, Volume 1, Issue 4, pp 615-623
Date: 16 Aug 2011

Improving chronic illness care for veterans within the framework of the Patient-Centered Medical Home: experiences from the Ann Arbor Patient-Aligned Care Team Laboratory

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ABSTRACT

While key components of the Patient-Centered Medical Home (PCMH) have been described, improved patient outcomes and efficiencies have yet to be conclusively demonstrated. We describe the rationale, conceptual framework, and progress to date as part of the VA Ann Arbor Patient-Aligned Care Team (PACT) Demonstration Laboratory, a clinical care-research partnership designed to implement and evaluate PCMH programs. Evidence and experience underlying this initiative is presented. Key components of this innovation are: (a) a population-based registry; (b) a navigator system that matches veterans to programs; and (c) a menu of self-management support programs designed to improve between-visit support and leverage the assistance of patient–peers and informal caregivers. This approach integrates PCMH principles with novel implementation tools allowing patients, caregivers, and clinicians to improve disease management and self-care. Making changes within a complex organization and integrating programmatic and research goals represent unique opportunities and challenges for evidence-based healthcare improvements in the VA.

Implications

Practice: This portfolio of innovative services may improve the intensity and quality of self-management support without unacceptable increased demands on clinician time.
Policy: The VA PACT Demonstration Laboratories will not only provide evidence regarding specific innovations for improving chronic illness care, but more generally will provide evidence about the impacts of Patient-Centered Medical Home principles.
Research: The VA PACT program provides unprecedented opportunities to evaluate novel care management interventions in real-world primary care settings.