PACT Demonstration Labs - 23 -Department of Veteran Affairs

PACT-081512

**Department of Veterans Affairs**

**Patient Aligned Care Teams Demonstration Labs**

**Facilitating the Nursing Role Transformation in PACTs**

**Lisa Meredith, PhD, Bonnie Wakefield, PhD, RN, Greg Stewart, PhD**

**August 15, 2012**

Moderator:  As we are about at the top of the hour, I would like to introduce our speakers at this time.  

Speaking first today is Dr. Lisa Meredith.  She’s an associate investigator at VISN 22  in the PACT demonstration lab.  She is part of the VA Greater Los Angeles Health Care System.

Speaking next will be Bonnie Wakefield, who will introduce the PACT Demo Lab in Iowa City and Greg Stewart, who is a Core Leader Team Formative Evaluation for VISN 23 PACT Demo Lab in Iowa City Health Care Systems will present some of his findings.  

And then, we will return back to Dr. Wakefield, who is an investigator and co-director for the VISN 23 PACT Demo Lab in Iowa City Health Care System.

We are very grateful for our three presenters taking the time to join us today and to our attendees.

So, at this time, I would like to turn it over to Dr. Meredith.  Are you prepared to share your screen, Dr. Meredith?

Lisa Meredith:  All right.  Thank you very much.  Good morning everybody.  I really appreciate all of you joining his seminar today.  I’m going to try to be as succinct as possible so that we can get through my part and make sure we get through all three parts of this.

I want to mention that I’m, obviously, part of a much large team at the Sepulveda and West LA VAs, who are running the VISN 22 Demo Lab and my colleague at RAND, Nichole Schmidt, who’s a graduate student, has helped a good deal with putting this presentation together.  I thank her.

All right.  Can you all see the slide, only; or, are you also seeing my control panel?

Moderator:  We are only seeing your slides and your cursor as a pointer.

Lisa Meredith:  Okay.  Great.  Thank you.  All right.  So, I wanted to point out that the VAIL evaluation at Greater LA has a lot of different components and I’m going to be reporting only on the clinician and staff surveys that we collected for Wave 1 data.  And, I won’t be commenting on much of the other pieces.  But, I’m sure you’ll all be hearing more about those at some point.

I also want to point out that none of the data that I’m presenting are weighted for non-response, nor are they adjusted for any other variables that may be important for fully understanding our effects.  These data are pretty much hot off the press.  We got the data in March and we’ve been cleaning it and looking at it.  And so, while the data aren’t really hot, they’re still a little bit warm.  So, keep that in mind.

So, the goal of the clinician and staff surveys was to track change over time in knowledge, attitudes and behaviors to understand the PACT VAIL implementation and also to inform effective and primary care re-design and understand and identify best practices.

So, we surveyed primary care clinicians and also other clinical staff who worked with primary care.  And while we can’t exactly call this a pre-post survey, what I’m calling is a two wave evaluation that has an early and a later wave to look at change over time.  Since this is the first —Or, because the first wave of the Voice of VA survey was also implemented around the same time, at that point, we worked closed with Christian Helfrich and his organizational functioning group to incorporate many of the similar measures that we had in our survey and we used some of those in their survey.

So, the first wave for Greater LA opted out of the VOVA survey.  But, we have similar data.  So, we’re working together on that.

We’re also in the process of generating some formative feedback data, such as what I’m presenting today and working on some cross-sectional papers.  Ultimately, we do want to look at before and after changes.  So, we’ll be implementing a second wave beginning next summer.

Alright.  So, what I want to say here is that the VISN 22 primary care clinicians included not only physicians; but also, nurse practitioners and some physician assistants.  We explicitly did not include residents because of their relative less experience working at these clinics.  And we included other staff that range from nurses to dieticians.  So a variety of different staff working in primary care.   

I already mentioned the timing of the survey.  The first wave survey took, on average, about twenty minutes.  So, it wasn’t terribly burdensome.

And we had reasonably good response rates for the clinician survey and even better for the other staff version.  I should have mentioned, we do this in two versions, given the differences.  And the response rates were the highest amount RNs.

Alright.  And here are the demographics for the different —for T-groups of the primary care providers and other staff.  You can see that the RNs that I’m kind of focusing or highlighting were mostly women, as you might expect.  There was a relatively high proportion of Latinas and folks in mid-range on the age and a middle amount of minorities among the RNs.  And like the LPN/LVNs, RNs tended to have a shorter tenure at the clinics relative to primary care clinicians.

So, we asked respondents on both forms of the survey to tell us whether or not they were a member of a teamlet and the good news is that almost everybody told they were a member of a teamlet.  Theoretically, most everyone should be.  

A bit fewer of the nursing staff —Excuse me.  A bit fewer of the primary care clinicians relative to nursing staff told us that they were currently members of a team.  That’s —It’s possible that this may include some of the part-timers, for example. 

We also asked people how many teamlets they supported and right here, I’m just showing you the RN and the LPN/LVN bars and most nurses tend to support one or two teamlets.  But, there are some who support as much as nine teamlets.  We actually had a couple dozen people who supported more than nine teamlets; upwards, almost thirty.  But, those tended to be clerical staff.  I think we had a few pharmacists and maybe, mental health providers.  But, generally, this is the range of support among the nursing staff.

Now I’m going to show you some data on perceptions about teams related to PACT, here.  We asked folks whether or not they believed that the team skills were being well distributed relative to the other primary care clinicians.  And what we you can see here is that nurses tended to believe that skills were, in fact, being well distributed.   And you can see the average score on this five point scale is on the left hand side of this chart with LPNs/LVNs having the highest tendency to feel that team skills were being well used.

Okay.  This slide is organized similarly and here we asked about whether tasks that were expected in staff roles, whether they were able to do them within the time that they had.  And you can see that nurses, especially the RN staff, were more likely to feel that they are maxed out in terms of what they can do in the time that they have.  And that’s the blue —the light blue and the sort purple-blue is agreement

So, now I’m going to turn to showing some data on burnout.  We measured the three standard sub-scales that are you in the Maslach Burnout Inventory.  So, it was a fifteen item version.  And in our data, we create three multi-item scales that have excellent, in the case of emotional exhaustion on the left.  That’s because there are nine items which helps with the reliability and pretty good reliabilities for the two, three item scales on the right.  And the reason I italicized some of the items here is that those are the same items that are being measured in the Voice of VA survey.  So, we’ll be able to make comparisons nationally.

So, burnout is related to mental and physical health in health care workers, as well as job retention.  And, in some limited data that we find for nurses after controlling for some characteristics like age and nephrology nursing experience, results have shown that almost forty percent of mental health symptoms experienced by these nephrology nurses could be explained by burnout and about twenty-eight percent of physical symptoms could be explained by burnout.  So, it’s something that’s important to measure.  And, I believe that’s all I need to say about that.

Let me show you some data, now.  So, this is the total burnout score across all fifteen items.  And I’m just showing you the average score across the different clinical professions.  The RNs are in green and they tend to be on the higher side, on average, for burnout; along with physicians and PAs, MTs and pharmacists.  Behavioral health professionals have the lowest burnout scores.  And again, these are not adjusted for anything.  These are just raw means here.

And here are the average scores by job type for the emotional exhaustion scale and I’ve shown a red line here that presents an average threshold at a score of 21, within the range of 0 to 54 across all nine of those items.  And it, basically, indicates moderate burnout based on the limited literature that has calibrated these scores for health professionals.  So, on average RNs scored as moderately burned out as compared with other groups.

And this is the same data but for —or the same presentations for the cynicism scale.  And 21 —Not 21— 4 on that range represents moderate burnout.  And, here again,  you can see the RNs and some of the other groups would be classified as being moderately burned out because, on average, they are above the threshold line.

And then, finally, this is the professional efficacy scale which is scored, actually, as burnout; meaning, a lack of professional efficacy. And the scores are —there’s less moderate burnout.  RNs are much less burned out relative to the other scales.  We can see that physicians and pharmacists are moderately burned out on this scale.

And now I’m going to turn to some data on job satisfaction.  Here you can see that nurses are more satisfied with their jobs relative to primary care clinicians with about seventy percent agreeing or strongly agreeing — again, these are the blue and purple-blue sections.  —with the statement that overall I am satisfied my job.  So, the proportions in grey indicate disagreement.  And those, as you can see are larger for primary care clinicians compared with nurses.

And we didn’t find any difference in satisfaction with team lets.  It’s, basically, equivalent for both groups of nurses.  And we weren’t able to compare that with primary care clinicians because we worded that question sufficiently differently.

So, just to summarize some of the data that we have on exposure to PACT related activities, we asked about exposure to different kinds of change activities and the extent to which the survey respondents found them helpful.  And these included use of new measurements tools to assess team or teamlet performance, participation in teamlet huddles.  We also asked about clinic use of information systems to provide feedback to staff.  We asked about individual receipt of regular feedback reports about performance.  We asked about clinic level implementation of new scheduling approaches.  And then, we asked respondents if they were involved in small tests of change to improve quality of care.

And, in comparing RNs to the LPN/LVN group, we find that that RNs reported being less likely to use measurement tools, but more likely to use information —for those clinics, to use information systems to provide feedback.  And perceived helpfulness was similar across the two groups and both of the nursing groups reported that new scheduling approaches were more helpful relative to primary care clinicians.  

So, I’m going to step through some of the data that I just summarized for you.  

In this chart what stands out is that RNs were relatively —reported relatively more exposure to huddles and to new scheduling approaches compared to the other types of activities.  

And another way to look at this is that about half of the RNs have been exposed to all of the activities except for team huddles and new scheduling, which are much less likely.

And this is the same presentation, but for LPN/LVNs and it’s a very similar pattern.  However, for this group about fifty percent are using new measurement tools and only thirty percent report being in clinics with information systems for feedback to staff.  So those were the two significant effects.

And in terms of helpfulness, both the dark and the light blue represent shades of helpful where the green is not helpful, here.  And more RNs found huddles to be helpful compared with other activities.  Small tests of change were also more commonly found to be not helpful.

And here is the same presentation for the LPN/LVNs; fairly similar to RNs.  They found —Fewer found huddles to be very helpful and everyone found small tests of change to be, at least, somewhat helpful.  They were more likely than the RNs to say that information systems are not helpful and less likely to report that small tests of change, at the bottom, are not helpful.  In fact, everyone said that they were, at least, somewhat helpful.

So, we also received —We elicited and received a good deal of written comments at the end of the survey and we got 136 written comments of the 516 respondents, which is slightly more than a quarter of the sample who had something to say.  And among these comments, a quarter of them were from RNs and about a fifth of them were from LVN/LPNs.  So, that’s —Almost half of the comments were from the nursing staff.  

And so, these are some of the most common comments made by respondents over all across everyone.  And they, basically, convey that PACT is having some impact.  And some specific aspects of the PACT model that are working tend to be, again the huddles.  Despite the fact that we saw fewer being exposed —I’m sorry.  And also, despite the fact that we saw few people were exposed to performance measurement activities, some noted that it was important.  However, the reason that we might see this disconnect is that we hear a lot about limited staffing, limited clerical support, and lack of flexibility and increasing responsibilities, which makes incorporating performance measures somewhat daunting.  So, there’s also a sense that leadership is not in step with front line staff.

So now I want to show you some specific comments from the RN nurses.  These were the most common issues raised.  Again, we’re hearing about lack of clerical support.  It’s consistent with what we saw earlier in the presentation with nurses reporting —Well, nurses being relatively more likely to report that some tasks expected of my role in PACT aren’t really doable within the time that I have.  And so, that’s a common theme.

And here are some of the more common themes that we saw among the LVN/LPN group.  They also emphasized staffing insufficiencies.  But, they don’t focus so much on clerical support.  And they were more likely to talk about other types of challenges like an over-focus on performance measures.  

So, that’s all I have for you today.  I believe I stuck pretty close to my time allotment.  And, I guess, I’ll be back for questions after Bonnie and Greg.  So, thank you very much.

Moderator:  Thank you very much, Dr. Meredith.  

I just want to make a quick announcement.  It has been brought to my attention that we went —The link I sent you for the —I apologize.  The link I sent you for the slides actually did not contain Dr. Meredith’s at the beginning.  People have brought this to my attention.  I am remed —I’m fixing that right now.  And so, in just a moment I will have the full slide deck available in PDF.  In the meantime, you can use the Q & A function to write me your e-mail address and I can get you a PDF of hers, immediately.  Thank you for bringing it to my attention.  

And it does look like we have Dr. Stewart and Wakefield’s slide up.  So, we’re ready to go once we’re in slide show mode.

And you may go ahead Dr. Wakefield.

Bonnie Wakefield:  So, I’m just going to do a brief introduction to Greg’s talk and then follow him when I talk about the Community of Practice.

On this slide you can see our VISN 23, which is combined of five states, including Iowa, Nebraska, Minnesota, South Dakota and North Dakota.  And we are one of five demo labs that were established to evaluate progress of the PACT approach and then test innovations within the PACT teams.

Gary Rosenthal is our demo lab director.  And we’ve been consistently evaluating 30 PACT teams across our medical centers and community-based out-patient clinics.

So, our demo lab has five areas of focus; on-going formative evaluation and Greg will be talking a bit about that; the impact of PACT implementation on patient care, patient outcomes and perceptions; supporting nurse care manager roles in PACT through a Community of Practice and that’s what I will be talking about in a few minutes; and then, development and testing of interventions to improve chronic disease management.  

So, I’m going to turn it over to Greg.

Greg Stewart:  Thanks.  Well, I’m happy to share some of the work that we’ve been doing in part of our demonstration lab.  

And again, you can see on this slide that we’re doing lots of different things.  And today, I’m particularly going to talk about a work role survey, which is a quantitative survey that we took the first time, approximately, two years ago, and just as we began PACT implementation.  And then, some results from a year ago.  So, it’s longitudinal in the sense that it was taken at the —pretty close the baseline of these 22 teams as they were working in a collaborative and beginning PACT and then a year into it.  

We’re also picking up some data, again now, two years into it.  But, we won’t have that.   We’re just now collecting it.  So, we don’t have that available to share today.

Also, I’ll talk about some of the work that we’ve been doing in focus groups.  I’ll quickly —And, in fact, given some time constraints, I’ll probably skip, mostly, the first idea of some things that we did approximately a year in, to look at how they facilitated each other’s roles.  But, I’ll spend the bulk of my time, today, talking about a questionnaire that we’ve done in focus groups recently with nurses, particularly, two years into PACT implementation.

Let me talk first, though, about the results of our quantitative survey.  And this was done in the summer of 2010 and then again in 2011.  And you’ll notice a general overall trend towards decreasing job satisfaction across the roles.  Not exactly surprising; we find similar results in many large scale changes.  But, there was decreased job satisfaction.  And across all four of the core roles in these teamlets; the primary care provider, the RN Care Manager, we’ll call it the clinical associate and then the clerical association.  But, also on this slide you’ll notice that we picked up empowerment.  And one of the most interesting findings, from my perspective here, was a general decrease in empowerment for RN Care Managers.  

So, as they implemented PACT, during that first year, they tended to have decreased feelings of their work being meaningful, significant and autonomous.  And this is very much in line with other results that we have suggesting that this transition is perhaps most difficult for this RN Care Manager role.

We also asked them about, you know, their work roles and what we call challenging role characteristics.  How overloaded is their role?  And if you look at the slide here on the left hand side, I think the thing that sticks out the most, perhaps, it the clinical associate, that LPN or in some cases the health tech role, doesn’t feel as overloaded as everyone else.  And there’s not necessarily a balance across here.  And as we’ll talk about in a second, oftentimes these individuals in these teams feel like they’re not being taken full advantage of and that they could do more in the team.

And again, with role conflict having incompatible requirements and guidelines, once again, you’ll find that it’s the clinical associates, that LPN role in particular, that tends to not feel like they’re being as challenged by their role as much as others.

Well, building on these quantitative results, we went —and this is results from approximately a year in and I’m going to go over these fairly quickly, where we asked the people by role to tell us, you know, what can others on your team do to help you.  And right in the middle of this slide you’ll see that the RN said, hey, I can do more.  In other words, I can contribute more to this team than I am.  And then, we asked them, you know, in particular, what about others.  And if you look down at the bottom left there you’ll see that the providers, they said, we would like the provider to delegate more.  And if you go to the clinical associate, the LPN role or the health tech role, they’ll say, well, we wish you would take more initiative.  

Well, we also get a similar perspective from the clinical associates.  In the middle, they’re saying, look; I’m licensed to do more.  I can do more.  And when they look at feedback to other roles, again, to the provider and the Nurse Care Manager, in particular, they’re saying delegate.  Give me more.

And this could be summarized as what I often call the empowerment paradox.  And this is the teamlet, again.  In this case, we have the provider saying, Wow!  I wish others would take more initiative.  I’d like to delegate.  And everybody saying to the clinician, hey, why don’t you delegate more to us.  

And this tends to be kind of a common finding we have in organizations; that most of us think that we have more capability and can do more than we’re being asked and yet, we feel that others of us —others, in this kind of team setting, which might be in a hierarchy below us, are somehow incapable of doing that.  And this power paradox, then, becomes a pretty consistent finding across our data that would suggest part of the problems with these roles and overload in some roles and not enough, perhaps, in other roles is this problem around delegation.

Let me share with you, though, our most recent findings where we’ve gone in and we did a questionnaire at the end of the learning collaborative, which is approximately two years into this transition into PACT.  And we asked them questions about, well, what’s helped facilitate you doing better?  What barriers have you seen?  And, you know, what feedback would you have for people who are going in and doing PACT and just beginning it?

And we asked them to identify some barriers.  And again, I’ll show data by the RN Care Manager and the LPN or clinical associate.  And you’ll notice that the most frequently identified barrier, by far, was the roles; trying to figure out what they’re supposed to do and how their role fits in with the bigger team.  

Then, the other one that we’ll talk about today is delegation, which is somewhat consistent with that.  But, how do people delegate and share responsibilities in these teams.

We also found, you know, implementation issues, staffing issues, that Dr. Meredith just talked about and some team functioning issues.  But, because of time today, I’m going to focus on the first two in the next couple of minutes; roles and delegations.

So, the roles to —or the barriers that they identified to role and development; one was staffing, again.  And the RNs and LPNs often feel like their pulled to work in too many areas and they don’t have clear expectations.  The LPNs talked about this perspective that oftentimes they don’t get to function to the top of their license.  And that, you know, the clerical associates aren’t able to function to their capacity, either.  And, therefore, that makes their role as LPNs —They tend to have duties that might not be to the top of their license, that are assigned to them.

We did ask them, though, you know, what’s really helped you develop your roles?  And the RNs talk about getting some policy so that they can write orders and they don’t need to go to the MD for things.  Or, you know, one of the comments here, that was a theme, was when the team sat down and actually talked about it and established through a process of role negotiation who was going to do what.  The LPNs talked about open-mindedness, being able to try new ideas where everyone in the team was met as valuable and seen as a valuable resource, really helping facilitate these teams.

We also asked them, around this role development, again, what can you do in your role?  How would you improve it?  

The RN perspective brought up ideas like allowing ideas to be brought forth and listen to the rationale behind them; again, the empowerment idea; listening to the front line staff, helping give their input to it.   And so, there’s this clear sense that they have ideas that aren’t being implemented and fully utilized.  

The LPNs talk about continuing, you know, training and the important of that.  Once again, though, we get this idea that they really feel like it’s important and they have something to contribute and the more that they’re listened to and, actually, those suggestions are used, the more successful this transformation has been.

The other area that we talk about, real quickly, is delegation.  So, back to those three ideas:  What are the barriers?  What’s facilitated?  What feedback would you have? 

In terms of the barriers, there’s a structural issue that often comes up.  The provider’s boss is not there and the RNs boss and the clerks have different bosses and that becomes a problem for delegation.  Sometimes employees don’t want to step up and do new tasks and that was perceived as a barrier.  The LPNs talked about this idea, again, of balance and some people doing more than the others.  And that the teamlets, sometimes, get to be dumping grounds under the PACT from other people who haven’t done it.  So, the team might structure their work and create some time to do different things.  But, oftentimes, that was filled by somebody else.

What’s helped them, though, in the terms of delegation?  Well, one of the things they talked about is when the nurses opened up access and began to run their own clinics.  It helped to have consistency; the same RN where they could have this trust perspective and work together over a long period of times.  And, you know, from the LPN perspective, one of the things, again, that was really important is to get staff on board and to be able to develop a long term team.  It’s been really frustrating them, often, when they get trained and they understand their roles and then there’s been turnover within these teams.

Well, what feedback would they have to, maybe, improve delegation in the future?  You know, oftentimes, they feel dark and uncertain.  We have opinions.  We want to be included.  They also talk about going back and delegation can be improved by looking at administration processes and get rid of the requirements that may not really apply or be up to date anymore.  

And so, kind of the running idea here is that there have been these two things that nurses, in particular, have felt and it’s come up in our quantitative surveys and in our qualitative work that there’s this real problem with understanding this new role and getting balanced in there and getting delegation to work, where many of the tasks are spread throughout the team.

And with that, I’m going to turn it back to Dr. Wakefield, who’s going to talk about some of the effort, then, to work to overcome some of the these barriers and implement some of these ideas.

Bonnie Wakefield:  Thank you.  Okay.  I think we’re set.  

 So, I’m going to give a little background on the Community of Practice that we have implemented in VISN 23 and talk about a bit about what has been done in that community.

So, there are about 250 RN Care Managers in VISN 23 Pact teams who are transitioning to this new role that they have previously had.  Prior to PACT implementation some VA settings have had care managers in the out-patient setting, but the PACT role is new for these nurses.

And in general, not just in the VA, but in health care, in general, that role definition of care and case management lacks clarity and there’s discussion in the literature about what this role really is and means.

So, Greg just talked a bit about the formative evaluation core findings.  And one of the primary ones was that the negative perception of role changes were most pronounced in the Nurse Care Managers and their data.  

So, the Nurse Care Managers in VISN 23 expressed an interest in connecting with other nurses across the VISN, you know, to gain role clarity and definition and do some sharing about, you know, what they’re learning and what works.  So, in response, the demo lab initiated the PACT Nurse Care Manager Community of Practice.  

So, for those who aren’t familiar with the Community of Practice, it’s basically a group of people, like-minded people, I guess, you would say, who share a concern or some problems and who by interacting with one another learn more about how to solve that problem and gain expertise.  

Some characteristics of a community include members who have overlapping expertise.  So, not everyone has the same expertise; but, they do share some.  They have concern about a common topic.  They come together to collaborate, to solve problems on this topic.  They expect to learn from both their peers; and then, putting some of these suggestions from their peers in practice.  The group values both tacit and explicit knowledge.  So, they value, you know, what the nurse knows.  In this case, nurses —It doesn’t have to be said.  They just, sort of, know and then the explicit knowledge.

It should be a space where it’s safe to speak the truth and ask hard questions.  So, you know, it needs to be set up in such a way that this is enabled.  They consult each other for help.  They have a strong sense of identity and belonging.  And in this case, they’re all Nurse Care Managers in PACT.  And they’re focused on developing and sharing knowledge.

So, the goals of the VISN 23 Community of Practice are to, you know, support the Nurse Care Managers as they’re transitioning to this new role.  To the extent possible, standardize work processes across the VISN, better align their practice with the PACT model of care, and promote use of evidence-based practice to improve outcomes.

So, the initial formation of Community of Practice came from the primary care service line nursing directors who identified two nurses from each VISN 23 health care system to serve as the advisory group.  So, we have 8 health care systems in VISN 23 and one nurse was selected from the main facility and one from a community-based out-patient clinic.  And in total, there were 17 representing all health care systems; one system felt their CBOC were different enough that they needed one from each. 

So, the first meeting was last summer, in July, where the group developed objectives for the Community of Practice, including the overall purpose to support and empower Nurse Care Managers to increase their voice in the implantation process, define what nurse care management practice is, develop and share expertise and facilitate alignment with the PACT model of care.

And some of the goals they set for themselves were to share information with each other and engage with other practitioners who have similar, you know, situations or problems, develop expertise from each other and felt that multiple perspectives were valuable for complex problem-solving and they felt the need to challenge their thinking, serve as a living repository of knowledge so that they would help each other stay abreast of current knowledge, standardize baseline knowledge and focus on advanced issues that they might be dealing with in the clinics, empower the members to be heard.  So, I think, you know, you hear d some, in the prior two presentations, about communications with leadership.  So, they had identified that as a goal.  And then, engage in specific sub-projects of interest.  So, possibly, evidence-based practice projects or research projects that might come up.  So, this would be, sort of, a venue to do that.

They had a second one saying, meeting; a face-to-face meeting that usually lasts about a day and a half in November.  And in that meeting, the focus was on the lack of clarity around the Nurse Care Manager role and task delineation and delegation.  And again, many of these issues I’m talking about you’ve heard Drs. Meredith and Stewart talks about some of these issues.

And I felt the need to identify what tasks the care managers were, actually, doing and the frequency of their time devoted to these tasks.  So, a survey was developed.  At that meeting there was small group work for them to just sort of write out everything that they did; all their tasks.  The nurses in the community-based clinics did this separately because they felt their tasks were somewhat different.  So, that was —And they were also characterized, somewhat, separately.  

The care managers, then, reviewed the big list to clarify or add to the list.  And then, the tasks were categorized according to domains and the nursing intervention classification, which is a standardized taxonomy labeling nursing interventions.

So, the group, the advisory group was surveyed in the winter of 2012.  And I’m not going to go over all of these, obviously.  This was from 9 nurses in the community-based clinics and 8 in the main facility.  And the blue is the community-based clinics and the red are nurses from the main facility.  But, you’ll see there are some differences.  For example, in group visits, much more, you know, common in community-based clinics.  Community-based clinic nurses, down here at the bottom, are also more likely to be staffing special clinics than are the main facility nurses.  And then, not surprisingly, the community-based out-patient clinic nurses are more frequently doing things like facility maintenance, supply management, slight more clerical duties.  And I think —And here’s another; care coordination.  So, there are differences between, you know, what sort of gets done; maybe, not the expectations.   But, what is perceived to be done in the community-based clinics versus the main facilities.  And we do expect to, you know, expand this survey to the broader population of nurses in VISN 23 —Nurse Care Managers.  Excuse me.

A third meeting was held this spring, in March.  At that meeting the results from the task survey were discussed.  The group was updated on the formative evaluation group that Dr. Stewart (break in audio) and the finding from their surveys and data collection within the VISN.  There was also some training for use of the PACT tools.

So, we will —So, it felt like that this is a good vehicle for Nurse Care Managers to share expertise and work on problems with one another.  So, we will be having another face-to-face meeting next month, in September.  And we’ve decided to expand beyond the initial 17 nurses.  So, at this meeting we will have 40 nurses; five from each facility, coming.  They will have some review and training on the PC Almanac and Disease Registry, some presentation on shared medical appointments and care coordination; and then, some discussion on obstacles to role implementation.

So, this is just a brief summary of the things I’ve talked about that we have done to date.  There is a monthly call for the core group, of the initial seventeen, to raise issues and discuss problems that can be taken to the VISN, to help solving.  And then, some communication methods have been established within the groups.  There’s a Yammer site where just the Nurse Care Managers can discuss issues with one another.  And then, a Sharepoint site has been established.  

Here’s just a picture of it where there are shared protocols, policies, some articles of interest that people might find and then they’re able to share with one another; and then, just some acknowledgements from our demo lab for both Greg and my presentations.

Moderator:  Thank you very much for everyone’s presentation.  And, Bonnie, if you don’t mind just leaving up that last slide; the acknowledge slide and then we have something to look at while we do the Q & A forum.

Bonnie Wakefield:  Okay.

Moderator:  Thank you.  So, we do have some good questions that have come in and we have about half a dozen or so.  And for those of you that joined us after the start of the meeting, if you would like to submit a question or comment, simply use the Q & A function next to —on your Go to Webinar dashboard.  Also, I have —I in the process of replacing the link that you all received to contain all three slide decks.  So, please, standby for that.  And it will be sent to you, also, in a reminder e-mail tomorrow.  Thank you for your patience.

So, the first question that came in was what does VAIL stand for?  And I can assist in that.  It is Veterans Assessment and Improvement Laboratory, located in Sepulveda, California.

The next question —This came in during Dr. Meredith’s portion.  Does primary care include home-based primary car?

Lisa Meredith:  Hi.  Home-based care would not be included, as I understand it.  These are just physicians, nurse practitioners and physician assistants who work in the VISN 23 clinics.  I’m sorry; VISN 22.  I was thinking of the other one.

Moderator:  Thank you, Dr. Meredith.

Lisa Meredith:  You’re welcome.

Moderator:  Oh, go ahead.

Lisa Meredith:  I’m finished.

Moderator:  Okay.  The next question — This also came in, I believe, during your portion.  What types of information systems are you referring to?  Are these specific to VAMC?

Lisa Meredith:  Yes. We are referring to information systems that are used by all —by VA clinicians.  

I’m trying to look at the survey to see what kind of examples we, actually, included in that question.  I’m not sure if I’m going to come to it quickly, though.

But, hopefully, that answers your question for now.

Moderator:  Thank you very much.  The next question is —I believe this came in during Dr. Wakefield’s portion.  RN Care Manager here in Rochester, New York at an out-patient clinic:  How do you suggest allowing the LPNs to be working to the top of their scope with all of the administrative duties such as answering phones, scheduling IPA and patients for secure messaging, et cetera, now being given more and more to them?  The roles of the LPN and health tech, I feel, are being made to be interchangeable other than —And, I’m sorry, he didn’t spell out this word.  — other than an injection here and there?  This can be creating a field of —a feeling of respect or working to scope for the LPNs.

Bonnie Wakefield:  So, I’d welcome some input from Greg on this one, too.  I mean, that’s kind of a hard question to answer without knowing the local context.  And, I think, I’m not surprised that this question has come up, given some of the data that we’ve seen.  And, I think, it’s probably something that needs to be looked at in terms of roles and tasks, you know, at the local medical center to determine, you know, who is doing what and is it appropriate and not appropriate.  

I don’t know, Greg, if you have some other thoughts on it or not?

Greg Stewart:  Yeah.   I mean, it’s really consistent with what we find, in that, you know, of all the four roles in there, I think that LPN role is, oftentimes, the one that people don’t know how to deal with fast.  And, you know, there’s kind of a sense that, well, let’s wait for somebody else to define how we do this.  But, some of our most successful teams we’ve studied have engaged in what I’ll call role negotiation where, you now, they get together with the team and, maybe, the leaders and they really have to sit down and eye to eye talk about it and it may depend on the skill sets of the particular individuals there.  But, you know, that’s what’s really hard about some of the team issues and working through them.  But, when they do, those become some of our more successful teams.  

And so, yeah, I would agree it’s a very difficult issue and, you know, we’ve seen some work through it; but, it’s been, you know, a rather time consuming process, oftentimes, to sit down and talk through that and make sure you get all the leaders that are around involved in it, too.

Moderator:  Thank you both for those responses.  The next question:  Do you have any RN protocols that your RNs are using and, if so, would you share them?

Bonnie Wakefield:  Sure.  I think —I’m in Outlook.  So, just sort of shoot me a message and we’ll see what you need and what we can share.

Moderator:  Thank you very much.  The next question:  In regard to the designation of members to the PACT teamlet and given the multitude of responsibilities, for example, full-time in our clinic and volume of phone calls, we are considering not assigning clinical associates to the teamlet.  This may, ultimately, increase satisfaction, given they will not have expectations of being on a specific teamlet, when the reality is that they often are required to float due to unscheduled absences or other reason such as tele-health.  Another option is to assign them and make every effort to get them to the team, one to three days per week, so they can have stability or a home.  Do you have any recommendations or suggestions, given the research, on which method would improve employee satisfaction best?

Greg Stewart:  Well, I’ll take this one.  You know, I think our sense would be that the satisfaction goes up when they feel like they’re included in a team.  And so, if you could get them, you know, to the extent that you can get them to be part of the team, it’s going to be helpful.  Now, what we see in practice, sometimes, is exactly what you’re alluding to, the —you know, they’re spread so far on so many teams that they’ll have a teamlet meeting and oh, the clerical worker can’t come because they’re, you know, working in some other station.  Well, not surprisingly, that person doesn’t feel like a team.  And yet, I think to the degree that you left them out and didn’t, somehow, organize them into the teamlet, you would be losing some of the advantages of the PACT model, obviously.  You know, we come back to the question before.  You know, how you get people to spread some of these tasks and I think that’s —requires them to be a part of the team.  And so, you know, just leaving that off, I think, would, probably, be detrimental.  

And, on a broader perspective, we find when people are members of teams, you know, performance goes up and satisfaction, definitely, goes up.  And so, although, we may not have total data specific to PACT, there’s a lot of data out there that would support this notion across context that the degree you put people into teams and allow them to be a part of a team, their work satisfaction will increase.

Moderator:  Thank you for that reply.  The next question we have in the queue, and there are quite a few, so thank you for taking the time to answer these, have you include tele-care nurses in any of your surveys?  Do you consider them as part of the PACT extension?

Greg Stewart:  That’s probably for me, again.  And, in our’s, let me —You know, not specifically.  We haven’t looked at them and it is —you know, other than what we would call neighbors or the extension.  But, our particular survey didn’t look at them.

Lisa Meredith: And I’ll add that we didn’t, in particular, include them.  We did allow for folks who took the survey to write in an “other” if they didn’t fit one of the listed job titles.  So, it’s possible we have them in our survey; but, we wouldn’t have enough of them or be able to really identify them specifically to understand that role.

I also just wanted to go back to the question about what information systems.  And we had listed, for example —We had EG Compass or PCMM as just a few types of VA systems.

Moderator:  Thank you for those replies.  The next question we have:  Our LPNs are striving to increase their role.  Could anyone share a comprehensive list of LPN responsibilities in your primary care clinics?

Bonnie Wakefield:   This is Bonnie.  The only thing that I have seen on that —And I haven’t look at it for a while.  There were some sample, sort of, job descriptions posted when PACT was initially implemented.  So, that might be one source that they could look at.

Moderator:  Would you like to add anything, Drs. Meredith or Stewart?

Greg Stewart:  The only thing I would add is, you know, there is some work done by Office of Nursing Services that has looked at that.  And again, you know, that’s one piece of it.  But, I also think it’s really important for team members to sit down and kind of work through their own list and it may vary somewhat depending on, you know, the state where you’re located, depending on the skill set of the people involved.  So, I think it’s a little bit hard to come up with, you know, a set that comes there.  And I know there are a lot of people out there working on that and it continues to be part of it.  But, I see this, really, as a two-prong kind of a thing that, you know, there’s more direction that will come.  But, also a bottom up where the teams need to take initiative and spend time talking about it, working together.

Moderator:  Thank you for those replies.  We do have several more questions, although we are approaching the top of the hour.  So, I’d like to ask our presenters, at this time, do you have a few minutes to remain answering questions on the call, so that we can capture in the archive recording?

Lisa Meredith:  I’m available.

Bonnie Wakefield:  Yes.

Greg Stewart:  Yes.

Moderator:  Great.  That sounds like three resounding yeses.  The next one is directed at Bonnie.  I am new to the VA.  So, I apologize if this seems obvious.  Has the VA considered leveraging other entities’ work; for example, clinical guidelines, case management practice guidelines, as to not re-invent the wheel in order to get full care manager implementation sooner and to promote practices consistent with case or care management professionals?

Bonnie Wakefield:  So, that’s a good question, because as I alluded to briefly in my presentation, the distinction between care management, case management, care coordination is a bit fuzzy.  And actually, interestingly, the VA may be defining it for the rest of the country by implementing PACT.  There are —You know, there are the care management associations who have guidelines.  But, there’s just a lot of controversy, that might be too strong of a word, about, you know, what the role actually is.  So, I guess, the best I can say is we’re working on it.

Moderator:  Thank you for that reply.  Next question.  Actually, this is a comment.  One of our attendees would like to let us that he is, actually, a nurse management —He’s in nurse management, working for a chronic care program at the Department of Health in Catalonia in Spain.  So, we’d like to thank our international people for joining us today.

And the next question:  Have you included tele-care — Oh, we got to that one.

Are there —Are any of the NCM roles and responsibilities automated?

Bonnie Wakefield:  Could you repeat that question, because you broke up a little bit?

Moderator:  I apologize.  Are any of the NM roles or responsibilities automated?

Bonnie Wakefield:  I’m not sure what that question means.

Greg Stewart:  I’m the same way.  

Moderator:  Okay.  Our attendee —I’m sorry.  Dr. Stewart, go ahead.

Greg Stewart:  I just have the same response.  I’m not sure either.

Moderator:  Okay.  They’re more than welcome to type in further information to help us clarify that.  

In the meantime, we’ll move on to the next question.  

I find this information very interesting and re-affirming that we are not alone in our experiences.  Any idea or comments about what is being done to help get leadership to “buy in”?

Lisa Meredith:  This is Lisa.  I can speak to what I know the VISN 22 folks are doing.  Lisa Rubenstein, in particular, is very interested in making sure that voices are heard from the data that we have.  Obviously, we can’t identify people and we would take all precautions with our IRB regulations and agreements.  But, getting some information to the leadership so that they can be working towards coming up with solutions is a big part of the effort.  So, that’s what we say, oftentimes, when we talk about formative data; really using it to improve processes, not just to evaluate and 

—You know, from the researcher side.  

So, I don’t know if others have comments.

Greg Stewart:  Yeah.  So, you know in VISN 23 we’re similar.  We work very closely in this learning collaborative with our, you know, service line leadership; Dr. [Mike Cuminer’s], particularly.  And we have, you know, on-going dialogue to share ideas and work with that at a VISN level.  You know, there’s also cyber seminars like this, I think, is one avenue to do that.  And part of the entire demo lab idea is we continue to share this back.  You know, as Dr. Meredith said, we’re doing what we call formative evaluation which means that we’re, you know,  constantly feeding it back and I know that there’s a lot of efforts that go —that information that goes back, it’s not always quick.  You know, the VA is a very large organization.  But, I think there is a lot of on-going effort in real time to share this back and help improve the implementation of the PACT.

Moderator:  Thank you all for those replies.  This is a very interested group.  We have several more questions pending.

Is it possible to know additional information about PACT and PCM Medical Homes?

Lisa Meredith:  Maybe —

Moderator:  I can also offer a suggestion.  There are several archived cyber seminars regarding PACT and if you write back in I can send you the link to that archive page.  Also, there are some web pages I can direct you to.  And I’ll turn it over to the presenters if they’d like to add any more information.

Greg Stewart:  We’re all pretty quiet.  I think, you know, there’s a lot out there.  It’s just finding it and —You know, links to lots of training tools that have been used.

Moderator:  Thank you for that reply.  The next question:  I did not see any information of the role of the clinic coordinator in PACT implementation.  Can you discuss their role?

Greg Stewart:  Well, you know, again, let me share a little bit.  One of the things that we do is we go and do site visits, which we didn’t talk about today.  That’s where we really see the clinical coordinator.  

I think it’s a really important role.  There are cases where we’ve had clinical coordinators that, you know, didn’t buy in to the PACT model, I guess.  And it has —It’s been difficult for those teams to go and implement.  We’ve had other cases where we’ve seen the clinic coordinator buy in and be very successful in helping facilitate that.  So, I think it’s a really important role.  It’s not what we talked about today.  But, yeah, I think it is a key role.

Moderator:  Thank you for that reply.  The next question is another one about NCM.  I hope we know what that acronym stands for now.  

How you do determine which patient population is assisted by the NCM?

Bonnie Wakefield:  That’s kind of a broad question, I think.  But, again, it would probably be determined within the teamlet.  It’s my understanding that the Nurse Care Managers, in part, should be focusing on what I would call high risk patients; patient who have, you know, multiple problems and/or difficulty adhering to their current treatment plan.  But, again, there may be local variation in that.

Moderator:  Dr. Stewart or Meredith, would you also like to contribute any information?

Lisa Meredith:  I think what Bonnie said, pretty much, covers what I would have been able to contribute.

Moderator:  Okay.  Great.  Next question:  We are a newly formed off-site homeless PACT, March 2012.  What tools and resources are available?

May I suggest, again, that you can go ahead and e-mail me your e-mail address and I can send you to some cyber seminars on PACT also some links to some web pages and if our presenters have any further information they’d like to contribute, feel free at this time.

Bonnie Wakefield:  Yeah.  I don’t have a lot of the knowledge of the details.  But, I believe that one of the teams is working on a quality improvement effort around homelessness in VISN 22.  So, it may be that —I’m not sure if that information is publicly available.  But, I can try to find out and, maybe, share that information with Molly and she can get that to you, if it’s available.

Moderator:  Thank you very much.  The next question we have:  Have you prioritized the responsibilities —No, we’ve gone over the NCM question.

I would like to receive additional information about PACT teams and PC medical homes?

Again, you can go ahead and e-mail me your e-mail address and I will get you links and further information and send you on the right path.

Also, is there going to be published recommendations from the Community of Practice as far as what the “role” of the NCM should be; published and distributed to each VA facility?

Bonnie Wakefield:  You know, I think once we get a larger sample size that would —That’s a great idea.  So, yeah, I think we should be able to do that.  But, again, we only have responses at the current —from the current survey, from eighteen people.  So, we’d like to get a bit of a broader representation.

Moderator:  Thank you for that response.  We do have just a few questions remaining.  And so, we’ll try to get through them rather quickly.  Please interrupt me if any of you need to get off the call.

So, this one is more of a comment.  In regard to the question from Rochester, I think it is a normal response to change.  The RNs are used to work tactically and not strategically.  We need to create a vision to help them transition to the CM role.  They feel lost giving up their tactical functions.

I’d like thank that attendee for responding.  Would any of you like to add anything to it?

Okay.  Next question:  Is it fair to say that we have a lot of work to do in what I like to call the S&S, staffing and sufficiency and [Silo’s] culture aspects?

Lisa Meredith:  I would agree that it’s fair to say that.

Greg Stewart:  I mean, yeah, those are big issues that continually come up in all of our work.

Moderator:  Okay.  Moving on to the next question:  Do you track who refers patients to the NCM, the provider versus patient self-referral versus NCM initiated?

Lisa Meredith:  That’s not something we’re doing in the Community of Practice.

Greg Stewart:  It’s not something we’ve done.

Bonnie Wakefield:  And I’m not aware of anything like that.

Moderator:  Thank you.  And the next question.  We do have one more for us to reiterate, what does VAIL PACT stand for?

Lisa Meredith:  As you said before, VAIL stands for Veterans Assessment and Improvement Laboratory.  So, that’s —I should have explained that at the beginning of my presentation.  That’s the name of the VISN 22 demonstration lab, which is kind of an enhanced version of PACT that we’ll be evaluating over time relative to the regular PACT or Patient Aligned Care Team.

Moderator:  Thank you.  I would have answered that one, but I had already deleted the answer.

Okay, next question.  Staffing is a major issue with implementation of PACT at our out-patient clinic.  I have considered certified nursing aides, medical assistants or health techs to round a PACT teamlet that does not have an LPN and/or a Clerk.  These personnel would cost less and may be more palatable to administration regarding costs.  What are your thoughts on that?

Greg Stewart:  Well, let’s just say that —You know, I mean, I think there are lots of different ways to try and do this.  And, you know, part of the idea of the transformation is to have some trials of change.  And so, I think, it would be interesting to look at that and, obviously, sit down with leadership and think through that and, perhaps, try it and see how it works.  And, you know, part of the change transformation is to have some of these bottom of processes.  And again, I think it would just depend on your local circumstances and working with your leadership to think through this.

Lisa Meredith:  Yeah.  I’d like to that one of the other components of the VISN 22 demo lab is in doing implementation —excuse me, teamlet effectiveness evaluations.  So, that component is being led by Dr. Hector Rodriguez.  And we’re actually —Well, first of all, in the survey we’re asking people about who is on their team.  So, we’ll be able to look at team composition at two points in time, at each wave.  So, we can look at whether teams have changed, generally speaking.  And then, Hector is selecting a sub-set of teams and doing individual interviews with team members to try to understand better the process of teamlet formation and team functioning.  So, we should know a lot more about this when we finish the evaluations.

Moderator:  Thank you all for those replies.  I do have remaining questions.  I’m not sure if you’re all still available.  We do appreciate you taking this extra time.  But, I did want to check in now.

Lisa Meredith:  I’m still free.

Bonnie Wakefield:  Yes.

Moderator:  Great.  Excellent.  Staffing —I got that one taken care of.

My question relates to concerns about managers who place quantity of meeting performance measure, taking a center role versus quality of care.  For example, personal health plans completed without direct assessment of the veteran by the RNs; times to complete the initial evaluations are disregarded as important by managers who received bonuses based on quantity only.

Lisa Meredith:  Well, that’s a really important question.  It has a lot to do with both performance measurements and reimbursements or sort of incentives for particular performance.  And, you know, generally speaking, there’s a whole move in this nation about pay for performance and that is should be aligned with quality of care as opposed to quantity of care.  I think that’s an evolving process.  And within the VA, I’m a little bit less familiar with some of those nuances of the performance measurement.  But, I think that it’s, generally, agreed that quality of care should be tied to performance.

Moderator:  Drs. Wakefield or Stewart would you like to contribute?

Bonnie Wakefield:  I don’t really have anything to add to that.

Moderator:  Great.  We will just move right along.  The next question we have:  LPNs and care managers are not being utilized the top of their license.  As a care coordinator, I spend a great part of my time responding to refills, my healthy vet recruitment, move recruitment and any other program that needs referrals.  Is leadership looking at the cost when assessing these tasks to the Nurse Care Manager?

Greg Stewart:  Again, you know, based on the work that we’ve done, I would say yeah, that’s, obviously, an issue and there’s this delegation kind of paradox that works down.  And, you know, from my perspective, I’ve heard them documented.  Yeah, I think people are looking at those different issues.

Lisa Meredith:  And I didn’t present these data today, but we do have some information from the VISN 22 survey that asks about the extent to which primary care team members rely on other clinical staff for doing various types of clinical activities.  And then, we asked staff about, to what extent they believe that primary care relies on them to do different —those same activities.  So, we can kind of look at the mirror image of how, at least, perceptions play out among the two, you know, key types of roles.  So, those data are pending.  And, I think, that will eventually address, at least, a part of that question.

Moderator:  Thank you very much for that response.  The next question:  How are you measuring outcomes based on sharing and education that is done by the Community of Practice participants to achieve the goal of increased job satisfaction and role clarity?  This would seem to be an important component to measure —to assure that the entire loop is functioning effectively and the information is being shared consistently with all necessary entities (back at the home site facility) by the Community of Practice members.

Bonnie Wakefield:  Well, one piece of data that we didn’t present today is that the work role survey has been conducted with the members of Community of Practice.  So, we can use that data to follow that issue.

Moderator:  Thank you for that reply.  The next question we have that’s come in:  Do you have specialty clinics run by nurses, such as Coumadin clinics?

Lisa Meredith:  I don’t believe —I think that’s probably Coumadin.

Moderator:  I apologize.

Lisa Meredith:  I think —We don’t include those clinics in our evaluation activities because we really are focused on primary care.

Greg Stewart:  They’re out there.  I know that.  I’ve —I mean, I’ve people talk about them.  But, it’s not part of, you know, what we focused on.

Moderator:  Thank you very much.  The next question we have:  We often have so many voice mails and secure messages.  If the LVN and RN who are on our team don’t stay on top of them, together, we will get very behind.  This does become quite time consuming and in the end, as an RN, you feel like a glorified clerk.  How do you get away from this?

Bonnie Wakefield:  Again, I —You know, this is Bonnie.  I would say it’s just something that has to be locally negotiated how that is —work load is going to be handled and by whom.

Moderator:  Thank you for that reply.  We are down to just a few more questions.  If extra time is needed to meet performance measures due to challenges posed by walk-in members, occasionally as high as 9 to 11 walk-in veterans in a teamlet, in a day, is it okay for an RN to work over, on their own time; but, near disciplinary actions are proposed to address those who attempt to or charge for overtime compensatory time. How do you address this issue?

Bonnie Wakefield:  Again, this is Bonnie.  I think, you know, that’s clearly a management issue at the local level.  So, we really can’t comment on that.

Moderator:  Thank you for attempting to.  A lot of these questions coming in are localized questions.  And, I think, we’re referring them back to their local medical centers, which is correct.

The next is a comment and a couple of questions.  Lack of clerical support —I believe, the clerks in the call center, have  little or no medical training and this is the root cause for clinical staff having to do their work over and over on a day-to-day basis.  What support from the PACT leadership should we have to have an efficient system?  Should we utilize the LPN/LVN for this function to save full-time employees and, of course, the money?

Greg Stewart:  You know, again, I would just say that, you know, those are different things that ought to be in the discussion and, you know, the comments that ride that role of the clinical associate is on that’s, you know, an entry into many VA systems, that people don’t stay in very long, turnover is very high, compensation is not very high.  And so, there’s a lot of turnover there.  I think that creates issues.  You know, the solutions —You know, certainly, I’m not in a place where I could say this is exactly what you can do.  So, those would be things, again, that we’d turn back, probably, to your group.  And my only thing would say, that’s exactly what you ought to be talking about and working with the local area people, in your area, to try and figure these out.

Moderator:  Thank you for that reply.  We are down to just the last few questions.  I promise.

Do you have any means to measure the performance of each PACT team?

Greg Stewart:  Yeah.  I mean, so, we have lots of them.  There are Compass measures that they turn in.  They’ll look at Access measures.  You know, I mean, we’re an on-going research program where we’re looking at, you know, re-admissions rates in PACT teams.  And so, there’s a lot of stuff that we’re doing and evaluating there.  It’s just —It’s still, you know, in earlier phases and wasn’t the focus today.  But, there’s work being done on that.

Lisa Meredith:  VISN 22 will also be doing —looking at some of those issues in a number of different ways, such as through patient surveys and implementation evaluations and practice level surveys.  So, we’ll have a lot more qualitative information to complement the fairly broad survey-level information that I’ve started to look at.

Moderator:  Thank you both for those replies.  Okay, next question is more of a comment.  But, I’ll read it aloud.

In our CBOC, the PACT RN is also doing the tele-health.  

Thank you for that feedback.

What effect does top down role-modeling have on PCP buy in to the PACT model?

Greg Stewart:  I think that’s a big issue.  And, you know, we didn’t talk about it a lot today.  But, that’s one of the big things that come out of this and any large scale change effort is, you know, buy in from top and model it down.  And so, yeah, it’s a big issue.  It’s very helpful when it’s there.

Bonnie Wakefield:  Right.  And, in fact, in some of the other work that I’ve done with chronic care evaluation, you know, leadership buy in is one of the six essentially components of successful quality improvements.  So, it’s a very good point.

Moderator:  Thank you both for those replies.  The next question we have:  What were your findings, if any, related to RN/LPN disparities within the teamlets?  We find that some our LPNs feel that calling veterans is an RN responsibility and just the opposite, some RNs feel certain duties within the teamlet belong the LPNs.  It is noted that it varies among teams.

So, we can move on to the next one.  Just another comment; I am new the VA, as well, and I too agree that the VA needs to collaborate more with other entities.  There should be much more sharing between the VA hospitals across the nation.

Thank you for that comment.  And we are quite aware of that.  Would any of you like to comment?

Lisa Meredith:  I’ll just note that there are a number of different efforts that are, at least, bringing together the different demonstration labs, you know, that are evaluating PACT.  So, it may not be every entity in the VA system.  But, many of them share with regular quality council meetings and other activities.  So, some of that’s being done.

Moderator:  Great.  Thank you very much.  The next question:  Are there —There are software programs available that call patients to remind them about screenings, due dates and reminders.  

So, thank you for that comment.  And, I invite people to look into those software programs that will call patients and remind them about their screenings.

In regard to the question on automated NCM roles and responsibilities, we have been creating automated tools; for example, fillable forms using MI scripts for specific diseases, chronic care conditions, for the care manager to use.  We do not believe that these exist already in the VA and, if so, we have not found them.  

Would any of you like to comment?

Okay.  We can move on.  Bonnie could you refresh your screen, real quick?  Thank you.

Next question —We are just about done.  Do we have any data on the success or failure of different PACT coaches?

Lisa Meredith:  I’m not familiar with what PACT coaches are.  And I don’t believe we have any data.

Greg Stewart:  We have, you know —I know in our VISN we have PACT coaches that have been trained to work and help the team facilitate and carry out the PACT.   And, do I have data?  No.  Am I collecting data in those areas?  Yes.  So, I don’t have it.  But, we are thinking about that.

Moderator:  Thank you very much.  The next question we have:  Do you have specialty clinics run by nurse —Oh. We got that question already covered.

Are there any face-to-face training for PACT’s to newly hired members of the team and what would be the schedule and locations?

Greg Stewart:  That would be, again, a local thing.  I mean, I know there are some within our VISN.  And, you know —Yes, they are here.  But, I have no —It would have to be something that would need to be addressed much more locally.

Moderator:  Thank you.  I do want to mention one of our attendees brought —is plugging the next PACT session, which is very helpful.  PACT sessions are always the third Wednesday of the month at 12 p.m. eastern.  And there is one about homelessness and PACTs, next month on the nineteenth; Wednesday, the nineteenth.  So, please, do feel free to go to our cyber seminar catalogue and sign up for that.

The next thing we have are —It looks like we have a few more questions.  Just let me know if you guys need to head out and I can send you these off-line and we can disseminate the answers in writing.

The next one:  Do you have specialty clinics run by nurse—Oh.  We got that one taken care of.

Do you have any specific, just one or two suggestions for resolving the staffing physician fee and Silo syndromes?  That’s kind of related to the last question.

None at this time?

Well, I do invite our question submitter to contact you guys individually or their local PACT leader for more suggestions on that.

We do have many thanks that have come in for you all sharing your expertise.  And we do have —Delegation seems to be an issue across all roles.  I know PCPs are hesitant to delegate care responsibilities.  Also, due to limited time they do not develop care protocols.  It seems, if existing care protocols were accessible to each VISN it may increase adoption and delegation of care to RNs and, in turn, to LPNs.  Is there any evidence where use of care protocols improves adoption of PACT models?  Is there a single place to share existing protocols to use as potential templates for care protocols to be reviewed and adopted?

Bonnie Wakefield:  I’m not aware of one.  We have protocols shared within VISN 23 on our Community of Practice Sharepoint site.  But, other than that I’m not aware of any.

Moderator:  Thank you very much.

Lisa Meredith:  And I believe that VISN 22 shares, as well.  But, I’m not exactly looped in to the details there.

Moderator:  Great.  Thank you.  So, I’m just going to announce, because we did have several people writing in that they want further information.  So, what I’m going to do is when you received your follow-up e-mail reminder tomorrow, it will have a direct link to this archive and I will also include the link to our cyber seminar archive catalogue which will have all previous PACT sessions and I will include a link to the general PACT page where you can go to different VISN PACTs from there.  Other than that, I would suggest that you contact, and I apologize in advance, Nancy Sharp e—Nancy.Sharpe@VA.gov for further information just on this PACT cyber seminar series.  And then, in the question that were regarding locality, please refer to your local PACT management.

And, once again, we do have lots of people thanking you.  And, we do have one piece of comment.

I believe that VISN 22 should work on a standardized clerical associate training program including taking legible telephone messages.  

So, we thank you for that feedback.  And we do have one final comment for Dr. Stewart.

Dr. Stewart does seem to more or less identify that RNCM’s feel their work is less fulfilling because we feel that we are frequently putting out fire and staffing concerns; for example, increased walk-in numbers, placed on specific teamlet view alerts, lack of provider buy in we’re experience from some; but, of course, not all providers.  Lastly, not respecting those like myself, an RN III, who challenges the lack of quality of care and addressing these, especially, psychological barriers our veterans are experiencing including significant depression.  I personally have been told that it is not my job to identify these types of needs.  Many providers I work with only want single focused evaluations based on veteran’s own identified medical needs.

And then there is an e-mail address provided, which I can pass along to you, Dr. Stewart.  And they would like to make themselves available for a conference call with one or more of your group.  So, I invite that writer to go ahead and contact Dr. Stewart, individually.  And, perhaps, he would be willing to do so.

Greg Stewart:  Yeah.  Sure.

Moderator:  Okay.  That is all of the questions.  Everything else is regarding follow-up information and as I mentioned, I will send that to everyone in a follow-up e-mail tomorrow with helpful links.

And, I would like, at this time, to thank you for your time and expertise and allow you make any concluding comments to your audience.

Would you like to start, Dr. Meredith?

Lisa Meredith:  Sure.  I’m just very —I’m impressed with how much participation there has been for this cyber seminar and I think it’s a great venue for sharing information and, in a sense, addressing some of the questions that people have, at least, through these small steps.  And, I’m sure there will be much more information that we have to share with you as we continue with the VISN 22 demo lab evaluations.  I’m sure others on your team will be doing more cyber seminars.  And, I’m happy to come back if invited.  So, thank you.

Moderator:  And Dr. Stewart?

Greg Stewart:  Yes.  So, again, thanks.  It’s always fund to listen and think.  You know, I think it’s important to step back and say, you know, this is a huge transformation.  I would argue it’s the largest health care transformation that’s ever been attempted and there are just a lot of things that we’re working through and it’s an exciting thing to be part of and to understand.  It’s, oftentimes, frustrating.  But, thanks to the comments, the participation and things like this, I think we’re making a difference in improving it.

Moderator:  And Dr. Wakefield?

Bonnie Wakefield:  I would just echo what the other two presenters have said.  And, you know, thank everyone for participating and asking questions.  It’s given us something to think about.

**[End of Recording]**

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