Work Role Transformation d

PACT Implementation: Successes and Challen

ges

VISN 4 Center for Evaluation of Patient Aligned Gala True, PhDVISN 23 Patient Aligned Care team DemonstratiS h L S li PhD MPH Samant

h

a L S

olimeo, PhD, MPH

Gregory L Stewart, PhD
How familiar would you say that yo

with the Patient Aligned Care Team ( ) PACT

) model?

V f ili Very familiarS h t f ili Somew

h

at familiar

I’ h d f it I’ve heard 

of it

Wh t’ PACT? Wh

at’

s

a PACT?

03.21.2012 Solimeo, True,

& Stewart “Work Role Transformation”
What is a “PACT” and where did it 

from?

Patient Centered 

Medical Home (PCMH)

+

Veteran’s Health 

Administration

Patient Aligned 

Care Teams (PACTs)

03.21.2012 Solimeo, True,

& Stewart “Work Role Transformation” 

Image credit: http://srd.vssc.med.va
What does a PACT look like?

Clerical Associate

(MSA/ PSA) Teamlet

Provider Clinical P ti t

Teamlet

Associate

(LPN/

LVN)

(MD, DO,

APRN,

NP, PA)

P

atien

t

Panel Teamlet Neighbo

RN Care Mana

ger

Teamlet

03.21.2012 Solimeo, True,

& Stewart “Work Role Transformation” 
PACT Demonstration Laboratorie

1. PACT Demonstration Lab 

Center: Directed by Stephan Office of Analytics and Busine

WA. 

2. VISN 4 Center for Evalua

(CEPACT): Directed by Ra

Philadelphia VA Healthcare SyPA.

3. VISN 11 PACT Demonstr

Directed by Eve Kerr, MD, MPHealthcare System (VAAAHS

4. VISN 20 PACT Demonstr

Directed by David Hickam, MHealthcare S 

System in Portland

5. VISN 22 Veterans Assessm

Improvement Laboratory 

Lisa Rubenstein, MD, MSPH, VA at Sepulveda, Sepulveda, CA. 

6. VISN 23 PACT Demonstr

Directed by Gary Rosenthal, Healthcare System in Iowa Ci

03.21.2012

Solimeo, True,

& Stewart “Work Role Transformation”
National PACT Demonstration Laborat

Support and evaluate the VA Evaluate the effectiveness transition to PACT through effective clinical-research partnerships developed by the 

impacts of VHA’s PACT mApply robust research designmethods in: 

PACT Demonstration Lab Coordinating Center and the PACT Demonstration Labs

Different practice settingsDifferent geographic locationsDevelop and test innovativfor the core com

ponents o

modelEvaluate solutions for effects CostsClinical outcomesPatient and provider experience

03.21.2012 Solimeo, True,

& Stewart “Work Role Transformation”
Overview of Lab Study Areas

03.21.2012 Solimeo, True,

& Stewart “Work Role Transformation” 
Digg g p in Deeper: An Overview

1. PACT provider and team surveys 2. Interviews with PACT providers3. Interviews with RN Care Managers 

(RNCMs) and PACT leaders

4. General trends5. Questions03.21.2012 Solimeo, True, & Stewart “Work Role Transformation” 
Quantitative Surveys

VISN 4• Fall of 2010

VISN 23• Summer 2010, S

• Responses from 211 

Providers

• Responses from 

– Providers

– MD/DO =127 / Other = 84– VAMC = 135 / CBOC = 76

– RN Care Manag– Clinical Associat

– Clerical Associa

03.21.2012 Solimeo, True,

& Stewart “Work Role Transformation”
Staffing Barriers

Percent of Providers Saying Insufficient NumberIn This Role Is a Barrier

Moderate BarrierLarge Barrier 

Personnel PCPs Outpatient

Nurses

Adminis

& Sup

Sta

03.21.2012 Solimeo, True, & Stewart “Work Role Transformation” 

Source: 2010 VISN4 CEPACT 
Stressful Work Demands

Percent of Providers Agreeing with Statements 

AgreeStrongly Agree 

Staff 

Frequentl

y

Clinicians 

Frequentl

y

Practice

Is Experienc

Overwhelmed

By Work Demands

Overwhelmed

By Work Demands

As Stressfu

03.21.2012 Solimeo, True,

& Stewart “Work Role Transformation” 

Source: 2010 VISN4 CEPACT 
General Work Perceptions

5 534

Series1Series2Si3

ProviderRNCM

34

2

Series3Series4

ClinicalClerical

23

1

J b S f

2010 2011

E

2010 20

1

J

ob Satis

faction

Empowerment

General level of satisfaction with 

getting what is wanted out of job

Psychological feeling that wo

meaningful and significant & au

03.21.2012 Solimeo, True,

& Stewart “Work Role Transformation” 

Source: 2011-12 VISN 23 PACT Demonstration 
Engaging Role Characteristics

5 534

Series1Series2Si3

ProviderRNCM 3

4

2

Series3Series4

ClinicalClerical

2

Skill Variety

2010 2011

Role Fit

2010 20

1 1

Skill Variety

Extent to which the job requires 

various and complex skills

How well the role fits the s

abilities of the perso

03.21.2012 Solimeo, True,

& Stewart “Work Role Transformation” 

Source: 2011-12 VISN 23 PACT Demonstratio
Challenging Role Characteristics

5 534

Series1Series2Si3

ProviderRNCM 3

4

2

Series3Series4

ClinicalClerical

2

Rl O l d

2010 2011

R l C fl

2010 2

1 1

R

ole Overloa

d

R

ole Conflict

Feeling of being asked to do too much Feeling of having incompa

requirements and poor guid

03.21.2012 Solimeo, True,

& Stewart “Work Role Transformation” 

Source: 2011‐12 VISN 23 PACT Demonstration 
Quantitative Survey Summary

• Staffing is major concern of 

teamlets

• Transitionin

g to PACT creates work stress 

everyone

• Providers report having a difficult role both 

and during PACT transformation 

• Transition to PACT is particularly stressful 

Care Managers

• Cl i l A i t lik l d tili d Clerical Associa

tes are likely un

derutilize

d

03.21.2012 Solimeo, True,

& Stewart “Work Role Transformation” 
Digg g p in Deeper: An Overview

1. PACT p y rovider and team surveys 2. Interviews with PACT providers3. I i i h RN C M Interviews with RN Care Managers

(RNCMs) and PACT leaders

4. General trends5. Questions03.21.2012 Solimeo, True, & Stewart “Work Role Transformation” 
VISN 23 PACT Provider Early Adopte

“There is some cynicism that [PACT] is the way o“There is some cynicism, that [PACT] is the way o

providers to work [harder] --to take care of mo

“I think most of the people in the group have a sense of everybody buys into the VA as a whole, and taking care population. ... Now, I think one of the things that helped buy

-in was in the past some idea would come down from 

in was in the past some idea would come down from 

and would just say, “Here: Do this with what you’ve got.” this collaborative came with warm bodies. ... So that dieasi t b ier t

o buy-i f th b i i thi ki th t “ h 

in from th

e beginning, thi

nking th

a

t, “yeah 

do some of these ideas. We know there’s going to be moinvolved but there are [more] people involved.”03.21.2012 Solimeo, True,

& Stewart “Work Role Transformation” 
Hierarchy;

Working 

independently

wo

independently

Filling appointment 

slots Pan

A

Face-to-face 

encounters

te

digi

03.21.2012 Solimeo, True, & Stewart “Work Role Transformation” 
Delegation Is Integral to PACT

Connecting the dotsTrustInstitutional support03.21.2012 Solimeo, True,

& Stewart “Work Role Transformation” 
“Oh h i ll d i h if ’ “Oh, what i

t

all comes down to i

s

t

hat if you’re

going to make PACT work, your providers have to buy into it. ... And they have to do access clinic They have to manage their panels clinic. They have to manage their panels effectively. And they don’t do that: They’re not willing to do that. And unless they’re willing to do that there that, there s no time for anybody to do anything ’s no time for anybody to do anything but see patients. And so that’s their excuse for not doing anything, because they’re spending all their time seeing patients

”

03.21.2012 Solimeo, True,

& Stewart “Work Role Transformation” 
“Access is something that we are working really h d ar 

scrub my schedule the week before. So yesterday I d

week and identified 7 or 8 people that maybe don’t n

So our access is definitely improved. Before I started 

overbooked—gosh, almost every day I had an extra 

a 4:00 ( ) chuckles) p , atient, and that was a bit overwhe

haven’t been overbooked in the last couple weeks sin

scrubbing. Just to open up—even if it’s just 2 or 3 app

week—it does help. So that has been a huge benefit benefit 

for the patients because they’re getting in right away

03.21.2012 Solimeo, True, & Stewart “Work Role Transformation” 
“The other thing I really think is [important] [important] and it s’ happening happening slowly

providers to buy in to the use of their care managers and the pharma

team, because that could change their workload so much if they just 

members. members. That s’ a huge, huge part and if they stay in their silo and ar

any of that help, they’re just going to continue to practice medicine lik

they’ll get burned out and frustrated and won’t like what they’re doin

move into handing something off to a nurse manager that you’re not 

that that nurse will go ahead and follow that protocol verbatim. Tha

time to build up that trust with a nurse, because you as the provider a

responsible, but the care manager should be making you a co‐signer, 

conversation with you at all times and not making any changes. So, I 

thing there is getting that trust built between the nurse and the provigoing to be following protocols there has to be very good buy‐in from 

involved before you even start that process. ... I know myself, there’s c

within our building that I will just handle things myself, because you blevel and I don’t think [that issues is] going to go away.”

03.21.2012 Solimeo, True, & Stewart “Work Role Transformation” 
“I think PACT’s a good idea, 

the concept is there that it’s the ground level that have to the processes to really changbig thing is that administrat

idea how to work with team

they do, they [do it by] askin

paperwork. That’s the last th

needs. Once in a while they’

around [on the floor], but th

everything.”

03.21.2012 Solimeo, True, & Stewart “Work Role Transformation” 
“I think you need to sit down and, and look 

parameters. ... . For example, our performa

based on percent of appointment slots ope

month. We’re being assessed from a measu

actually can’t see in an easy way and we’re information about another access measure

don’t necessarily understand. ... I think not 

administrative goals aligned with the provi

This is the way that we had problems befor

when we started open access that problem 

evident in that if I opened up slots then tho

taken up by patients for other providers. An

automatic disincentive to try to open up an

you j t us work h d ar er and you’re never goin

enough slots to take care of all the patients 

03.21.2012 Solimeo, True, & Stewart “Work Role Transformation” 
Digg g p in Deeper: An Overview

1. PACT provider and team surveys 2. Interviews with PACT providers3. Interviews with RN Care Managers (RNCMs) 

and PACT leaders

4. General trends5. Questions

03.21.2012 Solimeo, True, & Stewart “Work Role Transformation” 
Care Coordination and Nurse Care C

Care Managers (RNCMs) and Ma

Focus opatient

•Id 

•M•C

Im

prov

Which PACT processes most involve RNCMs?

•Pr•C

Improv

b t 

RNCMs?Which PACT policies affect 

b

e

twee

•In•Sp•Br

professional/team roles of RNCMs?H d RNCM f l b t PACT? How d

o RNCM

s feel a

bout PACT?

What might be in store for RNCMs as PACT implementation moves forward? 

03.21.2012 Solimeo, True,

& Stewart “Work Role Transformation” 
How Does a PACT “Do” 

Care Coordination? 

3⁄4Team members working at “top of license;” patient sees most appropriate team member 3⁄4Develop and implement RN medication protocols3⁄4 Coordinate hospital & community resources, involve family when needed3⁄4Call (some) patients within 72 hours of discharge from inpatient care3⁄4C t t ( ) ti t ithi 24 h f ED i it Con

tact (some) patien

t

s

withi

n 24 hours

of ED 

visit 

3⁄4Create and maintain “high risk registry”3⁄4Offer alternatives to single provider, face Offer alternatives to single provider, face

-to

-face care 

(e.g., shared medical appointments, telephone appointments, secure messaging)

03.21.2012 Solimeo, True,

& Stewart “Work Role Transformation” 
“It s a completely different approac

’s a completely different approac

“(With) t ’ t j t l “(With) care management... you’re not just loothe patient medically. You’re really supposed to the whole p y erson as a whole. You really should looking at the patient from a social, financial, mecaregivers view. You should be looking at the wsystem in order to make it go.Because if you treat a patient let Because if you treat a patient, let s say ’ that has , that has Alzheimer’s and you don’t look at their family uyou’re really missing a lot. So we’re trying to reprocesses di h h h ll h to coordinate the care through all thcontinuums.” (RNCM on a pilot team)03.21.2012 Solimeo, True, & Stewart “Work Role Transformation” 
Clinical Nurse Leads and RNCMs o

Teams Expressed Initial Excitemen

Opportunity for 

RNCM role 

familiar to some 

f j b 

RNCMs to take 

initiative, 

t 

CC

path

highe

from j

o

b

s

outside VA

grea

ter

collaboration & 

teamwork

highe

care

enga

03.21.2012 Solimeo, True,

& Stewart “Work Role Transformation” 
Initial Excitement Tempered by: 

3⁄4Resistance/push back from some team memb & l d hi bers & lea

dershi

p

3⁄4Concern over potential negative impact on RNs,, ( burnout, loss/turnover 

(and 

barriers to placing new hires in a timely manner)3⁄4L k f l l it l di t t i & Lack 

of role

clarit

y leading t

o tension & 

mistrust between team members3⁄4Desire for 

g g reater direction & 

guidelines 

from VA Central Office3⁄4Questioning feasibility of full i l i f HRR & bili ‘ l implementation

of HRR & 

ability to ‘scale

up’ given staffing03.21.2012 Solimeo, True,

& Stewart “Work Role Transformation” 
Two Views on Change 

Q: How has your day changed? “How has your day changed?

” Q “D thi k 

A: “It’s more busy... we are constantly 

on the phone. People are walking 

in because with this new approach 

Q: “D

o you thi

nk you

to do (care managemuch as you do?”

A: 

“I have to tell you t

in, because with this new approach, we have opened up our days to what we call walk-in patients. People are being seen on the same d f th i bl th 

A: I have to tell you t

know. You have to the people that wothis department, ha

day

of th

eir problems, so they are

happy with that. People who are scheduled, we have a certain slot for that, and 

peo

ple who need 

this department, hahere a long time, I’27 years, and I’m nemployee, age wise

f h l h 

p p urgent attention, we are keeping 

some slots for that. So everybody gets the right attention in a timely manner We’ve done this (PACT) 

of 

t

hese people hav

things here for a lotime... Change is h

manner think it’s a different 

. We ve done this (PACT) by making a schedule. “(RNCM on pilot 

team)

think its a different nursing. “ (RNCM on p

03.21.2012 Solimeo, True,

& Stewart “Work Role Transformation” 
Reflections on 

What the Future Might Bring

9 Success in one area (e g 

Success in one area (e.g., demand) leads to openingareas 

9 F li h 

Frontline teams have cominnovative approaches; (eat LPN role, realigning RNoth i li ) her service lines) 

9 Clarification of roles, pro

training, p standardized polwould ease stressors on and conflict between team 

9 New hires can receive PA

from the start

03.21.2012 Solimeo, True, & Stewart “Work Role Transformation” 
“I find it really rewarding”

“I I’ b d i i i lik th l ‘“I guess I’ve been doing primary care since, like, the early ‘

gotten kind of bored with it just doing reminders and tthat. You’re familiar with that [in the] VA system. And slove it (care management) I guess I feel like it just enablove it (care management). I guess I feel like it just enabhelp patients in ways that we haven’t been able to do s

O i f i h l i Th i One patient of ours is a heart transplant patient. The socia

our PACT) was able to get infusions (for him) until a heavailable. And then he had a successful heart transplantbecause I had been in communication so much with the transplant nurses from [name of university hospital] anworker and the diabetic educator and everything, I was things in really a very concise good format to just show things in really a very concise, good format to just show what had been done, what his needs were, what his meAnd so everything just came to fruition.” (RNCM on a pilo

03.21.2012 Solimeo, True, & Stewart “Work Role Transformation” 
Digg g p in Deeper: An Overview

1. PACT provider and team surveys 2. Interviews with PACT providers3. Interviews with RN Care Managers 

(RNCMs) and PACT leaders

4. General trends

5. Questions03.21.2012 Solimeo, True, & Stewart “Work Role Transformation” 
The View from Here

• Team members are called upon to change quickly on a variet

but success is mediated by variations in capacity, resources & 

• Role transformation is a ‘double-ed

gp 

ed sword’: 

promise of in

satisfaction & professional development but demonstrated inworkload & burnout;

• PACT implementation hinges upon effective organizational in

PACT implementation hinges upon effective organizational, inand clinical skills-- training in these areas should be tailored alevel; 

• Ongoing success requires the engaged support of administra

leadership:

• Despite perceived increases in workload demands enthusias

Despite perceived increases in workload demands, enthusiasand for Veteran care remains high. 

03.21.2012 Solimeo, True,

& Stewart “Work Role Transformation” 
Acknowledgements: 

VISN 4 Center for Evaluation of Patient AligneTeams (CEPACT)O i ti rganizations CEPACT • Philadelphia VA Medical Center• Center for Health Equity Research and 

CEPACT • Rachel Werner, MD Ph

Director)

Promotion (CHERP)

• University of Pennsylvania• VA Healthcare-VISN 4 Offices

• Judith Long,, MD (CEPA

Director)

• Judy Shea, PhD 

• VISN 4 Medical Centers• Office of Patient Care ServicesIndividuals 

• Anneliese Butler, MSS

• Anne Canamucio, MS• Jennifer Gutierrez, MA Individuals 

• Michael Moreland , FACHE• David Macpherson, MD

J Sk k MHA

• Bozena Lamparska, ME• Michele Lempa, DrPH• Mary Pelak, MSW • Jen Skoko, MHA

• PACT Implementers at VISN 4 sites

y ,

• Debashree Sengupta, B

03.21.2012 

Solimeo, True, & Stewart “Work Role Transformation”
Acknowledgements: 

VISN 23 PACT Demonstration Lab Formative Evaluation Core

VISN 23 P ti t Ali d C T D t ti L b t D t t f V t Aff i VISN 23 Patient Aligned Care Team Demonstration Laboratory, Department of Veterans Affair

Healthcare System, Iowa City, IA

• Nichole Carroll, BA; Research Coordinator

• Michelle Lampman, MA; Associate Director of Operations

• Sarah Ono, ; PhD Director of the Qualitative Core

• Monica Paez, BA; Qualitative Core Coordinator

• Jenna Reishus, BA; Research Assistant• Gary Rosenthal, MD; Director• Kenda Stewart, PhD; Health Research Science Specialist

VISN 23 Primary and Specialty Medicine Service Line• Jaime Bland, MS, RN; HPDP/PACT Coordinator, Omaha VA Health Care System, Omaha, NE.

• A. Christine Emler, MD; Physician, Lincoln, NE

• Sally Frohn RN BSN CPHQ; Sally Frohn, RN, BSN, CPHQ; Administrative Officer Department of Vetera Administrative Officer, Department of Veterans Affairs ns Affairs VISN 23 Lincoln Office Linc

, VISN 23 Lincoln Office, Linc

• Marsha Herke, MPH, RD; Assistant Administrative Officer, Department of Veteran Affairs, Minneapolis VA Health C

• Michael Koopmeiners, MD; Medical Director, Department of Veterans Affairs, Minneapolis VA Health Care System, 

• the instrumental participation of the VISN 23 PACT Collaborative team members.

Center for Comprehensive Access & Delivery Research and Evaluation (CADRE), Department 

Iowa City VA Healthcare System, Iowa City, IA; 

Iowa City VA Health Care System, Iowa City, IA; and theOffice of Patient Care Services.

03.21.2012 Solimeo, True, & Stewart “Work Role Transformation” 
Note:

Th d h The views expressed in this presentatiothose of the authors and do not necessreflect the position or policy of the Dep

of Veterans Affairs or the United States 

government.

03.21.2012 Solimeo, True, & Stewart “Work Role Transformation” 
Digg g p in Deeper: An Overview

1. PACT p y rovider and team surveys 2. Interviews with PACT providers3. I i i h RN C M Interviews with RN Care Managers

(RNCMs) and PACT leaders

4. General trends5. Questions03.21.2012 Solimeo, True, & Stewart “Work Role Transformation”