Primary Care Medical Home Primary Care Medical Home Veterans Health AdministrationVeterans Health Administration

Joanne M. Shear MS, FNP-BCJoanne M. Shear MS, FNP-BCNational Clinical Program Manager, National Clinical Program Manager,

Primary CarePrimary CareVA Central Office, Washington, DCVA Central Office, Washington, DC

joanne.shear@va.govjoanne.shear@va.gov

Primary Care in the Veterans Health Primary Care in the Veterans Health AdministrationAdministration

Largest integrated health care system in the countryLargest integrated health care system in the country Comprehensive electronic medical recordComprehensive electronic medical record 820 sites of Primary Care820 sites of Primary Care

152 Medical Centers152 Medical Centers 668 Community Based Outpatient Clinics (CBOC)668 Community Based Outpatient Clinics (CBOC)

4.5 million primary care patients-each assigned to an 4.5 million primary care patients-each assigned to an individual primary care providerindividual primary care provider

• 12 million encounters/year12 million encounters/year• Revisit rate (visits/yr): 2.5Revisit rate (visits/yr): 2.5• 21% had encounter in Mental Health21% had encounter in Mental Health• 6.3% had admission6.3% had admission

• 5,000 provider FTEE5,000 provider FTEE• 72% physician, 20% Nurse Practitioner, 8% Physician 72% physician, 20% Nurse Practitioner, 8% Physician

Assistants. Assistants. PCMM/VSSC data as of 5/15/09 2

VA Primary Care: VA Primary Care: Integrated ModelIntegrated Model

Mental Health ServicesMental Health Services Comprehensive Women’s HealthComprehensive Women’s Health Returning Combat VeteransReturning Combat Veterans

Traumatic Brain InjuryTraumatic Brain Injury PTSDPTSD

Spinal Cord Injury ServicesSpinal Cord Injury Services Geriatric ServicesGeriatric Services Clinical PharmacyClinical Pharmacy

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VA Patient Centered Medical Home: VA Patient Centered Medical Home:

StrengthsStrengths WeaknessesWeaknessesPrimary Care MoPrimary Care ModdelelTeam ConceptTeam Concept

Interdisciplinary decision making Interdisciplinary decision making unusual. Some employees not working at unusual. Some employees not working at "top of license“. Provider oriented, not "top of license“. Provider oriented, not “patient-centered”“patient-centered”

Access: Delays for primary Access: Delays for primary care; visits infrequentcare; visits infrequent

Poor phone service; secure messaging Poor phone service; secure messaging proceeding slowly; Focus on face-to-face proceeding slowly; Focus on face-to-face visitsvisits

Service agreements Service agreements implemented to support implemented to support specialty care interfacespecialty care interface

Efforts to manage chronic disease to Efforts to manage chronic disease to optimize outcomes still limited.optimize outcomes still limited.

Support programs and Support programs and services (Home telehealth, services (Home telehealth, Home Based PC)Home Based PC)

Limited coordination available to manage Limited coordination available to manage crucial transitions of carecrucial transitions of care

Comprehensive Electronic Comprehensive Electronic Medical RecordMedical Record

Minimal Decision Support; lack of Minimal Decision Support; lack of improved CPRS user functionalityimproved CPRS user functionality

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American College Physicians Home Builder American College Physicians Home Builder assessment nationwide-completion October assessment nationwide-completion October 2009.2009.

Start-up resourcesStart-up resources Funding to support new staffing modelFunding to support new staffing model

Team retraining and system redesignTeam retraining and system redesign CollaborativesCollaboratives

• Medical Home including Chronic DiseaseMedical Home including Chronic Disease• Telephone CareTelephone Care

Medical Home Learning “Colleges”Medical Home Learning “Colleges”• Primary Care Team DynamicsPrimary Care Team Dynamics• Care Management and CoordinationCare Management and Coordination

Consultation TeamsConsultation Teams

Veteran-Centered Medical HomeImplementation Strategies

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• Demonstration “Laboratories”Demonstration “Laboratories”• Intensive research, innovation and effectiveness Intensive research, innovation and effectiveness

evaluationevaluation

• Communication and EducationCommunication and Education• VA StaffVA Staff

Primary CarePrimary Care SpecialtySpecialty AdministrativeAdministrative LeadershipLeadership

• VeteransVeterans• StakeholdersStakeholders

Veteran Service Organizations Veteran Service Organizations CongressCongress PublicPublic

Veteran-Centered Medical Home:Veteran-Centered Medical Home:Implementation StrategiesImplementation Strategies

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Medical Home Readiness Evaluation (ACP Home Builder)September 2009 Pilot Data

Structure Measures

Process Measures

Outcome Measures

SafeSystems to manage high risk pts

Medication reconciliation

Anticoagulation pts. hospitalized for bleeding

EffectiveTeams completing Chronic Illness Care Survey

Composite quality metrics for select chronic conditions

Risk adjusted readmission rate

EfficientPanel size, support staff

Use of Group

Visits Unadjusted costs per unique

Patient-centered

Patient Self-Management program

Continuity of Care Index

Patient satisfaction survey

EquitableHomeless veterans who receive timely primary care

Male vs. female difference in prevention services

Urban vs. rural difference in patient satisfaction survey

TimelyUse of Secure messaging and “virtual visits”

Wait time less than 14 days for primary care

Patient satisfaction survey

Patient-Centered Medical Home EvaluationIn

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