**Transcript of Cyberseminar**

**Patient Aligned Care Teams (PACT) Demonstration Labs**

**Building the Foundation for PACT in a Large VA Academic Medical Center: Access and Continuity for Part-time Providers**

**Presenters:  Jane Forman, ScD, MHS; Ann-Marie Rosland, MD, MS**

**June 19, 2013**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact:  jane.forman@va.gov or**ann-marie.rosland@va.gov**.*

Moderator:We are at the top of the house so at this time, I would like to introduce our speakers. Speaking first, we have Dr. Jane Forman. She is a research scientist at Ann Arbor VA Center for Clinical Management Research. Joining her speaking second is Dr. Ann-Marie Rosland. She’s a Research Investigator, Ann Arbor VA Center for Clinical Management Research and also Assistant Professor in the Division of General Internal Medicine at the University of Michigan Medical School. We really appreciate both of them joining us today. And at this time, Jane, are you ready to share your screen? Let me unmute you real quick so you can answer that question. Thanks for your patience, everybody. Okay, Jane, are you ready to share your screen?

Dr. Jane Forman:Yes, I am.

Moderator:Great. I’m going to turn it over to you right now. 

Dr. Jane Forman:We just lost our... Oh, we got it. Just one minute. Okay, great. So good afternoon or morning, everybody, depending where you are. Thanks for being with us today. In my talk, I’m going to share with you findings from qualitative interviews and optimizations that we did with providers and staff at a VA academic medical center during early PACT implementation. I lead the implementation evaluation group of the PRIISM Demonstration Laboratory in Ann Arbor, one of five demo labs funded by the VA Office of Patient Care Services to evaluate PACT. The other four labs, which some of you are familiar with, are VISN 4, 20, 22, and 23. 

I’d like to start with some audience poll questions to get a sense of who’s in the audience. The question is how are you involved with PACT implementation. And the responses are involved in PACT implementation at an academic medical center, not at an academic medical center; you are a research whose work relates to PACT, other, or not involved with PACT implementation.

Moderator:Thank you very much. So for our attendees, you do see a blue screen right now and please click on the circle that best represents your answer for the question. Once you have clicked n the circle, click submit. We do already have 60% of our attendees that have voted and answers are still streaming in so we’re going to give everybody a few more seconds to make their option choice. While we’re waiting, I just want to mention that some attendees are raising their hand. I cannot unmute you. If you have any question or concern, please type it into the control panel on the right hand side of your screen.

And with that, I see that over 68% have already voted so we’re just going to go ahead and close the poll now and I’m going to share the results. And Jane, if you want to talk through them real quick, you may go ahead. 

Dr. Jane Forman:Okay. Well, it looks like there are a lot of people on the line who are involved in PACT implementation in academic medical centers, which is terrific. I’m really glad you’re able to make it and there are a variety of other folks and welcome to everyone. 

Moderator:Thank you very much. And give me just one second. I’m going to close the poll and turn it back over to you.

Dr. Jane Forman:Okay. Here we go, great. All right, so first, I wanted to give you some background. The literature on implementation of the Patient-Centered Medical Home has focused mostly on relatively small practices in non-academic settings. There is little in-depth evaluation of PCMH implementation in larger, more complex settings. Out of 152 VA primary care clinics housed in medical centers, 80% are academically affiliated. Our purpose was to better understand how the academic context and large clinic size affects PACT implementation.

So let me give you details about the Ann Arbor VA Primary Care Clinic where we did our study. The clinic has over 20,000 patients and 20 teamlets, which are small interdisciplinary groups that consist of one primary care provider full time equivalent, one registered nurse, one licensed practical nurse, and one clerk who work closely together to deliver care to a panel of patients. In Ann Arbor, there are 70 PCPs and residents that comprise 20 full time equivalent employees, and this has been a big issue for us as team. So 80% of the PCPs worked less than 16 hours a week, 30 residents work four hours a week. The residents, there is an average of 3.5 PCPs per teamlet and the residents are distributed across teamlets with at least one resident per teamlet. Residents care for about 15% of clinic patients.

The clinic was dealing with a lot of growth, both in staff and patient population during early PACT implementation and still today. As you can see from April 2010 to April 2013, the patient population grew 42%. Non-physician staff, to meet the mandated three-to-one staffing ratio, moved 126%. And the number of physicians to keep up with patient growth would be 21%. So staff transformation was occurring in the context of rapid change.

Our methods are the following. We collected data from January 2011 to March 2012. And to understand the experience of PACT implementation from those directly involved, we conducted 33 open-ended, in-depth interviews with key informants at AAVA, which is the Ann Arbor VA. The topics included knowledge and attitudes toward PACT, communication among physicians and staff, and main challenges to implementation. We also observed RNCM, which is RN case manager staff meetings, in which the nurses talk about policies, changes in work roles and responsibilities, new work caps and other issues that arise in day-to-day work. We conducted qualitative content analysis of the interview transcripts and field notes using two frameworks, which I’ll describe. 

The first, and dominant, framework we used for analysis was the Consolidated Framework for Implementation Research or the CFIR. It provides a framework of construct to understand contextual factors that affect implementation of the programs in this case, PACT. Based on our preliminary reading of the data, we identified five prominent constructs that we saw in the data. I will use the construct to organize the findings in this presentation. Oh, there are not five, there are four. 

The definition of these constructs. First, compatibility, which is how the intervention – in this case, PACT – fits with existing workflows and systems. Second, available resources, the level of resources dedicated. Third, networks and communications, the networking quality of social networks and informal and formal communications within an organization. And finally, access to knowledge and information, which is ease of access to digestible information and knowledge about the intervention and how to incorporate it into work tasks. And you’ll see these constructs come up during the presentation.

The second guiding framework was a schematic that identified essential elements of PACT implementation in VA. The diagram shows the foundation with pillars built on top of it. It became clear early on in our analysis that specific elements of part of the foundation – mainly, resources down here – particularly staff and space, were especially important to successful PACT implementation in the clinic. So that is part of the foundation.

On top of the foundation stands three pillars that represent PACT goals and the redesign of roles and work processes integral to achieving them. For example, if you look at the Access pillar, an important process for increasing patient access is for teamlets to understand each member’s scope of practice so PCPs and other teamlet members can delegate appropriate tasks and open up more face-to-face visit slots to achieve same-day access. 

The idea of the importance of a foundation came from this diagram and from the way leadership has conceptualized implementation. What it meant that teamlets could not be formed and moved into the pillar in absence of a solid foundation. A member of the leadership team told us if the foundation isn’t built, then you can’t have anything on top of it and expect it to be functional.

So first, in terms of compatibility or how the intervention fits with existing workflows and systems, the PACT Model was, in many ways, incompatible with the preexisting care delivery system. The clinic was organized into four large teams, each with an average of 15 PCPs in residence, two RNs, two LPNs, one clerk, each responsible for about 3,500 patients. In the team model, two RNs got input from all the PCPs on the team and had to work together to respond to them. LPNs were outside the team, mainly checking in patients for just about all providers in the clinic. These teams had to be reorganized into 20 teamlets in one RN, one LPN, one clerk worked collaboratively with an average of 3.5 providers. And then the leadership team noted that forming teamlets with part time providers and residents was out of the norm and more difficult. And she said, “You’re linking up one nurse, one LPN with one document, very different, and that’s in smaller clinics with full time providers. And that’s very different from linking up with at least two or up to five or six docs that are on different half days. It’s a very different model.” So this is what the clinic was dealing with in terms of reorganizing staff and work. And it wasn’t until May 2011 – I jumped the gun here – that teamlets were formally applying and another year and a half before teamlets were able to start getting into the pillar with a few exceptions. 

So in addition to compatibility, there challenges associated with available resources or the level of resources dedicated for implementation. As you may recall, the staff needed to be more than doubled. There were several factors that made this process difficult and prolonged. First, leadership, who were already stretched, had to devote a lot of time and resources to the hiring process – that’s working with HR, interviewing people, making final selections, doing the paperwork. And she said, “That’s taken a huge amount of time.”

Second, PACT implementation requires rapid changes in roles and responsibilities, and that created a lot of stress. This made hiring and retention more difficult, even though most staff were positive about the concept of PACT. “We all think the concept’s good. But right now, pretty much the RNs are really in an uproar. We have four out of 12 leaving.” 

So stepping into this environment, its’ especially difficult for new hires and especially those who came from outside primary care. “We’ve hired some excellent non-primary care nurses. Two of them have both said very clearly that they didn’t realize how hard this work was.” 

So it’s taken a long time to hire sufficient staff and the staff shortage, delayed teamlet formation, requires staff to cover vacancies in other teamlets and that disrupted workflow and it was a barrier to staff working at the top of their license. You can read the first two points but I’m going to talk about the third. And this is an example of not working to the top of license. The LPNs spent most of their time checking in patients for many PCPs and not doing more advanced tasks and coordinating patient care within a teamlet. An LPN told us, “We check the patient in. All we do is take the vitals and go sit down. And if we have this all set up – meaning if we have tasks set up – the patient gets better contact with you. He knows you’re his nurse.” And so this LPN was really hoping to be more integrated into the teamlet and do more advanced work. And the delay in having LPNs do that actually caused a lot of dip in morale, which has since improved but it was a difficult thing to manage at the time.

The next thing I’ll talk about is space, which was another scarcity for us, in addition to staff. The leadership described their efforts to procure adequate and well-configured space as “scavenging.” And that required taking advantage of opportunities presented when other services relocated or moved to newly constructed space. And a nurse described the situation with, “not being co-located, as just wandering around the halls looking for each other.” Which you can imagine what would that do to efficiency and being able to adjust to patient needs quickly.

The second thing about space, the lack of co-location was a barrier to bringing care to the patient, which is an important part of patient-centered care. An LPN said, “I think being co-located will help the Veterans move through the clinic a little quicker. Right now, to get an EKG, patients have to go to the Clerk window, have a seat, then come back out and call them. The doctor could just come in and say, ‘This patient needs an EKG.’ I could just come right into the room and do the EKG and then continue on.” 

The third issue with space is that there was no stable space for RNs and they regularly got kicked out of rooms and had to move around the clinic.

Now we come to the third CFIR construct, which is Networks and Communications or the nature of quality of formal and informal communications within an organization. Not surprisingly, when we look at communication among teamlet members in clinics, it’s an intimately related space. Remember, the teamlets were not co-located and so communication was actually a really, really difficult issue. Another thing that made it more difficult was the need to schedule a changing roster of part-time PCPs and residents so that the rooming schedule was really kind of an unsolvable puzzle. With the space available, it was really hard, and communication was thwarted. A member of the leadership team said, “We have so many docs from a given team in clinic that you may be 200, 300 feet away from your nurse so that direction communication where you can just walk out of the office two feet away is somewhat limited.” Not only did team members work at a distance from each other, it was also difficult to reach, particularly, nurses via telephone because of the unstable space.

Finally, staff had to deal with multiple modes of communication from multiple providers. So you can see where people could spend a lot of time trying to communicate with each other. 

The second big communications issues was that residents were not often in clinic. They were there four hours a week, and still are there four hours a week and communication is often delayed. So an RN said, “The biggest group of people that we have trouble communicating with are the residents because they’re not here very much and have other obligations.” 

Also, when residents were offsite – and this is one of the reasons they were so hard to communicate with – they had to deal with multiple and difficult to access communication systems. And they had to check CPRS to get alerts when they were at the university. They didn’t do that very often and they also had trouble with going through CITRIX. So they were hard to reach.

Also, they felt they had no clear point of contact with the teamlet. And one of them said, “If I get a message from a nurse of somebody within the team through CPRS, I don’t always know who I’m supposed to direct that to.” 

The last construct I’ll talk about is Access to Knowledge and Information, and this has to do with training. The challenge of training staff on the PACT model wasn’t limited to residents. Oh, I’m sorry; I’m on the wrong page. I’m backing up.

Okay. So what I have to say about this is that this slide should also have the subtitle, “Residents Not Often in Clinic.” Just like the previous slide about communication. Having very limited clinic hours limited residents’ ability to learn how to learn about and work in the PATH model. In CFIR terms, access to digestible information, knowledge about PACT, and how to incorporate PACT into work tasks was difficult. It was difficult to leverage the resident-mentor relationship for PACT education because many physician mentors themselves had limited clinic hours. A member of the leadership team said, “The mentors can educate them on heart failure, lung disease. What they have a harder time doing is educating them on practice management. They don’t live those things themselves.” 

Also, residents were occupied with the clinical curriculum. “Our heads are spinning in terms of like trying to know what’s going on in our residency program.” And it was also difficult for residents to attend meetings. They were finishing up with patients at 12:30 and they’d have to leave right away and that’s when the meetings took place. So it was really difficult for them to do that.

Second aspect that’s a challenge is information was, in addition to residents, it was challenging to train the rest of the PCPs and staff. First of all, the staff was very large. “Because we’re an academic medical center, we have almost two, three, four times as many people to educate about this program as hospitals that are not academic.” That’s a member of the leadership team said that. It was a challenge to train many new staff in the midst of rapid change and a challenge to train new nurses who came from outside of primary care. 

Finally, because teamlet formation was delayed, national teamlet training had been discontinued before more AAVA teamlets were formed. There were actually a couple who were able to attend the national training and it was very beneficial for them.

So let’s fast forward to 2013, which is now. Where are we? Since we collected these data a year and a half to two years ago, in terms of teamlets and staffing, we have 20 teamlets formed and functioning with almost full staffing. Recently, leadership hired float nurses to cover teamlets when nurses are on annual leave or sick leave, which they get a lot of. This should improve workflow and access. 

Second, co-location and communication has improved with the incremental addition of, and reconfiguration of space. But there’s still a challenge, especially communication with residents. There is heavy use of instant messaging and staff are very enthusiastic about it and at times, it’s very difficult.

On the subject of training, now that there are functional teamlets that can implement new processes, leadership has recently developed the PACT Training and Coaching Model, which is aimed at engaging all staff and especially part-time providers from coaching sessions with each teamlet. The sessions are helping teamlets get into the nuts and bolts of implementing new processes – sorry – specifically aimed at improving access and continuity. It’s still really difficult to include residents and they have not been included. I’m sure you’ve seen a common theme here, which is that it’s really difficult to integrate our residents. And we’re present evaluating this coaching process.

So I’ll stop here just for a break before my final slide to take another poll. The question is if you are implementing PACT in an academic medical center, what are the main challenges you face? And please check all that apply. I wish we had a write-in option here but unfortunately, we don’t. I guess maybe you could put a few things in a comment if you want to.

Moderator:Yeah, if people would like to, feel free to write in using the write-in section on your dashboard. If I get a couple, then I will intervene and read those aloud. But otherwise, just try to answer with the options we have. So those options are staffing, space, communication, training, or other. And there are quite a few people answering. Almost half the audience have voted but answers are still streaming in, so we’ll give people a few more seconds. And just as a reminder, please write in any questions or comments you have and we will get to those at the end of the session. 

Okay, looks like the answers have stopped streaming in. I’m going to close this and share the results. And Jane, feel free to talk through them real quick.

Dr. Jane Forman:Well, this is kind of what I expected [interruption] all that applied because I think a lot of these issues are very common to academic medical centers, and this is actually helpful to see how valid our study was. But I think a lot of the academic medical centers are struggling with the same thing. And also not surprised to see space come out as a really big issue because I’ve heard that across the demonstration lab and at other venues. 

So here are the conclusion and recommendations. Large academic medical centers face special challenges in implementing the PACT model. Building the foundation to support functioning teamlets was complicated by having residents and PCPs with limited clinic hours – and you can see the kinds of things that they affected. Inadequate space was a big problem and it was intimately related to communication challenges. 

So our recommendations are the following. First, it’s important to focus on space and to establish technological means of communication. Second, it’s important to develop strategies to engage part-time PCPs and residents in the PACT model, and to train all staff early in important. And as we’ve seen, this is easier said than done, and it’s something for us to study and understand how to do. And I think that some places are already trying to tackle that. Third, think creatively about staffing models. And fourth, we need to better understand how clinics with chronic staffing shortages can successfully implement PACT.

I just want to leave you with this last thought. So although the time it took to build the foundation was considerable, it has proven essential here in Ann Arbor. With functioning teamlets in place and the coaching model implemented, the clinic is now seeing more rapid uptake of work processes needed to provide true patient-aligned care, and have seen improvement in access and continuity metrics.

So I’d like to acknowledge my co-authors listed here and give a thanks to the Ann Arbor VA Primary Care Management providers and staff. And to Eve Kerr, who was the Principal Investigator of our PRIISM Demo Lab and the Director, Center for Clinical Management Research. Thank you.

Moderator:Excellent. Thank you very much. We had a lot of good questions come in during your presentation and we will get to those at the end of the session. So at this time, we’re going to turn it over to Ann-Marie Rosland and keep on going.

Dr. Ann-Marie Rosland:Hi, everyone, this is Ann-Marie. I am also one of the investigators at the VA Ann Arbor Center for Clinical Management Research and I also work with the VISN 11 PACT Demo Lab. I am going to talk about a couple of phenomenons that Jane mentioned that are specific to academic centers and also many other VAs, especially VAs that are a center of their region or facility. And that is having a lot of providers who are part-time or partly available in the primary care clinic. And as you heard from Jane, that raises the challenges in meeting some important PACT goals – you know, what she called moving into the pillar. So working on improving access, improving continuity with an assigned PCP and really enacting care coordination and panel management. 

And so to demonstrate how that can be a challenge – and this talk I’m going to focus in on how the performance measures are used to measure PACT’s access and continuity are effective when a clinic has a lot of part-time PCPs. 

So quickly, I’m going to expand our viewers for a moment outside of the VA and point out that the phenomenon of physicians working part-time is very common and rapidly increasing. So a couple years ago was the last data I could find; 22% of men and 44% of women physicians work part-time – again, this is overall in the United States. And most of those, or many of those, are in primary care specialties – family medicine, internal medicine. And one important point is that in multiple studies, being a physician who worked part-time is associated with having less burnout in your job and higher job satisfaction. Similar or slightly greater productivity per hour so the important point is that productivity is not decreased. And similar process performance, meaning important clinical processes like order cancer screening tests, appropriate labs, things like that, process performance was similar between part-time employees.

So as far as meeting productivity and clinical goals, there doesn’t appear to be a disadvantage to having part-time physicians in the clinic.

Now I don’t have the specifics on what percentage of VA primary care physicians are part-time. And really, I want to point out that when I’m saying “part-time,” I’m meaning people who are personally available in primary care clinic. And this happened in VA facilities for many reasons. So you’ll see some people, they just work part-time, they work less than 40 hours a week. Other people are full-time but they spend part of their week in administrative duties, which are very important and are increasing in importance due to trying to meet some of the PACT goals that administrators work toward like organizing teamlets, providing panel management. Some primary care physicians work part-time in areas of the hospital or center that are not primary care so network in urgent care and inpatient floors. Some physicians spend part of their time doing research, teaching, and some are trainees or they’re mentoring trainees.

So I will enter my first – only – poll question, which I’m curious what type of part-time availability doctors people on the call have experience with. So the question being asked is primary care providers work part-time in our primary care clinic for the following reasons. Check all that apply. So work part-time hours overall, work part of the time in administration, work part of the time in another clinical area, research part of the time, or teaching and mentoring part of the time. 

Moderator:Thank you very much. This is our third and final poll question. We do appreciate answers from the audience as it helps guide the rest of the talk. It looks like we’ve had just about 40% response rate so far and we’ll give people a few more seconds to get their answers in. So once again, thanks for your participation in this.

Okay, looks like we’ve capped at 41% so I’m going to go ahead and close the poll and share the results and you should be able to see those now, Ann-Marie.

Dr. Ann-Marie Rosland:Okay, great. So it looks like for a lot of the attendees there are physicians in their clinics who also work part of the time in administration. And like I said earlier, that could mean partly that they’re working in enacting PACT in various ways. Also many work part of the time in another clinical area and then also, there are a lot of physicians that work part-time overall. So it looks like there are physicians that work in all of these ways represented here, to a large degree.

Okay, great. So I’ll just quickly revisit this model of PACT that we’ve seen already. And I just wanted to point out that access, so as we build the foundation of PACT and moved into the functions of PACT, two of the key goals are to increase patient access and to increase – and I’ll circle it over here – continuity. And previously in the past, a lot of centers had taken a step of assigning patients to a specific primary care physician and limiting panel sizes, especially for physicians that were part-time in clinic to a size that’s proportional to the time that they’re there. And then we had started to implement, open or add advanced access techniques. 

So those methods you could access were already going on and some of the newer methods that are emphasized by PACT are newer appointment types; for instance, telephone appointments or care by instant messaging, and visits with other members of the teamlets like the nurse care manager or the pharmacist. So I wanted to mention that here because that will become relevant to our discussion about how performance measures might be adapted to those PACT goals.

And finally, I just want to make sure that everyone has in the back of their mind what a teamlet is. Again, normally, it would be, from the model, it would be one full-time provider assigned to 1,200 patients with one RN, LPN, and clerk. At the sites that we examined – and I expect many other sites would be something similar – the provider is assigned a panel size that is set to 120 patients per half day per week that they’re in clinic. So for example, if I’m in clinic two half days per week, I would be assigned a patient panel of 240 patients. 

So what are the performance measures that are emphasized in PACT? Many of you are familiar with Compass, which collects data on how... various data that describes how clinics are doing related to access and continuity among other PACT goals. The active measure that’s really emphasized in Compass and in PACT performance measurement, in general, is the percent of requests for same-day appointment accommodated that same day of the patient call or the next day. And I think the key thing is that they only count for this measure if they are completed with the patient’s assigned primary care provider.

We look at continuity. What we're talking about with continuity is the percent of appointments overall completed the patient’s assigned PCP. Now the emphasized continuity measure in the past Compass includes in the denominator – so among the visits that are looked at – visits to the ED or Urgent Care, telephone appointments, and primary care mental health visits. And so even though in the pure sense, continuity simply is how often do you see your primary care doctor when you’re in primary care clinic. This measure really also, that’s used by Compass, really incorporates aspects of how often people are not being seen in primary care clinics altogether. Because for the most part, when patients visit the ED or are seen in primary care mental health, they’re not being seen by their assigned PCP.

Now what do I mean when I say that these are the emphasized measures? I won’t spend time getting into the details but as many of you know, there is a PACT recognition score that is emphasized. So there are many Compass measures of PACT implementation and performance, but there are particular ones that are really emphasized as far as figuring out how far clinics are in implementing tasks, what their performance is. And they’re often being used to evaluate individual PCP performance in PACT, as well. And two of the four measures that go into this recognition score are the continuity measure we described for the percent of provider visits with the assigned PCP. And also, same day access with the assigned PCP. Those are the measures accompanying access that go into the PACT recognition score.

So our study research question would be how do part-time PCPs – and this, again, part available PCPs – compare to full-time PCPs in VA PACT performance measures of access and continuity in the current measure? Second – would alternate performance measures better reflect important aspects of access and continuity. And third question, the question of are patients’ experiences with access and continuity different for patients assigned to part-time versus full-time PCPs.

So our method, we used data from one VA healthcare system. This is not actual pictures of the site we used, they’re generic. But many people will recognize, perhaps, that their sites look like one of these. So one study was a hospital-based site with a co-located Urgent Care clinic that had at least 51 separate providers, at least within our data. And then the other site was a community-based situation and it was pretty large. It had 17 providers but no co-located Urgent Care. So patients who were advised to go to Urgent Care were told either to go to the hospital-based site or to go to a non-VA site.

Now the data that we had available to look at performance measures came from scheduling data and encounter data. We also used, as you’ll see, from clinical and demographic data about the people making the appointment. And the data that we used came from July 2010 to December 2012. PACT was initially begun in April 2010 but as you heard from Jane and as you all probably well know if you have experience with PACT, building that foundation of the teamlets took a while so this work on improving assets and continuity came later. We really consider this data looking at early PACT implementation, not evaluating the effects of PACT’s efforts to improve access and continuity.

Our data on patient experience came from the CAHPS PCMH version patient survey. This is being used now in place of what is commonly known as the SHEP to measure patient experience in VAs across the country. Of our sites that we were examining, we give an over sample and you’ll see, a little bit later, some details on how many patients who got that sample responded.  And this survey was done in October 2012, so near the end of the period when we looked at or measured data.

So encounter data came from completed primary care and urgent care encounters. We looked at only for this analysis, we looked at in-person encounters with physician-level providers. We did end up excluding encounters for patients who were assigned to a resident PCP partly because including additional residents made the analysis much more complicated. But also because I think that different sites include residents or not include residents in PACT in different ways and including the residents made our data, we feel, more generalizable to other centers.

The data we had available was the date the patient called to schedule and appointment, the patient’s desired appointment date – what they told the scheduler when they called what they desired for their application date – the date the encounter was actually completed and, of course, then either assigned provider and then which provider they actually saw when they completed the encounter.

And one thing I really want to emphasize about the data up at the top is that we only had data from appointments that were completed. So if someone called and wanted to schedule an urgent appointment but ended up not scheduling one or now showing up or going to the ED instead, we don’t have data on those requests and I’ll revisit that point at the end.

So as a predictor, we wanted to use – predictor for how people fared in the clinic measures – we used physician availability. Because we had a panel size of 120 patients per half-day session per week, we used that panel size as a processes for often the physician was available in the clinic. We analyzed the availability to clinic continuously in the model and when we did break it up dichotomously into part-time versus full-time physicians, we used a cut-up five sessions per week – five half-day sessions per week or more. Partly because, as I’ll show you here, there was natural... our distribution had a natural nadir there. So if you look at the second column, you’ll see “Half-Days Per Week in Clinic” – one half-day, two half-days, all the way up to ten and even more than that for some people. And how many of the PCP Months Examined fell into those categories. You see a cutoff right here between four and five half-days per week, there is sort of a natural dip and we captured about 48% of PCP months at part-time and the rest is full-time at that cutoff. 

So for access measures, we defined as the PACT Compass says, a same-day request as meaning that the day the patient called was also their desired date for the appointment. And the asset measure, clinic measure is the percent of same-day requests that were accommodated with a same-day appointment. Now, the measures in italics are the ones that are most closely parallel to what Compass measures. So we calculated requests accommodated the same day with the assigned PCP and it was both following the technicals details of either day zero of the phone call or the day after.

Another measure we calculated was same-day with another PCP other than the assigned PCP. And we specifically made these measures so that they were mutually exclusive. So the differences between them are more clear. So another measure is same-day with another PCP. And then we calculated same-day request accommodated with an appointment with the assigned PCP but within two to seven days so looking at a week to see what happened with those requests. 

The continuity measures – again, looking at the percent of in-person physician appointments completed with the assigned PCP. One measure we calculated was among all primary care and urgent care appointments, so that most closely parallels the PATH continuity measure, we also calculated continuity among primary care appointments only.

And I will go quickly through this but again, if anyone is interested in the very technical details, we modeled performance on these measures with the three-level nested logistic regression. Our predictor was PCP panel size, comes with a different performance measure. And we did adjust for changes over time, the site of the assigned PCP. A lot of patients, sociodemographic and clinical variables including chronic diagnoses, so diagnoses that the patient had over time – not diagnoses from the encounter or reasons for the actual encounter. We also adjusted same-day models for the number of same-day requests made by that patient in that month in case there was something different about those patients that made a lot of same-day requests or how the staff handles their requests. 

Just to give you a sense of the scope of our data, we examined 1,375 total PCP months of care. Almost half were from part-time PCPs. We have 23,000 – over 23,000 – encounters from same-day appointment requests, 110,000 total primary care encounters, and over 28,000 urgent care encounters.

So now to get to our results. So I’ll orient you to this graph. These bars show, in general, the probability – and this graph, in general, shows the probability of accommodating a same-day appointment request. So each bar shows the probability of when a request is made, whether it’s actually completed within the timeframe or in the way that the performance measure is looking at it. The blue bars give the results of the performance for physicians working two half-day sessions per week. The red gives the performance for physicians working five sessions per week and the green is for a full-time physician working ten sessions per week. The way we determine these probabilities is based on that model, adjusted for all the patient and physician and site characteristics. We were able to calculate out, again, the chances, the probability of someone calling and getting a request. So the first group of bars show the probability of getting your request accommodated the same day with your assigned PCP. So for someone with two sessions per week, the probability was 17% that that would occur. Five sessions per week was 20% and ten sessions per week, 27%. The asterisk means that there was a statistically significant difference between two, five, and ten sessions per week.

So the overall message of this graph is that there was a significant difference in whether patients got an appointment the same day with their assigned PCP based on PCP availability in clinic, which is the measure that represents the Compass measure. However, if you look at whether cases got an appointment within two to seven days with their assigned PCP, there was no statistically significant difference. If you look at whether they got an appointment the same day with another PCP that wasn’t their assigned PCP, there was no statistically significant difference. And at that point, you’re reaching levels of accommodating same-day appointment request of almost 50%.

So the second piece of our results was that probability of continuity so again, the chance that you will see your assigned PCP when you come for an appointment. Again, the blue bars are physicians with two sessions per week, red is five sessions per week, and green is ten sessions per week. We did find interaction between the effect of PCP availability by site; so in other words, the effective PCP's availability was different than a hospital-based site versus a community-based site. So we’re showing probability separately. 

These first two groups of bars are for the hospital-based sites. When you look at primary care and urgent care clinics, there’s a big difference in continuity or chances of seeing your assigned PCP by PCP availability that was statistically significant. But if you look at primary care clinics only, technically, there was a statistically significant difference but if you look at the actual probability, even at the lowest PCP availability, the chance of seeing your assigned physician was 92%. So if you’re really focused in on just appointments in primary care, patients were seeing their assigned PCPs at a very high rate no matter how often that PCP was in clinic.

At the community-based sites, even though visually, these bars are decreasing a little bit, there was no statistically significant difference in continuity when looking at all the appointments – the primary care/urgent care or just primary care alone.

So finally, going back to the patient experience with access and continuity, how do those compare to what we’re seeing from our performance measures. So again, the VA – and CAHPS stands for Consumer Assessment of Healthcare Providers and Systems – survey done in October 2012. [In aud.]looking at these same sites at people who had two or more outpatient primary care visits in the year prior to the survey. We had 2,881 respondents who were assigned to a PCP at those two sites where we examined the performance measures, which was a 53% response rate. And we were able to match patient respondents to their assigned PCPs and PCMMs and were able to designate them based on that four session a week cutoff as patients assigned to a part-time versus a full-time PCP.

So in this survey, we had 436 respondents who were assigned to a part-time PCP and 2,000 that were assigned to full-time PCPs. And they were asked when you had an urgent need, how often did you get an appointment as soon as you needed it? 73% of those that had a part-time said usually always as opposed to 81% of those assigned to full-time PCPs, which was a statistically significant difference. 

So another question about urgent need – how many days reported waiting for an appointment when they had an urgent need. There was also a statistically significant difference here with 43% of patients assigned a full-time PCP saying they did get in on that same day or one day as opposed to 34% of patients with part-time PCPs. However, for routine needs, when asked how often they got an appointment as soon as they needed it or desired, there was no statistically significant difference between patients of part-time or full-time PCPs.

And then patients’ experiences of continuity were measured in the survey with two questions. They were asked when they see their primary care physician, how often it seemed like that physician knew their important pieces of their medical history. No statistically significant difference between patients of part-time versus full-time PCPs. And similarly, they were asked how often their PCP seemed informed about their... up-to-date and informed on their latest specialty care. No difference between patients between part-time and full-time PCPs.

Here’s a summary of the results that we’ve looked at. Overall, at these two sites, there were relatively high levels of same-day access and continuity. Patients assigned to part-time PCPs had less same-day access to their assigned PCPs. And there were some indications – we weren’t able to examine this directly – but based on the continuity data that looked at combined primary care and urgent care visits, indications that part-time assigned patients at the site with the contiguous urgent care use urgent care more often. However, both were equally likely to get an appointment with their assigned PCP within two to seven days. And patient experiences of access mirrored the encounter data results – reported slightly less urgent access but similar routine access and continuity.

So you know, I will point out and we might discuss this in a minute, that these are only two healthcare sites so the generalizability might be limited. And as I pointed out before, we don’t have data on people who call with urgent issues and don’t get a primary care appointment but have some other resolution. 

So to sort of take a broader view of the patients – right? That’s the patient centered care. Someone’s calling with an urgent issue and they’re told their doctor isn’t available and this is what they might be imagining that their doctor’s doing – surfing on the beach. When in reality, most of us – and I say “us” because I’m a primary care physician but most of us who are good primary care physicians, too – know that if the physician isn’t there they’re usually doubling, there are things that are important to the VA center like administration, research, and teaching.

So implications for PACT performance measurement that would help us better reflect the goals of PACT but without sort of unnecessarily or without unintended consequences for these part-time physicians that are becoming more and more important. So one question we should ask ourselves is are we capturing all important elements that reflect good access to urgent care. One is when there is appropriate triage to urgent care, as I mentioned, we’re not capturing that now but could we be? I started these down here because I believe that they are things that with the VA data that we could start capturing in a performance measurement relatively easily. So one of them is whether a request for urgent access is stated at the telephone encounter. It’s not currently a performance measure but probably could be. And then another piece of data we could consider adding is whether a request for access with a nurse encounter or with a visit with a PCP on a shared teamlet. As Jane pointed out, our academic center, as many others with part-time physicians, are combing them as a teamlet. Right now, there’s no way that a performance measure could capture whether a patient sees another physician on the same team or teamlet. But perhaps with some changes in PCMM, they could do that.

The last implication question is when – you know, taking an even further step back – when is it important to see the assigned PCP for an urgent clinical matter. And so again, to start, the two stars representing that we might be able to immediately implement, we could measure assets at a clinic or a team level as opposed to an individual PCP level. We could consider changing the emphasis to a three or seven-day measure of urgent access. And really, the better question is what is clinically important for access? What do patients prioritize? Some people might prioritize continuity over access and other people vice versa. And can continuity effectively reside within a team of physicians and within a broader team of RNs and physicians?

So in conclusion, ideally, PACT access performance would reflect the urgency of the patient’s need and appropriateness of the mode and timing for meeting that need. And in the future – and I believe that with the data that the VA has available, we could be at the forefront of really finessing these performance measures that capture the... Or I would say the goals that we are working towards at the moment are that PACT access measures recognize and encourage the full use of PCMH approaches to improving access and continuity, like a non face-to-face visit, like teamlet-based care. And the PACT measures will avoid unintended consequences to part-time providers who are providing important PACT and VA functions.

I want to thank my collaborators, including the VISN 11 PACT Lab, and I’ll open it up for questions.

Moderator:Thank you very much, Dr. Rosland. We do have quite an interested audience with 18 pending questions. So without any further ado, I’m going to jump right into them. I will switch back and forth between questions that came in between Jane and your presentation.

So the first question that came in, this one is for Jane. In the initial slides, were NPs included in the “non-physician staff numbers?”

Dr. Jane Forman:We don’t have any NPs so no. 

Moderator:Fair enough.

Dr. Jane Forman:We would have. I think we would have if we did have them. They would be called PCPs.

Moderator:Great. Thank you for that reply. This one came in during Ann-Marie’s talk. Presentation based on VA “with attached urgent care clinic,” is that an ER? If different, isn’t the PACT supposed to provide urgent care?

Dr. Ann-Marie Rosland:That’s a great question. So the site that we examined had provided both urgent care in the sense of lower... people walking in with urgent needs but that were lower acuity, that also had ER. And I think this points to a broader issue that affects the performance measures, which is that a lot of PACTS are handling urgent needs in very different ways. Some are sending patients to urgent care because they have that available. Others are working them into PACT’s primary care schedules and sometimes that’s tempting them when patients walk in as accommodating a same-day access request. And in other cases that I’ve heard of, PACTs are creating a separate team list of providers that are there just for urgent cases and walk-ins. But that is considered part of primary care. And how those visits affect performance is a good question. I suspect it lowers, makes their performance look worse, even though they’re accommodating those requests.

So again, it really highlights the issue of when is it important just to get the patient seen and when is it important for them to be seen in primary care for an urgent issue and when is it important for them to be seen by their assigned PCP for an urgent issue. Those are your outstanding questions.

Moderator:Thank you for that reply. Back to Jane. Are residents used as “associate providers” to help with continuity PACT performance measure?

Dr. Jane Forman:I’m not sure what you mean by associate providers.

Moderator:Okay. That person is more than welcome to write in and clarify that question. Here’s another one for you. 

Dr. Jane Forman:Oh, actually, I can comment that they do have their own panels so if that’s what the question is getting at, no, they have their own panels.

Moderator:Great. Then we’ll jump along to one for Ann-Marie. For the second presenter, related to patient experience/access slide, I am wondering if there is any information on how the term “urgent” was defined.

Dr. Ann-Marie Rosland:I do have the wording of the question. So if you wouldn’t mind me speeding through my extra slides to kind of ignore all these crazy numbers. Okay, so if you look down – can everyone see the slide?

Moderator:Yeah, we can.

Dr. Ann-Marie Rosland:Okay. So for urgent access, I’m going to point it out here and it’s the middle of the slide. In the last 12 months when you phoned the provider’s office to get an appointment for care you needed right away, how often did you get an application as soon as you needed? That was the official question. And that, again, is on the case experience survey that’s being used nationally in all clinics. 

Moderator:Great, thank you for that reply. [interruption] Back to Jane. Is VA's central office considering alternative access measures for highly academic medical centers? We did poorly on the recent PACT recognition process but the significant majority of our teams were fundamentally ineligible for recognition because they did not have panels of at least 400.

Dr. Jane Forman:I don’t know the answer to that question. I know that they are diligently looking at metrics with a lot of interest. And the specific ones I can’t speak about but I know that they’re very interested in looking at these issues.

Dr. Ann-Marie Rosland:And this is Ann-Marie. You know, again, this is what I’ve heard from informal conversations with leadership. There’s a lot of attention on how we can best implement PACT in places where there are physicians with part-time availability. And I know there’s a lot of different ideas being floated. I don’t know that there’s one or another that’s being acted upon. So you know, one idea could be changing the floor or the goal for these measures to be different for academic medical centers or centers with part-time availability physicians. 

I think – I’ll put my opinion out there – it might serve everyone across the country better if we did sort of adjust the way that these measures were capturing  access and continuity to reflect the actual care that’s being given in a way that captures what all the physicians are doing. And it probably would reflect better on centers that have part-time physicians.

Moderator:Thank you for that reply. We do have one of our audience members that write in with regard to the urgent care and emergency department question. They wanted us to know, for our information, Urgent Care operates during business hours only and is not covered by EMTALA whereas the Emergency Department is 24/7. So thank you for that tidbit. 

Also, I just want to note that I do realize we’re at the top of the hour but I am going to ask our speakers are you available to say on and answer the remaining questions so that we can capture them in the recording?

Dr. Jane Forman:Yes.

Moderator:Great. Thank you so much. Okay, so moving right along. Incredible population growth. What is the source of the data? And this came in during Jane’s. 

Dr. Jane Forman:We have worked with Operations to get this data and to tell you the truth, I am not exactly sure what the source is. They keep very good administrative records and I can’t say exactly which database it comes from. But I can check on that.

Moderator:Thank you. You two were both kind enough to leave your contact information on this slide so people can feel free to contact you offline. And yes, I did just open a can of worms there. [laughter]

This one came in during Ann-Marie’s portion. How does PC plus UC model – I’m sorry. How does PC plus UC model the measure? Is your PCP working the UC?

Dr. Ann-Marie Rosland:This is a really good point to clarify. So some of the physicians who work in primary care also do some time in urgent care but most don’t. And when patients present for urgent care, they’re not directed towards their primary care physician if their primary care physician happens to be there. So if a patient went to Urgent Care and saw their assigned PCP, it would merely be by chance and the chance of that is very low.

So I believe what the goal is of looking at the measure that way from a national kind of perspective the way it was designed that way would sort of combine a measure of continuity and private care funding with sort of  a measure of how often urgent issues are being taken care in primary care versus urgent care. So really, it’s one performance measure with two goals.

Moderator:Thank you. I believe this question is somewhat related so I’m just going to take it on. I believe it was when you were talking about requesting for appointments. Is that with their assigned PCP or any PCP?

Dr. Ann-Marie Rosland:It sounds like the question is asking when someone calls for the appointment, did we limit it based on who they were requesting the appointment be with. So if that was the question, the answer is no. We look at all requests for appointments. And I think the assumption within PACT is that patients will want to see their assigned PCP if at all possible. So we didn’t record what doctor they were requesting to see. All patients were assigned to a PCP in PCMM.

Moderator:Great. Thank you for that reply. We’ll go back up to Jane. Do you have a percent of your residents trained, or even your non-resident staff?

Dr. Jane Forman:I keep saying I don’t know exactly what the question means so I apologize but I’m not sure what the definition of “trained” is. 

Moderator:Well, that person is still with us so they are more than welcome to write in and clarify. 

Dr. Jane Forman:I could say that residents have not attended the coaching sessions that have been established, and that’s been a big issue that we need to tackle. A lot of training goes on during when residents are actually working in clinic. So there isn’t a kind of way to measure that. In that sense, all the residents are being trained to the extent that teamlets are functioning as PACT teamlets and doing PACT work.

Moderator:Thank you for that reply. I did mention to him that he’s welcome to write in for further clarification. And he says you answered it with your comment, so thank you. 

Okay, this one came in during Ann-Marie. So do you have a sense of what’s more important to patients? Is it more important to patients that they be seen quickly regardless of who or that they be seen by their PCP, even if they have to wait?

Dr. Ann-Marie Rosland:That is a wonderful question. If anyone else out there wants to collaborate with us [laugh] ... that question over here. Yeah, but I should say there are some studies that have looked at that question and as you might imagine, it really varies by patient. So the data that I’m aware of looking at this issue, there are a couple of studies that I’m thinking of, basically had a similar result, which said that younger patients, patients without chronic medical issues more often prioritized access. So you can imagine this might be an isolated incident – I have a cold, I hurt my wrist - and/or people who are going to school and working and need to be seen when it’s convenient. As opposed to older patients who have chronic medical issues that their urgent issue might be related to, tend to prioritize continuity over access. So as you can imagine, in that case, it might be okay to wait three days if you can see a physician who was really familiar with your diabetes or CHF or COPD. 

Dr. Jane Forman:And this is Jane. I want to add that we have just started interviews with patients, which we’re very, very happy about. And we are looking at this issue exactly. We have very, very early indications – and I don’t want this to... you know, this is not a rigorous finding, it’s a very early reading of the data. But I think it does mirror what Ann-Marie said, that it seems that it really makes a difference whether the condition is acute or chronic, also. I mean, that people are more willing to wait to see their physician if it’s about a chronic issue that the physician knows a lot about. But if it’s something acute, it’s okay for them to see... They feel that... It’s more likely for them to feel that they would see any physician.

Another thing is the relationship with the PCP. We’ve talked to a couple of patients – a few patients – who see residents and they seemed a little less... they cared a little less about seeing their PCP because their relationship – and this is conjecture to some extent – but it seems that the relationship with their PCP also matters. 

Moderator:Thank you both for those replies. And we are getting through these questions quite quickly and we have a lot of our audience members still on. Is it the assumption that all academic facilities are set up like your PCP with large numbers of part-time PCPs? Or do you have hard numbers for VA facilities?

Dr. Jane Forman:We don’t have hard numbers and it is not our assumption that all centers are set up the way, the part-time PCPs. There are many different models for the way academic medical centers deliver care and there are some that have full-time PCPs with, I think, what the earlier questioner called “residents as associate providers.” So there are many models. This is a report on what our center looked like.

Moderator:Excellent. Thank you for that reply. And moving right along for Ann-Marie, has there been any difficult in assigning two or more part-time providers to one team even if the providers are not associate providers or residents? We have been told that two part-time providers (two MDs) are not allowed to be assigned to the same team.

Dr. Ann-Marie Rosland:So that is a really good question. So the way the – and this highlights one of the challenges of the performance measures. The performance measures look at each individual PCP separately, whether they’re in clinic full-time or part-time. So the site that we stand in does group participants together sort of on paper. So in other words, two part-time physicians might share one full-time RN, one full-time medical associate so they function as a team on a local level. But when you’re examining national PACT measures, those measures are calculated for each of those part-time physicians separately.

So I do think that is a challenge for centers who are trying – and I do think there are other centers that are doing this that are trying this method of combining part-time physicians. One question, I guess, is, is that a good way to provide access and continuity and if so, could that be captured in the performance measures in the future.

Dr. Jane Forman:And this is Jane. I’d like to add that I think the jury’s out on the degree to which part-time providers on the same teamlets really do communicate with each other, and that the continuity would probably – well, I don’t know – but I’m projecting that continuity might be through the teamlet more so than the kind of communication between part-time providers in some cases. But in other cases, that would not be true. So again, I think there’s a lot of variations.

Moderator:Thank you both for those replies. If ED and primary care mental health visits are in the denominator for continuity, then continuity with the assigned PCP can never reach 100%, is that correct?

Dr. Ann-Marie Rosland:This is Ann-Marie. The short answer is yes, I would assume. And so again, I think the way that the performance measure is designed is it’s looking at something very important, which is how many of the patient’s concerns are being addressed in the primary care clinic as opposed to other sites of care. And then I guess the next question moving forward is which measure of continuity really captures tactical data. 

But you’re right. Unless the same doctor’s seen them in primary care mental health and in urgent care, it would be pretty impossible to reach 100%.

Moderator:Thank you for that reply. You may have already touched on this. Can you say a little more about which databases, specifically, the performance measures data came from?

Dr. Ann-Marie Rosland:This is Ann-Marie. So we had which PCP the patient was assigned came from PCMM and then the encounter data was from VISTA. And scheduling data was from VISTA. But they were from two... The scheduling, as far as what date the patient called was desired they wanted had to be linked to the encounter data so they came from two separate sources. I hope that answers your question.

Moderator:Thank you. As always, they’re more than able to write in for further clarification. Is assigned PCP meaning the same provider, not a resident that falls under that provider or other providers that are tied together? Are patients seeing the same face?

Dr. Ann-Marie Rosland:So again, a really good question that highlights, it sounds like different centers are addressing, incorporating residents differently in PACT. So at this particular site, residents are considered separate providers and patients are assigned to the residents as their main PCP. So in that instance, continuity would be defined as to whether they see that same doctor – either a resident or an attending on the exact same date. 

It sounds like at other sites, the resident is assigned as associate and it would count as continuity if they saw the attending or the resident. If you’re looking for validation from [inaud.]. And then I know that at other sites, residents are sort of carved out of PACT altogether and not looked at when PACT metrics are calculated.

That’s one of the things that we’re interested in documenting is there’s a variety of ways that academic centers are incorporating residential trainees into PACT.

Moderator:Excellent, thank you for that reply. How do you utilize midlevels as associate providers aligned with your PT providers?

Dr. Ann-Marie Rosland:At this site, we haven’t. There are a couple of NPs or PAs and they function as separate primary care providers with their own teamlets.  

Moderator:Thank you. We are down to the last three questions. How have other facilities handled continuity with part-time providers? For example, can two part-time MDs be each other’s “associate providers” so their PACT continuity and same-day appointment measures is not affected? Or can there be two “associate providers?”

Dr. Jane Forman:Both of us are kind of shaking our heads because we’re not sure how other facilities are doing this. I don’t think in PCMM you can link two providers together. But I like that idea. [laughter] You know, I think that could be one really exciting way to move forward is to find a way to link providers who are working in a team together. And that doesn’t mean that you couldn’t look at them individually but then you could also quite easily examine their access to continuity as a group of two or three physicians. 

So if anyone has any good ideas on how to do that, I would love to hear about it offline. [Laugh]

Moderator:Great. How easy was it to obtain PACT metrics data and how often were you looking at it?

Dr. Ann-Marie Rosland:This is Ann-Marie. So when I mentioned the Compass – and I’m guessing a lot of people on the call are familiar with the Compass – those are PACT performance metrics that are calculated nationally. And there are many, many performance measures on there, not just the two or four that we talked about, that are available to all primary care sites and physicians over the internet. And those are calculated on a monthly basis. So but these are the official national program metrics; you can access them over the web. 

What we did in our study, we sort of recalculated the measures from the raw data and we aggregated all the data from that one and a half year period. So we looked at it once but it was an aggregation of a year of a half of data. Again, I hope that answers the question but feel free to ask a clarifying question.

Moderator:Thank you. And our last remaining questions. Some of the residents are used as “associate providers” with an attending listed as the PT PCP. So that continuity is not lowered when different residents see patients.

Dr. Ann-Marie Rosland:Again, this is Ann-Marie. I’m just conjecturing here. It sounds like some sites do manage to assign patients that way and I’m pretty sure that at our site somehow it’s the other way around – that the residents, the primary PCP, and then the mentor is sort of an associate sort of additional provider on the encounter. But again, I think it highlights the ways that... I think there are differences in how patients are assigned. It could have a big impact on how performance measures look when they compared amongst sites.

Moderator:Thank you for that reply. That is the final question so at this time, I’d like to give each of you a chance for some concluding comments. Jane, would you like to go first?

Dr. Jane Forman:I would just like to say thank you to all of our audience members and for your great questions. We are continuing as a demo lab to look at how academic medical centers incorporate residents into PACT and what the different models are for doing that. What are some of the challenges and what are some of the solutions that people have come up with to do this. And so we hope to be able to report on that in the future.

Moderator:Thank you. Ann-Marie?

Dr. Ann-Marie Rosland:And I’ll just echo what Jane said. This has been a really interesting and fun discussion and I appreciate all the really engaged listeners. Again, in a similar vein, we’re also hoping to move forward on looking at different alternate performance measures to really capture and reward people enacting the goals of PACT such as more face-to-face care, teamlet-based care. So again, anyone who has any suggestions or ideas or questions about that, feel free to contact us and thanks a lot.

Moderator:Thank you. And while I have a captive audience, I would like to plug our next PACT session, which will take place Wednesday, July 17 at the same time, 12:00 to 1:00 p.m. Eastern, and it is on Integrating Resident Education into PACT.

So with that, I would like to encourage our attendees to please fill out the survey that will pop up on your screen when you exit the meeting and I very want to thank Drs. Forman and Rosland for presenting for us today. It has been very valuable to the field. And this session has been recorded so you will receive a followup email with a direct link to the recording. Feel free to pass that along to any colleagues that weren’t able to come to the live session or anyone you feel may be interested in this topic. 

So once again, thanks to our presenters and thanks to our very attentive and thoughtful audience. Have a nice day, everyone. 

Page 1 of 24