The patient-centered medical home in the Veterans Health Administration.

BACKGROUND 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 team based care, improved access, and care management for more than 5 million primary care patients nationwide. OBJECTIVES To describe PACT and evaluate interim changes in PACT-related care processes. STUDY DESIGN 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. METHODS Nonparametric tests of trend across time points. RESULTS 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. CONCLUSIONS Thirty months into PACT, primary care staff levels and phone and electronic encounters have greatly increased; other changes have been positive but slower.

[1]  R. Deyo,et al.  Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. , 1992, Journal of clinical epidemiology.

[2]  Katie Coleman,et al.  The Group Health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. , 2010, Health affairs.

[3]  E. Yano,et al.  Variations in nurse practitioner use in Veterans Affairs primary care practices. , 2004, Health services research.

[4]  E. Wagner,et al.  Multipayer patient-centered medical home implementation guided by the chronic care model. , 2011, Joint Commission journal on quality and patient safety.

[5]  J. Feussner,et al.  Reinventing VA health care: systematizing quality improvement and quality innovation. , 2000, Medical care.

[6]  K. Stange,et al.  Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home , 2009, The Annals of Family Medicine.

[7]  James T Tufano,et al.  Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. , 2009, The American journal of managed care.

[8]  Carlos Roberto Jaén,et al.  Summary of the National Demonstration Project and Recommendations for the Patient-Centered Medical Home , 2010, The Annals of Family Medicine.

[9]  Elizabeth E. Stewart,et al.  Improve office efficiency in mere minutes. , 2007, Family practice management.

[10]  M. Goldstein,et al.  The role of mental and behavioral health in the application of the patient-centered medical home in the Department of Veterans Affairs , 2011, Translational behavioral medicine.

[11]  Timothy Hoff,et al.  The Patient-Centered Medical Home , 2012, Medical care research and review : MCRR.

[12]  T. Bodenheimer,et al.  The Teamlet Model of Primary Care , 2007, The Annals of Family Medicine.

[13]  J. Tomcavage,et al.  How Geisinger's advanced medical home model argues the case for rapid-cycle innovation. , 2010, Health affairs.

[14]  Lisa V Rubenstein,et al.  The evolution of changes in primary care delivery underlying the Veterans Health Administration's quality transformation. , 2007, American journal of public health.

[15]  D. Berwick,et al.  Advanced access: reducing waiting and delays in primary care. , 2003, JAMA.

[16]  Adam B. Wilcox,et al.  The Effect of Technology‐Supported, Multidisease Care Management on the Mortality and Hospitalization of Seniors , 2008, Journal of the American Geriatrics Society.

[17]  D. Scharfstein,et al.  Guided care and the cost of complex healthcare: a preliminary report. , 2009, The American journal of managed care.

[18]  Harold Alan Pincus,et al.  Care for veterans with mental and substance use disorders: good performance, but room to improve on many measures. , 2011, Health affairs.

[19]  Jason Roy,et al.  Value and the medical home: effects of transformed primary care. , 2010, The American journal of managed care.

[20]  Susan Michie,et al.  Patient-centredness in chronic illness: what is it and does it matter? , 2003, Patient education and counseling.

[21]  I. Miake-Lye,et al.  Systematic Review: Comparison of the Quality of Medical Care in Veterans Affairs and Non-Veterans Affairs Settings , 2011, Medical care.