A PACT with vets

VA initiative transforms how care is delivered

Veterans Affairs  hospitals  are complex and growing health care systems in which it would be easy for patients to get lost in the shuffle. Thanks to a recent initiative from the VA, veterans are front and center when it comes to health care.

Most know their primary care providers. They have direct access to physicians and nurse managers via telephone and email. They can make appointments when they want, sometimes on the same day.

They are educated about their conditions and get help coordinating visits with outside specialists.

Today’s veterans benefit  from a team-centered approach that the VA calls PACT (Patient-Aligned Care Team).

“We started talking about changing our care delivery about seven years ago, and had rolled out the PACT model for primary care by 2010. The Atlanta VA Medical Center was one of the first in the country to implement it,” said Sandy Leake, MSN, RN, associate director of nursing and patient care services and chief nursing officer at the Atlanta VA Medical Center.

“The overall goal was to transform our delivery system in order to provide more patient-centered care,” she added. “Ours is a challenging patient population, and we wanted to give veterans better access to primary care, which is the entry point into our system, as well as good alternatives to face-to-face visits using technology, and seamless coordination with their outside providers and specialists.”

In 2012, the Robert Wood Johnson Foundation’s Charting Nursing’s Future policy brief recognized PACT as an innovative model “to provide patient-centered, coordinated, and cost-effective care by taking advantage of nursing’s strengths.”

In the PACT model, each veteran is assigned to a small core teamlet that coordinates care over the long term. A teamlet consists of a primary care provider (physician, nurse practitioner or physician assistant), an RN care manager, a clinical associate (LPN or nursing assistant) and a clerical associate. At the Atlanta VA Medical Center, there are about 76 teamlets, which are part of larger teams that include social workers and others.

Teamlets partner with veterans to design individual plans of care and to provide clinical, educational and motivational support to help them meet their goals.

“This means that when a patient comes in for a primary care appointment, he’s going to see familiar faces who know him and his medical history,” Leake said.

Veterans get help managing their conditions and making the appointments they need. Because there is better coordination with outside providers, the teamlet is notified when a patient enters the hospital and can help with followup care after discharge.

Technology helps teamlets care for patients more efficiently. Telehealth nurses use in-home monitors to manage and coordinate the care of at-risk patients who have chronic conditions . Two-way conferencing expands the reach of specialists, such as mental health counselors.

“We wondered whether patients would warm to telehealth versus in-person visits, but the quality of the image and audio are really good and there is no delay in the transmission,” Leake said. “We found that patients would rather go to a telehealth appointment at a clinic near their home than have to drive to the medical center in Atlanta. Since it’s more convenient, they are more likely to meet appointments.”

A health promotion disease prevention program manager (an RN) and a behavioral health coordinator (a psychologist) work together  to show PACT teams how to teach and motivate patients to meet health goals.

In September 2009, the Atlanta VA rolled out PACT with a pilot program in its Stockbridge Outreach Clinic.

“When you roll out a new model that will change the culture, you begin by educating leaders and getting their input in the planning process,” said Kathy B. Williams, RN, MA, BSN, associate nurse executive for the primary care service line. “Our previous model was more provider- and facility-driven. We wanted to improve teamwork, redesign processes, introduce technology to create more efficient systems, and maximize team roles with this new model. There were a lot of challenges.”

To meet the challenges, the Atlanta VA hired  more support staff so physicians and nurses could spend their time  delivering care; utilized technology to increase access for patients and save time for clinicians; promoted greater communication between team members; and made veterans full partners in their own health care. Those efforts have paid off.

“I’m proud to say that we’re making great strides. We get positive feedback from our veterans, who like knowing their team and having a nurse manager they can contact directly,” Williams said.

As part of the rollout, nursing leadership performed a needs-assessment of what additional skills nurses might require to serve as patient care managers and decision-makers, Williams said.

“The foundation of nursing has always been high-quality and safe patient care,” she said. “With PACT, nurses are practicing to the full extent of their training and licensure. They have an integral role in managing patient care, which makes the nursing more rewarding. It’s a win/win for patients and the health care team.”