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Patient Aligned Care TeamsDepartment of Veterans Affairs

pact-032112

**Department of Veterans Affairs**

**Work Role Transformation during PACT Implementation:**

**Successes and Challenges**

**March 21, 2012**

Moderator:  And, we are at the top of the hour. I’m going to go ahead and introduce what this new series is about. This is the first of ten PACT sessions that we will be presenting, one per month. This series is intended for clinical and administrative staff, and leadership participating in the patient aligned care teams, also called the PACT initiative. For research and personnel evaluating this position, PACT is a transforming VHA primary care to patient centered medical home model. The PACT demonstration labs were established in five VISNs to evaluate PACT implementation and developed programs to support and enhance PACT. The presentations by PACT demonstration labs, and laboratory clinical and research personnel, cover key components and emerging issues in PACT implementation. We are very happy to kick off this new series of cyber seminars, and with that I would like to introduce our three speakers today, in order of their appearance. The first will be Dr. Greg Stewart. He is part of the VISN 23 PACT demonstration laboratory team and formative evaluation core leader. Also a Henry B. Tippie  research professor of management and organization at the University of Iowa. Next speaking, I believe, is Dr. Gala True. She is a research assistant professor in the division of geriatric medicine at the University of Pennsylvania, Perelman School of Medicine core investigator. Also, she works at the center for health equity research and promotion at the Philadelphia VA medical center. And finally, Dr. Samantha Solimeo is a medical anthropologist and qualitative investigator for VISN 23 PACT demonstration laboratory team, and former evaluation core. Also, she worked for the center of comprehension access and delivery research and evaluation at the Iowa City VA healthcare system. So, I am glad to present these experts, and Gala, when you’re ready, I’d like to share your screen. Your line is muted, so just go ahead and let me know when you’re ready.

Dr. Gala:  I am ready

Moderator:  Excellent. I’m going to turn it over to you, and I’d like to invite Greg to begin the presentation. 

Dr. Stuart:  Great. Well, we will go ahead and begin, and we are looking forward to this opportunity to share with you some of our research and findings and ideas that we’ve been able to work on over the last couple of years. We will introduce our demo labs a little more the in the next few minutes. Today, we’re going to focus on this role transformation that occurs as we move in patient aligned care teams, or medical homes in a broader sense. To start today, we’d like to pause for just a second and have you complete a short survey so we can get a little bit of a better feel for the level of familiarity each of you have with PACT. So, we will go ahead and turn this back to Molly for just a second. How familiar are you with the PACT model; choose one of these:  very familiar, somewhat familiar, I’ve heard of it, or what’s a PACT? 

Moderator:  Thank you, Greg. All right, the answers are flowing in, and everybody seems to have figured out how to use it pretty well. Just click the circle next to your answer. And we’ve already had about seventy-eight percent of the people vote, and we'll leave it open for just a few seconds to let those remaining people answer it. Then, I will share the results with everybody and Greg, you can come and talk through them. It looks like about eighty-five percent of people have voted and the answers are no longer flowing in, so I’m going to go ahead and close the poll at this point, and share the results with everybody. 

Dr. Stewart:  Great. It looks like most people are either very familiar or somewhat familiar. I think about ninety percent would say very to somewhat familiar, which is very helpful. We’ll use that as a guide today; we won't spend a lot of time talking about the details of PACT. We‘ll spend time getting into the findings about where you are. All right, a real quick overview of PACT. Most of you probably are familiar with this model that we’ll put up here in a second. It kind of combines the idea of medical homes in the general literature with our branding of it in the VA, which we call PACT. And with the three pillars that most of us should be very familiar with again are axis, care coordination management, and practice design. They are all built on this notion of patient centeredness- How do we change care to make it more responsive to the needs of our Veterans? Inside of these three pillars is kind of a notion of what should a PACT look like. And the core of that is a team of 4 members:  a provider, an RN care manager, a clinical associate, and a clerical associate. And, if you notice on the right hand screen here, each of these team-lets is put into what we might call a bigger team. That is, it has a variety of team-lets and also neighbors, and those neighbors would include people like clinical pharmacy specialists, social workers, and nutritionists. Our focus of our presentation today is going to be on these core individuals of the team-let. What are they perceiving in terms of role transformation? How are providers, RN care managers, clinical associates, and clerical associates dealing with this transition into PACT? And, most of the people that we’ve been working with closely have been doing this over the past couple of years now, so they’re early adopters. But, we do have some general sense of what’s going on, and some of the issues that they have had to deal with since they’ve moved into PACT. 

Let’s explain first what the real quick idea of what the demonstration laboratories are. For those of you that may not know, we have a coordinating center located in Seattle, Washington, number one here on this map. It helps to coordinate the efforts of 5 demonstration labs. Today, we have representation from two of the labs. Gala will talk to us. She’ll be our last presenter today, and she’s from VISN 4 in Philadelphia, the center from the national pacts, which is one of the demo labs. Samantha and I are from what appears on your map here as number 6, VISN 23 demonstration lab located in Iowa City, IO. We have some demonstration laboratories in Ann Arbor, Michigan, in Portland, OR, and in the greater Los Angeles Sepulveda area in California. We work together to do a couple of general things. The first thing that we do is represented by the top box in this slide, and that’s to evaluate the effectiveness and impact of the PACT model. We’re involved in going out and getting assessments, and trying to figure out what’s working, and what we could improve in terms of PACT implementation. We did this, by and large, in something called formative evaluation, with the idea that we don’t withhold our results until transformation is over. That might not be of any value to the VA, but we’re on an ongoing dialogue with others and the VA with trying to find ways to improve our PACT transformation, and they will share some of our findings that we hope can be applied, and will help those of you going through this transition, and trying to implement the PACT model in your work. The other thing that we do, which we won't focus on in our presentation today, but will probably come up later in some of our cyber seminars, are some of these innovative solutions. To go out and pioneer particular efforts, and to assess them, and to see how well they’re operating, and to see what we might do again to improve this PACT implementation. 

To give you a good idea of what two VISNs we’re talking about today, we’re talking about VISN 4 and VISN 23. On the left hand side, there’s a map that captures VISN 4. It’s located in Pennsylvania, West Virginia, southern New Jersey, and Delaware. It represents fifty-six primary care clinics and ten VA medical centers. On the right hand side of your slide is VISN 23, which is roughly 390,000 square miles of Iowa, Nebraska, North Dakota, South Dakota, and Minnesota. One of the things that is important, and we think helps explain some of the value of our findings, is that in our two VISNs we cover very rural areas, such as those in VISN 23, to some of the more urban areas that exist around the VA in VISN 4. These two VISNs together, we believe, can give us some good insight into some of the factors and issues that are being faced. 

An overview of what we want to do today- I’m going to spend a few minutes talking about some provider and team surveys that we’ve done over the last couple of years to give you a snapshot of some quantitative statistics, and then ill turn it over to Gala. She will talk about the PACT providers and some of the work that she’s been doing, and interviewing and working with them. Then, we’ll turn it over to Samantha, who will talk about some of the work with our RN care managers, and we’ll look at some of the general plans, and then continue going with our work that we have today, kind of with the general are we are. 

So, let’s talk about these surveys. We have two surveys. The VISN 4 survey was in 2010. About a year and a half ago, it gave us a snapshot about what providers in particular were feeling in the early stages of PACT implementation. We also, in VSIN 23, have done a series of 2 interviews. One was done in the summer of 2010, so soon after we began implementing PACT. The other was done in the summer of 2011, about a year into PACT implementation. The VISN 4 survey focused specifically on providers, and VISN 23 focused on all of the 4 roles. This slide shows one of the things that was done as identified early on by the providers. We asked the question of the providers, “Is there a sufficient number of people in this role, or is this a barrier?” And, what we found was that about seventy-five percent of the providers said that it was either a moderate or large barrier, that barrier being staffing issues. Whether or not they had enough individuals to deal with the roles needed to carry out PACT. More specifically, we found that just a little under seventy percent of them said that they were short on primary car providers, and just a little more than seventy percent said that they were short on outpatient nurses. About fifty percent said that they were short on administrative and support staff, the general idea being that early on the in the PACT implementation, the providers perceived this to be a significant barrier. There weren’t enough staff to carry out the duties of things that were required of them by PACT. 

Now, another question that we asked of the providers was focused on the work demands, and we simply asked the question, “How stressful are your work demands.” One of the things that we knew going into this transformation is that changes are often times very difficult, and, once again, you’ll find that about eighty percent of the respondents said that they were frequently overwhelmed by work demands and that was true of staff and clinicians. There was this stressful impact of the transformation to this new way of doing things, and that created, again (about seventy percent) that they experience their practice as stressful. And, we can combine this with some work that we’ve done in VISN 23 again, where we’ve looked at surveys of satisfaction, and responses from team members over a two-year period. Again, you’ll notice it in these graphs. Let me walk through these a little bit. We started in 2010, which would’ve been the first two or three months of PACT implementation, and then another survey in 2011 about a year into PACT implementation. One of the things that we learned here is that it’s a stressful role and things have actually got a little bit more difficult in that first year. We’ll see some declining trends in desirable things. I might say that isn’t real surprising. I’ve been involved in a number of transformations across organizations, not just in the VA. And anytime we go about a rule transformation or a large-scale change project, we see data that would be similar to this. That is, stressful. We will see some declines in work perceptions.

So the first graph on the left there talks about job satisfaction, and you’ll notice that overall job satisfaction declined slightly between 2010 and 2011. So, the first year of PACT implementation, we saw approximately a .3 percent drop in job satisfaction across roles on a five-point scale. And, that drop in job satisfaction was most apparent for the RN care managers. Over there, in 2010, they were up closer to the top, and then by 2011 they were the group that had to lowest level of job satisfaction. This is consistent with the trend that we’ve observed in many of our activities, that this transition to PACT is particularly difficult for these RN care mangers. Now, the graph on the right of this slide talks about empowerment. In empowerment we try to capture the psychological feeling that work is meaningful and that you have a high degree of autonomy here. And, once again, we’ll see the drop particularly for RN care mangers. Most of the other groups stayed somewhat similar, but the RN care managers went form a place where they felt more empowered and they felt their work was more meaningful, to a year into PACT; they were actually struggling more with perceptions of autonomy. Why this might be so is something we’re going to drill into in some of our other presentations, but this is intended to give you a snapshot hopefully of some of the issues that we’ve perceived and captured around PACT implementation. We also we went out and did some survey work on engaging role characteristics, and these might be things in a person’s role that engage them and capture them. How will they fit with that role? In the left hand graph here, we talked about skill variety. One of these that it probably most important to give a sense of is the purple line, there, which are the clerical workers. These would be the role in the PACT team that that might have the least amount of status. With this idea in PACT that most of your are familiar with of working to the top of your license and the top of your capabilities, we would expect actually that the clerical workers would take on some more duties and more activities than they’ve were doing before pact. Well, we find the trend is actually the opposite of what we would expect in this work, and those clerical workers actually were less likely to engage in work that captured their true skills, or that was difficult work, or challenging and interesting work. We find the same thing in the right hand graph on this page where we measure role fit, which is how well this person really fits with their abilities. Again, we find the biggest drop in the clerical associates. So taken from this snapshot, one of these things we might find is that so far in our PACT transition work we haven’t taken full advantage of this clerical role. Often times they still feel we like we aren’t doing all we might do to take advantage of their skills and abilities. 

Now the next slide captures some of the challenging things that have been experienced by participants in the role transformation. And the left hand side of the graph talks about role overload. Do they feel like they’ve been asked to do too much? And, you’ll see across the board the providers have the strongest sense of this- that they feel like there are more demands on their role than what they’re able to do. And, we find the trend once again most significant for RN care managers, that they feel more overloaded a year into PACT since they did before PACT started. If you go over to the right hand graph here, we have a picture of role conflict, which is this perception of “I’m being asked to do more things than I’m capable of doing”. And, again, you know, it’s the providers that have felt pretty significantly throughout the process, but its increase after PACT implementation. Once again, the RN care managers are a group that has an increase in role conflict given PACT work. So, if we summarize these snapshots that we might pick up from the quantitative surveys, we’d say that one of the major issues that was identified very early on was that there were some staffing concerns within the team-lets. Most of the team-lets in practice feel like they need more help and more support in terms of the staff, the nurse care mangers, the clinical associates, and the clerical associates that support them, and that’s one of the barriers to actually impact PACT. We know that it creates a very stressful work environment for everyone. All four roles in these team-lets would say this has been stressful, and job satisfaction has generally gone down over that first year. Were interested to see, as we do another survey over the next couple of months, to see how that’s looking two years after PACT implementation. It’s not really surprising to us that over the first year that we would feel that stress, but I think it’s important for us to understand and to see how it’s part of the implementation.

We also get a picture that the providers have this difficult role, and well talk more about the providers, and the RN care managers find this particularly stressful and those are the two areas were going to talk about. And the idea that comes clear to this stage is that clerical associates are like underutilized, and we could benefit from finding ways to bring them in more and take advantage of their skills to a higher degree than we have already. So, we continue to look at some of our data from interviews with PACT providers. And I’ll go ahead and switch. 

Dr. Solimeo:  Hi, this is Samantha. I’m going to talk to you about the work we’ve done in VISN 23 with providers that have been adapting PACT as part of our pilot transformation. 

Moderator:  Samantha, I’m terribly sorry to interrupt. This is molly. Can you increase the volume on your phone and speak a little louder for us.

Dr. Solimeo :  Sure, is that better?

Moderator:  Yeah, just project your voice as much as possible for your portion. 

Dr. Solimeo:  Ok, sorry about that. So, last spring in VISN 23, we interviewed thirteen primary care providers as part of our formative evaluation here. Five of those providers were in leadership positions, but the majority of them were serving on PACT teams and trained as either MDs, nurse practitioners, or a parent. So, those providers really represent practitioners with a wide range of experience. There’s really a shared bias towards positive disposition towards PACT, and I want to say at the outset that this isn’t to say that some providers weren’t, to some degree, disillusioned by PACT at some point during this first 18 months of implementation. But, a majority of the more negative comments were directed towards colleagues that they viewed as being unable to see how the larger vision of PACT could function to improve patient care work life. That overall positive bias is probably a product of pilot team selection. In our VISN, leadership selected pilot teams according to previously demonstrated high performance and expressed enthusiasm for PACT. So first, I wanted to share with you a couple comments from the interviews that give you a feeling for the disposition we’re talking about. 

First, we hear from this provider who’s saying, “There’s some cynicism that PACT is a way of getting these providers that take care of more patients to work harder, or this idea that’s what the lack of buy-in is coming from”. And, there’s second comments sort of reflecting the idea that the buy-in is coming from this idea of leadership and backing it up with staffing, and that there’s some enthusiasm on the side of the providers who were on these pilot teams. Gala, do you want to go to the next one for me? Thanks. So, what are all these ideas that these early adopters were interested in pursuing? When the providers adapt the pact model, they’re really being challenged to change their practice on a number of levels simultaneously. Three of these really rose to the surface on the first year’s implementation. Providers were called to relinquish some ownership of patient care to the team, and really share patient care duties with other staff according to licensure. This brings them into closer and ongoing communication with their other teammates. As part as quality improvement, providers are asked to think beyond the individual patients and sort of the responsive-appointments based fashion towards a population-based model where the focus becomes more of a proactive panel management, really assessing quality indicators for these key conditions across the panel, and then targeting practice-wide changing. In order for the program to improve appropriate access to care, PACT providers are asked to examine their return to clinic intervals and become more familiar with the alternative to the traditional face-to-face encounter. So, we’re losing more one-on- one, face-to-face visits, and increasing virtual encounters.  This really brings things full circle and requires that providers validate some clinical tasks of other people on their team. 

So, really the practice is looking towards to the top of one’s licensure, and the requisite validation that accompanies that process was really central to providers who transited to PACT. When we looked closely at what providers have to say about validation, there were some [inaudible] themes that speak to what makes PACT implementation more or less successful. The ability of providers to sort of “connect” to that, and to really understand how their individual actions over the course of the day, or even an appointment, can aggregate into larger patient and practice level outcomes. Establishing trust with other core team members is really essential to delegation. Providers are reluctant to hand off work if they feel that the delegated tasks will either increase the number of questions and interruptions in their day, or result in a lower standard of care for their patients. And ultimately, providers compare their relative value of liability with the value of this trusting relationship. And finally, delegation is contingent upon several kinds on institutional support.  PACTs need to have examines for the lead providers to see patients, but they often need rooms for the RN care managers or LPNs to meet with Veterans when the providers examines are being utilized. Providers need the support of administrators who assure that there’s adequate time away from direct patient care to work on the pact planning work, as well as sort of protect the axis schemes that they’re trying to achieve. 

So, earlier adopters really expressed frustration with their colleagues who were unable to see how their own actions contributed to their sense of overwork. The thinking of this idea is connecting the dots. And, here is an example of what I’m talking about. This provider is saying, “What it all comes down to is if you’re going to make PACT work, your providers have to buy into it, they have to do axis clinics, and they have manage the panel effectively. Unless they’re going to do that, there’s no time for anybody to do anything but see patients. So, that’s their excuse for not doing anything because they’re spending all their time seeing the patients”. What does it look like when providers can connect the dots? Here’s a perspective of an avid provider who’s committed to adapting the PACT model. And this provider is saying “axis is something were really working hard on, and I usually scrub my schedule a week before, so yesterday I did it for next week, and identified seven or eight people who maybe don’t need to come in. Before I started scrubbing, almost every day I had an extra 3:45 patient, and it was a bit overwhelming. Now I haven’t been overbooked in the last couple of weeks since I’ve been scrubbing. So that has been a huge benefit to me, and also for the patients, because they’re getting in right away”. There’s really this idea of fostering these connections, saying that PACT ideals and that practices on the ground. One critical piece in enabling these connections is really the ability of the provider to delegate to their teammates. When listening to the providers talk about delegation, its really clear that it’s a lot less about the task that they’re delegating and more about the relationship between the provider and the staff. I know this is a long quote here, but I just want to pull out some of these key ideas. This provider is saying “the one thing I think I’m really trying to implement, and it is happening slowly, is getting providers to buy into the use of their care managers and the pharmacists on the team, because that can change their workload so much if they just used the team member. That’s a huge, huge part of it. And if they stay in their silo and are opposed to any of that help, they’re just going to continue to practice medicine like they are, they’ll get burned out and frustrated, and won’t like what they’re doing. It does take some time to build up that trust with a nurse, because as the provider you’re ultimately responsible. If you’re going to follow protocol, they’re has to be a very good buy-in from everyone involved before you even start the process, I know myself there are certain RNs that I’ll just handle things myself, because you build up that trust level, and don’t think that issue is going to go away.” So really, it’s not so much about the task, but about that relationship. 

So, these relationships and then the gains made by non face-to-face work really need to be facilitated and protected by administrative leadership if providers are able to maintain their enthusiasm for PACT implementation. Facilitation takes a lot of different forms, but one common perception was that of the disconnect between the frontline experience of balancing patient care, team building, and non face-to-face work with administrative needs. You can really see this in this provider’s comments- “I think PACT is a good idea, I do. I think the concept is there. It’s the people at the ground levels that have to come up with the process to really change things. The administration has no idea how to work with teams, and if they do, they do so by asking for more paperwork. That’s the last thing anybody needs! Once in a while, they’ll walk around on the floor, but that doesn’t tell everything”. Really, this pervasive sense that there’s a disconnection there, between what’s going on the frontline and sort of the leadership support that providers need. And finally, providers rely on their leadership to correct the gains they achieve through the work they’re doing through schedule scrubbing and panel management. And, really, helping to align an organizational directive, provide access to data, and ensure that organizational weaknesses don’t really erode the strength that individual providers are bringing. And, this is a [inaudible] set of ideas here, but this provider’s talking about this idea that there’s a lack of connection between what there being I assessed on and what they’re able to access themselves. They’re saying:  “I think not having the administrative goals aligned with the provider of clinicals is the way we’ve had problems in the past when we started open access. Those problems became very evident, and that if I open up slots then those slots would be taken up by patients for other providers. And so, that was an automatic disincentive to try and open up anything, because you just work harder and you’re never going to open enough slots to take care of all the patients.” There’s really this nested idea of access support and an understanding of what its like to be managing all of these different tasks at the same time. And these are challenges that are not unique to the provider’s role. So, Dr. True is also going to be talking about these care manager perspectives. 

Dr. True:  Hi, my name is Gala True, and I’m with the VISN 4 center evaluation of patient alignment care team. Just to distinguish, because I think people seem to confuse Samantha and I a lot. I’m going to follow up on Samantha’s presentation on providers, but shift the focus to looking at how PACT related changes are transforming the professional and team roles of registered nurses within the VA. So, if you can think back for a second about the three PACT pillars, what I’m really going to focus on today is to talk about is care management and coordination, and how the nurse’s role is changing under that. So, under PACT, the role of the RN is reimagined as the RN care manager. Day to day work for this new role is clustered around three main areas, and since most of you are familiar with PACT, I’m not going to go over all of this. But basically, the first area is providing enhanced care medicine for patients on a high-risk registry. The second involves health promotion and disease prevention for all the patients on the panel, ideally. And, the third is managing transitions for patients on the panel. So, we conducted interviews over the first eighteen months of PACT implementation with frontline staff and managers, and what I’m going to do today is pull from that to talk about how some of the evolving changes to policies and practices that mostly directly affect the work of RNs, how that’s happening, what’s been going on, and highlight the perspectives of nurses on PACT pilot teams regarding their hopes and expectations as well as their concerns about their changing roles. So this goes back to an earlier slide where Greg talked about the fact that transition to PACT is particularly stressful for nurses, and trying to understand in their voices some of why this might be the case. Finally, ill describe some experiences of registered nurse care managers and PACT implementation has moved forward, and out ine some opportunities to support nurses during this period of changes in their work and profession roles. 

So I’ve heard some people refer to the PACT model as a way to provide the right care, at the right time, by the right person, in the right place. The idea is to accomplish this goal by balancing supply and demand in a clinic, and reconfiguring the schedule so the team members have a verity of appointment types built into their day, and so that patients are in contact with a team member who can best meet their needs.  Samantha already talked about this, but basically, one key part of this is that team members should be doing work only they can do, which is often referred to as working to the top of a license. But what does this mean if you’re an RN at the VA? How is this change going to impact your responsibility in your work role? One of the early ideas is that there would be approval and implementation of nurse medication protocols. So, that would mean if you were an RN on a PACT, you’d be able to initiate medication changes for patients with conditions such as diabetes, hyperlipidemia, and high cholesterol, but only with a sign off from the primary care provider on your PACT, or someone else at your facility. You would also maybe be making calls to pats on your panel who had visited the emergency department, and those who had been recently discharged from an in patient hospitalization. The purpose of those calls would be to determine what resources or follow up, if any, the patient needed, and to coordinate those resources for the appointment when possible. You would also be likely to be responsible for providing enhanced care management to patients on your panel who have been selected for high-risk registry. But first, this kind of opened what patients were put the high-risk registry. They might be patients who have a lot of walk in appointments, or who have uncontrolled diabetes, or complicating mal-health issues, things like that. Ideally, your schedule would look very different than it did before PACT. You’d have a variety of types of appointments to meet the needs of patients on your panel, including time to respond to secure to email, times for telephone appointments for some patients, time to provide shared medical appointments when appropriate, and time for same day appointment for patients who need to be seen that day. So, it goes back to a lot of what Samantha talked to- sort of figuring out how to manage a panel of patients rather than dealing with each individual patient’s needs as they come in. So, I think this quote really illustrated what many RNs said about this new approach, which is that they thought it to be very holistic. Not waiting for problems to arise, but anticipating and meeting the needs of complex patients. A lot of care managers talked about it as being not just about fixing a problem in the short term, but about taking the long view. And, this holistic approach was very familiar for many nurses we spoke with. Our interviews with RNs, clinical nurse leads, and others involved with PACT implementation captured some of their initial excitement about the changes taking place. RNs who had worked in areas such as pediatrics or cancer care coming to the VA found that elements of care management were already familiar to them, so they talked about the scope of practice outside the VA had included responsibilities such as coordinating community resources for patients and initiated medication orders, and these nurses really welcomed having these responsibilities being part of their role at the VA. Others who had been working in primary care within the VA for a number of years talked about how they found the changes coming within their role exciting. One nurse on a pilot team said she had become bored with doing clinical reminders and was ready for new opportunities to stretch herself. She gave the example of how she’d taken the initiative to solve a long standing problem with a patient with high blood pressure, saying that the PACT model made her feel as if she had permission to take action. Some nurses talked about there being an improvement early on in teamwork and cooperation between different roles, other people, and their co-workers. For example, they’d say that thought they had a better and more collaborative relationship with the provider on the team, the clerk on the team, and so on. A number of nurses said they believed their patients would receive higher quality care out of the PACT model. They hoped PACT would lead the patients to take on more responsibility and participate more actively in their own care. Some RNs reported very early on that they were hearing positive comments back form their patients. In particular, they said that patients appreciated when someone on their team followed up with hem by phone after they visited the ED or had an inpatient stay. Overall, the care managers we talked to said that they felt that giving patients more direct contact with someone working on their care would lead to improved patient satisfaction, and that they were looking forward to seeing some measures that would show that. 

But at the same time, many frontline staff expressed a lot of reservations and concerns about the changes related to PACT. So, these go along a lot of the same themes that Samantha talked about- Initial resistance, issues of trust and mistrust, and issues with delegation and institutional support. I’m just going to touch on some of these briefly. We did hear form providers who were concerned about how things might start falling through the cracks if RN managers took over some aspect of care for patients on the high-risk registries. Some RNs told us that they had experiences with primary care providers who agreed to the high-risk regulations in principle during group meetings, but then privately said to them, “I don’t want you calling my patients.” Some people expressed concerns about variation in enthusiasm among nurses embracing PACT. One nurse said, “Some people here will be very resistant; You can’t teach an old dog new tricks.” I think we heard a variation of this from many people. Early PACT implementers observed that RNs vary very widely in their background skills and experience, and they express concerns that some teams with weaker or less prepared nurses might struggle with PACT. A number of people though it was likely that some RNs would leave the VA, or primary care altogether rather than adapt to this new mode. 

Just to touch on some issues that came up with implementation of the nurse’s medication protocols. Those are very complicated early on by the fact that the nursing laws differed from state to state. An additional barrier was concern form some people in leadership and management positions who felt that these protocols would lead to nurses working beyond the scope of their licenses. Some of the people we interviewed were frustrated with these concerns. They thought it showed a lack of understanding that they thought the nurse medication protocol would actually work, because they thought even if they could initiate a medication care change of an RN care manager, the medication wouldn’t actually be released, or the pharmacy wouldn’t actually release the order until a primary care provider had signed off on it. So, they really felt there was a lack of understanding about how these protocols might work. RN care managers also talked about a lot of the tensions that were coming up between team members when role definitions were unclear.  They talked a lot about particular lack of role clarity between RN care managers and LPNs, and said this led to problems where primary care providers don’t seem to know whether something was a responsibility of an RN care manager, an LPN, a clerical associate, and they would often just sort of grab the person they saw in the hall or the person they were closest to in terms of communication, or they trusted the most. It made it hard for some of the RN care managers to do their work. They also talked about difficulties in delegating work; I think this is very similar to what Samantha brought up. Some RN care managers said they found themselves doing work outside their role, often because a patient was sitting in front of them or they were on the phone with them and they knew the task was more likely to get done if they just went ahead and did it themselves. Many nurses said it was a challenge to find time to care manage patients in the high-risk registry, and they talk about how they fall to the bottom of their to-do list on a very busy day. They often talked about how they were often pulled away from care management activities when someone as out sick, or on leave, or when an LPN needed help triaging pats to keep the clinic schedule running on time. Despite some of the early successes with high-risk registry, there were concerns about the ability of nurses to provide care management to the target goal of five percent of the patient panel given their other work. For example, one nurse care manger who was successfully managing 19 patients, but would need to have seventy-five in order to meet the target, was asked if she could imagine having seventy-five patients in the high-risk registry, and she said “I’m having trouble picturing doing fifty and doing it well.” So, an essential theme running through a lot of our interviews centered on concerns about the ability to spread care management activities in the absence of additional staff, and in particular, many people talked about RN positions that had opened up and were going unfilled, or instances of positions being posted but taking six months or longer to fill. They really had a lot of concerns about whether or not they were going to be able to scale up what they were doing or spread it to tradition PACT teams. 

So, I think these two quotes nicely illustrate how the changes that PACT brings for RN may be embraced by some and not by others. You can see on the left, the RN is sort of talking about how she’s actually feeling more busy, but she’s perceiving it in a way that it’s a positive thing. So we’re busy, but we’re getting everyone the attention they need in a timely manner. And then the right hand side is a quote from another RN care manager who said that she’s really not sure that this change is going to be workable for everyone and all of her colleagues. So, what are some of the things we learned about opportunities? We learned to support PACTs, and in particular, RN care managers during this period of transition. We saw that when RNs see that the changes they make in one area have a positive impact on the patients, it encourages them to keep going. So, for example, if they see that making calls to patients making visits to the ED means fewer unnecessary follow-up appointments, or they see that providing care management to the appointment results in resolution of a long standing medical problem, that’s very encouraging to them. They also might see that their having successes in these areas frees up some space in the schedule to provide same day appointments to patients who need them. But, on the flipside, we heard that RN care managers who were able to clear space in the schedule for telephone clinics and same day appointments, were then the same those slots filled in with patients from other providers, and their enthusiasm was really waning when that would happen. A lot of early PACT implementers were very excited because PACT came with a promise of new staff to support changes. But as PACT spreads, the early successes of pilot teams are sometimes giving way to concerns about the ability to affect the spread of PACT to additional teams. So, for example, its not uncommon now that PACT is being spread to additional teams, but an RN care manager who was covering one primary care provider and doing a good job is now being pulled in different directions to cover additional primary care providers. Those are the staffing challenges, and they are something that really need to be addressed. Despite these staffing challenges, many PACTs continue to move forward with making changes with their resources at hand. So, for example, in some sites the RN care managers have developed collaborations with nurses who work in programs such as tele-health and tele-move to see whether they can provide some of the needed services to patients in high-risk registries. In general, the people who are guiding PACT implementation in settings where there’s less than ideal team staffing really need acknowledge from leadership about the challenges they face, and they need some guidance or some examples on how to move forward, and at least some activities on the staff they do have. Overall, RN care managers and other team members expressed a desire for guidance form leadership, and particularly the central office about expectation for management of patients on the high-risk registries, and a clear job description for different members of the team. So, there’s really an opportunity for position description for what the RN care manager role should look like, as well as the clinical and clerical staff roles. What these should look like under PACT?  They need to be accompanied by training and education guidelines that take into account some of the variations in team staffing and titles across all of the VA abilities. We found that the local PACT champions, people who have been working on this since the beginning, really know what’s going on and are a great resource for determining how to best implement new position descriptions and training, and things like that. But, they really need constant support from local executive leadership, and managers, and relevant service lines. 

So, just to end with a quote that really illustrates what’ s possible when an RN care manager is invested in taking on the challenges of a new role and is part of a team with good communication and built up trust and report between team members. She felt that this was really a win for her, and a win her team, and a win for her patient, and she was very excited about this. So, I’m just going to touch really quickly on some of the trends across our different findings, and then I’d like to open things up to questions. So basically, what we found was that team members on all levels are really being called upon to make changes quickly in a rapidly moving environment, and they’re doing a great job. They’re definitely able to have success if being challenged or mediated by variations in team staffing, their resources that are available to them, there may be guidelines out there that are coming out. For example, there’s a new care assessment needs score, and I am told that it is coming out to help teams automatically identify patients for a high-risk registry. This is being piloted in two VISNs, but that’s really coming out a year and a half to two years after they’ve been asked to do this. So, it’s a great resource, but it needs to be exploited and get out to them and then they need to be educated on how to use it. Role transformation, we found, is really a double-edged sword. There’s a lot of promise for increased job satisfaction and professional development, but as Greg’s talk pointed out, there’s also a real increase in workload and burnout for some people. So, I think our take home points would be what people really need to be able to absorb these changes, and hopefully see an upward trend in things like roles and whether or not they feel stressed in their job. They would be that they need some organizational and interpersonal clinical training that can be tailored to different people at the team level. So each of the different roles, I think, really need some training and guidance that is tailored to them, and that needs to be able to get to them on the ground. And, they also need to engage the part of administrative leadership, at their site and from the top. But, despite the perceived increases in workload demands that Greg talked about, the enthusiasm for PACT or for Veteran care remains very high among people that we talk with. And so, we hope to see some positive trends going forward. 

Moderator:  I think we’ll open it up for questions? Great, thank you all very much. Just a reminder to our presenters, please mute your line if you’re not speaking. We are getting coughing and sneezing in the background. For all of those of you that have joined us after the top of the hour and are wondering how to submit a question, simply go to your gotowebinar dashboard on the right hand side of your screen and you can just submit your question right there. Send it to me, and I will pass it along to the presenter. Again, just a reminder to please mute your line if you’re not speaking at that time. And the first question we have is for Dr Stewart. Can you please address the possibility that your survey findings are a response set? 

Greg:  Yeah, I mean anytime we do a survey, that’s one of the issues we struggle to get at. One of the things that’s helpful to take in is that the data we’re picking up could be of different periods of time. The data we’re picking up, we’re pretty confident, shows the perceptions of the people that are there and the fact that their perceptions have changed over time. If we survey different people, we may get different perceptions. So where those perceptions lie and what’s causing them, I think, are some of the issues underlying the [inaudible] in your question. And yeah, we’re pretty confident that this is what the people feel. Unfortunately, we haven’t gotten to get out and do a long interview and talk to people to get general support from a qualitative perspective, but quantitative view. 

Moderator:  Thank you very much for that response. The next question we have-  would someone mind sharing what a “high-risk registry” looks like? Is it a listing on the end drive that the PACT can access? Is there a specific criterion for a Veteran to be in the high-risk registry?

Gala:  I can try to address that, and maybe others will jump in if it miss something. It’s a really good question because one of the things we’ve been finding is that the high-risk registry varies widely. The expression, “if you’ve seen one VA, you’ve seen one VA”- I would apply that to the high-risk registries in some way. But, in general, what we’re finding is that some sites have created an excel spreadsheet where they put the names of the patients on the high-risk registry, and other info about them. It is saved to a secure drive, sometimes it’s a SharePoint site for primary care, and sometimes it’s a folder on a secure drive. The initial high-risk registries were populated in very different ways. So, one way to create it was to literally have the provider or the members of the team sit down and say, “These are the patients we think of as being high-need”, and we can go through and identify who those patients are. At other sites, they maybe approached it in a different way. So they said, “We’re going to pull for you someone at a higher administrative level who can work with the data. We’re going to pull for you your patients who have outliers in terms of their A1C, or outliers in some other way.” Maybe they have frequent hospitalizations. And, that data was pulled for the teams and sent to them, but again, someone of the team, usually the RN care manager, would put this on an excel spreadsheet or something like that, and that’s what they look like. I hope I answered all of the question.  

Moderator:  Would anyone else like to contribute to that?

Greg:  I think you captured that really well. 

Moderator:  Excellent, we will move on to the next question. What does it mean to “scrub” your schedule? 

Samantha:  This is Samantha. I guess I can speak to that. The way that the providers are using that term is to review your upcoming scheduled appointments to determine whether or not all of those require a face-to-face visit with the provider, and whether some of those might be appropriately managed by the nurse care manager, the LPN, a pharmacist, or another venue, like a phone visit or something. 

Moderator:  Thank you for that response. 

Gala:  If I can just add one thing to that? I think it also would entail the calls to patients who, let's say, have been seen in the ER and have been told just to follow up with their provider within a couple days. To sort of treat calls to patients like that to see if they really need to come in- I think that falls under schedule scrubbing. 

Moderator:  Thank you. Do you have anything to add, Greg?

Greg:  No, I think again just this idea of trying to clear up some space by putting people into other resources that the team would bring. 

Modearator:  Thank you all for your responses. The next question- please describe data that is being fed back in formative evaluation.

Greg:  Yes. So, similar to what we’ve talked about today to several of these reports that give back through our VISNs and through the coordinating center that would include our interviews, we would include the survey like we’ve talked about today. So, those things are getting fed back to the leaders and to different areas as we continually feed it back, and the idea really is to be very open and just share all that we have. Realize that were still a couple of years into this process, and so a lot of the data is just now becoming available and being analyzed. We have this ongoing dialogue with leadership to share back ideas and perceptions. 

Moderator:  Samantha or Gala, do you have anything to add to that? 

Samantha:  No, I work very closely with Dr. Stewart, so we have the same opinion. 

Moderator:  Excellent. I want to make a quick announcement before we go on. The first being that I do realize these seminars are scheduled for an hour, so for any of our attendees that need to exit this session, I strongly urge you to fill out the feedback survey that will pop up on your screen once I exit the session. We do take into account your feedback, and it does inform what sessions we will be presenting later. I’d just like to encourage you to take a few seconds to answer those six questions.  In addition, I would like to ask our three presenters- are you available to stay on and answer the remaining questions? The reason why I ask is we like to capture it on the recording as opposed to having to cut it off. 

Gala:  This is Gala, I’m available to stay on the call. 

Greg:  Yes, I think we’re going to be here for a while longer. 

Moderator:  Ok, excellent, thank you very much, I appreciate that. Ok, so the next question that we have is- who does the task of panel management work with, and what tools do they use? 

Gala:  Another really good question. So, if I take panel management to mean some of the activities that I was talking about, we’re finding that it really varies depending on the teams. So there are a lot of teams where the RN care manager is taking on this very central role of taking on a lot of these tasks of contacting patients, both post discharge and after an ED visit. Trying to identify who are the patients who might be appropriate for a shared medical appointment, for example, and what kind of shared medical appointment does that PACT want to offer. What would be most useful for their patients? A lot of that is really falling to the RN care manager. But, on a lot of other teams, the primary care provider is maybe taking the lead on that, or is very closely partnered with the RN care manager. We’ve also seen teams that were either missing an RN care manager, didn’t have someone in that role, or wasn’t staffed in that role, or maybe thy have a primary care provider who would work very closely or had a very good relationship with an LPN who was on their PACT, and in those cases it could be the primary care physician and the LPN doing it together. So again, it kind of goes back to what I think I was trying to say about position descriptions, that in the absence of being told exactly what to do from the top, a lot of PACTs have really just tried to figure out what works best for them based on their staffing situation, the complexity of their patient panel, and the personalities of the team and the relationships on the team. 

Moderator:  Thank you for that response. Does anyone have anything to add?

Samantha:  This is Samantha. That was great Gala. I would just add, or maybe underscore, that it really is dependent on the goals of the individual team and the facilities’ goals and how they interact. So, for some teams panel management, it might be reviewing the patients on their panel to determine whether or not those patients are actually all real appointments. For that provider, it might be whether they’re active patients, whether they still need to be seen and live in the area, and are still alive and well. For others, it might mean reviewing the provider practices for A1Cs and triaging to develop aims around improving their patients A1Cs. So, there’s really quite a variety of goals related to panel management, and so depending on what the goal is, the person tied to that particular task might vary. So, it could be an AO, it could be a clerical associate, or it could be a provider. But, I think it’s typically coupled around the provider and their care manager. 

Moderator:  Would anyone like to add to that response? No? Ok, we can move on the next question. Can you say a bit more about RNCMs perceptions of autonomy and the extent to which they feel that they are working to the top of their licenses? 

Gala:  Im going to let you take it for now. 

Greg:  It’s a great question, too. You know, we find variants. So, some of them feel very empowered in their teams that they’re able to do a lot, and some feel that lack of empowerment. I think that one answer here would be that notion that there’s variance there, and that some feel much more empowered than others. It has to do with issues about the providers they work with. We find that they have different leadership styles. It also has issues to do with local leadership. These teams are matrixed into the 4 team-lets, and they’re led by the provider of shared leadership. Being the provider and nurse care manager, and also facility level leadership, can impact some of their perception. We see a lot of variation, for instance, on protocols. For instance, how much a nurse care manager is able to do, and so I would just say that I think it's very dependent on the situation, and that we’re still learning about that. I don’t know if you have something else to add, Gala?

Gala:  No, I would just kind of go back to a point that I think we’ve all made earlier, which is that with sort of being told, “Ok, this is where you need to get to, this is what needs to be happening.” But, in the absence of lots of strong direction and exactly how to get there, one of the things that happens is that personalities and relationships, and having trust between key members or not having trust, or having long established relationships that are either positive or negative. That seems to really take up a lot of space in terms of what happens and accounts for a lot of the variation. Otherwise, I think I would add that because the role has been defined that there are various memos saying what an RN care manager is, but a lot of the changes that still need to take place in terms of giving them some of the tools that would let them be more autonomous varies so widely that whether or not they feel like they have that autonomy really does depend on their personality, the provider they work with, executive leadership, and nurse mangers at their facility. A lot of those different things account for the variation.

Moderator:  Thank you, does anyone lese want to contribute more to that? Ok. The next question is actually a comment. Wow. Here in Boise, we have many of the same challenges. We’re working on creating some noticeable wins early on, but changing roles and work duties don’t come easily. Thank you for that comment. The next question- since according to your findings the clerical staff is underutilized, do you have any recommendations for duties they can absorb?

Greg:  Well, I think this gets back to what Gala was talking about- this idea that there’s a lot of variation in these teams. We find that, again, there’s variation in the clerical role and that our really successful teams are those that sit down and look at it and say, “Here are some paths, and what can be moved form each of these roles.” It’s somewhat context dependent, depending on the clerical person. One of the things we find is that there’s a lot of turnover in this role, and so if they’re brand new, it is harder to have them engage in things. The more experienced they are, the more that they can take on, and what we find is that great teams sit down and just go through the list of things that are done. And, based on licensure requirements and the skills of the people, divvy those up and go through a process we call “role negotiation.”

Moderator:  Gala or Samantha, would you like to add to that?

Gala:  I would just add that I don’t have specific tasks they could take over. But, one thing someone asked earlier, for example, the formative evaluations that were going back to leadership. Within our VISN, our chief medical officer Dr McPherson has spearheaded PACT virtual collaboratives to take the place of these learning centers that were going to be providing pact training to teams. One of the things that we’ve been able to feedback to him, and there were other people telling him the same thing, but we were able to reiterate it, was that the clerical associates really need some really targeted training and resources to support their role, and to support them making changes in their work. We hope to see that happening through the virtual collaborative, but also hopefully at the times level. That they’re will be able to connect more with each other and talk about what they’re doing on teams so that people maybe who aren’t taking on those responsibilities and tasks might be encouraged to do so by seeing that their colleagues are doing it, and also, they just really clearly need more concrete nuts-and-bolts feedback about what they should be doing on a daily basis. 

Moderator:  Thank you for that response. Are there some basic first steps facilities and teams should be focused on in the beginning in order to get the PACT process moving forward?

Gala:  that’s a big one. I’ll just say one thing and then hopefully Greg and Samantha will be able to add something. I think one of things we’ve seen is that you really need somebody at the team level or the facility level who can access patient data and organize it in such a way that you can use it to make changes. So, for example, the ideal thing would be that one member of each PACT takes on this role, that they know where the resources are. There are a lot of resources out there related to making PACT changes. There are all these SharePoint sites with lots of resources, documents, and guidelines that are very helpful. What we’re hearing is that it’s overwhelming and that no ones taking on the responsibility of finding these things and getting them to the other team members. It would be a good first step to find somebody who both has some skills in the area, is able to do that, has that kid of personality or character traits where they’d be really into that, and having them start doing that and then having someone either at the team level or the facility level who an actually go and pull data on the patient panel so that the people on the team can figure out who is being discharged form the emergency department, from our patient panel, or who has been hospitalized. But, how do we figure out who are really the patients with diabetes who really need something else from us? Starting with that, I think it actually probably heads off a lot of headaches. 

Moderator:  Thanks for taking a stab at that one. Would Greg or Samantha like to add anything? No? Ok. I do want to stop and make sure our presenters are available for a few more minutes. We have eight questions to go, if you’re not, it's perfectly fine. I can send them to you offline and get written responses, which I can then post with the archive video. But, if you are around, we’d be happy to continue on. 

Greg:  This is Greg. I do need to jump off. I’m sorry, and I'll either be able to answer them or hopefully Samantha and Gala will have all the answers. 

Moderator:  Not a problem and no need to apologize. We truly appreciate you bringing your expertise to this session, so thanks very much, Greg. Samantha and Gala, do you have any other obligations you need to get to, or would you like to continue on?

Gala:  It is probably easier to answer them verbally, so I’d like to keep going. 

Moderator:  It really, truly is. Are your future data sets going to include qualitative data on patients and their info (blood pressure, LDL, A1C), and how the PACT model has affected this. I like to know if this clinical model has made a difference, regardless of how people feel about it?

Gala:  Would that be qualitative or quantitative data? It sounded like you said qualitative, but as the question went on, it sounded more like quantitative. 

Moderator:  That is correct, they wrote qualitative and they meant quantitative. So, if it’s not clear, you can feel free to skip it. 

Gala:  Because I’m a qualitative person, I’m not as up on what’s going on but I definitely know that there will be some of the other demo labs that are looking at some of that, and that this will be coming out. I don’t have specifics, so hopefully one of the future demo lab presentations might focus on those areas. 

Moderator:  Thank you for that response. I did just write back to the person who wrote the question and asked if they’d like to clarify, so we’ll see if we hear from them. In the meantime, how do the care treatment needs of unassigned patients being managed?

Samantha:  That’s a really good question that comes up quite a bit with the providers I’ve spoken with. Everyone is required to care for Veterans regardless of whether they’re your patient or not, they need to be seen and they deserve to be seen when they need care. And we need to focus on what Veterans need as a higher priority than our implementation despite our enthusiasm for it, right? But, there are a number of efforts to try to figure out what to do with unassigned patients, or patients that are patients for providers who may have left the VA, or have fallen off the panel in some way. That is sort of a moving target. I don’t know, Gala, if you’ve heard about this in your VISN, but it is mostly being talked about in terms of overload. They’re just being seen by providers through triage or as overload until they’re assigned. At least that’s my understanding at this time. 

Gala:  We’ve been hearing the same thing. 

Samantha:  I think the move is to have everyone assigned to a primary care provider. I think a later issue will be with Veterans who are vested in say Iowa City where I am, but then spend time in Arizona during the winter months and have another provider down there. Trying to establish primary care for patients who like to be seen in different places that are not near each other. So, there are a number of similar kinds of issues. 

Moderator:  Thank you both for those responses. The person who submitted the previous question did in fact intend on writing quantitative, though I believe that Nancy Sharp is also joining us and is happy to help contribute to that answer. Nancy, just so you know, to get on your telephone line, enter your audio PIN which should be listed in the audio section. Until we hear form you, Samantha and Gala- do you have any further answers considering now that it’s quantitative? Ok, we can come back to this question if Samantha is able to unmute her line. If not, we can always address it in writing after the session. Where can PACT resources be located? For instance, we’re looking for an easy to PACT handoff template.

Gala:  I might need to get back to you with the answer to that. I mean, I know at the VISN level they’re trying to create a central place for those resources and I know that they’re collaborative, so whatever region of the country you’re in has a SharePoint site. There’s also PACT tools. Samantha, can you help me here?

Samantha:  The PACT tool kit, which is believe is through the national PACT collaborative of the PCF office. I know our VISN has its own SharePoint. I’d be happy to try and track one down for you, but this is a recurring issue. There are a number of tools out there, but they can be difficult to track down. I promise you that it is on a SharePoint somewhere. 

Nancy:  Can you hear me now?

Moderator:  Thank you. I would recommend coming up in volume. 

Nancy:  There’s a website about pact that is maintained by patient care services, and there are some links there. There may be a link to the toolkit. If not, we will find the link and make it available to Molly, and maybe she can distribute it to the people who are on the call. Last, I wanted to respond to the question a couple of questions ago about clinical outcomes data, and to say that and about what these speakers are doing is just a part of the demonstration labs and coordination centers are working on, and the important part- that their data is coming up first because they’ve been doing ongoing work with the teams. We are also working on clinical outcomes, economic outcomes, utilization and cost, and organizational outcomes at the national level through the coordinating center and we will be starting to get some publications out, were doing a [Inaudible] and were providing those [Inaudible] services VHA and facility leadership, so I’m hoping we will be seeing those [Inaudible]

Moderator:  Thank you for that contribution, Nancy. Did you want comment on the clinical data?

Nancy:  That will be part of the national evaluation, and we’ll be looking at that data now.  We’re looking at trends and even before the initiation of PACT, but those analyzes are still in process. 

Moderator:  I apologize; I may have lost focus for just a second while you were answering. In regards to the underutilization of clerical associates, do you anticipate redefining the position description or role of the clerical associate in PACT to include additional responsibilities?

Samantha:  This is Samantha. I don’t know that I would necessarily add anything at this time. Our VISN has recently issued a new job description for the clinical associate. We want to caution about with that role is that because it’s not linked with a clinical license it does seem to be open game for anything. So, because it can't be framed by ‘this is not what’s in your scope of practice' many clerical associates feel that they get everything else. And so, some really ride to that and like to take on more data related activities, and other feels that they’ve become the dumping ground for thing that really have nothing to do with providing care and may not be appropriate for them to do. Again, I think it's about dealing that person as a professional and as an integrated member of the team who has a viable contribution to make, and that’s probably the biggest change that we would advocate for. 

Moderator:  Thank you for that response. What is the average panel size of the pact?

Gala:  I think if you’re talking about a full time provider who is an MD, it’s 1200 patients. If you're talking about a full time provider who is a PA or nurse practitioner, I think its 900 patients. 

Moderator:  We only have two questions left. The first one is “there has never been a clear delineation of individual PACT team roles and responsibilities. Attempts to do that have not been supported by management or administration, so there has been resistance and refusal by team members and support services to accept additional responsibilities. Do you have any recommendations on who to educate and how to get all disciplines to support, and become actively willing participants?

Gala:  I think that’s the message we’ve been hearing loud and clear in the qualitative interviews we’ve been doing, and that we're trying to relay it to people at the VISN level and central office level as much as possible. I don’t know that we have the recommendations at this point except for some of the things we’ve talked about today, which is the need for physician descriptions that clarify roles, but also recognition that there’s so much variation of the ground in terms of how teams are staffed. Even the titles that are used or the types of people, especially when you get to the clinical and clerical associates, are so many different titles and different scopes of practice of what people are allowed to do that just coming up with a position description and sending it out as an action item is not going to be helpful. It’s going to have to be guided by the realities on the ground. I think what I was trying to say was that there are people at every site who have been working on this for a couple of years now, who can really say these are the conditions at our C box, or these are the conditions are our medical center, and this is what we need. I guess I would just say that were trying to [Inaudible] that box as much as we can. 

Samantha:  I do think that some of that tension comes from VA culture. The implementation process is really different than what were used to. Were used to having clear definitions and expectations, and when you’re given something that has more fuzziness to it, it has some wonderful opportunities but it's also kind of a scary thing for people. Were not used to being told to come up with it on our own, and so that has been met with some resistance and some confusion, I think, for some groups. 

Moderator:  We do have two questions left, and about two minutes of allotted time left. Do the clerks in your PACT feel that they are not doing anything different than before. What do other sites find in their clerical staff? 

Samantha:  I’m guessing that if they feel they’re not doing anything differently, they’re either working at a higher level of professionalism, or they aren’t doing things like pre-calls or polling data and they’re not participating in team meetings and developing aims with their teams. They might not be developing patient handbooks or sort of orientation materials. I'm trying to think of our specific activities. 

Gala:  I would agree with what you said. I think that they either were already making pre-appointment calls, which is possible. But, that’s a lot of what we were seeing. The clerks making a lot of pre-appointment calls, helping to identify patients. We talk about scrubbing, scrubbing the schedule. A lot of the clerks are involved in that. 

Samantha:  I’m trying to encourage people to enroll in myhealthyvet, and walking people through that process. 

Gala:  Are they involved in helping to triage secure messages? Figuring out when secure messages come in, who needs to answer the question and whom does it need to go to?

Samantha:  That I don’t know, to be honest. 

Moderator:  Well, I believe you’ve made your contact information avail to people that want to specifically follow up with it. Could someone explain the role of the PACT social worker?

Gala:  The PACT social worker is a neighbor to the team, so the role is no different than a social worker in general. But, the idea is to be integrating the social worker more closely with primary care so that referrals can be more appropriate, and probably increase the number of referrals so more people can get the care that they need. I’m trying to think or the specific difference. Some teams are starting to have interdisciplinary meetings where the social worker would be pretty central in coming to that meeting, so they might discuss either respective patients who have a need, and the social worker would suggest resources or step in and take over some contact with the patient, or they may troubleshoot a particular issues that’s coming up with their patient panel and their social worker might take a step forward and take responsibility for a specific issue they could address for a bunch of patients at once. They also might be in contact more with a care manager who is managing higher-risk registry because a lot of what the care manager sees might be able to identify things the social worker can be contributing for those pats. 

Samantha:  There are just so many kids of social workers; Some provide mental health care, and some do primarily referral to community service. At the minimum, my experience has been the primary care teams working more closely with social work have expressed the need to have more social work staff, and really love to have social work involved. 

Moderator:  Thank you both for those responses. I have seen one more question come in, but before we address it, I just wanted to make a couple comments. I very much appreciate the eighty people who have remained at attendance with us. Please, again, do fill out that brief six-question survey when you exit the session, it really does inform us of what to present on next. Maybe we can get a quick comment on a follow up to the last question. Is there specifically asking about OES OIS OND programs? 

Gala:  the question about the role of social work was in the context of a post- deployment clinic? 

Moderator:  Yeah. 

Gala:  I’m not sure that it’s that much different. I know that a lot of post-deployment clinics are already imparting under a lot of the principles of PACT, so whatever the social worker was doing before PACT came along might already be in line with what the social worker under a primary care PACT. I don’t know that I have a lot to add about that. What do you think Samantha?

Samantha:  I just don’t know. 

Moderator:  Not a problem at all. 

Nancy:  Can I address something very briefly? One of the things that the PACT demonstration labs are doing that we haven’t touched on today are these clinical projects. I know that a couple of labs have projects specially aimed at OES, OIS, etc.  One of the seminars that will be coming up later in the series is I believe one on homelessness which affects many of our younger Veterans who are returning from deployment. So, you might be interested in listening that one. 

Moderator:  Thank you, Nancy. That session will be coming up in November. Along those same lines, I would like to promote our next PACT session, which is taking place next month. It wil be April 18th, at noon eastern. The tentative title is “Unpacking the post discharge or post ED telephone call.” It will be presented by Christina Cordasco, Devon [Inaudible], and Jenny Richardson. Please do look for an email regarding that session. I want to very much thank our presenters for sharing your expertise and staying on the call for so long, and I’d like to give you the opportunity now to give any concluding comments.

Samantha:  I just like to say thanks to everyone who attended. I really appreciate your enthusiasm. I know that many of the PACT teams are [Inaudible], but I’ve been really honored to work with them. To be honest, it's been nice to work with people so dedicated to caring for patients, regardless of the stresses they’re under. I don’t know if we have primary care staff on the line, but it's been a really nice project to be working on. 

Moderator:  Thank you. Anyone else? 

Gala:  I would just really like to reiterate what Samantha said and that I think we maybe because were getting to interact and speak with frontline staff quite a bit, we just want them to get the resources and support that they need. I think that they can say it better than we can. And that’s one of the reasons why Samantha and I both tried to use a lot of quotes. They really do have very good insights about what resources and support they need, and a lot of the questions asked today really reflect that.  There must be some frontline people on this call who have done PACT work or who are starting to do PACT work, and we both just hope to get those voices heard and this is a nice opportunity to do that. So, thank you. 

Moderator:  Nancy? No? All right, thank you once again for coming, and this does formally conclude today's HSRND cyber seminar. Thank you for joining us. 

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