The Patient-Centered Medical Home in the Veterans Health Administration

The patient-centered medical home (PCMH) model is being implemented by a growing number of health organizations, with the goal of providing more comprehensive, coordinated, and patient-centered care. The major primary care medical societies have endorsed the PCMH as the desired model for primary care. Large health systems and primary care practice collaboratives are implementing the PCMH model, and the Centers for Medicare & Medicaid Services is funding PCMH demonstration and innovation projects in diverse clinical sites. Nonetheless, published evaluations of PCMH initiatives to date have been limited to single-practice or smaller groups of practices, and often focus on limited clinical conditions.

In 2010, the Veterans Health Administration (VHA) became the largest integrated US health system to begin implementing the PCMH model at all primary care clinics throughout its nationwide system. The VHA delivers primary care to more than 5 million veterans in 16.4 million encounters annually—either at 160 large hospital-based primary care facilities, most of which are in urban areas, or 783 Community- Based Outpatient Clinics, many of which are in rural areas. Thus, VHA is facing the challenge of substantially redesigning major systems of care in an extremely large system across diverse clinical and community settings. In addition, veterans served by VHA typically have more chronic physical and mental illnesses, and are more socioeconomically vulnerable, than patients who receive care outside VHA.

The VHA’s PCMH initiative, called Patient Aligned Care Teams (PACTs), builds upon foundations established in the 1990s, when VHA undertook a major transformation from loosely organized hospitals that provided mainly inpatient and specialty care into a regionally integrated system focused on outpatient primary care. As part of that process, large numbers of primary care providers (PCPs) and nurses were hired by VHA, and several key elements of the PCMH model (as defined by the National Committee for Quality Assurance) were implemented, such as comprehensive electronic medical records and performance measurement and improvement programs (including programs addressing clinical outcome goals such as glycemic control and blood pressure control for patients with diabetes and cancer screening; Table 1). Since that time, VHA has demonstrated better clinical quality of care and outcomes in many areas than have been reported in other parts of the healthcare sector, including Medicare.

However, in the 2000s the level of primary care staffing and resources remained steady, despite steady increases in numbers of primary care patients.14-16 In addition, VHA identified room for improvement in care continuity and coordination (eg, by decreasing the amount that VHA patients relied on providers not part of the Department of Veterans Affairs [VA] for acute care) and in patient-centeredness of care (eg, by providing care through telephone or electronic access when patients prefer it).17 Thus, the PACT initiative aims to enhance comprehensive and coordinated care, improve patient experience, and further improve health outcomes by increasing and reorganizing primary care staffing, and introducing several PCMH components that were not already in place.

The PACT initiative began in April 2010, and full implementation is anticipated to continue through 2014. Patient Aligned Care Teams also include a concurrent plan (and budget) for nationwide evaluation, including quantitative and qualitative data collection and analysis. In this study, we describe the design of PACT and the extent of structural changes made by facilities in response to the PACT plan to date. Then, we present an interim nationwide evaluation of observed changes in patient care processes related to PACT goals.