Medical Homes Require More Than an EMR and Aligned Incentives
Published Online: February 13, 2013
Samantha L. Solimeo, PhD, MPH; Michael Hein, MD, MS; Monica Paez, BA; Sarah Ono, PhD; Michelle Lampman, MA; and Greg L. Stewart, PhD
The US healthcare system is facing systemic change driven by urgent needs to rein in unsustainable costs and deliver higher-quality care. Successful transformation will require a robust primary care infrastructure that provides first-contact, comprehensive, coordinated, and continuous care.1 Toward that end, the patient- centered medical home (PCMH) has been proposed as a model not only for reforming healthcare delivery but also for rejuvenating primary care as a field.2-5
Building on long-standing investments in organizational, technological, and fiscal infrastructure to support integrated, team-based care,6 the Veterans Health Administration (VHA) has emerged as a champion of the PCMH model— branded the Patient Aligned Care Team (PACT). Formal adoption of the PCMH model began in 2009, when Secretary of Veterans Affairs Eric K. Shinseki initiated several large-scale transformational initiatives to position the VHA as a patient-centered, team-based, continuously improving, and data-driven organization.7,8 Foremost among these initiatives was fully implementing PACT. This included increased primary care clinic staffing, technical and interpersonal skill development, and development of highly functional interdisciplinary care teams. In-person learning collaboratives were implemented using the model of the Institute for Healthcare Improvement (IHI) Breakthrough Collaborative Series methodology,9 including training seminars, virtual communities of practice, and virtual lectures. The extensive nationwide change effort involves all 21 Veterans Integrated Service Networks (VISNs) and every VHA healthcare facility.
The VHA’s recent implementation efforts and long-standing infrastructural investments in key PCMH components such as electronic medical records are intrinsic advantages for PCMH implementation. Moreover, the VHA’s focus on providing patients with healthcare for life in the context of a limited global budget creates organizational incentives for investing in health promotion, disease prevention, and chronic disease management.10 Yet these structural advantages that on the face appear to make the VHA example unique are counterbalanced by the recognition that the VHA is implementing PCMH across the entirety of its primary care network, composed of approximately 5000 full-time-equivalent primary care providers (PCPs) who have a wide range of clinical experience and understanding of the PACT model. Accordingly, the VHA experience can inform the broader adoption of PCMH. In this study we present the results of a formative evaluation of PACT implementation in the VHA among 22 teams working to transform their interpersonal and clinical practices in the first wave of implementation. We then draw on these early findings to present a set of lessons learned.
A qualitative observational design was used to gather experience- near data in order to understand implementation barriers and facilitators from the perspective of the teams involved in putting PACT into practice. These observations focus on the experiences of 22 primary care teams distributed across the VA Midwest Healthcare Network (VISN 23), which includes 8 hospitals and 56 outpatient clinics located throughout 6 upper Midwest states, providing care to approximately 300,000 veterans. The teams in this study were selected because they all participated in the first wave of PACT training provided in VISN 23. Individual team members were selected by administrative leadership based on perceived high performance and their expressed interest in PACT. Each team was composed of 4 distinct roles, as prescribed by the VHA model based on previous medical home transformations: a PCP, a registered nurse care manager, a licensed practical nurse, and a clerical associate. A clerical associate is similar to an administrative assistant and is typically responsible for greeting patients, telephone work, scheduling, and data entry and retrieval. These core teams were supported by closely aligned staff referred to as “neighbors” such as pharmacists, social workers, and mental health specialists.
VISN 23 leadership selected the IHI Breakthrough Series Collaborative methodology to facilitate the development of PACT teams in VISN 23 because it is designed to assist health systems with large-scale quality improvement efforts and to establish a framework for the creation of systemwide learning communities.9 The IHI framework presents a process whereby leaders and outside experts come together to develop and deliver training content that is tailored to the needs of the specific organization. To help organizations learn and deploy this methodology, IHI provides a Breakthrough Series College.11 The training delivery process guides participants to acquire knowledge, experiences, and skills via a series of didactic inperson 3-day learning sessions. Experience-based action periods occur between learning sessions, with teams engaging in implementation of self-selected rapid cycle small tests of change using “plan-do-study-act.”12 Responding to expressed needs, demonstrated knowledge gaps, and goals of the change effort, the content of the learning session and action period activities are created iteratively by faculty content experts and Collaborative leadership. In the present context, the VHA Office of Quality Safety and Value also developed and supported the VHA-wide PACT Collaborative.
Prior to the transformation reported in this study, VISN 23 leadership had used the Collaborative methodology to implement a systemwide chronic disease management program.13 Under the guidance of an expert consultant and building on the skills and knowledge from the prior Collaborative and the national PACT implementation work, VISN 23 Collaborative leadership partnered with expert faculty brought together from the 8 healthcare systems in VISN 23. Together they created the initial scope and aims, as well as the learning session content and structure. As the Collaborative progressed, content was modified, added, or deleted in response to emerging themes, identified knowledge gaps, and shared learning. The content of the training was thus tailored specifically to the VISN 23 context and is presented in Table 1.
Learning collaboratives are labor intensive and require sustained organizational commitment of resources. The VISN 23 PACT Collaborative required weekly 60-minute planning sessions; monthly team action reporting, review, and feedback for all submitted materials (eg, monthly team reports); and substantial time dedicated to logistical planning and content development for the learning sessions. The VISN 23 PACT Collaborative lasted 18 months and required 4 months of preplanning and preparation.
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