PACT Implementation: Findings from primary care surveys 

Christian Helfrich, Ph.D., Chair, Organizational Function Working Group, 

PACT Demonstration Lab Coordinating Center, VA Puget Sound Health 

Care System 

Michele Lempa, Dr. PH, Administrative Director, VISN 4 Center for 

Evaluation of PACT (CEPACT), Philadelphia VA Medical Center 
 

Overview 

•	 First of two cyber seminars on findings on PC 

personnel experience from surveys 

•	 January 16 - PACT Implementation: Findings from 

primary care surveys 

•	 February 20 - Provider and Staff Experience with 

PACT: Results and recommendations from national 

and regional primary care surveys 

– Sandra Joos, PhD, VISN20 PACT Demonstration Lab
 

– Lisa Meredith, PhD, VISN22 PACT Demonstration Lab
 

VETERANS HEALTH ADMINISTRATION
 
 

Patient Aligned Care Team (PACT) initiative 

background 

• VH!’s patient-centered medical home model 

• Launched April 2010 

• Multiple components 

– Emphasis on team-based care 

• PCP, RN care manager, clinical assoc. & clerical assistant 

• Share responsibility for defined panel of patients 

– Scheduling & alternatives to in-person visits; 

– Use of nurse care managers and additional health 

promotion support 

VETERANS HEALTH ADMINISTRATION
 
 

Patient Aligned Care Team (PACT) initiative 

background 

•	 Resources to support PACT implementation 

–	 Funding to support the expanded staffing model 

– Training, e.g., Regional Learning Collaboratives w/ VA 

Systems Redesign 

•	 5 PACT Demonstration Laboratories: VISNs 4, 11, 20, 

22 & 23 

•	 National Demo Lab Coordinating Center 

VETERANS HEALTH ADMINISTRATION
 
 

 

2012 PACT Primary Care Personnel Survey: 

Team functioning and organizational support for 

change 

Christian Helfrich, PhD	 Survey fielded by the Healthcare 

Analysis and Information Group Emily Dolan, PhD (HAIG) Organizational Function Working Julie Kurutz – Project Manager Group 

John Witzlib, MBA – Project PACT Demonstration Lab Coordinating 

Manager Center 

VETERANS HEALTH ADMINISTRATION
 
 

Overview 

• May 2012, PACT Demo Lab Coordinating Center 

fielded survey to all VA Primary Care personnel
 

• Goal was to help answer 3 questions: 

1.	 To what extent has PACT been implemented? 

2.	 What factors foster or hinder PACT implementation? 

3.	 What’s P!CT’s effect on employee burnout, 

satisfaction , perceived improvements in care, and 

training? 

VETERANS HEALTH ADMINISTRATION
 
 

 

Survey methods 

•	 Web-based survey 

•	 Fielded via e-mail from 10N through clinical 

leadership in Primary Care, Nursing, Pharmacy, Social 

Work, Nutrition 

•	 Data collected from May 21, 2012 – June 29 , 2012 

•	 6,476 respondents, 5,404 are teamlet occupations 

•	 Approximately 30% response rate 

VETERANS HEALTH ADMINISTRATION
 
 

Respondent demographics for PACT survey
 

30-49 years 

Age >= 50 years 

5-10 years Tenure with 

VA > 10 years 

Supervisory No supervisory responsibility 

level Some supervisory responsibility 

Teamlet PCP, RN Care Manager, Clinical 

occupations VETERANS HEALTH ADMINISTRATION Associate or Admin Associate 

(n=6,476)
 

46.9%
 

48.3%
 

21.8%
 

36.3%
 

62.9%
 

37.1%
 

78.2%
 
 

Are clinicians assigned to a PACT teamlet
 

and conducting “huddles”? 

Percent report Hrs/day in 

being on at least teamlet 

one teamlet huddles 

Provider 90.5% .54 (1.2) 

Care Manager (RN & NP) 94.0% .71 (1.1) 

Clinical Associate 87.4% .86 (2.2) 

Administrative Associate 74.1% .54 (1.1) 

VETERANS HEALTH ADMINISTRATION
 
 

What factors foster or hinder PACT 

implementation? 

•	 Most frequently cited barriers? 

•	 Most frequently cited facilitators? 

•	 Differences among teamlet members in team 

functioning? 

•	 Differences among teamlet members in self-efficacy 

and outcome expectancy? 

VETERANS HEALTH ADMINISTRATION
 
 

Facilitators of PACT implementation, 

proportion of respondents who say “Very 

helpful” (n=6,467) 

Teamlet huddles 44% 

Regular teamlet meetings (not huddles) to discuss process / performance 

improvement. 34% 

Information systems to provide timely data and feedback to staff on PACT activities 21% 

Disease registries, such as for Diabetes and Heart Failure 20% 

New approaches to scheduling 19% 

Measurement tools associated with PACT to help assess your team's performance 19% 

Local (i.e., station, VISN) education sessions specifically about PACT 19% 

Regional or national learning collaborative specifically about PACT 18% 

PACT Toolkit by Office of Systems Redesign (care delivery and organization tools 11% 

Quality improvement methods to conduct small tests of change, such as VA System 10% Redesign's TAMMACS model, or Lean Six Sigma 

VETERANS HEALTH ADMINISTRATION
 
 

Top 6 facilitators by PCPs and Nurse Care 

Managers: % reporting “very helpful” 

Facilitator PCP 

(rank & 

%) 

Nurse Care 

Manager 

(rank & %) 

Clinical 

Associate 

(rank & %) 

Admin 

Associate 

(rank & %) 

Pvalue 

d. Teamlet huddles 1 (37%) 1 (48%) 1 (48%) 1 (42%) <.001 

e. Regular teamlet meetings (not 

huddles) to discuss process / 

performance improvement. 

f. Information systems to provide timely 

data and feedback to staff on PACT 

2 (27%) 

3 (17%) 

2 (37%) 

3 (23%) 

2 (40%) 

4 (23%) 

2 (33%) 

4 (23%) 

<.001 

<.001 

activities 

g. New approaches to scheduling 4 (15%) 6 (18%) 3 (24%) 3 (24%) <.001 

a. Local (i.e., station, VISN) education 

sessions specifically about PACT 

5 (14%) 5 (20%) 5 (22%) 5 (21%) <.001 

VETERANS HEALTH ADMINISTRATION 

c. Measurement tools associated with 

PACT to help assess your teams 

performance 

6 (14%) 4 (21%) 6 (22%) 6 (21%) <.001 
 

Proportion of respondents who say “limits a 

great deal” your ability to provide optimal, 

patient-centered care? 

Clinical reminder volume 48%
 

Recruiting and retaining providers 44%
 

Difficulty accessing specialty care 37%
 

CPRS view alerts volume 38% Lack of control over my schedule 31% 

Recruiting and retaining non-provider clinicians 37% Lack of support from clinical leadership 32% 

Poor communication with specialists within VA 35% Delivering opiate therapy 28% 

Inadequate time allotted to provide counseling Inadequate support for patient behavioral 34% 22% or education change needs 

Inadequate time allotted to provide follow-up 34% Poor communication around inpatient care 20% 

care
 

Time & effort to input notes 34% Preferred medications are difficult to obtain 22%
 

Lack of responsiveness to my requests for Recruiting and retaining non-clinicians 33% 17% assistance from my team members 

Poor communication with specialists outside 32% Patients have limited VA benefits 14% the VA 

VETERANS HEALTH ADMINISTRATION 
 

Top 5 barriers identified by PCPs and Nurse 

Care Managers: % reporting “limits a great 

deal” 

Barrier PCP (rank 

& %) 

Nurse 

Care 

Manager 

(rank & %) 

Clinical 

Associate 

(rank & %) 

Admin 

Associate 

(rank & %) 

P-value 

p. Clinical reminder 

volume 

1 (64%) 1 (49%) 2 (38%) 7 (19%) <.001 

s. CPRS view alert volume 2 (56%) 10 (35%) 12 (25%) 9 (18%) <.001 

m. Recruiting and 

retaining providers 

3 (51% ) 2 (47%) 1 (39%) 1 (32%) <.001 

r. Time and effort to input 

notes 

4 (49%) 12 (33%) 13 (21%) 10 (18%) <.001 

q. Delivering opiate 

therapy 

5 (46%) 13 (29%) 19 (13%) 19 (9%) <.001 

VETERANS HEALTH ADMINISTRATION
 
 

Team functioning scores, by profession, mean(sd) on a 

scale from strongly disagree(1) to strongly agree (5) 

Decision- History of Chaos Communication making change (higher= n (higher=better (higher= more (higher= overwhelmed communication) participatory numerous by workload) approach) changes made) 

Provider 1,721 3.50 (.64) 3.23 (.80) 3.45 (.89) 3.48 (.88) 

Care Manager (RN & NP) 1,123 3.50 (.63) 3.25 (.75) 3.41 (.91) 3.51 (.83) 

Clinical Associate 1,303 3.41 (.66) 3.27 (.74) 3.20 (.91) 3.41 (.89) 

Administrative Associate 534 3.44 (.66) 3.30 (.80) 3.34 (.92) 3.38 (.92) 

2011 Survey: All on a 

teamlet - 3.59(.65) 3.37(.74) 3.30(.94) 3.47(.91) 

Group Health baseline 

data 3.70(.82) 3.68(.77) 2.80(.76) 3.46(.67) 

ULTRA Trial 3.31 3.29 3.05 3.09 

VETERANS HEALTH ADMINISTRATION 
VETERANS HEALTH ADMINISTRATION 

Self-efficacy and outcome expectancy: % 

reporting “very much” or “a lot” 

PCP 

(%) 

Nurse Care 

Manager 

(%) 

Clinical 

Associate 

(%) 

Administrati 

ve Associate 

(%) 

Pvalue 

How well do you 

understand what PACT is? 

75% 75% 67% 64% < 0.01 

How confident are you 

that you are capable of 

implementing PACT? 

56% 61% 63% 56% 0.02 

How confident are you 

that your teamlet/clinic 

team is capable of 

implementing PACT? 

45% 52% 59% 55% < 0.01 

How confident are you 

that PACT will improve VA 

primary care? 

38% 49% 48% 45% < 0.01 
 

Hospital-based (HBOCs) vs. communitybased outpatient clinics (CBOCs)? 

•	 Overall, not substantially different for respondents 

from CBOCs vs. HBOCs. 

•	 Exception: slightly higher % of CBOC respondents 

report problems accessing and communicating with 

specialists; 

VETERANS HEALTH ADMINISTRATION
 
 

 

Limitations 

•	 Response bias; no true denominator 

–	 Comparisons to AES demographics positive 

•	 Not possible to link observations to teamlets (only 

clinics) 

– Limits ability to test for convergence at teamlet level.
 

VETERANS HEALTH ADMINISTRATION
 
 

 

Conclusions 

•	 PACT model is being implemented 

–	 PC personnel understand PACT 

–	 >90% report being assigned to teamlets 

•	 Reported barriers and facilitators 

– Volume of clinical reminders reported as greatest barrier to 

PACT implementation 

–	 Teamlet huddles reported as greatest facilitator 

– PACT-specific training has been very helpful for some but a 

minority 

•	 Next steps are assessing relationship of PACT 

implementation with utilization, patient experience; 

assessing correlates of personnel burnout, turnover 

VETERANS HEALTH ADMINISTRATION 
 

 

Thoughts? Questions? Suggestions?
 

• We welcome your input now and later: 

• Christian.helfrich@va.gov, 206-277-1655
 

• Emily.dolan@va.gov, (206) 277-4771
 

VETERANS HEALTH ADMINISTRATION
 
 ́ιΊ΢̯ιΘ C̯ι͋  ́ιΪϭΊ͇͋ιν͛  ́͋ι̽͋ζχΊΪΣν 

of the Quality Improvement Climate 

at their Facilities
 

Michele Lempa, MPH, DrPH
 

January 16, 2013
 
 

Project Team
 

Rachel Werner, MD, PhD, CEPACT Director 

Judith Long, MD, Associate Director 

Judy Shea, PhD 

Anneliese Butler, MSW 

Anne Canamucio, MS 

Jennifer Gutierrez, MA 

BΪϼ͋Σ̯ Lamparska, MEd, MM 

Michele Lempa, Dr.PH 

Mary Pelak, MSW 

Gala True, PhD 
 

VISN 4 PCP Survey 

•	 EΜΊ̽Ίχ ζιΪϭΊ͇͋ιν͛ ζ͋ι̽͋ζχΊΪΣν Ϊ͕ χ·͋ ̽Ϣιι͋Σχ 

quality improvement climate: 

– To what degree change is encouraged and 

supported 

– Identify barriers to improving performance and 

implementing changes 

•	 Determine if and how the organizational 

climate has changed over time 
Survey Topics
 

• 32-Ίχ͋΢ νϢιϭ͋Θ ̯νν͋ννΊΣͽ  ́C ́ν͛ ζ͋ι̽͋ζχΊΪΣ Ϊ͕ ́ 

– Improvement processes 

– Data usage for improvement 

– Barriers to improving performance 

– Practice setting experience 

– Communication and cooperation 
Data Collection
 

•	 Administered in 2010 and 2012 

to all VISN 4 PCPs 

•	 2010 administered via email 

with telephone follow-up 

(Summer/Fall 2010) 

•	 2012 administered via Survey 

Monkey with telephone followup (Summer/Fall 2012) 

•	 Confidential not anonymous 
Survey Respondents
 

•	 Overall Response Rate: 

–	 2010: 61% (n=211/347) 

–	 2012: 57% (n= 204/360) 

–	 104 PCPs responded to both surveys 

•	 Individual station response rates ranged from 

42% to 70% 

•	 VAMCs and CBOCs had the same response 

rate (57%) 
Analysis 

• 2012 Data 

– Frequencies 

– Compared providers at CBOCs to those at VAMCs
 

• No statistically significant differences 

– Compared MD/DOs to PA/NPs 

• No statistically significant differences with one exception 

• 2010 to 2012 comparison 

– Compared changes for the 104 PCPs who answered 

both surveys 
 

2010 Survey Highlights
 

•	 Barriers to improving performance: 

–	 Insufficient staff and competing demands 

–	 Resistance was not considered a barrier 

•	 Providers agreed that staff and clinicians are 

overworked and stressed. 

– They did not believe that there was chaos or that they 

were not able to keep up. 

•	 Providers reported effective communication 

between physicians and nurses 

– Room for improvement in cooperation with senior 

administrators and other departments. 
2012 Survey
 
Improvement Processes
 

100
 

90
 

80
 

70
 

60
 

50
 

40
 

30
 

20
 

10
 

0
 

We make sure that we The organization does a good Staff promptly resolve 

regularly take time to figure job of assessing current patient complaints
 

out ways to improve our patient needs and 

work process expectations 

45.1 47.55 

78.43 

Percent agree or strongly agree 
Data Usage for Quality Improvement 

Data Usage for Quality Improvement
 
Data Usage for Quality Improvement
 

60.29% 

58.83% 

45.09% 

43.13% 

0% 20% 40% 60% 80% 100% 

We use a wide range of data and 

information about the quality of care and 

services to make improvements 

We use data from patients to improve 

services 

Patients complaints are studied to 

identify patterns and prevent the same 

problem from recurring 

The organization uses data on customer 

expectations and/or satisfaction when 

designing new services 

% agree or strongly agree 
Barriers to Improving Quality: 

Topics Covered
 

• Staffing 

• Finances 

• Resistance 

• Competing Demands
 
 

Barriers to Improving Quality: 

Staffing
 

16% 

Percent saying great or very 

ͽι̯͋χ Ϯ·͋Σ ̯νΙ͇͋ ·To what 

extent was there sufficient 

personnel support to 

implement mandated QI 

̽·̯Σͽ͋ν ͛ͅ 
Barriers to Improving Quality: 

Staffing
 

% moderate or 

large barrier 

Insufficient number of PCPs 57.84 

Insufficient number of specialists in target 

acute care conditions(e.g. cardiac care) 

59.80 

Insufficient number of outpatient nurses 

Insufficient number of administrative and 

64.22 

47.55 

support staff 

Limited personnel to support needed changes 74.02 

Limited ability to shift financial or human 66.18 

resources when most needed 
Barriers to Improving Quality: 

Finances
 

58% of PCPs agreed 

·ͫΊ΢Ίχ͇͋ ͕ΊΣ̯Σ̽Ί̯Μ 

resources to support 

Σ͇͇͋͋͋ ̽·̯Σͽ͋ν͛ Ϯ̯ν ̯ 

barrier to improving 

quality 
 

Barriers to Improving Quality: 

Finances
 

20% 

Percent saying great or 

very great when asked ·ΑΪ 

what extent was there 

sufficient financial support 

to implement mandated 

Ά͜ ̽·̯Σͽ͋ν ̈́͛ 
Barriers to Improving Quality:
 

Resistance
 

50.98% 

37.75% 

47.55% 41.87% 

Resistance from Resistance from Resistance from Resistance from 

PCPs subspecialty local managers local support staff 

providers 

No barrier Small barrier Moderate barrier Large barrier 

100.00% 

90.00% 

80.00% 

70.00% 

60.00% 

50.00% 

40.00% 

30.00% 

20.00% 

10.00% 

0.00% 
Barriers to Improving Quality
 

73.4% of PCPs said 

·CΪ΢ζ͋χΊΣͽ 

demands across too 

΢̯ΣΘ ΊΣΊχΊ̯χΊϭ͋ν͛ 

was a barrier to 

improving quality 
Cooperation and Communication
 

To what extent...
 

36.98 

32.61 

79.1 

0 10 20 30 40 50 60 70 80 90 100 

Was there cooperation between 

physicians and senior administration 

Was there cooperation between 

departments 

Was there effective communication 

between physicians and nurses 

% great or very great 
Practice Setting Experience
 
Practice Setting Experience
 

Things have been changing so fast in our practice 

that is hard to keep up with what is going on 

The practice is almost always in chaos 

Practice experienced as stressful
 

The clinicians in this practice very frequently feel 

overwhelmed by work demands
 

The staff members of this practice very frequently 

feel overwhelmed by work demands
 

It is hard to make any changes in this practice 

because we are so busy seeing patients
 

36.27% 

23.04% 

70.59% 

77.45% 

79.90% 

65.20% 

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
 

Percent agree or strongly agree 
Recognition
 

34.8% 

Percent of PCPs who 

thought providers are 

adequately recognized 

(non-financially) for 

improving quality 
Takeaway Messages
 

•	 Biggest area for caution: overwhelmed 

•	 Staffing, funding, and competing demands 

remain barriers 

•	 Room for improvement in using data for 

quality improvement 

•	 Can build on strengths (communication, low 

resistance, process for addressing patient 

complaints) for gains in other areas 
Thank you
 

•	 PCPs and other staff implementing PACT at 

VISN 4 sites who generously share their time 

and thoughts with us 

•	 VISN 4 Leadership and staff, in particular Dr. 

Macpherson and Jen Skoko 

•	 Demo Lab Coordinating Center and Primary 

Care Services 
Questions? 
1

3

Journal of General Internal Medicine

ISSN 0884-8734

J GEN INTERN MED

DOI 10.1007/s11606-012-2279-y

Open Access in the Patient-Centered

Medical Home: Lessons from the Veterans

Health Administration

Gala True, Anneliese E. Butler, Bozena

G. Lamparska, Michele L. Lempa,

Judy A. Shea, David A. Asch & Rachel

M. Werner
1

3

Your article is protected by copyright and

all rights are held exclusively by Society of

General Internal Medicine. This e-offprint is

for personal use only and shall not be selfarchived in electronic repositories. If you

wish to self-archive your work, please use the

accepted author’s version for posting to your

own website or your institution’s repository.

You may further deposit the accepted author’s

version on a funder’s repository at a funder’s

request, provided it is not made publicly

available until 12 months after publication.
Open Access in the Patient-Centered Medical Home: Lessons

from the Veterans Health Administration

Gala True, PhD1,2, Anneliese E. Butler, MSS1, Bozena G. Lamparska, MEd1,

Michele L. Lempa, DrPH1

, Judy A. Shea, PhD1,2, David A. Asch, MD, MBA1,2, and

Rachel M. Werner, MD, PhD1,2

1

Center for Evaluation of Patient Aligned Care Teams (CEPACT), Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, USA; 2

University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.

BACKGROUND: The Veterans Health Administration

(VHA) has undertaken a 5-year initiative to transform

to a patient-centered medical home model. An early

focus of implementation was on creating open access,

defined as continuity and capacity in primary care.

OBJECTIVE: We describe the impact of readiness for

implementation on efforts of pilot teams to make

changes to improve access and identify successful

strategies used by early adopters to overcome barriers

to change.

DESIGN: A qualitative, formative evaluation of the first

18 months of implementation in one Veterans Integrated Service Network (VISN) spread across six states.

PARTICIPANTS: Members of local implementation

teams including administrators, primary care providers, and staff from primary care clinics located at

10 medical centers and 45 outpatient clinics.

APPROACH: We conducted site visits during the first

6 months of implementation, observations at Learning

Collaboratives, semi-structured interviews, and review

of internal organizational documents. All data collection

took place between April 2010 and December 2011.

KEY RESULTS: Early adopters employed various strategies to enhance access, with a focus on decreasing

demand for face-to-face care, increasing supply of

different types of primary care encounters, and improving clinic efficiencies. Our interviews with key contacts

revealed three important areas where readiness for

implementation (or lack thereof) had an impact on

interventions to improve access: leadership engagement, staffing resources, and access to information

and knowledge.

CONCLUSIONS: Key factors related to readiness for

implementation had an impact on which interventions

pilot teams could put into place, as well as the viability

and sustainability of access gains. Wide variations in

interventions to improve access occurring across sites

situated within one organization have important implications for efforts to measure the impact of enhanced

access on patient outcomes, costs, and other systemslevel indicators of the Medical Home.

KEY WORDS: patient-centered access; primary care; continuity of care;

veterans health; qualitative evaluation.

J Gen Intern Med

DOI: 10.1007/s11606-012-2279-y

© Society of General Internal Medicine 2012

BACKGROUND

In the face of growing concerns over quality and viability

of the current system of primary care, the PatientCentered Medical Home (PCMH) has emerged as a

promising alternative care-delivery model.1,2 In a PCMH,

team-based primary care is employed to assess and

address the patient’s medical and psychosocial needs,

bringing in outside resources and specialists as needed.3

There are more than 100 demonstration projects across the

US piloting core principles of the PCMH.4,5 In April 2010,

the Veterans Health Administration (VHA) launched one of

the largest PCMH initiatives to date, with the ambitious goal

of transforming primary care clinics across more than 850

hospital-based Medical Centers and Community Based

Outpatient Clinics (CBOCs) by the end of 2014 to what

was dubbed the Patient-Aligned Care Team (PACT) model.6

VHA is the United States’ largest integrated health-care

system, providing and paying for comprehensive care to over

5 million veterans each year. Recognized as a leader of

innovation in the development and use of electronic medical

records, as well as improvements in quality and cost control,7

VHA has embraced the PACT model as a means to provide

continuous, comprehensive care to a diverse population of

patients, many of whom have complex comorbidities.

The focus of early PACT implementation was on training

pilot teams from each facility, funding additional staff,

leveraging existing space and technology resources, and redesigning existing processes with an emphasis on developing new ways to coordinate and deliver care.8 Pilot teams

were charged with making changes along the full spectrum

of PCMH activities; however, particular emphasis was

Electronic supplementary material The online version of this article

(doi:10.1007/s11606-012-2279-y) contains supplementary material,

which is available to authorized users.

Received June 1, 2012

Revised October 11, 2012

Accepted October 19, 2012

Author's personal copy
placed on moving toward “open access,” a strategy for

improving quality of care and patient satisfaction that has

been widely adopted across outpatient settings in the US.9–13

Open access is defined in terms of improved continuity in the

patient-provider/care team relationship and increased capacity in the team’s schedule to accommodate patients’ desire for

same-day and future scheduled appointments.12,13

Concurrent with implementation, VHA funded evaluation efforts, including the Center for Evaluation of PatientAligned Care Teams (CEPACT). CEPACT’s mission is to

evaluate PACT implementation processes and outcomes

across one Veterans Integrated Service Network (VISN 4),

comprised of 10 VA Medical Centers and 45 CommunityBased Outpatient Clinics across six states. As part of an

ongoing qualitative formative evaluation, we tracked implementation activities and experiences of pilot teams

during the first 18 months of PACT implementation.

Our evaluation is informed by the Consolidated

Framework for Implementation Research (CFIR), which

provides a unifying theory for examing the impact of

multiple constructs on uptake of new interventions across

a variety of organizational settings.14 Our objective in this

article is to describe the impact of readiness for implementation, defined as “tangible and immediate indicators

of organizational commitment to an intervention,”14 (p 9)

on pilot teams’ efforts to improve open access. We also

elucidate strategies used by pilot teams to overcome

barriers to implementation in order to inform other

health-care organizations interested in providing open

access care.

METHODS

We used multiple qualitative data collection methods

including site visits, observations at PACT Learning Collaboratives, semi-structured interviews, and review of internal

organizational documents. All data collection took place

between April 2010 and December 2011. Our approach to

data collection and analysis is summarized below; a detailed

description of methods is provided in an Online Appendix.

Data Collection

We conducted site visits to each of the ten VA Medical

Centers in VISN 4 during the initial 6 months of PACT

implementation to better understand the variety of settings

in which PACT was being introduced. We conducted semistructured interviews in either one-on-one or group settings

with administrators, primary care clinical leads, and

members of pilot teams involved in local implementation.

Interviews focused on the history and organization of

primary care, local decision-making processes around

PACT implementation, initial plans for implementing

changes in primary care, attitudes toward and knowledge

about the national PACT initiative, and perceived barriers

and facilitators to change. Between 8 and 16 individuals

were interviewed at each site visit. Interviews lasted 30 to

90 min and were audio-recorded and transcribed.

We conducted field observations at six VHA-sponsored

Learning Collaboratives over an 18-month period. These 3­

day conferences were designed to provide centralized

training and support to local implementation teams. Members of our qualitative research team shadowed pilot teams

and took extensive field notes to capture details about

evolving implementation efforts at each facility, as well as

barriers and facilitators to change encountered by pilot

teams over time.

Interviews with key contacts were conducted in April

2011, August 2011, and December 2011 in order to track

progress of PACT implementation across the VISN. Key

contacts were selected based on their knowledge about the

overall strategy for PACT implementation at their facility

and their level of day-to-day involvement in PACT

implementation, as assessed from site visits and field

observations. These interviews were designed to elicit

details about local activities undertaken to improve processes of care, as well as barriers and facilitators encountered along the way. In addition, we asked about the

perceived level of support from administrative and clinical

leadership and the capacity to access and use patient- and

facility-level data to help guide implementation.

The number of key contact interviews increased over

time as PACT activities spread to additional pilot teams and

primary care clinics; the number of interviews therefore

ranged from 10 for the first round to 33 for the final round.

Most key contact interviews were conducted over the

phone, except where the respondent preferred to be

interviewed in person at a Learning Collaborative. Key

contact interviews averaged 30–45 min in length. About

half the interviews were audio-recorded and transcribed.

Due to a VHA regulation regarding phone interviews the

remaining interviews were not recorded; instead the

interviewer typed summary responses into a templated

form.

Data collection activities were led and supervised by at

least one of four CEPACT qualitative investigators (GT, JS,

ML, or AB), with assistance by trained members of the

qualitative research team.

Data Analysis

Qualitative data were formatted and imported into

ATLAS.ti software to facilitate data management, coding,

and analysis.15 We developed a common coding scheme to

conduct thematic analysis across all qualitative data. An

initial set of deductive codes was developed based on our

evaluation objectives (e.g., tracking views of staff in

True et al.: Open Access in the Medical Home JGIM

Author's personal copy
different roles regarding PACT implementation). Open

coding of eight transcripts by four members of the

qualitative research team led to identification of emergent

themes. Independent line-by-line coding of site visit transcripts and a subset of other qualitative data (e.g.,

fieldnotes, follow-up interviews), followed by constant

comparison of coding by two of the authors (AB and GT),

resulted in a codebook consisting of definitions, inclusion

and exclusion criteria, and examples for each theme. Four

members of the research team completed coding of qualitative data with training and supervision from the lead author.

Members of the qualitative team met regularly to review

coded texts, resolve any coding discrepancies through

consensus, and discuss emerging barriers and facilitators to

achieving open access PACT during early implementation.

(Additional details provided in the Online Appendix.)

FINDINGS

Thirty-two Patient Aligned Care Teams (PACTs) piloted

interventions to enhance access during this period. Below

we delineate three key characteristics of readiness for

implementation and describe how each facilitated or

impeded the ability to implement interventions related to

open access. We also describe successful strategies undertaken by early adopters to overcome barriers to open access.

Barriers and strategies described here were common across

facilities and pilot teams; however, not all barriers were

encountered by every team or facility.

Leadership Engagement

The CFIR model idenitifies leadership engagement as an

important indicator of organizational commitment to

change. A common theme emerged around how attitudes

and actions of local administrators (e.g., facility directors

and primary care clinic managers) operated as a barrier or

facilitator to making changes toward open access. At one

site, a PACT lead described administration at her medical

center as buying into the PACT initiative early on:

“We have been very fortunate. We have very

supportive leadership who gave us the money and

said, ‘Do what you have to do to get this model up and

running.’ So we are renovating all of the primary care

spaces. They’ve also supported us making changes to

[the role of] the clerks so we can staff our pilot teams.”

Associate Chief of Staff, Site 4

A key step in this site’s progress toward open access

involved a complete restructuring of the PCP’s and RN

Care Manager’s clinic schedules to accommodate time for

same-day/walk-in patients, telephone clinics, and shared

medical appointments. In preparation for this new schedule,

each team spent 2 weeks reviewing their patient panel to

identify patients who could go with longer intervals

between visits, be seen by a team member other than the

PCP, or receive telephone care. During this period, the team

did not see patients other than those with the most pressing

needs. Even though this had the potential to reduce access

and other measures in the short-term, leadership was

described as supportive:

“Our administration here, they went along with it,

and they absolutely appreciated that the teams

needed more time.” Primary Care Nurse Manager,

Site 4

A number of key contacts emphasized the importance of

allowing each PACT to exercise a degree of control over its

own schedule, something that was only possible with

support from leadership. One strategy used by pilot teams

at several facilities was to review the schedule for the prior

2 weeks to identify peak demand for walk-in appointments

and then to restructure schedules to offer open access slots

during those times.

In contrast, early adopters at sites that had difficulty

making changes toward open access perceived administration as unsupportive of PACT, as evidenced by administrators’ comments that PACT was just “the flavor of the

month,” and by their refusal to approve new hires for

PACTs or renovations to primary care spaces. One key

contact observed that local leaders were unfamiliar with

PACT concepts and goals, leading to problems with

engagement:

“They [leadership] really don’t understand the concepts, and they’re not getting any of the training that

we are...we’re expected to go back and ‘teach up’ but

we’re in no position to do that. They [VHA] really

need to get medical center leadership to come together

for some training about PACT if they want [leadership]

to support what we’re doing.” PCP, Site 9

When local administrators with authority over primary

care scheduling did not understand or support the concept

of open access, it became very difficult for early adopters to

create or maintain open slots in their clinic schedules. As

one PACT provider observed during the early implementation phase:

“From what I understand, the Chief of Staff is not

into having open time. They [call center schedulers]

are filling up open slots with other [providers’] panel

patients and not giving it a chance to work the way

it’s supposed to. It gets to be very depressing.” PCP,

Site 6

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The experience of early adopters at one facility illustrates

how lack of leadership engagement posed a barrier to open

access and how strategies undertaken to engage administrators led to successful interventions to enhance access.

At this facility, pilot teams requested permission to leave

“open slots” in the schedule to accommodate requests for

same-day appointments. In response, they were allowed to

create a mid-morning “carve out.” However, this slot often

went unfilled because patients requesting same-day appointments called too late in the day to make that appointment

time. A key contact described how her colleague presented

leadership with data demonstrating that their facility was

falling behind on access goals relative to other facilities in

the VISN and made the case for allowing each PACT to

have a number of open slots throughout the day based on

patient needs. This effort was credited with fostering greater

buy-in and garnering support for PACT. Pilot teams were

then able to implement a highly successful approach to

creating open access slots each day that involved reviewing

appointments ahead of time and calling patients to cancel

unnecessary appointments or move some appointments to

telephone care (also referred to as “schedule scrubbing”).

Engendering leadership support was not always a viable

option; a key contact at one facility reported:

“Our executive leadership is involved in decisionmaking, but [they] won’t sign off on hiring RN Care

Managers [for pilot teams] because they think

[PACT] funds are going to dry up after next year.”

RN Care Manager, Site 1

Despite lack of support from leadership, pilot teams at

this site implemented a number of smaller-scale interventions to improve access, such as extending intervals

between visits from 6 to 9 months for patients who did

not need to be seen as often. However, given their inability

to implement larger change processes, teams at the facility

continued to struggle with improving access.

Staffing Resources

The level of available resources, and in particular personnel

to staff PACT teams, was a near-universal barrier for pilot

teams seeking to implement change processes related to

open access. The VA Central Office suggested a PACT

should consist of one full time equivalent (FTE) PCP

supported by three FTE staff, including an RN Care

Manager, a Clinical Associate (e.g., LPN), and a Clerical

Associate. At sites where leadership made funds available

to hire new staff, early adopters indicated that having a fully

staffed PACT enabled them to implement open access

interventions by assigning specific tasks to the appropriate

team member. LPNs started making pre-appointment calls

to patients to ensure they were getting the type of

appointment they needed (i.e., face-to-face or telephone) and

that they came to appointments prepared. This freed up RN

Care Managers to contact patients who had visited the ED to

determine whether or not they required a follow-up visit to the

PCP. One Nurse Practitioner on a pilot PACT talked about

how RN Care Managers in her clinic had taken over

responsibility for making return calls to patients. She said:

“There are many in this neck of the woods who don’t

have answering machines. And it’s a pain in the neck

when you try and call them and you can’t get

anybody. So for [the RNs] to make the calls and be

persistent enough, they can make the calls probably

sooner than I can...it’s really nice to see them

managing the stuff that I had to do in the past.” PCP,

Site 7

More commonly, pilot teams faced barriers to panel

management and open access that stemmed from being

understaffed. For example, a PCP who led a pilot team that

had an assigned RN Care Manager but no LPN or clerk said

she struggled with fitting in a backlog of patients, which

had a negative affect on her team’s access:

“Unfortunately, things still slip through the cracks

and we try the best that we can to gather it up, and I

think most of our patients are being managed quite

well, but I just worry that it’s all going to fall apart.”

PCP, Site 8

In the absence of additional staff, efforts to enhance

patient access were contingent upon local implementers’

ability to develop alternate strategies based on the local

resources they did have. Some facilities responded by

forming different team configurations based on available

staff, resulting in variable team composition within the

same primary care clinic. Other sites focused on creation of

what they called “hybrid PACTs” in which two PCPs shared

one assigned RN Care Manager and other support staff and

took turns holding “walk-in access clinics” where they saw

each other’s patients. In addition to developing alternate

team configurations, sites adapted to staffing constraints by

harnessing other local resources. One common strategy was

to make greater use of extended team members such as

social workers and clinical pharmacists, which allowed

some aspects of patient care to be shifted away from the

PCP. A key contact talked about the problem of not having

enough RN Care Managers to staff every pilot team and

went on to describe how PACT implementers had decided

to deal with this resource constraint, saying:

“We’ve been looking around at what we do have...

and creating access by providing more services

through pharmacy, nutrition, social work...and doing

more via telehealth.” PACT Lead, Site 2

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Thus, while staffing resources challenged early adopters’

ability to implement the full spectrum of activities related to

open access, many facilities and pilot teams succeeded in

leveraging existing resources in order to make some

changes toward improving access.

Access to Information and Knowledge

Ability to access information and knowledge (including

experts, other experienced staff, and computerized information systems)14 was essential to pilot teams, both in order to

implement targeted activities to achieve open access and to

measure progress toward open access goals. Patient-level

data useful for tracking progress toward open access was

available through VHA’s comprehensive electronic medical

record (EMR); however, many teams were unable to access

information in the EMR in a timely or easily digestible

manner. As a PACT lead who was familiar with the system

pointed out:

“The electronic medical record is a wonderful thing,

but it does not make getting information out of it

very easy. The structure of the medical record does

not lend itself to collecting information. It’s tough to

get what you’re looking for in a nice, neat package.”

PACT Lead, Site 9

Accuracy and reliability of information in the EMR also

came up as an issue. An essential first step to facilitating

continuity—one of the metrics for access—rested on ensuring

that every patient was assigned to a PCP and every PCP had a

defined panel of patients (referred to as “empanelment”).

Many facilities experienced a delay in accurate and complete

empanelment. This hampered efforts to implement access

changes on a number of levels. For example, an early strategy

used successfully by pilot teams seeking to enhance access

was referred to as “panel scrubbing,” whereby team members

identifed “co-practice” patients with outside providers who

primarily came to the VA to refill medications; they would

then move these patients to once-yearly in-person visits, thus

opening up access for higher need patients. Pilot teams from

facilities that had problems with empanelment were unable to

implement this intervention.

Having someone on the implementation team who knew

how to pull information from the EMR was a major

facilitator of changes to increase open access. A number of

facilities had success with using centralized data to generate

daily reports of patients seen at any VHA Emergency

Department, which were then forwarded to each PACT. At

an early site visit, an RN Care Manager explained the role

this process played in enhancing capacity for her team:

“Every morning we pull up the ER list. I review the

chart, why they came in [to the ER]. Every ER note

says ‘follow up with your PCP.’ So I go over them;

if they’re on an antibiotic and they’re being told to

come see their PCP in 2 or 3 days, and they’re on an

antibiotic for 7 to 10 days, they’re not going to be

feeling better yet. So I call them to see how they’re

doing, and then I say I’ll call them back in 3 days or

so to see how they’re doing, and then that may even

alleviate [the need for] a doctor’s appointment.” RN

Care Manger, Site 5

Conversely, lacking involvement from someone with

expertise in using data to inform process improvement and

planning emerged as a barrier to implementing access

interventions. A PACT lead described the problem this way:

“Our access is not good. We know that already, you

don’t have to tell us that again. What we need is

someone who can tell us what we can do. What are

the tactics? What is the systems redesign that we

need to do? What’s the process?” PACT Lead, Site 10

Pilot teams at this site implemented a short-term solution

aimed at improving access by creating four carve-out slots

each day, which resulted in their access scores worsening.

PACT leads then sought and received funding from local

leadership to bring an expert in systems redesign from

another VA Medical Center for on-site consultation. By the

end of the early implementation period, two out of three of

the pilot teams at this facility were able to offer same-day

access to their patients.

CONCLUSIONS

Readiness for implementation has been identified as a key

element in making the transformation to a PCMH from a

primary care model that is fragmented, episodic, and

reactive to demand for clinical visits.16,17 Our interviews

with key contacts revealed three important areas where

readiness for implementation (or lack thereof) had an impact

on interventions to improve access: leadership engagement,

staffing resources, and access to information and knowledge.

When local administrators with responsibility for disbursing funds to hire staff and approving changes to clinic

schedules either were not exposed to medical home

principles or lacked confidence in VHA’s commitment to

the PACT initiative, their actions created barriers for teams

trying to enhance access. An important aspect of leadership

engagement is managerial patience—“taking a long-term

view...to allow time for the often inevitable reduction in

productivity” as pilot teams endeavor to test and implement

new interventions14 (p 9). Organizations seeking to improve

access in the medical home should have strategies in place

to engage administrators and engender managerial patience

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before introducing a new intervention in order to provide a

solid base of support for early adopters. When leadership

remains unsupportive of change efforts, pilot teams may be

able to implement minor interventions with creative workarounds, but true and sustainable change is less likely to

occur.

Another key factor affecting implementation was the ability

of pilot teams to leverage available health information

technologies to improve access. A recent Commonwealth

Fund report noted that “empanelment plays a key role in

facilitating continuity of care and enabling teams to monitor

patients and identify those requiring higher level of attention

and services.”

18 Barriers to complete and accurate empanelment impeded pilot teams’ efforts to improve access. This

was further compounded by the absence or lack of

involvement of someone with the skills needed to access

and make use of data to support improvement efforts. Having

someone with appropriate expertise in health information

technology, or at the very least providing regular training and

support to staff who must deal with such technology, is

essential to any systems change initiative.19,20

We acknowledge several limitations to our study.

Because CEPACT is tasked with evaluating PACT implementation across the VISN, it was unfeasible to track pilot

teams’ activities more closely, and our face-to-face interactions with early adopters were limited to initial site visits

and observations at Learning Collaboratives. Our follow-up

interviews were typically conducted with just one person,

who was often a champion of PACT implementation. The

extent to which this person knew the consistency with

which changes were implemented may have been limited.

In addition, though we emphasized the neutrality of the

interviews and the fact that the interviews were confidential,

some interviewees may have tended to overstate the

positives.

Despite these limitations, our findings suggest many

broader lessons with relevance to non-VHA health systems

attempting large-scale systems change. Organizational

attention to key elements of readiness for implementation

—leadership engagement, available resources, and access to

information and knowledge—is essential to building the

foundation on which early adopters can test change

processes and find what works best locally.

Pilot teams used a number of effective strategies for

improving access, including extending time between

appointments for some patients, reorganizing clinic schedules in order to provide a mix of face-to-face, telephone,

and same-day appointments, and contacting patients after an

ED visit to determine whether they needed in-person or

phone follow-up care. However, our data also revealed

factors impacting which interventions could be put into

place by which teams; these factors may also lead to erosion

of access gains in the long-term. Such varations within one

organization have important implications for efforts to

measure the impact of enhanced access on patient outcomes, costs, and other systems-level indicators of the

Medical Home.

Acknowledgments: The authors wish to thank the staff of the

Center for Evaluation of Patient Aligned Care Teams (CEPACT),

members of the CEPACT Advisory Board and the VISN 4 PACT

Steering Committee, the VISN 4 Offices, and staff at VISN 4 Medical

Facilities. We are also grateful for the insightful comments and

suggestions from the three anonymous reviewers. Funding for the

VISN 4 Center for Evaluation of PACT is through the Office of Primary

Care, Veterans Health Administration, Department of Veterans

Affairs. The views expressed in this paper do not necessarily

represent the official views of the Department of Veterans Affairs.

Conflict of Interest: The authors declare that they do not have a

conflict of interest.

Corresponding Author: Gala True, PhD; Center for Evaluation of

Patient Aligned Care Teams (CEPACT), Philadelphia Veterans Affairs

Medical Center, Building 4100, University and Woodland Aves,

Philadelphia, PA 19104, USA (e-mail: Jennifer.True2@va.gov).

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