Translational Behavioral Medicine

, Volume 1, Issue 4, pp 615–623 | Cite as

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


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.


Information technology Access-to-care Veterans Chronic disease Self-management Telehealth Health system change 




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.


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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

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