Integrating Post-Combat Care into the Patient Aligned Care Team (PACT) - PowerPoint Presentation

1. Integrating Post-Combat Care into the Patient Aligned Care Team (PACT)Lucile Burgo, MDNational Co-Director Post Deployment Integrated Care InitiativeAssociate Primary Care Director VA Connecticut

2. Disclosure StatementI have no conflicts of interest to disclose2

3. OUTLINESome primary care history PACT as a framework for “best care”Post combat care in the PACTHow can the WRIISC help?

4. VHA Primary Care Milestones

5. Primary Care in the VHA

6. VHA Primary Care by Age & Gender44%25%6.1% Female21% had encounter in Mental Health

7. 7 VHA Primary Care Providers 7371 Providers, 5008 FTE (Avg. 0.69 FTE)(5% Trainees)

8. VHA Primary CareStrengthsWeaknessesPrimary Care ModelTeam ConceptProvider oriented, not “patient-centered”Interdisciplinary decision making unusualSome employees not working at "top of competence”Access: Delays for primary care visits infrequentPoor phone service; secure messaging proceeding slowly; Focus on face-to-face visitsService agreements implemented to support specialty care interfaceEfforts to manage chronic disease to optimize outcomes still limitedSupport programs and services(Home telehealth, HBPC)Limited coordination available to manage crucial transitions of careComprehensive Electronic Medical RecordSub-optimal CPRS user functionalityMinimal Decision SupportPreventive Care ProgramLarge burden of chronic diseases; Poor health behaviors contributeHealth behaviors often not addressed and interventions often not providedHealthcare staff need additional training

9. 9Select Emerging National Health Care Delivery TrendsPatient-Centered CareAccess to CareExploding consumer information and direct marketingElectronic Health RecordsPersonal Health RecordsIncreasing demand for transparency and qualityIncreasing POC Diagnostics and Monitoring at home Minimally Invasive ProceduresConvergence of TechnologyTelehealth and TeleradiologySocial Media25 August 20119

10. Patient Centered Care per IOMHealth care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisionsSuperb access to carePatient engagementClinical information systemsCare coordinationIntegrated and comprehensive care Smooth transfer of informationOngoing public informationPublicly available information to choose a practice and a physician10

11. First Step: American College of Physicians Medical Home BuilderN= 850 VHA Primary Care PracticesOverall Average Score: 69%

12. Total Score

13. Veteran Centered CarePhysicalPsychological VeteranPsychosocial

14. 14Essential Transformational Elements:Patient (Veteran) Centered CareDelivering “health” in addition to “disease care”Veteran as a partner in the team Empowered with educationFocus on health promotion and disease preventionSelf-management skillsPatient Advisory BoardEfficient AccessVisitsNon face-to-faceTelephoneSecure messagingTelemedicineOthers?14

15. Redesign Primary Care PracticeTasks and relationships defined Redesign team member functions and tasksImprove Team DynamicsBuild team roles to support a Chronic Care ModelWorking at top of competencyTime for non-face to face activities Encourage Primary Care staff professional growthLeadership opportunitiesTeaching opportunities On-the-job provider training for comprehensive Primary CareWomen’s healthPain managementPost-deployment healthGeriatricsSpecialty experienceEssential Transformational Elements:Comprehensive Team-based Care

16. Improved coordination for all transitionsInpatient and outpatientPrimary Care and Specialty CareVA and non-VA co-management (Dual Care)Incorporate telehealth and Home Based Primary Care (HBPC) servicesHighlight home care & rural healthCare ManagementPanel basedConnecting all services and points of careCare across the continuumEssential Transformational Elements:Coordination of Care

17. Chronic Care ModelDisease managementInterface with specialty careCase managersPain managementReturning combat Veteran DepressionSubstance abuseDisease registriesIdentification of outliersVeterans at high risk for adverse outcomes Essential Transformational Elements:Case/Chronic Disease Management

18. Improve technological clinical supportCPRS user-friendlinessDecision supportPCMM enhancementsPredictive modelingInformation processingTelephone SupportMy HealtheVetSecure Messaging Essential Transformational Elements:Technology

19. CHRONIC CARE MODELEd Wagner & Institute for Healthcare Innovation (IHI)Informed,ActivatedPatientProductiveInteractionsPrepared,ProactivePractice TeamFunctional and Clinical OutcomesDeliverySystemDesignDecision Support ClinicalInformationSystemsSelf-Management SupportHealth SystemCommunity Health Care OrganizationResources & Policies

20. Patient-Centered Perspective

21. PATIENT ALIGNED CARE TEAMSReplaces episodic care based on illness and patient complaints with coordinated care and a long term healing relationship   THE PRIMARY CARE TEAM

22. 22Veteran Centered, Team based, coordinated carePatient Aligned Care TeamTeam Function and CultureCare Coordination & Care ManagementVeteranVA (VHA and VBA) PACT

23. Pillars of the Medical Home

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26. Primary Care (PCMM) National Staffing Ratio

27. Primary & Specialty Care: Becoming True Partners27

28. In the end we know…Primary care is best when it does these four things well:

29. If Primary Care does those things well, then patients who receive care in those practices….

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31. Other Team MembersClinical Pharmacy Specialist: ± 3 panelsClinical Pharmacy anticoagulation: ± 5 panelsSocial Work: ± 2 panelsNutrition: ± 5 panelsCase ManagersTraineesIntegrated Behavioral HealthPsychologist ± 3 panelsSocial Worker ± 5 panelsCare Manager ± 5 panelsPsychiatrist ± 10 panelsThe Patient’s Primary Care TeamMonitored via Primary Care Staffing and Room Utilization DataPanel size adjusted (modeled) for rooms and staffingFor each parent facilityHealth Promotion Disease Prevention Program Manager:1 FTE Health Behavior Coordinator: 1 FTEMy HealtheVet Coordinator: 1 FTE

32. Patient-Centered Primary Care Model Implementation StrategiesDemonstration “Laboratories”Intensive research and effectiveness evaluationCommunication and EducationInformatics and TechnologyMeasurementStart-up resourcesGap analysisFunding to support new staffing modelTeam retraining and redesignPCMH Summit, April 2010Learning CollaborativesMedical Home including Chronic DiseaseTelephone CareMedical Home Learning CentersPrimary Care Team DynamicsCare Management and CoordinationConsultation Teams

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34. Learning, Discovery, Continuous Improvement

35. Patient Aligned Care Teamfor Returning Combat VeteransPatient centered, team based, integrated careEvidence based, continuously improving care Communication Combat Veteran Care/Case Manager Collaboration Coordination Post-Combat Care moves our PACTs forwardThe PACTs move our Post-Combat Care forward

36. Post Deployment Care for Recent Combat VeteransESSENTIAL ELEMENTS FOR CAREComprehensive psychosocial and medical intake performed on all veterans: Ideally Medical, Mental Health and Social Work see every new patient at the first visit.PACT and extended team(MH,SW) trained and have tools to accomplish thisIntegrated, de-stigmatized MH treatmentActive participation by OEF/OIF program staff and specialized teams in mental health, polytrauma, pain, SA featuring full integration of all post deployment servicesClose links to allied clinics and programsAlign resources around VeteranIntegrated team meets to formulate Veteran centered care plan Extended hours availability36

37. Post Deployment Care for Recent Combat VeteransThe PACT will have tools and training to accomplish comprehensive intake ongoing support and coordination of post deployment care Teamlet: Primary Care Provider(s), RN care manager, clinical associate, and clerk trained in combat Veterans unique needsExtended team: PACT social worker, PC-MHI, pharmacist trained in combat Vet unique needsOEF/OIF program : trains and supports PACT joining core team when neededPDICI champions assist with facility education and consultative support of PACTCoordination with specialty care: Polytrauma, PTSD, Pain, Ortrho, Rehab, Neurology, WRIISCs, (join the Veteran’s team) 37

38. TASKS FOR POST DEPLOYMENT CARE IN THE PACT ESSENTIAL ELEMENTS FOR CARE IN THE PACTRisk assessment at each encounter F 2 F and non F 2 FProactive visit needs assessment by teamlet (prescreens?)to coordinate services on day of visit (MH, SW, 2ary TBI, specialty care, labs, xrays)Orientation to team, roles understood, partnership with VeteranAssist with MHV-IPA, discuss communication methods (SM, telephone), demonstrate web resourcesWeekly (extended) team huddles for complex casesAssure knowledge of/connection to OEF/OIF program for each combat Vet38

39. TASKS FOR POST DEPLOYMENT CARE IN THE PACTInitiate appropriate assistance from OEF/OIF program manager and social worker, primary care champions, Consultative TeamBenefits, C+PLegal assistanceVet centersCase managementCommunity resources and servicesSchoolsAssure coordination of care with specialty clinics and programs especially Polytrauma, pain, substance abuse, specialty mental health(PTSD), physical therapy, orthopedics, neurology(points of contact, service agreements)Consider care provision via telehealth ( telerehab, telepain , video conferencing), group visits for orientation, intake39

40. PACT can care for special populationswith support and training. The PACT expands as needed to meet the Veteran’sneeds . We the team cares for the CV.8/25/201140Substance Abuse Polytrauma PainSpecialty Mental HealthOrthoPTNeurologyVet CentersOEF/OIF/OND Consult TeamPIDICI ChampTeamletVBAC+PChaplainWRIISCDHCNCPTSD

41. Where do the WRIISC fit in?80-90% of Veterans have a primary care provider: longitudinal relationship of trust and connection Over 50% are cared for in CBOCs/rural sites: poor access to specialty care35% of OEF/OIF/OND cared for in CBOCsFocus groups : Vets want teams who understand their culture, their experience , thus we need more training, expectation of basic knowledge base in PACTRisk assessment and communication and better communication skills are essential competenciesPACT with Veteran at the center is your stakeholder

42. How will the WRIISC best support the PACT?PACTs need education and consultative support.VA SCAN pilot Exposure conferencesOn site provider trainingVirtual consultative service for MUS, exposure concerns ? Comprehensive assessment complex cases

43. FamilyPRIMARY CARE TEAMHOSPITALISTSSPECIALISTSNON-VA CAREMental HealthPharmacistNursingDietitianBehavioristCase ManagerAdministrativeSocial WorkerClinicalAssociatePATIENTTEAMLETPC ProviderClerkRN Care Manager43WRIISCNCPTSD

44. PACT Resourceshttp://vaww.infoshare.va.gov/sites/primarycare/mh/pcmhinfo/default.aspx