Skip to main content

Advertisement

SpringerLink
Log in

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

  • Published:
Translational Behavioral Medicine

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig 1

Similar content being viewed by others

References

  1. Coleman, K., Austin, B. T., Brach, C., & Wagner, E. H. (2009). Evidence on the chronic care model in the new millennium. Health Aff (Millwood), 28, 175–185.

    Article  Google Scholar 

  2. Chen, E., Thorn, D., Hessler, D., et al. (2010). Using the teamlet model to improve chronic care in an academic primary care practice. Journal of General Internal Medicine, 25(Suppl. 4), 610–614.

    Article  Google Scholar 

  3. Ostbye, T., Yarnall, K., Krause, K., Pollack, K., Gradison, M., & Michener, J. (2005). Is there time for management of patients with chronic disease in primary care? Annals of Family Medicine, 3, 209–214.

    Article  PubMed  Google Scholar 

  4. Yarnall, K., Pollack, K., Ostby, T., Krause, K., & Michener, J. (2003). Prmary care: Is there enough time for prevention? American Journal of Public Health, 93(4), 635–641.

    Article  PubMed  Google Scholar 

  5. Bodenheimer, T., Wagner, E. H., & Grumbach, K. (2002). Improving primary care for patient with chronic illness: The chronic care model, part 2. Journal of the American Medical Association, 288(15), 1909–1914.

    Article  PubMed  Google Scholar 

  6. McGlynn, E., Asch, S., Adams, J., & Kessesy, J. (2003). The quaity of health care delivered to adults in the United States. The New England Journal of Medicine, 348(26), 2635–2646.

    Article  PubMed  Google Scholar 

  7. Chobanian, A. V., Bakris, G. L., Black, H. R., et al. (2003). The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report. Journal of the American Medical Association, 289(19), 2560–2571.

    Article  PubMed  CAS  Google Scholar 

  8. Boyd, C. M., Darer, J., Boult, C., Fried, L., Boult, L., & Wu, A. (2005). Clinical practice guidelines and quality of care for older patients with multiple comorbid disease. Journal of the American Medical Association, 294(6), 716–724.

    Article  PubMed  CAS  Google Scholar 

  9. Glasgow, R. E., Funnell, M. M., Bonomi, A., Davis, C., Beckham, V., & Wagner, E. H. (2002). Self-management aspects of the improving chronic illness care breakthrough. Annals of Behavioral Medicine, 24(2), 80–87.

    Article  PubMed  Google Scholar 

  10. Barlow, J., Wright, C., Sheasby, J., Turner, A., & Hainsworth, J. (2002). Self-management approaches for people with chronic conditions: A review. Patient Education and Counseling, 48(2), 177–187.

    Article  PubMed  Google Scholar 

  11. Holman, H., & Lorig, K. (2004). Patient self-management: A key to effectiveness and efficiency in care of chronic disease. Public Health Reports, 119(3), 239–243.

    Article  PubMed  Google Scholar 

  12. American College of Physicians (2007) Joint principles of a patient-centered medical home released by organizations representing more than 300,000 physicians. http://www.acponline.org/pressroom/pcmh.htm. Accessed September 2, 2008.

  13. Barr M, Ginsburg J (2008) The advanced medical home: A patient-centered, physician-guided model of health care. www.acponline.org/running_practice/pcmh. Accessed 5 December 2008.

  14. Stange, K. C., Nutting, P. A., Miller, W. L., et al. (2010). Defining and measuring the patient-centered medical home. Journal of General Internal Medicine, 25(6), 601–612.

    Article  PubMed  Google Scholar 

  15. Paulus, R., Davis, K., & Steele, G. (2008). Continuous innovation in health care: Implications of the Geisinger Experience. Health Affairs, 27(5), 1235–1245.

    Article  PubMed  Google Scholar 

  16. Reid, R., Fishman, P., Yu, O., et al. (2009). Patient-centered medical home demonstration: A prospective, quasi-experimental before and after evaluation. The American Journal of Managed Care, 15(9), e71–e87.

    PubMed  Google Scholar 

  17. Bitton, A., Martin, C., & Landon, B. E. (2010). A nationwide survey of patient centered medical home demonstration projects. Journal of General Internal Medicine, 25, 584–592.

    Article  PubMed  Google Scholar 

  18. Crabtree, B. F., Chase, S. M., Wise, C. G., et al. (2011). Evaluation of patient centered medical home practice transformation initiatives. Medical Care, 49(1), 10–16.

    Article  PubMed  Google Scholar 

  19. Crabtree, B. F., Nutting, P. A., Miller, W. L., Stange, K. C., Stewart, E. E., & Jaen, C. R. (2010). Summary of the National Demonstration Project and recommendations for the patient-centered medical home. Annals of Family Medicine, 8(Suppl 1), S80–S90. S92.

    Article  PubMed  Google Scholar 

  20. Friedberg, M. W., Safran, D. G., Coltin, K. L., Dresser, M., & Schneider, E. C. (2009). Readiness for the patient-centered medical home: Structural capabilities of Massachusetts primary care practices. Journal of General Internal Medicine, 24(2), 162–169.

    Article  PubMed  Google Scholar 

  21. Miller, W. L., Crabtree, B. F., Nutting, P. A., Stange, K. C., & Jaen, C. R. (2010). Primary care practice development: A relationship-centered approach. Annals of Family Medicine, 8(Suppl 1), S68–S79. S92.

    Article  PubMed  Google Scholar 

  22. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association (2007) Joint Principles of the Patient-Centered Medical Home. http://www.medicalhomeinfo.org/downloads/pdfs/jointstatement.pdf. Accessibility verified 2011.

  23. American College of Physicians (2006) The advanced medical home: A patient-centered, physician-guided model of health care. http://www.hhs.gov/healthit/ahic/materials/meeting03/cc/ACP_Initiative.pdf.

  24. Affairs USDoV. Patient-Centered Medical Home Concept Paper. Patient Aligned Care Team (PACT) [2010; http://www.va.gov/PrimaryCare/docs/pcmh_ConceptPaper.doc. Accessed March 22, 2011.

  25. Homer, C. J., & Baron, R. J. (2010). How to scale up primary care transformation: What we know and what we need to know? Journal of General Internal Medicine, 25(6), 625–629.

    Article  PubMed  Google Scholar 

  26. Takach, M. (2011). Reinventing Medicaid: State innovations to qualify and pay for patient-centered medical homes show promising results. Health Affairs (Millwood), 30(7), 1325–1334.

    Article  Google Scholar 

  27. Jaen, C. R., Crabtree, B. F., Palmer, R. F., et al. (2010). Methods for evaluating practice change toward a patient-centered medical home. Annals of Family Medicine, 8(Suppl 1), S9–S20. S92.

    Article  PubMed  Google Scholar 

  28. Jaen, C. R., Ferrer, R. L., Miller, W. L., et al. (2010). Patient outcomes at 26 months in the patient-centered medical home National Demonstration Project. Annals of Family Medicine, 8(Suppl 1), S57–S67, S92.

    Article  PubMed  Google Scholar 

  29. Nutting, P. A., Crabtree, B. F., Miller, W. L., Stewart, E. E., Stange, K. C., & Jaen, C. R. (2010). Journey to the patient-centered medical home: A qualitative analysis of the experiences of practices in the National Demonstration Project. Annals of Family Medicine, 8(Suppl 1), S45–S56.

    Article  PubMed  Google Scholar 

  30. Stange, K. C., Miller, W. L., Nutting, P. A., Crabtree, B. F., Stewart, E. E., & Jaen, C. R. (2010). Context for understanding the National Demonstration Project and the patient-centered medical home. Annals of Family Medicine, 8(Suppl 1), S2–8.

    Article  PubMed  Google Scholar 

  31. Stewart, E. E., Nutting, P. A., Crabtree, B. F., Stange, K. C., Miller, W. L., & Jaen, C. R. (2010). Implementing the patient-centered medical home: observation and description of the National Demonstration Project. Annals of Family Medicine, 8(Suppl 1), S21–S32.

    Article  PubMed  Google Scholar 

  32. Bojadzievski, T., & Gabbay, R. A. (2011). The patient-centered medical home and diabetes care. Diabetes Care, 34(4), 1047–1053.

    Article  PubMed  Google Scholar 

  33. Nazi, K. M., Hogan, T. P., Wagner, T. H., McInnes, D. K., et al. (2010). Embracing a health services research perspective on personal health records: Lessons learned from the VA My HealtheVet system. Journal of General Internal Medicine, 25(Suppl 25), 62–67.

    Article  PubMed  Google Scholar 

  34. Kilbourne, A., Schulberg, H., Post, E., Rollman, B., Herbeck Belnap, B., & Pincus, H. (2004). Translating evidence-based depression management services to community-based primary care practices. The Milbank Quarterly, 82(4), 631–659.

    Article  PubMed  Google Scholar 

  35. Nobel, J. J., & Norman, G. K. (2003). Emerging information management technologies and the future of disease management. Disease Management, 6(4), 219–231.

    Article  PubMed  Google Scholar 

  36. Wagner, E., Austin, B. T., Davis, C., Hindmarsh, M., Schaefer, J., & Bonomi, A. (2001). Improving chronic illness care: Translating evidence into action. Health Affairs, 20(6), 64–78.

    Article  PubMed  CAS  Google Scholar 

  37. Wagner, E. H., Austin, B. T., & Von Korff, M. (1996). Organizing care for patients with chronic illness. The Milbank Quarterly, 74(4), 511–544.

    Article  PubMed  CAS  Google Scholar 

  38. Rice, K., Dewan, N., Bloomfield, H., et al. (2010). Disease management program for chronic obstructive plumonary disease: A randomized controlled trail. American Journal of Respiratory and Critical Care Medicine, 182(7), 890–896.

    Article  PubMed  Google Scholar 

  39. Grumbach K, Grundy P (2010). Outcomes of implemented patient centered medical home interventions: A review of the evidence from prospective evaluation studies in the United States. Patient-Centered Primary Care Collaborative. http://www.pcpcc.net/content/pchm-outcome-evidence-quality. Accessed 5 April 2011.

  40. Fihn, S. D., McDonell, M., Martin, D., et al. (1993). Risk factors for complications of chronic anticoagulation: A multicenter study. Annals of Internal Medicine, 118(7), 511–520.

    PubMed  CAS  Google Scholar 

  41. Brooks, F., Kendall, S., Bunn, F., Bindler, R., & Bruya, M. (2007). The school nurse as navigator of the school health journey: Developing the theory and evidence for policy. Primary Health Care Research and Development, 8, 226–234.

    Article  Google Scholar 

  42. Carroll, J. K., Humiston, S. G., Meldrum, S. C., et al. (2010). Patients' experiences with navigation for cancer care. Patient Education and Counseling, 80, 241–247.

    Article  PubMed  Google Scholar 

  43. Druss, B. G., Marcus, S. C., Olfson, M., Tanielian, T., & Pincus, H. A. (2003). Trends in care by nonphysician clinicians in the United States. The New England Journal of Medicine, 348(2), 130–137.

    Article  PubMed  Google Scholar 

  44. Freeman, H., Muth, B., & Kerner, J. (1995). Expanding access to cancer screening and clinical follow-up among the medically underserved. Cancer Practice, 3(1), 19–30.

    PubMed  CAS  Google Scholar 

  45. Robinson-White, S., Conroy, B., Slavish, K., & Rosenzweig, M. (2010). Patient navigator in breast cancer: A systematic review. Cancer Nursing, 33(2), 127–140.

    Article  PubMed  Google Scholar 

  46. Unutzer, J., Rubenstein, L., Katon, W. J., et al. (2001). Two-year effects of quality improvement programs on medication management for depression. Archives of General Psychiatry, 58(10), 935–942.

    Article  PubMed  CAS  Google Scholar 

  47. Dohan, D., & Schrag, D. (2005). Using navigators to improve care of underserved patients: current practices and approaches. Cancer, 104, 848–855.

    Article  PubMed  Google Scholar 

  48. Seek, A., & Hogle, W. (2007). Modeling a better way: Navigating the healthcare system for patients with lung cancer. Clinical Journal of Oncology Nursing, 11(1), 81–85.

    Article  PubMed  Google Scholar 

  49. Shockney, L. (2011). Becoming a breast cancer nurse navigator. Sudbury: Jones and Barlett.

    Google Scholar 

  50. Ruland, C. M., Holte, H. H., Røislien, J., et al. (2010). Effects of a computer-supported interactive tailored patient assessment tool on patient care, symptom distress, and patients' need for symptom management support: A randomized clinical trial. Journal of the American Medical Informatics Association, 17(4), 403–410.

    Article  PubMed  Google Scholar 

  51. Bosworth, H., Powers, B., & Oddone, E. (2010). Patient self-management support: Novel strategies in hypertension and heart disease. Cardiology Clinic, 28, 655–663.

    Article  Google Scholar 

  52. Darkins, A. (2009). Remote patient monitoring in home healthcare: Lessons learned from advanced users. Journal of Management and Marketing in Healthcare, 2, 238–252.

    Google Scholar 

  53. Darkins, A. (2009). Care coordination/home telehealth: The systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions. Telemedicine Journal and e-Health, 14, 1118–1126.

    Article  Google Scholar 

  54. Inglis, S., Clark, R., McAlister, G., et al. (2010). Structured telephone support or telemonitoring programs for patients with chornic heart failure. Cochrane Database Syst Rev. doi:10.1002/14651858.CD007228.pub2.

  55. Piette, J. D., Weinberger, M., Kraemer, F. B., & McPhee, S. J. (2001). Impact of automated calls with nurse follow-up on diabetes treatment outcomes in a Department of Veterans Affairs Health Care System: A randomized controlled trial. Diabetes Care, 24(2), 202–208.

    Article  PubMed  CAS  Google Scholar 

  56. Wasson, J., Gaudette, C., Whaley, F., Sauvigne, A., Baribeau, P., & Welch, H. (1992). Telephone care as a substitute for routine clinic follow-up. Journal of the American Medical Association, 267(13), 1788–1793.

    Article  PubMed  CAS  Google Scholar 

  57. Darkins, A., Ryan, P., Kobb, R., et al. (2009). Care coordination/Home telehealth: The systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions. Telemedicine Journal and e-Health, 14(10), 1118–1126.

    Article  Google Scholar 

  58. Piette, J. D., Weinberger, M., & McPhee, S. J. (2000). The effect of automated calls with telephone nurse follow-up on patient-centered outcomes of diabetes care: a randomized, controlled trial. Medical Care, 38(2), 218–230.

    Article  PubMed  CAS  Google Scholar 

  59. Piette, J. D., Weinberger, M., McPhee, S. J., Mah, C. A., Kraemer, F. B., & Crapo, L. M. (2000). Do automated calls with nurse follow-up improve self-care and glycemic control among vulnerable patients with diabetes? The American Journal of Medicine, 108(1), 20–27.

    Article  PubMed  CAS  Google Scholar 

  60. Piette J, Beard A. Automated telephone monitoring and behavior change calls (IVR). Interactive Health Communication Technologies: Promising strategies for health behavior change. (in press)

  61. Piette, J., Gregor, M. A., Share, D., Heisler, M., Bernstein, S., Koelling, T., et al. (2008). Improving heart failure self-management support by actively engaging out-of-home caregivers: results of a feasibility study. Congestive Heart Failure, 14(1), 12–18.

    Article  PubMed  Google Scholar 

  62. Heisler M (2006). Building peer support programs to manage chronic disease: seven models for success. pp. 1–41. http://www.chcf.org/topics/chronicdisease/index.cfm?itemID=127997. Accessed 4 May 2011.

  63. Boothroyd, R. I., & Fisher, E. B. (2010). Peers for progress: Promoting peer support for health around the world. Family Practice, 27(Suppl 1), i62–i68.

    Article  PubMed  Google Scholar 

  64. Fisher, E. B., Brownson, C. A., O'Toole, M. L., & Anwuri, V. V. (2007). Ongoing follow-up and support for chronic disease management in the Robert Wood Johnson Foundation Diabetes Initiative. The Diabetes Educator, 33(Suppl 6), 201S–207S.

    Article  PubMed  Google Scholar 

  65. Greden, J. F., Valenstein, M., Spinner, J., et al. (2010). Buddy-to-Buddy, a citizen soldier peer support program to counteract stigma, PTSD, depression, and suicide. Annals of the New York Academy of Sciences, 1208, 90–97.

    Article  PubMed  Google Scholar 

  66. Heisler, M., Vijan, S., Makki, F., & Piette, J. D. (2010). Diabetes control with reciprocal peer support versus nurse care management: A randomized trial. Annals of Internal Medicine, 153(8), 507–515.

    PubMed  Google Scholar 

  67. Baksi, A. K. (2010). Experiences in peer-to-peer training in diabetes mellitus: challenges and implications. Family Practice, 27(Suppl 1), i40–45.

    Article  PubMed  Google Scholar 

  68. Travis, J., Roeder, K., Walters, H., et al. (2010). Telephone-based mutual peer support for depression: A pilot study. Chronic Illness, 6(3), 183–191.

    Article  PubMed  Google Scholar 

  69. Davis, K. L., O'Toole, M. L., Brownson, C. A., Llanos, P., & Fisher, E. B. (2007). Teaching how, not what: The contributions of community health workers to diabetes self-management. The Diabetes Educator, 33(Suppl 6), 208S–215S.

    Article  PubMed  Google Scholar 

  70. Schopp, L. H., Hales, J. W., Quetsch, J. L., Hauan, M. J., & Brown, G. D. (2004). Design of a peer-to-peer telerehabilitation model. Telemedicine Journal and e-Health, 10(2), 243–251.

    Article  PubMed  Google Scholar 

  71. Heisler, M., Halasyamani, L., Resnicow, K., et al. (2007). “I am not alone”: The feasibility and acceptability of interactive voice response-facilitated telephone peer support among older adults with heart failure. Congestive Heart Failure, 13(3), 149–157.

    Article  PubMed  Google Scholar 

  72. Levine, M. D., Ross, T. R., Balderson, B. H., & Phelan, E. A. (2010). Implementing group medical visits for older adults at group health cooperative. Journal of the American Geriatrics Society, 58(1), 168–172.

    Article  PubMed  Google Scholar 

  73. Heisler, M., & Piette, J. D. (2005). “I help you, and you help me”: Facilitated telephone peer support among patients with diabetes. Diabetes Educator, 31(6), 869–879.

    Article  PubMed  Google Scholar 

  74. Kilbourne, A., Flanders McGinnis, G., Herbeck Belnap, B., Klinkman, M., & Thomas, M. (2006). The role of clinical information technology in depression care management. Administration and Policy in Mental Health and Mental Health Services Research, 33(1), 54–64.

    Article  PubMed  Google Scholar 

  75. Forster, A. J., Clark, H. D., & Menard, A. (2004). Adverse events affecting medical patients following discharge from hospital. Canadian Medical Association Journal, 170, 3345–3349.

    Google Scholar 

  76. Forster, A. J., Murff, H. J., Peterson, J. F., Ghandi, T. K., & Bates, D. W. (2003). The incidence and severity of adverse events affecting patients after discharge from the hospital. Annals of Internal Medicine, 138, 3161–3167.

    Google Scholar 

  77. Gonseth, J., Guallar-Castillon, P., Banegas, J. R., & Rodriguez-Artalejo, F. (2004). The effectiveness of disease management programmes in reducing hospital re-admission in older patients with heart failure: A systematic review and meta-analysis of published reports. European Heart Journal, 25(18), 1570–1595.

    Article  PubMed  Google Scholar 

  78. Kasper, E., Gerstenblith, G., Hefter, G., et al. (2002). A randomized trial of the efficacy of multidisciplinary care in heart failure outpatients at high risk of hospital readmission. Journal of the American College of Cardiology, 2002(39), 471–480.

    Article  Google Scholar 

  79. Forster, A. J., Boyle, L., Shojania, K. G., Feasby, T. E., & Van Walraven, C. (2009). Identifying patients with post-discharge care problems using an interactive voice response system. Journal of General Internal Medicine, 24(4), 520–525.

    Article  PubMed  Google Scholar 

  80. Boyd, C. M., Boult, C., Shadmi, E., et al. (2007). Guided care for multimorbid older adults. Gerontologist, 47, 697–704.

    Article  PubMed  Google Scholar 

  81. Coleman, E. A., Parry, C., Chalmers, S., & Min, S. J. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166(17), 1822–1828.

    Article  PubMed  Google Scholar 

  82. Corrigan, J. M., & Martin, J. B. (1992). Identification of factors associated with hospital readmission and development of a predictive model. Health Services Research, 27(1), 81–101.

    PubMed  CAS  Google Scholar 

  83. Weissman, J. S., Ayanian, J. Z., Chasan-Taber, S., Sherwood, M. J., Roth, C., & Epstein, A. M. (1999). Hospital readmissions and quality of care. Medical Care, 37(5), 490–501.

    Article  PubMed  CAS  Google Scholar 

  84. Blaum, C. S., Cigolle, C. T., Boyd, C. M., Wolffe, J. L., Tian, Z., Langa, K. M., et al. (2010). Clinical complexity in middle aged and older adults with diabetes: The Health and Retirement Study. Medical Care, 48(4), 327–334.

    Article  PubMed  Google Scholar 

  85. Creswell, J. W., & Clark, V. L. P. (2007). Designing and conducting mixed methods research. Thousand Oaks: Sage Publications, Inc.

    Google Scholar 

  86. Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4, 50.

    Article  PubMed  Google Scholar 

  87. Kitson, A., Harvey, G., & McCormack, B. (1998). Enabling the implementation of evidence based practice: A conceptual framework. Quality in Health Care, 7(3), 149–158.

    Article  PubMed  CAS  Google Scholar 

  88. Rogers, E. (2003). Diffusion of innovations (5th ed.). New York: Free Press.

    Google Scholar 

  89. Pettigrew, A., & Whipp, R. (1992). Managing change and corporate performance. In K. Cool, D. Neven, & I. Walter (Eds.), European industrial restructuring in the 1990s. New York: New York University Press.

    Google Scholar 

  90. Barnett, P. (2003). Determination of VA health care costs. Medical Care Research and Review, 60(Suppl. 3), 124S–141S.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

Funding

Funding for the VAAAHS Demonstration Laboratory is through the Office of Primary Care, Veterans Health Administration, Department of Veterans Affairs. Additional support is derived from the VA Health Services Research and Development Service and the VA Quality Enhancement Research Initiative. John Piette is a VA Senior Research Career Scientist. Dr. Blaum is supported in part by the Ann Arbor VA Geriatric Research Education and Clinical Center. Drs. Piette, Krein, and Kerr are supported in part by the Michigan Diabetes Research and Training Center (NIH no. DK020572).

VAAAHS PACT Steering Committee

Caroline Blaum, MD, MS; Jane Forman, ScD, MHS; C. Leo Greenstone, MD; Cathy Kerr, MHSA; Eve Kerr, MD, MPH; Tom Kerr, MPH; Sarah Krein, PhD, RN; Wendy Morrish, BSN, RN; John Piette, PhD; Denny Ramsey, BSN, MSN; Darcy Saffar, MPH; and Adam Tremblay, MD

Additional VAAAHS PACT Advisors

Davoren Chick, MD; Jean Malouin, MD, MPH; Robert McDivitt, FACHE; Richard Moseley, MD; Alan Pawlow, MD; Sanjay Saint, MD, MPH; Connie Standiford, MD; Brent Williams, MD, MPH; Ronald Wuthrich; and Eric Young, MD, MS

Conflicts of interest

None of the authors has any conflicts of interest related to this study. The views expressed in this paper do not necessarily represent the official views of the Department of Veterans Affairs.

Author information

Authors and Affiliations

  1. VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 300 N. Ingalls Bldg., Room 7E10, Ann Arbor, MI, 48109-5429, USA

    John D Piette PhD, Bree Holtz PhD, Ashley J Beard PhD, Caroline Blaum MD, Sarah L Krein PhD, RN, Jane Forman ScD, MHS & Eve A Kerr MD, MPH

  2. Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA

    John D Piette PhD, Ashley J Beard PhD, Caroline Blaum MD, C Leo Greenstone MD, Sarah L Krein PhD, RN, Adam Tremblay MD & Eve A Kerr MD, MPH

  3. Ann Arbor VA Geriatric Research Education and Clinical Center, Ann Arbor, MI, USA

    Caroline Blaum MD

  4. VA Ann Arbor Health Care System, Ann Arbor, MI, USA

    C Leo Greenstone MD & Adam Tremblay MD

Authors
  1. John D Piette PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Bree Holtz PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ashley J Beard PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Caroline Blaum MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. C Leo Greenstone MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Sarah L Krein PhD, RN
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Adam Tremblay MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Jane Forman ScD, MHS
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Eve A Kerr MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

Consortia

on behalf of the Ann Arbor PACT Steering Committee

Corresponding author

Correspondence to John D Piette PhD.

Additional information

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.

About this article

Cite this article

Piette, J.D., Holtz, B., Beard, A.J. et al. 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. Behav. Med. Pract. Policy Res. 1, 615–623 (2011). https://doi.org/10.1007/s13142-011-0065-8

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13142-011-0065-8

KEYWORDS

Search

Navigation