PACT: The VA s Medical Home

A5/B5 This presenter has nothing to disclose PACT: The VA s Medical Home What is working to change a big system Mike Davies, MD Director VA Systems Redesign Rich Stark, MD Director VA Primary Care Operations Joanne Shear, MS FMP-BC Program Mgr. VA Primary Care A5/B5 Tuesday 9:30-10:45 and 11:15 12:30 Session Objectives P2 Design of Collaborative Aims Planning phase People Venues Results 1

Group Exercise (5-10 minutes) 3 1. Have a conversation with your table colleagues 2. Topic: What are the top 3 challenges your organization has encountered in implementing a medical home model? (pick from the list) Leadership support at corporate, mid management, or point of care level Resources for clinical staffing infrastructure needed Resources for education & implementation Lack of interest in model overall Not enough outcome literature to support change Technology limitations no Electronic Medical Record or lack of integrated EMR\ Other reasons???? 3. Group Response: (compiling the list w/show of hands) Today, there are over 22 Million living Veterans. 8M+ Veterans are enrolled in the VA health care system 4 2

Hospital System to Health System In 1996, VA began the creation of Veterans Integrated Service Networks (VISNs) to transform VA Health Care from a Hospital System to a Health System. VHA currently has 21 VISNs. 152 Medical Centers 981 Outpatient Clinics 812 Community-Based 152 Hospital-Based 11 Mobile 6 Independent >5.2 Million Paneled Primary Care Patients 7800 Primary Care Teams 5 Changes in Primary Care Past The patient has one provider Patient Aligned Care Team (PACT) The patient has a team Care delivered only by provider Care delivered by team members Focus on visits Most care delivered by visits Virtual visits uncommon Continuity inconsistent High risk patients get routine care Hospitalizations common Care not well coordinated Prevention not stressed Focus on overall health New care delivery routes and tools Phone, telehealthvisits, secure messaging common Continuity consistent Identify and manage high risk patients Hospitalizations less frequent Care coordinated throughout the system Prevention and health promotion essential 3

Patient Centered Prevention and Population Based Provides Value Patient- Aligned Care Team Team Work Continuous Improvement Data Driven, Evidence Based Principles of the Patient Aligned Care Team 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 The care Veterans need when they need it Interdisciplinary team at the highest level of their competency Point of first contact for medical, behavioral, psychosocial needs Integrated with other VA health services, community resources Every patient has an established and continuous relationship with a personal primary care provider Communication between the Veteran and other team members is honest, respectful, reliable, and culturally sensitive The PCMH team coordinates care for the patient across and between the health care system including the private sector 4

Patient Aligned Care Team Replaces episodiccare based onillnessand patient complaintswithcoordinatedcareanda long term healingrelationship Takes collective responsibility for patient care Is responsible for providing all the patient s health care needs Arranges for appropriatecare withother specialties 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 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 Health Promotion Disease Prevention Program Manager:1 FTE Health Behavior Coordinator: 1 FTE My HealtheVet Coordinator: 1 FTE Patient Caregiver 5

PACT Implementation: Learning, Discovery, Continuous Improvement Readiness Assessment Staffing Support ACP Medical Home Builder Primary Care Staffing Training and Education PCMH Summit PACT Collaborative Transformation Initiative Learning Centers Consultation Teams Demonstration Labs Measurement: PACT Compass Access/Continuity Patient Satisfaction Coordination Panel Management IT Improvements PCMM enhancements Secure Messaging Communication Staff Patients Stakeholders Centers of Excellence in Primary Care Education Transformation Initiative Learning Centers Education and Training Intensive virtual and face-to-face training in: Team Function & Design Care Management & Coordination Patient Centered Care Begin training: Sep 2010 Continuous team training All Teams trained after 3 years Multi-disciplinary curriculum developed 6

Consultation Teams 5 Regional Teams PCP, RN, Administrative lead 5-6 Site visits per region per year Provides constructive feedback and on-site teaching at request of VISN Began site visits December 2010 VA s Medical Home: PACT P14 7

PACT Collaborative West Midwest Midsouth Southeast Northeast Intensive, experiential training 6 Learning Sessions Coaching 18 months 250 Primary Care Teams Multidisciplinary faculty, planning team Adopt Strategic Target Engage Leadership Organize Concepts Recruit & Educate Faculty & Coaches Recruit Team Create Materials Just in time Participants Pre-work Teach Coaches A Principles Strategies P Tests of D Change S LS 1 LS 6 Required Written Reports Phone Calls Coach Feedback Presentations Toolkit SharePoint Slides Videos Measure Papers Games Tools 2009 2010 2012 P16 8

Team Members P17 Physician Leader Nurse Leader Administrative Leader Primary Care Provider RN Care Manager Clinical Associate Clerical Associate Extended Team Member All Primary Care Practices Leadership Group = responsible for PACT Implementation in all practices Pilot Team Received teach back at home Mandatory AIMS 18 Access Aims: A1: Offer appointments on today A2: Increase non FTF Care Care Management AIMS: CCM1: Identify and actively manage high risk patients CCM2: Improve handovers with inpatient CCM3: Improve handovers with specialty Practice Redesign Aims PR1: Start appointments within 10 minutes of the scheduled time PR2: Improve team communication 9

Framework of Collaborative P19 Mission: Exceptional Care Changes Tools Process changes PDSA Strategies Principles PACT Learning Sessions P20 5 Regions with 300 participants each. Common agenda at each of 6 learning sessions in 5 regions. Local variation based on steering committee needs Adult learning principles Content followed by activity Team time to plan integration into practice Pre and post session presentations Most popular sessions Have you considered? Small group discussions Home made movies (Placeholder for movie clip) 10

Engineer Dedicated Resource P21 1 Per Region Created Measure Tools On demand help with Improvement (Lean) Methods Gave feedback and mined reports for best practices Coaching on demand Available for 1:1 coaching Coach Assessment Scale 0 = no effort in this area 1.0 = discussion has started and likely to move into action 1.5 = plans for action begun 2.0 = a few tests of change have occurred 2.5 = tests of change begun, no measureable progress 3.0 = several successful tests of change with outcomes 3.5 = testing multiple changes; measurable progress over > 2 data points 4.0 = achieved aim (s) 4.5 = surpassed team s aims; spread to wider area 5.0 = spreading work into other areas, coaching others 22 Last viewed slide 11

Scoring Methods 23 81% (3316/4087) pillar reports were submitted CCM was delayed was not required for the first two reporting cycle Rated by the coach to track progress Reports July 2010 February 2012 have 1 score for each pillar Reports October 2011 to the end have 1 score for each aim Reports show progress of individual pilot teams +/- home team. Overall Collaborative Results 24 80% of reports submitted 1514 PDSA s reported 85% of reported PDSA s ultimately implemented 15% amended and implemented ~ 2% abandoned Overall, teams achieved a 4.0 at least once for 51% of the 7 required aims AIM % of TeamsScoring = or > 4.0 A1 (Open access) A2 (Non- FTF) CCM 1 (Hi Risk) CCM 2 (Inpt Transitions) CCM 3 (Specialty Transitions) PR 1 (Appts.Start on time) PR 2 (Communicate) 53% 57% 52% 44% 24% 53% 76% 12

Total PACT Key PDSA s 25 600 National Cumulative PDSAs 500 Number of PDSAs 400 300 200 Access Care Coordination and Management Practice Redesign 100 0 LS1 LS3 LS4 LS5 LS6 LS2 AP1 AP2 AP3 AP4 AP5 AP6 Overall Progress All Teams; 7 Aims P26 Goal = 4.0 Overall, 145 evaluated teams pursued 7 aims each over 18 months and achieved ( at the 4.0 level) 51% of the aims. LS1 LS2 LS3 LS4 LS5 LS6 13

Summary of National Assessment Scores Access Pillar (AP 1-6) 27 Teams for Access achieve an average coach score of 3.0 or higher in January 2011 Access 5.0 4.5 Coach Score 4.0 3.5 3.0 2.5 2.0 4.0 = achieved aim (s) 1.9 1.8 1.9 2.4 2.7 2.7 3.1 3.0 3.2 3.2 3.0 3.3 3.6 3.4 3.6 3.5 3.9 3.6 3.8 1.5 1.0 0.5 0.0 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Feb-12 Summary of National Assessment Scores (AP 1-6) Care Coordination and Management Pillar Care Coordination and Management seems to be the most challenging pillar. It first approaches a score of 3.0 in January 2011 and achieves a score of 3.0 or higher in July 2011 5.0 Care Coordination & Management 4.5 4.0 4.0 = achieved aim (s) Coach Score 3.5 3.0 2.5 2.0 1.5 1.0 1.5 1.2 1.7 1.0 2.2 2.8 2.6 2.9 2.9 2.4 2.8 3.1 2.9 3.0 3.2 3.4 3.0 3.3 0.5 0.0 0.0 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Feb-12 14

Summary of National Assessment Scores Practice Redesign Pillar (AP 1-6) 29 Teams for Practice Redesign achieve an average coach score of 3.0 or higher in January 2011, and achieve AIMs in November 2011. 5.0 Practice Redesign Coach Score 4.5 4.0 3.5 3.0 2.5 2.0 4.0 = achieved aim (s) 1.9 1.8 1.6 2.3 2.4 2.5 3.0 2.9 3.2 3.5 2.8 3.0 3.5 3.5 3.3 3.6 4.1 3.8 3.8 1.5 1.0 0.5 0.0 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Feb-12 Most Common Strategies 30 Create alternative to traditional face-to-face visits Align expertise of care teams with patient needs Co-manage discharge & pre-discharge needs Identify patient transitions when they occur Implement care plans for high risk patients Identify patients in need of more intense management Assure provider, patient, equipment and information are all in an available exam room on time -- every time Communicate with teamlet throughout the day Commit to weekly planning meetings with teamlet and team A Match supply and demand 15

Summary of National Assessment Scores By Region 31 All Principles A-Reduce Demand P-Predict and Anticipate Patient Needs C-Improve transitions C-Focus on high risk patients A-Balance Supply & Demand for Appts C-Create an infrastructure to manage and P-Synchronize P-Manage the Constraint P-Optimize the Environment A-Reduce the Backlog A-Increase Supply P-Balance Supply and Demand for Non- C-Improve thru preventive care P-Other A-Develop Contingency Plans A-Other A-Reduce Appointment Types and Times C-Other West SouthEast NorthEast MidSouth Central 0 10 20 30 40 50 60 70 80 90 100 PACT Toolkits Electronic Order Sets Electronic Reminders Patient Education Material Patient Tracking Database Position Description Spreadsheet Clinician Competency Assessments The Clinical Associate s Role in PACT Hospital Discharge Report PACT Steering Committee Forms Teamwork Assessment Tool Case Management Tracking Tools 32 Access Offer same day appointments Increase shared medical appointments Increase nonappointment care Patient Aligned Care Team Care Management & Coordination Focus on high-risk pts: Identify omanage ocoordinate Improve care for: oprevention ochronic disease Improve transitions between PCMH and: oinpatient ospecialty obroader Team Patient Centeredness: Mindset and Tools Improvement: Systems Redesign, VA TAMMCS Resources: Technology, Staff, Space, Community Practice Redesign Redesign team: oroles otasks Enhance: ocommunicati on oteamwork Improve Processes: ovisit work onon-visit work Current Ave 45 New Users/Week User comments We are in the planning stages for implementation of patient navigators. The toolkit is a great idea...thank you! 16

Teachback P33 Teams were asked to teach-back what they learned at the FTF learning sessions to teams back home in any way they wanted to do it Teams given videos, slides, tools, faculty as available Some planned events to raise awareness Some went home and started organized formal facility PACT collaboratives & implementation efforts Some did nothing Independent Return on Investment Analysis of Collaborative 34 Database: 5116 Program Evaluations & 723 ROI Surveys Level 1 (satisfaction) = 97.5% SA/A Overall, the program was worthwhile Level 2 (skill) = 98% of respondents reported developing new skills/knowledge as a result of participating Most new knowledge in LS 1 Level 3 (job impact) = Teams report success in reporting team progress, setting clear aims, and establishing measures that would indicate improvement Less success: obtaining buy-in from others to implement changes, managing constraints, and balancing supply and demand Time, leadership, and resources are barriers Level 4 (Business Impact) (see following slides) 17

What we think we learned 35 Collaborative excellent focal point for VHA Medical Home implementation & system design decisions Mandatory aims worked Teams were reluctant to measure Rate of improvement related to # of PDSA s Ave 13 reported PDSA s per team Longer collaborative was better (continued improvement) Skill of the coaches matters (opinion) Access is the hardest part of medical home What we think we learned (continued) 36 Single strategies enjoyed the most adoption (Huddles, phone visits) Improvement in a single, or multiple processes (handovers with specialty, access) harder High achievers clustered by Region VISN Facility ~ 4X variation between highest and lowest teams Collaborative just first wave of medical home implementation We know (a lot) about what to do 18

National Changes since PACT Implementation (July 2010-July 2012) Primary Care Uniques PACT Provider Staff PACT Support Staff 7% 2% 29% PACT patients enrolledin Home Telehealth PACT Group Visits 65% 53% AveragePanel Size 4% PACT TelephoneVisits 927% Primary Care Capacity PACT Encountersper 1000 unique patients Continuity VHA Acute Admissions per 1000 unique PC patients VHA ED Visits per 1000 unique PC patients 5% 38% 3% 6% 6% PACT patients seen on desired date PACT patients seen within 7 days of desired date 3rd Next Available Appointment in PACT clinics Same day appointments with PCP 8% 5% 13% 35% VHA Urgent Care Visitsper 1000 unique PC patients 20% Patients contacted within 2 days after discharge 847% Patient Satisfaction CAHPS-PCMH Mar-Jul 2012 encounters N=51,233 responses Coordination Med Discuss Provider Rating 100% 80% Access Coordination Provider Informed Coordination Test Follow Up 60% 40% 20% 0% Communication Comprehensiveness Information Reminder Medication Decisions Information Care After Hours Self Management Office Staff 38 19

Effect of Training on PACT Metrics 100% 80% 60% 40% 20% 0% 68% 66% 64% 62% 60% PACT Survey score ED/Urgent Care Utilization Rate Untrained Learning Center Collaborative Phone util Same-day Access 2-d post-d/c 16.5% 16.0% 15.5% 15.0% 14.5% 14.0% Admission Rate 25% 20% 15% 10% 5% 0% Continuity PACT Recognition PACT Training, Burnout and Job Satisfaction PACT Personnel Survey, Summer 2012 50% 5 45% 40% 35% 30% 25% 20% 15% 10% Training not avail/not involved (14% of respondents) Somewhat or very helpful (66% of respondents) 4 5% 0% Burnout Job Satisfaction 3 20

PACT Survey 49 questions, Summer 2011 and 2012 5,025 PACTs (62.7%) completion Highest scoring domain: Patient Centeredness & Self Management (81.0%) Lowest scoring domain: Advanced Concepts (62.1%) Most questions showed an increase in the implementation of PACT principles comparing 2011 responses to 2012 Examples: 32% increase in process to contact patients within two business days after discharge 36% increase in use of secure messaging 27% increase in use of communication tools for patients 15% increase in use of standing orders/protocols for med refills 13% increase in daily huddles 15% increase in meetings to discuss complex cases 13% increase in PACT involvement in discharge planning Future of Training 42 Transformation Initiative Learning Centers Longitudinal Training & Coaching Support 2012 to 2014 Transition to complete virtual training modalities by 2015 Sustainment education & continued training for existing & new staff 21

Coaching Support: A Critical Element Assist teams with 3 aims between each Learning Session Keep teams accountable for progress: Ask teams to keep track of their progress each month Reporting template Reinforce PACT principles from Learning Center sessions Connect teams to appropriate resources (to move past barriers, access patient education materials, etc) Assist team report-outs (sessions 3 & 5) The Future: Virtual VA e-health University 44 22

VeHU: Not just for VA 45 Exhibit Halls Live Sessions On-Demand Social Media Chats VeHU: My Space 46 23

VeHU: Sustainment & Continuation 47 24