The VA and Relationship Based Care Leads to

The VA and Relationship Based Care Leads to Veteran Centered Care

* Transformational Initiatives Mission: - The VHA must change the way health care is delivered by moving from the current system which is problem-based …”find it, fix it” to one that is…. . * * * Proactive Personalized Patient Driven

• The VA decided upon a new veteran care initiative and implemented a patient centered medical home model referred to as PACT (Patient Aligned Care Teams) • At the center of care is the VETERAN!

Patient Centered Prevention and Population Based Team Work Patient. Aligned Care Team Provides Value Continuous Improvement Data Driven, Evidence Based

* PACT Principles Patient-Driven Team-Based Efficient Comprehensive Continuous Communication Coordinated • The primary care team is focused on the whole person • Patient-preferences guide the care provided to the patient • Primary care is delivered by an interdisciplinary team led using facilitative leadership skills • Veterans receive the care they need at the time they need it from an interdisciplinary team functioning at the highest level of their competency • Primary care is point of first contact for a range of medical, behavioral and psychosocial needs, fully integrated with other VA health services and community resources • Every patient has an established and continuous relationship with a personal primary care provider • The communication between the Veteran patient and other team members is honest, respectful, reliable, and culturally sensitive • The PACT coordinates care for the patient across and between the health care system including the private sector.

PACT Tools & Strategies v Teams Aligned Ø Ø 1 Provider 1 RN Care Manager 1 LPN 1 MSA v Team Extenders Assigned Ø Ø CCHT RN’s (Care Coordination Home Tele-health) Clinical Pharmacist Diabetic Case Manager Social Worker v Extenders Assigned to Primary Care Ø Dietician Ø Primary Care Health Psychologist Ø Primary Care Psychiatrist

PACT Tools & Strategies v Alternative Appointments Ø Telephone Clinic Appointments Ø Shared Medical Appointments (SMA’s) Ø Secure Messaging v Tools Ø Ø Ø Ø Daily Huddles Discretionary Appointments My Health-e-vet Schedule Scrubbing Team Contact Handouts Unscheduled Appointments Motivational Interviewing

PACT Measures ü Veteran’s enrolled in CCHT Goal - 1. 5 %, Team 4 – 1. 6 %, Clinic – 1. 8 % ü Ratio of Primary Care telephone encounters Goal - 20 %, Team 4 – 39. 4 %, Clinic – 22. 6 % ü Same Day Appointments with Primary Care Provider Goal - 70 %, Team 4 – 89. 5 %, Clinic – 87. 6 % ü Access within 7 days of desired date Goal – 92 %, Team 4 – 97. 7 %, Clinic – 88. 1 % ü Continuity with Primary Care Provider Goal – 77 %, Team 4 – 93. 5 %, Clinic – 90. 7 % ü 2 Day contact post discharge from the hospital Goal – 75 %, Team 4 – 80. 0 %, Clinic – 69. 8 % ü HA 1 C greater than 9 OR not done in 1 year Goal – Under 20 %, Team 4 – 15 %

* Patient Aligned Care Teams (PACT) *Transform the episodic primary care model to a longitudinal, relationship based model, where PACT team fully participates and contributes to the care of the panel of patients. VETERANS HEALTH ADMINISTRATION

PACT Success Story Veteran: • 69 year old, Caucasian male with hx of DM II, HTN, OA, and Obesity • 4/15/13 – HA 1 C = 9. 6 • 4/22/13 – Diabetic SMA • Consults placed to DM Case Manager, CCHT, Clinical Pharmacist (DM control clinic) • 6/26/13 – HA 1 C = 7. 6

We’re all in this together. Relationship-Based Care and Veteran. Centered Care *