“Implementing the Patient Center Medical Home in Veterans Health Administration Primary Care”

Introduction: Patient Centered Medical Home (PCMH) is an effective model healthcare delivery. While transformation of an individual practice is difficult, system-wide implementation of new modes of healthcare delivery presents its own challenges. In April 2010 the Secretary of Veterans Affairs outlined National Policy Initiatives (T-21) for Veterans Health Administration (VHA) that focused on improving Primary Care for 6 million veterans. Shortly thereafter, VHA committed to implementing the PCMH model (renamed Patient Aligned Care Team) over the 3 years. We describe initial implementation at multiple levels of the organization. Methods: Mixed methods descriptive approach using a multi-level systems perspective. In VHA, these levels include: National-VA Central Office; Regional-Veterans Integrated Service Networks (VISN) and VA facilities; and Local-individual primary care practice sites that are administratively (though not necessarily geographically) part of facilities. Results: National: Strategic planning involved a team of > 300 multidisciplinary members over 9 months with support from the Secretary and Undersecretary and involved decisions about the substantial funding allocation, redefinition of staff tasks, roles and responsibilities with Teamlets as the core unit (1 primary care provider and 2.8 support staff). Relevant national policies were drafted and standardized, education/training materials were developed and presented at large national meetings and teleconferences. Regional: Regional learning collaborative are underway involving 1500 individuals and 150 front-line Teamlets. Learning Centers of Excellence support team functioning; reach will be > 80% of all primary care within 2 years. Five funded demonstration labs for researcher/clinician collaboration on impact on care delivery. Money allocated specifically for health promotion and disease prevention programs with staff are currently in the hire and training phase. Care management staff will assist with high risk, or medically complex patients. Structured incentives for early adopters of the model elements are in place. How specialties integrate with this new primary care model is under development. Facilities: Teams forming, participation in regionalized team training improvement learning session content has included improvement skills and processes that map to PCMH tenets including: group visits, patient self management and shared decision making. Local best practices have begun to be implemented with data systems to track. Local: Teams are encouraged to utilize non face to face care delivery, telehealth and secure text messaging. Conclusions: While initiated top down, clinical teams are forming and learning skills requisite for implementation of PCMH processes and care delivery. Lessons learned in this implementation process may assist community adoption of the PCMH model.