decrease the panel. Misconception around the work – some people think the way to do this is to never book a future appointment, but this is wrong. If we’re really good at this, then up to 90% of work generated today (Tricare) and 20% (VA IM). The best systems have “smart appointing”. Computer systems will flag thresholds for future booking. Yellow, Orange, Red. We want to book smartly and move prescheduled demand to times of lower demand. Do they need it? All the patients I see today don’t need to be seen in 3 months. So some patients don’t need follow ups in 3 months. Why 3 months? If computer is open to 3 months, providers will stack up patients at 3 months appointments. So, one can open the computer out to make the appointment. What is the best venue? Best way to care for patients with chronic illness is not with doctor visits – it’s with a nurse and a computer. When we look at visits one at a time, we increase variation. Also, these patients are old and sick. They will generate a daily
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Creating Schedule Space
Work Harder = add capacity temporarily Work Smarter = reduce provider demand Improve continuity Reduce NS rate Extend RVI Schedule phone visit Delegate tasks to others Use group visits Increase self care
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Contingency Plans Predict and respond to variation in demand between days Seasons Plan for variation in supply between days Short Term Long Term Plan for variation of demand and supply WITHIN the day
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Shared Medical Appointments
One-on-one care with observers 15-20 patients in 90 – 120 min. Patients learn from staff and from each other Appeals to about ½ of those offered option Requires substantial planning & help
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When to Schedule an Appointment?
Is a physical exam needed? Is this a “relationship” visit? Is there a need for a critical conversation? The harder the problem, the more valuable the appointment strategy.
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Delivering Telephone Care in PACT
30% patient care can be done by telephone Telephone Care by all team members needs to be legitimized, formalized and accepted. Scheduled time on appointment grids & unscheduled visits Documentation of Telephone Care via telephone stop codes, telephone clinics, coding/encounters and progress notes supports VERA allocation & workload.
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POSTER
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Why Secure Messaging? 62% of Veteran population have access to the Internet Veterans are requesting timely access to their health information Veterans want to play an active role in partnering with primary care providers to manage their healthcare
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Goals of Secure Messaging
Improved Quality: patient-provider partnership promoting health, wellness, and informed decision-making. Improved Veteran Satisfaction: patients’ desire this type of automated service for enhanced efficiency, convenience, and satisfaction. Improved Access: reduction in unnecessary office visits, expansion of case management and ease of access to services. Improved Patient Growth: new generation of veterans are highly acclimated to the electronic environment
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Increase Supply Look inside of the appointment
What is the work? Who is doing it now? Who could be doing it? What is the provider doing that someone else could do?
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Future PACT Access
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PACT Access Opportunities
Face to Face Visits Group Visits Face to Face Telemed (CVT) TeleHealth Telemedicine (CVT) CCHT Store & Forward Telephones Transitions-DC/ED Chronic Illness HPDP Acute/Episodic Follow up FtF visit Secure Messaging
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Source: 2009 Voice of the Veteran Survey
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Prevention and Health Promotion Chronic Disease Management Transitions
Fireside Chat - PCMH & Chronic Care Maurilio Garcia-Maldonado, MD Care Management Prevention and Health Promotion Chronic Disease Management Transitions Inpatient Outpatient Primary Care Specialist VA Community
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The Global Burden of Chronic Diseases
Chronic diseases are the largest cause of death in the world. In 2002, the leading chronic diseases—cardiovascular disease, cancer, chronic respiratory disease, and diabetes—caused 29 million deaths worldwide Global response to the problem remains inadequate elevating chronic diseases on the health agenda of key policymakers persuading them of the need for health systems change. Yach et al. JAMA, June 2, 2004—Vol 291, No. 21
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Chronic Disease in the United States
Affects more than 180 million Americans Accounts for more than 75 cents of every dollar spent and nearly 2/3 of the total healthcare expense By 2030: Anticipated increase in healthcare costs tied to chronic disease, 25% to 54% 45% of the American population have at least one chronic condition
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Care Management Making sure the right things get done at the
Patient’s Care Needs Medication reconciliation Labs and other tests Orders Results Consults and Referrals Pre-requisites Protocols, SOPs, standing orders Contacts, local resources Institutional knowledge Making sure the right things get done at the right time by the right person in the right place
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Coordination Emergency Department Diagnostic Tests PCMH Teamlet
Specialty Care Patient Family In-Patient Care Home Care
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Tools of Care Coordination
Care Plan for Life Patient Registries Alerts Flags and Clinical Reminders Templates Huddles Team Meetings Screening Tools Community Resources Protocols: RN Driven LPN/HT Driven Clerk Driven
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CCHT uses Evidenced Based Disease Management Protocols (DMP)
Fireside Chat - PCMH & Chronic Care Maurilio Garcia-Maldonado, MD CCHT uses Evidenced Based Disease Management Protocols (DMP) Existing DMP’s Developing DMP’s Diabetes CHF COPD HTN Major Depression Substance Use Disorder Weight Management TBI Palliative Care Dementia PTSD SCI Disease Management Protocols (DMP) are a series of evidenced based questions and information based on a diagnosis that are approved nationally by VA experts. The Office of Telehealth Services is transitioning to a process of developing and approving any new DMPs. The DMP is delivered via a secure telehealth messaging device into the patient’s home and the patient responds daily to the protocol questions. Katherine Corrigan, MD
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Bridging Primary and Specialty Care (Any Discipline)
Shared Vision Patient-Centered Team-Based Coordinated Continually Improving Shared Agenda Meet face-to-face Involve key players Educate Seek common goals
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Outpatient and Inpatient Care Coordination: How To Do It
PCMM or CPRS alerts ED visits Admissions Phone call Review admission list Admission Notification Contact PACT soon after admission PACT involvement in care Contact PACT before discharge Service Agreement with Hospitalists Nursing Policy/Procedure Visit inpatients Virtual chart review Meet with discharge planners Pre-discharge involvement
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VA and Non-VA Care Coordination: How To Do It
Point of Contact Phone numbers Standard location Directory of Community Services/Resources Identify POC What When How Contact Local providers Contact local hospitals
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The Journey for a Patient with Diabetes
new complications Non diabetes admissions heart disease 85% life events stroke PREVENTION treatment change eg insulin ED EVENTS Diagnosis Initial Management Continuing Care Severe hypos Pregnancy Institutional care ketoacidosis Foot issues protenuria Eye problems
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PRIMARY CARE TEAM TEAMLET HOSPITALISTS NON-VA CARE PATIENT SPECIALISTS
Case Manager Social Worker PC Provider Clinical Associate TEAMLET HOSPITALISTS NON-VA CARE Behaviorist RN Care Manager Administrative Clerk PATIENT Mental Health Pharmacist Dietitian Nursing SPECIALISTS Family
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Practice Redesign Principles
Balance supply and demand for tasks and processes Synchronize patient, provider, equipment, room, and information Predict and anticipate patients needs Optimize staff, rooms and equipment Manage constraints
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Synchronizing to the Appointment Time
How do we get the provider, the patient, the equipment, the information to an available room-on time, every time? 10:00 Appt. Patient Provider Room Equipment Information
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Supply: The Link Between Access and Practice Redesign
Improved access leads to more efficient office processes More efficient processes increase supply Supply Increased supply leads to improved access
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VHA Preventive Care Program
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How will we know? Readmission rates
Ambulatory care sensitive admissions ED monthly rates Prevention (package) rates Outcome data by chronic disease Patient satisfaction Staff satisfaction Provider satisfaction
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PACT Implementation at a Glance
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High Performing PACTs: Outcome Measures
43% 47% Better Performance Better Performance
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6% decrease (8% FY11) 6% decrease (4% FY11)
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ACP Medical Home Builder
VHA Average Oct-09 69% Jul %
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High Performing PACTs: Access Measures
6 days 6% Better Performance Better Performance
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Nine sites for Primary Care
Mountain Home Nine sites for Primary Care 300 1500 500 400 2200 Existing CBOC ROC 22,000 1100 Planned clinic 1800 15,000 53
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Mountain Home Renewing Our PACT with Veterans
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