A tool to identify, manage, and coordinate patient care.

Tamara L. Box, PhD

Office of Analytics and Business Intelligence,

VHA OFFICE OF INFORMATICS AND ANALYTICS
POLL

What is your primary role in the VA?

A. PACT Physician

B. PACT Nurse

C. Other Primary Care Role (e.g., Dietician, 

Pharmacist) 

D. Investigator or Research Staff

E. Other
• VHA Patient Care Services

• Initiative to support 

VHA’s Universal Health 

Care Services Plan to:

– Increase access

– Improve coordination and 

communication

– Enable better continuity of care

Patient-Aligned Care Teams
• Patient have more active role

• Team-based Care

• Coordination and Management

– Across team members

– Longitudinally

Patient-Aligned Care Teams
PROBLEM:

With large patient panels, 

how do we appropriately 

target care to the right 

patients at the right time?
Many of these admissions are potentially avoidable 

with coordinated outpatient care

• Affective psychoses

• Heart Failure

• Chronic ischemic heart 

disease 

• Respiratory and other 

chest symptoms

• Pneumonia

• Cardiac dysrhythmias

• Schizophrenic disorders

• Chronic bronchitis

• Alcohol 

dependence

• General symptoms

Top 10 VHA Discharge Diagnoses 2008

Maynard and Fihn, Internet Journal Epi 2010
• Statistical model which reflects estimated 

probability of 

admission or death 

within a specified time period 

(90 days or 1 year)

Care Assessment Need (CAN) Score

0%

(lowest risk)

99%

(highest risk)

Wang, et al. Med Care. 2013;51:368-73.
8 

95th %ile – 39%

96th %ile – 42%

97th %ile -- 49%

98th %ile -- 57%

99th %ile -- 72%

Patients in highest percentile of risk 

have 62% probability of admission, 

30% probability of death, and 72% 

probability of either event
High Risk Patient Identification
PROBLEM:

With large patient panels 

and many clinical team 

members, how do we 

coordinate care?
The Patient Care Assessment System is a 

web-based application 

to provide 

Patient Aligned Care Teams (PACT) 

with 

tools to 

identify, manage, and coordinate care

for their paneled patients. 

Special emphasis is given to high risk patients. 
PCAS

VISTA

CDW

CAN OTHERS

ADMIN

Patient Care Assessment System (PCAS)
PCAS Functionality and Release Schedule

RELEASE

highly desired 

FUNCTIONALITY

implementation

GOAL

1.0

DEC 2013

Champion 

Site 

Training 

and Review 

in Jan & 

Feb, 2014.

• Infrastructure 

• PACT Team management

• Administrative access 

management module

• Panel overview

• Consults

• Patient demographics & 

contacts

• Risk characteristics 

(including CAN)

IDENTIFY 

1. National

awareness of 

PCAS

2. Manage PACT 

teams 

3. Identify highest 

risk patients

4. Track consults
PCAS Functionality and Release Schedule

RELEASE

highly desired 

FUNCTIONALITY

implementation

GOAL

2.0

Pilot early 

2014

• Outpatient encounters

• Discharge summaries 

• Care management tasks 

and notifications

• Query functionality

MANAGE

Adoption for tasks 

and notifications
PCAS Functionality and Release Schedule

RELEASE

highly desired 

FUNCTIONALITY

implementation

GOAL

3.0

Pilot 

August

2014

• Medications

• Problem lists

• Additional clinical and 

vitals data

• Legal documents

MANAGE

Establish routine 

tasks for patient 

management to 

facilitate 

implementation of 

care planning
RELEASE

highly desired 

FUNCTIONALITY

implementation

GOAL

4.0

Pilot Early 

2015

• CARE PLANNING

Service (VA and 

community-based) 

administration

COORDINATE

Adoption of care 

planning

5.0

Pilot Mid2015

• CARE PLAN NOTES

Advanced reports and 

query

• Additional community 

integration (where 

possible)

COORDINATE

Full use of PCAS 

for PACT care plan 

documentation

PCAS Functionality and Release Schedule
RELEASE 1 DEMO
POLL

Do you use any of these tools outside of CPRS 

to help you in your work? (check all that apply)

 CAN scores

 Primary Care Almanac

 PACT Compass

 VSSC

 Other(s)
RELEASE 1 DEMO

Individual 

(Unique) 

Patients

from 

Your Panel(s)




[?] TOOLTIP FOR HOMELESS ITEM

Source: PCP Panel Cube. Updated: Nightly. 

This field indicates if a patient has received 

any VA homeless servicesin the last 12 

months.










Ongoing Evaluation

CHAMPION SITE EVALUATION SUPPORT

• Implementation

• Standards of care

• Specific clinical goals

• Team-Based Care vs

Episodic Care

• Workflow Patterns

• Bugs/Issues/Suggestions! 
ROADMAP

2014 2015

Implementation 

& 

Communication 

Plans

PCS, PACT, ONS

Clinical Advisory 

Committtee

To assess Care 

Management

PCAS 

Requirements
TEAM

• Steve Krysiak

• Sophie Lo

• Indra Gupta

• Tom LaFontaine

• SP Thakur

• Fred Kirkland

• Shawn Loftus

• Elliot Lowy, PhD

• Charles Maynard, PhD

• Haili Sun, PhD

• Li Wang, MS

• PACT Nurse and Provider 

Members of Requirements 

Team

• Stephan Fihn, MD MPH

• Stephen Anderson, MS

• Richard Pham

• Scot Dingman

• Betsy Lancaster, MS

• Susan Kane

• Mary McDonell, MS

• Kathleen Frisbee, PhD(c)
THANK YOU

If you would like to begin using PCAS,

or coordinate training for your

facility or team, please

email me.

Tamara L. Box, PhD 

Tamara.Box@va.gov