Translational Behavioral Medicine

, Volume 1, Issue 4, pp 615–623

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

  • John D Piette
  • Bree Holtz
  • Ashley J Beard
  • Caroline Blaum
  • C Leo Greenstone
  • Sarah L Krein
  • Adam Tremblay
  • Jane Forman
  • Eve A Kerr
  • on behalf of the Ann Arbor PACT Steering Committee
Article

DOI: 10.1007/s13142-011-0065-8

Cite this article as:
Piette, J.D., Holtz, B., Beard, A.J. et al. Behav. Med. Pract. Policy Res. (2011) 1: 615. doi:10.1007/s13142-011-0065-8

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.

KEYWORDS

Information technologyAccess-to-careVeteransChronic diseaseSelf-managementTelehealthHealth system change

Copyright information

© Society of Behavioral Medicine 2011

Authors and Affiliations

  • John D Piette
    • 1
    • 2
  • Bree Holtz
    • 1
  • Ashley J Beard
    • 1
    • 2
  • Caroline Blaum
    • 1
    • 2
    • 3
  • C Leo Greenstone
    • 2
    • 4
  • Sarah L Krein
    • 1
    • 2
  • Adam Tremblay
    • 2
    • 4
  • Jane Forman
    • 1
  • Eve A Kerr
    • 1
    • 2
  • on behalf of the Ann Arbor PACT Steering Committee
  1. 1.VA Center for Clinical Management Research, VA Ann Arbor Healthcare SystemAnn ArborUSA
  2. 2.Department of Internal MedicineUniversity of MichiganAnn ArborUSA
  3. 3.Ann Arbor VA Geriatric Research Education and Clinical CenterAnn ArborUSA
  4. 4.VA Ann Arbor Health Care SystemAnn ArborUSA