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

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

2. Disclosure Statement • I have no conflicts of interest to disclose

3. OUTLINE • Some primary care history • PACT as a framework for “best care” • Post combat care in the PACT • How can the WRIISC help?

4. VHA Primary Care Milestones

5. Primary Care in the VHA

6. VHA Primary Care by Age & Gender 44% 6.1% Female 25% 21% had encounter in Mental Health

7. VHA Primary Care Providers7371 Providers, 5008 FTE (Avg. 0.69 FTE) (5% Trainees) 7

8. VHA Primary Care

9. Select Emerging National Health Care Delivery Trends Patient-Centered Care Access to Care Exploding consumer information and direct marketing Electronic Health Records Personal Health Records Increasing demand for transparency and quality Increasing POC Diagnostics and Monitoring at home Minimally Invasive Procedures Convergence of Technology Telehealth and Teleradiology Social Media 25 August 2011 9

10. Patient Centered Care per IOMHealthcare that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions • Superb access to care • Patient engagement • Clinical information systems • Care coordination • Integrated and comprehensive care • Smooth transfer of information • Ongoing public information • Publicly available information to choose a practice and a physician

11. First Step: American College of Physicians Medical Home Builder N= 850 VHA Primary Care Practices Overall Average Score: 69%

12. Total Score

13. Veteran Centered Care Physical Psychological Veteran Psychosocial

14. Essential Transformational Elements:Patient (Veteran) Centered Care Delivering “health” in addition to “disease care” Veteran as a partner in the team Empowered with education Focus on health promotion and disease prevention Self-management skills Patient Advisory Board Efficient Access Visits Non face-to-face Telephone Secure messaging Telemedicine Others? 14 14

15. Redesign Primary Care Practice Tasks and relationships defined Redesign team member functions and tasks Improve Team Dynamics Build team roles to support a Chronic Care Model Working at top of competency Time for non-face to face activities Encourage Primary Care staff professional growth Leadership opportunities Teaching opportunities On-the-job provider training for comprehensive Primary Care Women’s health Pain management Post-deployment health Geriatrics Specialty experience Essential Transformational Elements: Comprehensive Team-based Care

16. Improved coordination for all transitions Inpatient and outpatient Primary Care and Specialty Care VA and non-VA co-management (Dual Care) Incorporate telehealth and Home Based Primary Care (HBPC) services Highlight home care & rural health Care Management Panel based Connecting all services and points of care Care across the continuum Essential Transformational Elements:Coordination of Care

17. Chronic Care Model Disease management Interface with specialty care Case managers Pain management Returning combat Veteran Depression Substance abuse Disease registries Identification of outliers Veterans at high risk for adverse outcomes Essential Transformational Elements:Case/Chronic Disease Management

18. Improve technological clinical support CPRS user-friendliness Decision support PCMM enhancements Predictive modeling Information processing Telephone Support My HealtheVet Secure Messaging Essential Transformational Elements:Technology

19. CHRONIC CARE MODEL Ed Wagner & Institute for Healthcare Innovation (IHI) Community Health System Resources & Policies Health Care Organization ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Functional and Clinical Outcomes

20. Patient-Centered Perspective

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

22. Veteran Centered, Team based, coordinated care Patient Aligned Care Team PACT Care Coordination & Care Management Team Function and Culture Veteran VA (VHA and VBA)

23. Pillars of the Medical Home

26. Primary Care (PCMM) National Staffing Ratio

27. Primary & Specialty Care: Becoming True Partners

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….

31. Other Team Members • Clinical Pharmacy Specialist: • ± 3 panels • Clinical Pharmacy anticoagulation: • ± 5 panels • Social Work: ± 2 panels • Nutrition: ± 5 panels • CaseManagers • Trainees • Integrated Behavioral Health • Psychologist ± 3 panels • Social Worker ± 5 panels • Care Manager ± 5 panels • Psychiatrist ± 10 panels For each parent facility Health Promotion Disease Prevention Program Manager:1 FTE Health Behavior Coordinator: 1 FTE My HealtheVet Coordinator:1 FTE Panel size adjusted (modeled) for rooms and staffing Monitored via Primary Care Staffing and Room Utilization Data The Patient’s Primary Care Team

32. Patient-Centered Primary Care Model Implementation Strategies • Demonstration “Laboratories” • Intensive research and effectiveness evaluation • Communication and Education • Informatics and Technology • Measurement • Start-up resources • Gap analysis • Funding to support new staffing model • Team retraining and redesign • PCMH Summit, April 2010 • Learning Collaboratives • Medical Home including Chronic Disease • Telephone Care • Medical Home Learning Centers • Primary Care Team Dynamics • Care Management and Coordination • Consultation Teams

34. Learning, Discovery, Continuous Improvement

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

36. Post Deployment Care for Recent Combat Veterans ESSENTIAL ELEMENTS FOR CARE • Comprehensive 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 this • Integrated, de-stigmatized MH treatment • Active participation by OEF/OIF program staff and specialized teams in mental health, polytrauma, pain, SA featuring full integration of all post deployment services • Close links to allied clinics and programs • Align resources around Veteran • Integrated team meets to formulate Veteran centered care plan • Extended hours availability

37. Post Deployment Care for Recent Combat Veterans • The 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 needs • Extended team: PACT social worker, PC-MHI, pharmacist trained in combat Vet unique needs • OEF/OIF program : trains and supports PACT joining core team when needed • PDICI champions assist with facility education and consultative support of PACT • Coordination with specialty care: Polytrauma, PTSD, Pain, Ortrho, Rehab, Neurology, WRIISCs, (join the Veteran’s team)

38. TASKS FOR POST DEPLOYMENT CARE IN THE PACT ESSENTIAL ELEMENTS FOR CARE IN THE PACT • Risk assessment at each encounter F 2 F and non F 2 F • Proactive 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 Veteran • Assist with MHV-IPA, discuss communication methods (SM, telephone), demonstrate web resources • Weekly (extended) team huddles for complex cases • Assure knowledge of/connection to OEF/OIF program for each combat Vet

39. TASKS FOR POST DEPLOYMENT CARE IN THE PACT • Initiate appropriate assistance from OEF/OIF program manager and social worker, primary care champions, Consultative Team • Benefits, C+P • Legal assistance • Vet centers • Case management • Community resources and services • Schools • Assure 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, intake

40. PACT can care for special populations with support and training. The PACT expands as needed to meet the Veteran’s needs . Wethe team cares for the CV. VBA PT C+P Ortho Substance Abuse WRIISC Chaplain Pain Specialty Mental Health Teamlet Vet Centers Polytrauma PIDICI Champ Neurology DHC OEF/OIF/OND Consult Team NCPTSD

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 care • 35% of OEF/OIF/OND cared for in CBOCs • Focus groups : Vets want teams who understand their culture, their experience , thus we need more training, expectation of basic knowledge base in PACT • Risk assessment and communication and better communication skills are essential competencies • PACT 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 conferences • On site provider training • Virtual consultative service for MUS, exposure concerns ? • Comprehensive assessment complex cases

43. PRIMARY CARE TEAM Case Manager Social Worker PC Provider Clinical Associate TEAMLET HOSPITALISTS NON-VA CARE Behaviorist RN Care Manager Administrative Clerk PATIENT Mental Health Pharmacist Dietitian Nursing SPECIALISTS NCPTSD WRIISC Family

44. PACT Resources • http://vaww.infoshare.va.gov/sites/primarycare/mh/pcmhinfo/default.aspx