Richard Stark, MD

In 2010, the Veterans Health Administration (VA) began national implementation of its patient-centered medical home (PCMH) model, called Patient Aligned Care Teams (PACTs), to improve access, coordination, and patient-centered care. We evaluated changes in reported implementation of PCMH components in all VA primary care clinics, and patients’ utilization of acute and non-acute care and total costs after 2 years.

 Longitudinal study of 2,607,902 patients from 796 VA primary care clinics.

Clinics were surveyed for their implementation of PCMH components. Patient outcomes were measured by outpatient visits for primary care, specialty care, telephone care, and emergency department (ED) care; hospitalizations for an ambulatory care—sensitive condition (ACSC); and costs of VA care in fiscal years (FYs) 2009 and 2011. Multi-level, multivariable models predicted changes in utilization and costs, adjusting for patients’ health status, clinic PCMH component scores, and a patient fixed effect.

 Clinics reported large improvements in adoption of all PCMH components from FY 2009 to FY 2011. Higher organization of practice scores was associated with fewer primary care visits (

= .012). Greater care coordination/transitions was modestly associated with more specialty care visits (

= .018), but quality/performance improvement was associated with more ED visits (

= .032). None of the PCMH components were significantly related to telephone visits, ACSC hospitalizations, or total healthcare costs.

 Improvements under organization of practice and care coordination/transitions appear to have impacted outpatient care, but reductions in acute care were largely absent.

Take-up of medical home components appeared to be high after Patient Aligned Care Teams (PACTs) began in the Veterans Health Administration. However, while improvements under organization of practice and care coordination/transitions seemed to have impacted outpatient care, reductions in acute care were largely absent.

		Identifying areas that would benefit from ongoing improvement is critical for the long-term success of PACTs.

		Better measures of PACTs implementation are also needed to evaluate the longer-term consequences of PACTs.

The spread of the patient-centered medical home (PCMH) model to numerous healthcare systems can be attributed to the promise of revitalized primary care delivery through team-based care aiming to improve continuity, coordination, quality, and access, as well as to reduce costs. Based on these principles, the Veterans Health Administration (VA) began a vast initiative in 2010 to implement the PCMH model, called Patient Aligned Care Teams (PACTs), across the entire VA healthcare system, which included more than 800 primary care clinics caring for more than 5 million patients.

Several healthcare systems have implemented pilot programs of the PCMH and found significant improvements in quality of care, reductions in acute care, and cost savings.

 The PACT model is expected to experience similar results since it focuses on improving access to primary care, increasing telephone and other non—face-to-face care, as well as reducing unnecessary emergency department (ED) visits and hospitalizations. Lower costs are expected, in part, from a reduction in (often very costly) acute care episodes.

An early PACT evaluation found that after implementation, there were significant changes: greater use of telephone care, fewer face-to-face visits, improved appointment access and continuity, and better follow-up after hospital discharge.

However, PACT models encompassed a multiplicity of PCMH features that ranged from routinely scheduling same-day appointments to tracking specialty consultations, and from coordinating post discharge care to the use of electronic decision support systems. Baseline adoption of these features was highly variable across clinics

—and clinics may have implemented new PACT features to varying degrees&mdash;so it is unknown how differences in early implementation influenced utilization and costs.

This study evaluated the changes in adoption of different PCMH components by VA clinics, and the relationship to patients’ utilization of acute and non-acute care and total costs after 2 years. We focused on a cohort of primary care patients who used VA care from 2009 to 2011, and were therefore most likely to experience the effects of PACT. This examination can guide ongoing PACT implementation, suggesting what PCMH components and aspects of care might be emphasized most productively in later stages.

We conducted a longitudinal study of a panel of primary care patients using data from before PACT implementation (fiscal year [FY] 2009) and shortly after PACT implementation began (FY 2011); VA FYs begin the October 1 prior and end September 30, of the indicated year. We obtained VA patient-level utilization and cost records and linked them to clinic-level data for FYs 2009 and 2011. Patient data included sociodemographic characteristics, VA inpatient and outpatient utilization, diagnoses, lab test results, and costs of all care; clinic data included clinic characteristics and reporting of PCMH features. The study cohort was limited to patients who had at least 2 primary care visits in FY 2009 and used any VA outpatient care in FY 2011; altogether, 544,984 patients were excluded. Patients were linked to the clinic where they had a plurality of visits. The study cohort included 2,607,902 patients from 796 clinics; our cohort was older, predominantly male, more likely to be service-connected or below the means test, and sicker based on risk scores and chronic conditions compared with excluded patients. This study received approval from the Stanford University Institutional Review Board (protocol #20124).

Non-acute care outcomes were measured for each patient by number of primary care visits, specialty care visits, and telephone visits. Acute care outcomes were measured by ED visits and potentially avoidable hospitalizations. We also measured total annual costs of care in each study year. Outpatient visit data were obtained from the VA Medical Statistical Analysis System utilization files and categorized based on the visit location for outpatient services. Potentially avoidable hospitalizations were obtained from inpatient records and identified by primary diagnosis for an ambulatory care—sensitive condition (ACSC).

The total annual costs were obtained from Decision Support System records for services provided by the VA, and from Fee Basis records for services provided by non-VA providers and paid by the VA. Because of the short study period, we did not adjust costs for inflation.

Our main independent variable, reporting of PCMH features, came from the American College of Physicians Medical Home Builder (MHB) survey administered to all VA primary care clinics in 2009 and 2011. The MHB is a self-administered practice advisor used to support practices toward recognition of National Committee for Quality Assurance (NCQA) 2008 PCMH standards.

The MHB covers 7 PCMH components: patient-centered care and communication (support for patients’ self-management and decision making and staff communication training); access and scheduling (scheduling flexibility such as same-day appointments and non—face-to-face services); care coordination and transitions in care (coordinating visits to other physicians, creating individualized treatment plans, assessing treatment barriers); organization of practice (tracking procedures, test results, medication lists, team huddles); population management (patient registries, clinical guidelines, identifying unmet needs); quality improvement and performance improvement (performance measures, satisfaction surveys); and use of technology (practice management systems, electronic health records, decision support systems). These components overlap with 6 of NCQA’s standards for receiving PCMH certification, so the MHB captures elements similar to NCQA’s measures.

The MHB was self-administered by the clinic director or other clinic leader, and the survey response rate was 100% in 2009, and 98% in 2011. The sum of PCMH features within each component was obtained for the component scores. The component scores were grouped into low and high categories based on the baseline distribution below or above the median.

In multivariable models, we included measures of time-varying patient factors in both years. We measured the Charlson Comorbidity Index (CCI) score, a measure of comorbidity burden, for each patient based on diagnoses from inpatient and outpatient records.

We also created an indicator of risk based on available lab results reported during the study years. We chose lab tests that could, if increasing or decreasing during the study period, indicate higher risk of morbidity and mortality: cholesterol tests (>100 mg/dL), hemoglobin A1C test (>8%), anemia hemoglobin (<13 g/dL), and kidney function (eGRF <45).

For descriptive purposes, we measured several patient and clinic characteristics in the baseline year that were time invariant. Clinic measures included clinic rurality, assessed by metropolitan/nonmetropolitan codes from the Area Resource File.

Clinic type was categorized as based at a VA medical center (VAMC); VA-owned community-based outpatient clinic (CBOC)—owned by the medical center and staffed by VA providers; leased CBOC&mdash;staffed by VA providers with VA governance; or contracted CBOC&mdash;staffed by contract providers without VA governance.

Patient-level measures, including age, sex, race/ethnicity, marital status, service connection, means test, and insurance, were obtained from utilization records in FY 2009. Area income and education came from US Census data on income and maximum years of educational attainment linked to patients’ zip codes. We also estimated patients’ distance to their primary care clinic.

In bivariate analyses, we compared the mean number of primary care, specialty care, telephone care, and ED visits, and ACSC hospitalizations, and total costs of care per patient in FY 2009 and FY 2011 using 1-way ANOVA with year as the independent variable to determine significant changes over time. In multivariate analyses, we estimated the longitudinal association between changes in PCMH components scores with changes in utilization and cost measures using multi-level, linear regression models for each outcome. Regression models included a fixed effect for each patient and adjusted for time-varying patient factors (risk indicator and CCI score), dummy variables for high versus low clinic PCMH component scores, and an indicator for year. The regression model for costs used the log of costs as the dependent variable since costs had a skewed distribution.

In our models, the fixed effect controls for all factors fixed over time, such as patient sociodemographic factors and clinic characteristics (eg, rurality and size). The model estimates the “within” estimator; the coefficients represent the effect of a unit change in each time-varying predictor on patient outcomes.

The coefficient for the year indicator represented the time trend in outcomes that was not explained by changes in PCMH components or health status. Additionally, regression models adjusted standard errors to account for cluster (the intra-class correlations between patients within a primary care site).

We also conducted regressions using Poisson models for utilization measures since they were counts, but standard errors could not be adjusted for clustering within clinics since we used a fixed effect. The effect sizes were similar with linear models, and these results are presented in the 

). All regressions and data analyses were conducted using Stata 11.0 (StataCorp LP, College Station, Texas).

At baseline, most of the primary care patients in the study cohort were middle-aged (45%) or elderly (46%) (

). The study cohort was predominantly male (95%), a majority were white (67%), and a majority of patients were also married (58%). The largest proportion of veterans (42%) was eligible for VA care because of a service-connected disability, or they were within 5 years of military service. Relatively few patients (19%) had a disability rating greater than 50%, and many patients (40%) reported no other health insurance. Patients traveled a mean distance of 18 miles to their primary care clinic, the mean income of their area of residence was $40,541, and less than half of patients (46%) lived in areas where more than one-fourth of the population had a college degree.

The percent of patients with high risk (as measured by lab values) for cholesterol, diabetes, anemia, or kidney function decreased slightly from 61% of the cohort in FY 2009, to 56% in FY 2011. The CCI score, which measured total comorbidity burden, increased from 0.86 (SD = 0.84) to 0.90 (SD = 0.85) during that time.

In the baseline year, the low and high categories of each PCMH component represented roughly equal distributions of clinics; the exceptions were access and scheduling, which had more scores in the low category (

). The range of the component scores overall, and for low and high categories, is also shown in Table 2. The proportion of clinics in the high-scoring groups increased over time, and the majority of clinics reported PCMH component scores in the high-scoring groups for all components in FY 2011. Almost one-fifth of primary care clinics represented in the study sample were large VAMC-based clinics, and most were community-based outpatient clinics (CBOCs), with the majority of these being leased CBOCs. Almost one-third of clinics were in nonmetropolitan areas.

Changes in Utilization and Costs Over Time

During the study period from just prior to widespread PACT implementation to 2 years after PACT implementation began, the mean number of primary care visits decreased from 4.81 to 3.99 visits per patient, which represented a 17% decrease. The rate of specialty care visits was negligibly higher, and telephone visits rose by 85% (all 

). ED visits per patient rose slightly (7%), and ACSC hospitalizations per patient also rose from 0.02 to 0.03 per patient (all

<.001). The mean total costs of VA care increased from $8469 to $9887 per patient during the study period (

Increased Medical Home Features and Utilization and Costs

Multi-level, multivariable models adjusted for both time-varying factors and fixed effects for time-invariant factors, and estimated how changes in reported PCMH components in primary care clinics explained some of these increases or decreases in use of VA care over time (

). High organization of practice scores was significantly related to 0.13 fewer mean primary care visits per patient compared with patients in low-scoring clinics (

= .012). High care coordination and transitions in care scores were significantly related to 0.06 more specialty care visits compared with the low scores (

= .010), after controlling for patients’ health status and time trend. The change in telephone visits was significantly higher over time (

<.001), but changes due to increases from low to high PCMH scores across all components were not statistically significant. High scores in care coordination and transitions in care decreased the mean number of ED visits by 0.04 visits per patient (

= .018), but high quality and performance improvement increased ED visits by 0.03 visits per patient (

= .032), relative to low scores. Admissions for an ACSC also increased over time after adjusting for worse health status (both 

<.001), and none of the PCMH components were related to higher admissions. The only significant increase in costs was explained by high risk or worse comorbidity (

<.001), and again, none of the PCMH component scores were significantly related to total costs per patient.

VA primary care clinics reported large improvements in adoption of all PCMH components from FY 2009 to FY 2011, and there were significant changes in utilization and costs for a cohort of primary care patients during this time. While various PCMH components (eg, access and scheduling) were hypothesized to increase access to and frequency of primary care, the only component that was related in adjusted models was organization of practice. Features such as team huddles and tracking lab tests were actually associated with fewer primary care visits per patient, possibly through better efficiency of primary care practice. Greater specialty care visits were modestly related to higher care coordination/transitions in care scores, so better procedures to coordinate care appeared to facilitate referrals to specialty care.

While increased care coordination/transitions of care was significantly related to fewer ED visits, higher quality and performance improvement scores were related to more ED visits. Care coordination features that reduced problems due to transitions from hospitalization or referral appeared to reduce ED care that may be unnecessary. It is unclear why greater quality/performance improvement features would be related to more use of ED care by patients. There was a significant increase in telephone visits over time, and although it was not related to any specific changes from low to high PCMH components, the push overall to increase virtual care under PACT may have led to increased telephone care. None of the PCMH components were related to potentially avoidable hospitalizations for an ACSC, although the rates in both years were very low in this cohort. Changes in healthcare costs were also not associated with increased PCMH component scores.

Our findings contribute new evidence on the specific aspects of PCMH implementation that are related to different types of healthcare utilization, and some of these results are consistent with early evidence from a PCMH demonstration in Group Health, which showed that patients had higher rates of telephone visits and specialist visits, and lower rates of ED visits in PCMH sites after 1 year.

In addition, the Group Health demonstration showed significant reductions in hospitalizations and costs per patient after 2 years, which we did not observe.

 Unlike the Group Health demonstration, which was implemented in 1 clinic, VA’s PACT initiative was rolled out to all clinics—that have considerable heterogeneity in size, staffing, governance, quality improvement orientation, and patient populations served&mdash;which may partly explain differences in evaluation results.

An earlier VA study found that higher baseline adoption of PCMH components of access/scheduling and care coordination/transitions were significantly related to lower risk of avoidable hospitalizations among primary care patients.

While we found that increased scores of these PCMH components were not related to avoidable hospitalizations, there may be a lag between implementation of features and observing effects in patients’ outcomes. Moreover, reducing ACSC hospitalizations in a stable cohort of patients may be difficult to achieve.

It is also unknown to what extent individual PCMH features (eg, using an open-access model or maintaining a disease registry) were fully functioning. The percent of clinics in the high categories of all medical home components score jumped during the study period so that most clinics reported adopting a high number of possible PCMH features. Hence, some implementation may have been rudimentary. Preliminary evidence suggests wide variation in how VA practices adopted various PCMH features, such as enhancing open access through practice redesign, or new interventions

 with successful implementation influenced by local VA leadership engagement, staffing resources, and access to information and knowledge.

Additional challenges, including defining team roles and interpersonal confl ict, have also caused implementation barriers in some sites.

 In addition to site-specific factors affecting PACT implementation, the total number of VA enrollees increased from 5.1 million veterans in 2009, to 5.5 million veterans in 2011.15 The challenges of serving a larger volume of patients may have contributed to fewer face-to-face visits and placed additional burdens on providers in some sites.

The Medical Home Builder survey was self-reported, so we were not able to validate the adoption of reported PCMH features; because of ongoing PACT evaluation efforts, clinics may have been motivated to provide more positive responses as a result. While the statistical methods used here accounted for measurable and unmeasurable fixed factors over time, it did not account for any time-varying omitted factors, so if unmeasured time-varying factors such as some other technological change were related to reported PCMH features and patients’ utilization and costs, the effects of PCMH features would be biased.

We did not have reports of non-VA utilization, so if patients shifted to using more non-VA care such as ED visits, we could not measure this change. Finally, we focused on regular primary care users who continued to use VA outpatient care during the study period, so our results may not be generalizable to less frequent users of primary care or new users who were younger and had different demands for VA care.

These results document short-term changes during the early implementation of PACT that can provide feedback as PACT continues to be implemented and developed. While take-up of many PCMH features appeared to be high after the initiative began, certain improvements in care under organization of practice and care coordination/transitions appear to have affected only certain types of non-acute outpatient care; reductions in acute care ED visits and potentially avoidable hospitalizations largely remain to be seen. Identifying areas for ongoing improvement is critical to ensuring long-term success of care transformation under PACT. Refining PACT models in later stages may require more than adding new interventions; it may involve evaluation of staffing and other resource needs, better understanding of cost-effective care, ensuring support of clinical leadership, and widespread dissemination of successful practices. Better measures of PACT implementation are also needed to evaluate the longer-term consequences of PACT.

The authors wish to acknowledge Jack Needleman and Ciaran Phibbs for valuable comments on earlier drafts.

Health Economics Resource Center (JY, JL), and Center for Innovation to Implementation (JY), VA Palo Alto Health Care System, Menlo Park, CA; Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound (C-FL), Seattle, WA; Department of Health Services, University of Washington (C-FL), Seattle, WA; Patient Care Services, Veterans Health Administration (GS, RS), Washington, DC; Center of Innovation for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles (LVR, EMY), Sepulveda, CA; RAND Corp (LVR), Santa Monica, CA; Department of Health Policy and Management, Fielding School of Public Health (LVR, EMY), and School of Medicine (LVR), University of California, Los Angeles, CA.

This work was supported by the Department of Veterans Affairs, Veterans Health Administration, Patient Care Services (XVA 65-018). Dr Yano’s effort was covered by a VA HSR&D Senior Research Career Scientist Award (Project #RCS 05-195). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States federal government.

 The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. VA Patient Care Services designed and administered the survey, and Drs. Stark and Schectman from VA Patient Care Services contributed to the interpretation of results.

 Concept and design (JY, LVR, EMY, CL); acquisition of data (EMY); analysis and interpretation of data (JY, CL, JL); drafting of the manuscript (JY, CL); critical revision of the manuscript for important intellectual content (LVR, EMY, RS, GS); statistical analysis (JY, JL); provision of patients or study materials (RS, GS); obtaining funding (LVR, EMY); administrative, technical, or logistic support (JL); supervision (JY, LVR, EMY).

Jean Yoon, PhD, MHS, 795 Willow Rd (152 MPD), Menlo Park, CA 94025. E-mail: 

1. Reid RJ, Coleman K, Johnson EA, et al. The Group Health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. 

2. Reid RJ, Fishman PA, Yu O, et al. Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. 

Articles

Significant changes were found in patients' utilization of healthcare related to early implementation of medical home components in VA primary care clinics.

Early Changes in VA Medical Home Components and Utilization

The Veterans Health Administration (VHA) is the largest integrated US health system to implement the patient-centered medical home. The Patient Aligned Care Team (PACT) initiative (implemented 2010-2014) aims to achieve teambased care, improved access, and care management for more than 5 million primary care patients nationwide.

To describe PACT and evaluate interim changes in PACT-related care processes.

Data from the VHA Corporate Data Warehouse were obtained from April 2009 (pre- PACT) to September 2012. All patients assigned to a primary care provider (PCP) at all VHA facilities were included.

Nonparametric tests of trend across time points.

VHA increased primary care staff levels from April 2010 to December 2011 (2.3 to 3.0 staff per PCP full-time equivalent). In-person PCP visit rates slightly decreased from April 2009 to April 2012 (53 to 43 per 100 patients per calendar quarter; P <.01), while in-person nurse encounter rates remained steady. Large increases were seen in phone encounters (2.7 to 28.8 per 100 patients per quarter; P <.01), enhanced personal health record use (3% to 13% of patients enrolled), and electronic messaging to providers (0.01% to 2.3% of patients per quarter). Post hospitalization follow-up improved (6.6% to 61% of VA hospital discharges), but home telemonitoring (0.8% to 1.4% of patients) and group visits (0.2 to 0.65 per 100 patients per quarter; P <.01) grew slowly.

Thirty months into PACT, primary care staff levels and phone and electronic encounters have greatly increased; other changes have been positive but slower.

The Veterans’ Health Administration (VHA) is the largest integrated health system to implement the patient-centered medical home (PCMH) to date. This initiative (implemented 2010-2014) aims to achieve team-based care, improved access, and care management for more than 5 million primary care patients nationwide. Interim changes in care processes include:

		Decreased rate of in-person primary care provider visits and increase in telephone and Internet care.

		No significant increase in shared medical appointments.

		Slight improvement in appointment access and continuity, which started at high levels.

		Improved but still suboptimal post hospitalization follow-up.

The patient-centered medical home (PCMH) model is being implemented by a growing number of health organizations, with the goal of providing more comprehensive, coordinated, and patient-centered care. The major primary care medical societies have endorsed the PCMH as the desired model for primary care.

 Large health systems and primary care practice collaboratives are implementing the PCMH model, and the Centers for Medicare & Medicaid Services is funding PCMH demonstration and innovation projects in diverse clinical sites.

 Nonetheless, published evaluations of PCMH initiatives to date have been limited to single-practice or smaller groups of practices, and often focus on limited clinical conditions.

In 2010, the Veterans Health Administration (VHA) became the largest integrated US health system to begin implementing the PCMH model at all primary care clinics throughout its nationwide system. The VHA delivers primary care to more than 5 million veterans in 16.4 million encounters annually—either at 160 large hospital-based primary care facilities, most of which are in urban areas, or 783 Community- Based Outpatient Clinics, many of which are in rural areas. Thus, VHA is facing the challenge of substantially redesigning major systems of care in an extremely large system across diverse clinical and community settings. In addition, veterans served by VHA typically have more chronic physical and mental illnesses, and are more socioeconomically vulnerable, than patients who receive care outside VHA.

The VHA’s PCMH initiative, called Patient Aligned Care Teams (PACTs), builds upon foundations established in the 1990s, when VHA undertook a major transformation from loosely organized hospitals that provided mainly inpatient and specialty care into a regionally integrated system focused on outpatient primary care.

 As part of that process, large numbers of primary care providers (PCPs) and nurses were hired by VHA, and several key elements of the PCMH model (as defined by the National Committee for Quality Assurance) were implemented, such as comprehensive electronic medical records and performance measurement and improvement programs (including programs addressing clinical outcome goals such as glycemic control and blood pressure control for patients with diabetes and cancer screening; 

). Since that time, VHA has demonstrated better clinical quality of care and outcomes in many areas than have been reported in other parts of the healthcare sector, including Medicare.

However, in the 2000s the level of primary care staffing and resources remained steady, despite steady increases in numbers of primary care patients.

 In addition, VHA identified room for improvement in care continuity and coordination (eg, by decreasing the amount that VHA patients relied on providers not part of the Department of Veterans Affairs [VA] for acute care) and in patient-centeredness of care (eg, by providing care through telephone or electronic access when patients prefer it).

 Thus, the PACT initiative aims to enhance comprehensive and coordinated care, improve patient experience, and further improve health outcomes by increasing and reorganizing primary care staffing, and introducing several PCMH components that were not already in place.

The PACT initiative began in April 2010, and full implementation is anticipated to continue through 2014. Patient Aligned Care Teams also include a concurrent plan (and budget) for nationwide evaluation, including quantitative and qualitative data collection and analysis. In this study, we describe the design of PACT and the extent of structural changes made by facilities in response to the PACT plan to date. Then, we present an interim nationwide evaluation of observed changes in patient care processes related to PACT goals.

PACT DESIGN AND STRUCTURAL CHANGES TO DATE

To enhance continuity, staff are organized into teamlets that provide care to an assigned panel of about 1200 patients.

 A teamlet consists of 1 PCP, 1 registered nurse (RN) care manager, 1 licensed practical nurse (LPN) or medical assistant, and 1 administrative clerk. Teamlets are designed to optimize work flow by enabling each member to function at the top of their expertise. For example, PACT RNs are expected to manage care of patients with multiple chronic conditions through in-person and telephone encounters, and medical assistants are expected to provide preventive health screening. To facilitate communication and planning, teamlets are expected to hold regular huddles.

 The PACT clinical pharmacists assigned to a set of teamlets also manage patients with poorly controlled chronic illnesses through independent patient encounters.

To establish the teamlet model, the VHA mandated that facilities provide 3.0 full-time equivalents (FTEs) of primary care support staff per full-time PCP by the end of 2011, with dedicated funding to facilities for this. From April 2010 to December 2011, primary care support staff increased from 10,501 FTEs to 13,742 FTEs (

), corresponding to an increase from 2.3 FTEs to 3.0 FTEs support staff per PCP FTE nationwide. In addition, 76% of facilities reported holding daily teamlet huddles in July 2011 (up from 21% pre-PACT, Table 2).

Patient Aligned Care Teams aim to improve patient access through 3 methods. First, facilities are instructed to enact advanced access scheduling,

 including increased availability of same-day appointment slots. Second, facilities are asked to conduct more appointments via phone and by shared medical appointments. In response to this directive, 40% of facilities set aside hours during the clinical workday dedicated to scheduled phone visits by July 2011 (up from 14% pre-PACT; Table 2). It should also be noted that efforts were made to more accurately code and capture clinical encounters that occurred over the phone. Third, PACT aims to increase patient access to personal health data and providers via the Internet. This goal is accomplished through (1) an enhanced Internet-based personal health record (www.MyHealtheVet.gov), which allows patients to manage prescriptions and view test results and appointments; and (2) a secure messaging website, which allows patients to send electronic messages to their teamlet. To use either service, VA patients must complete an in-person registration and identity check. The PACT initiative directed each parent facility to add a personal health record/secure messaging coordinator, who encourages and facilitates patient and staff use of these technologies (Table 2).

The VHA hired 1271 primary care RN care managers between January 2010 and December 2011 (Table 2). The role of the RN care manager is envisioned to include chronic illness management, panel management of high-risk patients, and facilitation of patient care transitions. Among these responsibilities, post hospitalization follow-up was chosen as an early focus. Some RN care managers are assigned to telehealth monitoring of patients with chronic conditions. Telehealth consoles transmit patients’ health data (eg, blood glucose, blood pressure) from the patient’s home over a phone or Internet connection to the VA. Telehealth nurses at the patient’s home facility manage clinically relevant changes over the phone.

Also included in PACT is funding for a full-time health promotion/ disease prevention specialist at each facility to oversee screening and counseling programs related to healthy behaviors, such as healthy eating and tobacco cessation. Health Behavior Coordinators (typically clinical psychologists or social workers) at each facility support this program by training clinical staff in evidence based behavior change counseling techniques. Almost all facilities now have hired these 2 staff members (Table 2).

Providing accessible and broad care for mental health conditions and coordinating that care with other aspects of primary care are essential to providing comprehensive primary care in the VHA, as approximately 15% of veterans have a mental illness or substance use disorder.

 The Primary Care-Mental Health Integration program, which began pre-PACT in 2007, provides primary care—based treatment of common mental health conditions (eg, depression) and risky health behaviors (eg, heavy alcohol use) by mental health clinicians partnering with and co-located with primary care staff. The Primary Care-Mental Health Integration program is already quite robust across the VHA, and its critical role in PACT is more fully described elsewhere.

The PACT providers and clinical staff are being trained in patient-centered communication.

 By the end of 2011, facilitators were trained at all VHA facilities, and the 2012 PACT plan was to train 50% of the primary care teamlet staff. In addition, 36% of facilities followed the PACT plan to form patient advisory councils in July 2011, an increase from 18% in October 2009.

We used data from VHA Corporate Data Warehouse databases derived from VHA operational systems. All measures except appointment wait times were calculated from data on the total number of active patients assigned to a PCP in the relevant month or quarter. All primary care patients at all VHA facilities nationally were included, regardless of the status of PACT implementation at the facility. Point measures were assessed on the last day of each month starting in December 2009. For measures compiled on a quarterly basis, data were available starting with the April through June 2009 quarter for some measures and the October through December 2009 quarter for others (

We also used data from a national, facility-level survey based on the American College of Physicians (ACP) Medical Home Builder Practice Biopsy (ACP Biopsy). The ACP Biopsy assesses whether a practice has 127 PCMH components in place through yes/no items in 7 categories: patient-centered care and communication (ie, training in communication techniques and provision of self-management support); access and scheduling (ie, flexible and non—face-to-face scheduling); use of technology (ie, e-prescribing); care coordination and transitions; organization of practice (ie, electronic records and teamwork); population management (ie, patient registries); and quality improvement. The survey was completed by ambulatory care directors at 850 facilities (out of 862 eligible) in October 2009 (pre-PACT) and by 846 facilities in July 2011 (interim PACT).

We assessed changes in key patient care processes including in-person and telephone encounter rates across teamlet members, continuity of care with the patient’s assigned PCP, appointment access, access to care through shared medical appointments and new technologies, and reach of RN care management. Details on measures are available in 

. To assess overall progress toward PCMH implementation, we compared the total percentage of yes responses in each ACP Biopsy category at both time points.

We used nonparametric tests of trend for the ranks of measures across all quarters or months measured. All P values were based on 2-sided tests. Full quarterly and monthly data are available in Appendix A. The average age and comorbidity level (Deyo score)

 of the primary care population remained stable throughout the study period, so encounter rates were not adjusted for these attributes.

Interim Changes in Patient Care Processes

The overall rate of primary care encounters (in person or by phone) per 100 patients increased from 85 in April through June 2009 (corresponding to a rate of 3.4 encounters per patient per year) to 101 in April through June 2012 (corresponding to 4.0 encounters per patient per year; 

 for trend = .01). However, in-person encounter rates declined slightly over this time period (

). Among clinical staff, PCP visit rates declined slightly (53 to 43 visits per 100 patients per quarter; 

 for trend <.01), as did clinical pharmacist visits (2.6 to 2.4 visits; 

 < .01). Encounters with RNs and LPNs spiked each fall, but did not change significantly overall (P for trend RN = .39; P for trend LPN = .84). This pattern remained after encounters for flu shots were removed from the data.

As a measure of continuity, 80% of all PCP visits in October through December 2009 were with the patient’s assigned PCP (of 2,376,003 total PCP visits), which increased to 83% in April through June 2012 (2,570,618 total PCP visits) (

Patient requests for same-day appointments were accommodated 67% of the time in December 2009 and 73% in June 2012 (

 for trend <.01, Figure 2A). The proportion of patients seen within 7 days of their desired appointment date rose from 85% to 90% during the same time period (

Phone encounter rates, although a minority of overall encounters, increased more than 10-fold from April through June 2009 to April through June 2012, increasing for each clinical staff group (

). In-person shared medical appointments increased from 0.24 to 0.65 (

 <.01) per 100 patients per quarter over the same time period (Figure 1A).

The number of patients registered for the enhanced personal health record increased from 152,416 (3% of 4,759,668 primary care patients) in December 2009 to 694,206 (13% of 5,163,531 primary care patients) in June 2012 (

). Total secure messages from patients to primary care staff increased from 9852 in 2010 to 289,519 in 2011. Patients using secure messaging (sending at least 1 message to their primary care team) increased from 0.07 per 1000 primary care patients in October through December 2009 to 22.8 per 1000 patients in April through June 2012 (

The number of patients using telehealth increased from 38,747 (0.8% of patients) in December 2009 to 70,486 (1.4% of patients) in June 2012 (

 for trend <.01; Figure 2B). Patients evaluated by primary care clinicians within 48 hours of VHA hospital discharge increased from 6% of 46,195 discharges in December 2009 to 61% of 45,068 discharges in December 2011 (

Overall Progress Toward Implementation of PCMH Components. 

Facilities’ average overall score on the ACP Biopsy increased from 69% yes in October 2009 to 80% yes in July 2011. Pre-PACT, categories with the highest average scores were organization of practice (72%), population management (75%), and quality improvement (86%) (

). Categories with the lowest initial scores were also those with the greatest improvement by 2011: patient-centered care/communication (56% to 68%) and access/scheduling (66% to 76%).

Over the first 30 months of PCMH implementation, VHA made extensive nationwide structural changes in primary care staff levels and teamlet formation and capacity for telephone care, electronic access, care management, and healthy behavior promotion. The high scores noted on the ACP Biopsy pre-PACT reflect the investments made by VHA during the previous 15 years in comprehensive electronic health records, population management tools, and quality improvement programs. Larger increases on the ACP Biopsy related to patient-centered care, communication and access, and scheduling during the initial months of PACT correspond to the main components of the PACT initiative.

We describe the Veterans Health Administration's nationwide patient-centered medical home (PCMH) initiative and evaluate interim changes in PCMH-related patient care processes.

Richard Stark, MD

Articles

Early Changes in VA Medical Home Components and Utilization

The Patient-Centered Medical Home in the Veterans Health Administration