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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

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
THE PRIMARY CARE TEAM

Future of VA Health Care
Past
VA
“What can I fix?”
Physician
Present
VA
“How can we help what is wrong with you?”
Clinical Team
Case-Based Paper Medical
Record
“We’ll address your immediate concern.”
Disease-Based Electronic
Medical Record
“You have a risky problem, please follow this plan to improve by your next visit.”
Future
VA
“How can we help you live the life you want to live?”
Veteran, Family and
Health Care Team
Whole-Person Electronic
Health Record
“We can design your personalized health plan to meet your goals.”
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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

Patient Aligned Care Team
Access
Offer same day appointments
Increase shared medical appointments
Increase nonappointment care
Care Management &
Coordination
Focus on high-risk pts: o Identify o Manage o Coordinate
Improve care for: o Prevention o Chronic disease
Improve transitions between PCMH and: o Inpatient o Specialty o Broader Team
Practice Redesign
Redesign team: o Roles o Tasks
Enhance: o Communication o Teamwork
Improve Processes: o Visit work o Non-visit work
Patient Centeredness: Mindset and Tools
Improvement: Systems Redesign, VA TAMMCS
Resources: Technology, Staff, Space, Community

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
Other Team
Members
Monitored via
Primary Care
Staffing and Room
Utilization Data report in VSSC
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
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
Patient
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OLD New

Changes in Primary Care
Past
The patient has one provider
PACT (Patient Aligned Care Team)
The patient has a team
Care delivered only by provider
Focus on visits
Most care delivered by visits
Virtual visits uncommon
Care delivered by team members
Focus on overall health
New care delivery routes and tools
Phone, telehealth visits, secure messaging common
Continuity inconsistent Continuity consistent
High risk patients get routine care Identify and manage high risk patients
Hospitalizations common
Care not well coordinated
Prevention not stressed
Hospitalizations less frequent
Care coordinated throughout the system
Prevention and health promotion essential

Health Tech or
Clerk
Customer Service
• Initial point of contact
• Patient Advocate
• Address customer service concerns & coordinating solutions.
• Hand-off communication
Assists providers
• Prepare paperwork requested by the Veteran and/or PCP
•
Specialty consult completion tracking
• Coordinate information exchange for the co-managed patient
• Manage telephone demand
(receiving and documenting)
• Manage appointment scheduling including EWL & recall.
• Pre-visit patient reminder calls
Face to Face Visits
• Appointment check in
• Assists w/My HealtheVet registration
• Performs In-Person
Authentication
• Assists with updating and verifying demographics and insurance information
Team Work
• Daily huddle
• Team Meeting
Clinic support
• Identify & prepare required forms, documents/records prior to clinic session
• Faxing, copying, mail mgt
• Manage clinic grids
• Manage office supplies & setup
Provider
(Physician, NP, or PA)
Direct Patient Care
• Scheduled Clinic Visits
• Walk in or Urgent Visits
• Group Visits
•
Telephone Visits
• Incoming telephone demand
• Pertinent Clinical Reminders
Secure Messaging
• Triaged messages from patients
• E-mail with consultants
Care Management
• Virtual review of patients including inpatients
• Identify high risk for hospitalization.
• Appropriate for CCHT, OEF/OIF,
HBPC
• Preventive care needs
• Non VA records
• View alerts
• Diagnostic result
• Discuss care with/refer to specialty consultants
• Traveling veterans
• Medication Reconciliation
• Refer to other team members as appropriate
Team Work
• Daily huddle
• Team Meeting
• Midlevel Collaboration
Education
• New patient orientation
• Provider CME , Grand Rounds
• Teaching trainees
Veteran
Schedule appointments
As needed or requested by primary care team
Appointment check in
(including correct ID)
• Utilizes kiosk to check in when available (performs
In-Person Authentication)
•
Updates insurance & demographic info
Face to Face Visits
• Arrive on time
•
Bring medications
• Required Paperwork
•
Health risk assessment completion (with RN)
• Lab work completion
Prepare for Primary Care
Visit
• Discuss concerns and plan of care
•
Utilize My HealtheVet
• Contact PC “teamlet” with any problems/concerns that arise during/after face to face encounter.
Participate
• Attend committees, patient advisory groups, and task forces
RN Care Manager
Direct Patient Care
• Scheduled Clinic Visits
• Walk in or Urgent Visits
• Group Visits
•
Telephone Visits
• Incoming telephone demand
• Triage/place orders by protocol
• Pertinent Clinical Reminders
Secure Messaging
• Triaged messages from patients
• E-mail with consultants
Care Management
• Virtual/F2F in-depth and ongoing review of patients including inpatients
• Identify high risk for hospitalization.
• Initiate appropriate consultations for CCHT, CM, OEF/OIF, HBPC, hospice/palliative care
• Discuss care with specialty consultants
• Preventive/chronic disease care needs
• Triage to other team members as appropriate
•
Non VA records
• View alerts
• Follow-up calls
Team Work
• Daily huddle
• Team Meeting
Education
• New patient orientation
• Mentor/precept nurse trainees
• Patient health education/coaching
Health Tech, LPN or
Medical Assistant
Direct Patient Care
•Assist with triage
•Assist providers with exams/procedures
•Perform treatments (EKGs, V/S, blood sugar, etc)
•Administer meds, wound care
•Pertinent Clinical Reminders
Secure Messaging
•Triage messages from patients
Care Management
•Track/administer required immunizations
•Triage phone calls for appointments
•Coordinate group visits
•Identify additional services needed by Veteran/Family
Team Work
•Daily huddle
•Team meetings
Education
•New patient orientation
•Assist with patient education
Clinic Support
•Daily equipment/supply checks

Huddles
• 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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Team Meetings
• Once a Week
• One Hour
• Teamlet, Social Worker and Others as Related to Agenda
• Agenda
– Microsystem improvement
– Care decisions with interdisciplinary team regarding complex Veterans
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• 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
4/13/2020

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)

• 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

•
– Seasons
•
– Short Term
– Long Term
•

• 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

1. Is a physical exam needed?
2. Is this a “relationship” visit?
3. Is there a need for a critical conversation?
The harder the problem, the more valuable the appointment strategy.

• 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.

CPT Description Work RVU
Telephone Non Physician & Non Licensed Independent Professionals
98966
98967
98968
(RN, SW, RD, LPN/LVN, Pharm)
HC Prof Phone Call 5-10 min
HC Prof Phone Call 11-20 min
HC Prof Phone Call 21-30 min
0.25
0.50
0.75
T elephone Physician & Licensed Independent Professionals
99441
99442
99443
99211
(PA, NP, MD)
Phone E/M by Phys 5-10 min
Phone E/M by Phys 11-20 min
Phone E/M by Phys 21-30 min
0.25
0.5
0.75
Primary Care Provider Face to Face Visit
Office Visit, E/M est. pt, Minimal, Typically 5 min 0.18
99212
99213
Office Visit, E/M est. pt, Problem Focused, 10 min 0.48
Office Visit, E/M est. pt, Expanded Problem, 15 min 0.97
IMPORTANT: Telephone note must include history, assessment & plan

• 62% of Veteran population has 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

• 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

• 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?

Secure
Messaging
Face to Face
Visits
Telephones
• Transitions-DC/ED
• Chronic Illness
• HPDP
• Acute/Episodic
• Follow up FtF visit
TeleHealth
• Telemedicine (CVT)
• CCHT
• Store & Forward
Group Visits
• Face to Face
• Telemed
(CVT)

Test Results
9%
Questionconcern about medication
38%
Next Step in
Care?
14%
Urgent Medical
Issue
14%
Chronic-
Longterm
Medical Issue
12%
Clarification of
Information on
Last Visit
13%
Source: 2009 Voice of the Veteran Survey

PCMH Provider Time
Sample Weekly Schedule
Tue Wed Thu Mon Fri
8 Unscheduled Care Unscheduled Care Unscheduled Care Unscheduled
Care
Unscheduled Care
9 Telephone Clinic Telephone Clinic Telephone Clinic Telephone Clinic Telephone Clinic
10 Huddle/
Scheduled PC
11 Scheduled PC
12 Unscheduled
Care / Lunch
1 Scheduled PC
Huddle/
Scheduled PC
Scheduled PC
Unscheduled
Care / Lunch
Scheduled PC
Huddle/
Scheduled PC
Scheduled PC
Grand Rounds
Lunch
Scheduled PC
Huddle/
Scheduled PC
Scheduled PC
Unscheduled
Care / Lunch
Scheduled PC
Huddle/
Scheduled PC
Scheduled PC
Unscheduled
Care / Lunch
Scheduled PC
Scheduled PC Scheduled PC Scheduled PC 2 Scheduled PC Scheduled PC
3 Scheduled PC Scheduled PC
4 PC team meeting Unscheduled Care
Scheduled PC
Group Visit
Scheduled PC Scheduled PC
NP/PA oversight Unscheduled Care

•
•
•
– 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

• 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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Making sure the right things get done at the right time by the right person in the right place
Institutional knowledge
Contacts, local resources
Medication reconciliation
Labs and other tests
• Orders
• Results
Patient’s
Care
Needs
Consults and
Referrals
• Pre-requisites
• Results
Protocols,
SOPs, standing orders
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Diagnostic
Tests
In-Patient
Care
Emergency
Department
PCMH
Teamlet
Patient
Family
Specialty
Care
Home
Care

Care Plan for
Life
Patient Registries Email Alerts
Flags and
Clinical
Reminders
Templates Huddles
Community
Resources
Team Meetings Screening Tools
Protocols:
• RN Driven
• LPN/HT Driven
• Clerk Driven
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CCHT uses Evidenced Based
Disease Management Protocols (DMP)
Existing DMP’s
• Diabetes
• CHF
• COPD
• HTN
• Major Depression
• Substance Use Disorder
• Weight Management
Developing DMP’s
• TBI
• Palliative Care
• Dementia
• PTSD
• SCI
Katherine Corrigan, MD
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• Patient-Centered
• Team-Based
• Coordinated
• Continually
Improving
• Meet face-to-face
• Involve key players
• Educate
• Seek common goals
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Outpatient and Inpatient Care Coordination:
How To Do It
Admission Notification
• PCMM or CPRS alerts
• ED visits
• Admissions
• Phone call
• Review admission list
Service Agreement with Hospitalists Nursing Policy/Procedure
• Contact PACT soon after admission
• PACT involvement in care
• Contact PACT before discharge
Pre-discharge involvement
• Visit inpatients
• Virtual chart review
• Meet with discharge planners
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Directory of Community
• Point of Contact
• Phone numbers
• Standard location
Contact Local providers
• Identify POC
• What
• When
• How
Contact local hospitals
• Identify POC
• What
• When
• How
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V
E
N
T
I
P
R
E
O
N
The Journey for a Patient with Diabetes
85%
Initial
Diagnosis
Management
Continuing
Care
Non diabetes admissions life events treatment change eg insulin
Severe hypos new complic ations
EVENTS heart disease stroke
ED
Pregnancy ketoacidosis protenuria
Eye problems
Institutional care
Foot issues

C L E R K
P C
P R O V I D E R
C L I N I C A L
A S S O C I AT E
RN C A R E
M A N A G E R
F A M I LY
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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

How do we get the provider, the patient, the equipment, the information to an available room-on time, every time?
Provider
Room
Equipment
Patient
10:00
Appt.
Information

Improved access leads to more efficient office processes
Increased supply leads to improved access
More efficient processes increase supply
Supply

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• 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

High Performing PACTs: Outcome Measures
43%
47%
Better Performance Better Performance

48
6% decrease
(8% FY11)
6% decrease
(4% FY11)

VHA Average
Oct-09 69% Jul-11 80%

High Performing PACTs: Access Measures
6 days
6%
Better Performance
Better Performance

Existing
CBOC
ROC
Planned clinic
Mountain Home
Nine sites for Primary Care
300
400
1800
1100
1500
2200
22,000
15,000
500
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Mountain Home
Renewing Our PACT with Veterans