geriatrics Article
Geriatric Patient-Aligned Care Teams in Department of Veterans Affairs: How Are They Structured? Jennifer L. Sullivan 1,2, * ID , Marlena H. Shin 1 , Omonyêlé L. Adjognon 1 , Kenneth Shay 3 , Kimberly Harvey 1 , Orna Intrator 4,5 ID , Enzo Yaksic 6 , Jennifer Moye 1,7 and Samantha Solimeo 8,9 1
2 3 4 5 6 7 8
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*
Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152M), Boston, MA 02130, USA;
[email protected] (M.H.S.);
[email protected] (O.L.A.);
[email protected] (K.H.);
[email protected] (J.M.) Department of Health Law, Policy and Management, Boston University School of Public Health, 715 Albany St, Talbot Building, Boston, MA 02118, USA US Department of Veterans Affairs, Office of Geriatrics and Extended Care (GEC) (10NC4), Washington, DC 20420, USA;
[email protected] Department of Public Health Sciences, University of Rochester, 265 Crittenden Blvd, Rochester, NY 14642, USA;
[email protected] VA Geriatrics and Extended Care Data Analysis Center (GEC DAC), Canandaigua VA Medical Center, 400 Fort Hill Ave, Canandaigua, NY 14424, USA Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, 150 S. Huntington Ave (152M), Boston, MA 02130, USA;
[email protected] New England Geriatric Research Education and Clinical Center (GRECC), VA Boston Healthcare System, 150 S. Huntington Ave (152M), Boston, MA 02130, USA Center for Comprehensive Access & Delivery Research & Evaluation Center and the Veterans Integrated Service Network (VISN) 23 Patient Aligned Care Team (PACT) Demonstration Laboratory, Iowa City VA Health Care System, Iowa City, IA 52246, USA;
[email protected] Department of General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA Correspondence:
[email protected]; Tel.: +1-857-364-5298
Received: 18 June 2018; Accepted: 30 July 2018; Published: 1 August 2018
Abstract: Geriatric Patient-Aligned Care Teams (GeriPACT) were implemented in the Department of Veterans Affairs (VA) (i.e., Patient-Centered Medical Homes for older adults) to provide high quality coordinated care to older adults with more risk of negative health and psychosocial outcomes. The objectives of this paper are: (1) to present data on GeriPACT structural characteristics; and (2) to examine a composite measure of GeriPACT model consistency. We utilized a web survey targeting 71 physician leads resulting in a 62% response rate. We found GeriPACTs employed a range of staffing, empanelment, clinic space, and patient assignment practices. The mean value of the GeriPACT consistency measure was 2.03 (range: 1–4) and 6.3% of facilities were considered consistent to the GeriPACT model. We observed large variation in GeriPACT structure and in model consistency. More research is needed to understand how these variations are related to processes and outcomes of care. Keywords: patient-centered medical homes; chronic disease; implementation; geriatrics
1. Introduction The Patient-Centered Medical Home (PCMH) model was developed to provide more timely access, coordination and patient-centered care in primary care settings. To date, the evidence regarding
Geriatrics 2018, 3, 46; doi:10.3390/geriatrics3030046
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Geriatrics 2018, 3, 46
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the success of PCMH has been mixed, although some research has shown PCMH implementation was related to slightly better clinical outcomes [1–3]. However successful its implementation, PCMH was not designed with the unique needs of an older adult population in mind. The multiple interacting cognitive, functional, psychosocial, and medical challenges of older adults may surmount the capacity of a typical PCMH [4]. For example, about three-quarters of Americans who are 65 and older have multiple chronic conditions that require ongoing medical attention or limit activities of daily living [5] In addition, older patients can experience geriatric syndromes that require more intensive care management, such as dementia and frailty. Older adults also deal with psychosocial issues such as living alone, and/or geographic isolation, in relationship to family or in terms of rurality, which tend to negatively impact older adults in ways that they might not have imagined at earlier ages. As the medical complexity and psychosocial needs in older adults increase, the risk for negative outcomes, such as hospitalization or need for supportive care, also increases. Given the unique needs and considerable growth of this specific population (43.1 million in U.S. in 2012 to 83.7 million in 2050 [6]), tailoring the PCMH model for older adults may help to mitigate negative outcomes by providing: (1) better care coordination within an interdisciplinary care team; (2) better access to community resources; (3) longer appointments to address the needs of complex patients; and (4) access to specific resources, such as having a pharmacist on the team to manage polypharmacy concerns and increased social work support to address psycho-social issues. A PCMH model designed to meet the needs of older adults also may increase patient and provider satisfaction, and reduce costs and healthcare utilization. In recognition of the unique primary care needs of the older adult population (age 65 or greater), the Department of Veterans Affairs (VA) implemented a specialized PCMH called the Geriatric Patient Aligned Care Team (GeriPACT) in 2010. Approximately 51% of the current active VA patient population is comprised of older adults; in fact, it is projected that just the patient population of Veterans aged 75 and older alone will increase by approximately 38%. GeriPACTs deliver focused care to Veterans with multiple chronic diseases as well as coexisting cognitive, functional, and psychosocial and provides these patients and their caregivers with a single point-of-contact for intensive, interdisciplinary Geriatric Primary Care [7]. GeriPACT differs from other VA primary care teams (e.g., PACTs) in several ways: (1) the GeriPACT includes a social worker and pharmacist on the primary care team; (2) GeriPACT providers have a reduced panel size (2/3 the size of a PACT panel per full time provider); and (3) team members must have Geriatrics training or advanced, mentored experience in providing care to older adults [8]. VA has released a handbook outlining guidelines and criteria for the GeriPACT Model [7]. In fiscal year (FY) 2015, approximately 1.5 million enrolled Veterans aged 65 and older were found to have a high Jen Frailty Index (JFI) score (i.e., claims-based risk-adjustment measure that serves as a marker of functional impairment based on 13 condition categories found to be significantly related to need for long-term care services) [9]. Of these, an estimated 60,000 patients (
