Building the Foundation for PACT in a 

Large VA Academic Medical Center

Jane Forman, ScD MHS

Implementation Evaluation Lead

PACT Research Inspiring Innovations & Self Management 

(PRIISM) Demonstration Laboratory, VISN 11

Ann Arbor VA Center for Clinical Management Research
Audience Poll Question

How are you involved with PACT implementation?

1) Involved in PACT implementation at an academic medical 

center

2) Involved in PACT implementation, but not at an academic 

medical center

3) Researcher whose work relates to PACT

4) Other 

5) Not involved with PACT implementation
Background and Purpose

• The literature on Patient-centered Medical Home (PCMH) 

implementation has focused largely on relatively small private 

practices in non-academic settings.

• There is little in-depth evaluation of PCMH implementation in 

larger, more complex settings, including academically-affiliated 

medical centers.

• The VA has 152 primary care clinics housed in medical centers, and 

about 80% of these clinics are academically affiliated. 

• Our purpose was to better understand how the academic context 

and large clinic size affects PACT implementation.
Setting 

 Ann Arbor VAMC 

 Primary Care Clinic

 Clinic Structure

• Over 20,000 patients

• 20 Teamlets

• 70 PCPs and Residents = 20 FTEE

 80% of PCPs work <16 hrs/wk

 30 residents work 4 hrs/wk

 Average of 3.5 PCPs per teamlet

 At least 1 resident per teamlet 

 Residents care for about 15% of clinic patients
Large and Growing Staff and Patient Population

 April April April April % Increase

2010 2011 2012 2013 April 2010 – 

April 2013

Patients 14,803 16,148 18,340 21,024 42%

Non-physician 

Staff 23 33 43 52 126%

Physicians 62 69 70 75 21%
Methods

Data Collection:

• Jan 2011-March 2012

• 33 Interviews with key informants at AAVA

• PCPs, Residents, RNCMs, LPNs, MSAs, PharmDs, social workers, psychologists, 

dieticians, clinical management

• Topics

• Knowledge of and attitudes toward PACT

• Communication among physicians and staff

• Main challenges to implementation

• Observations of weekly registered nurse care manager (RNCM) staff 

meetings

Data Analysis:

• Qualitative content analysis using two frameworks

• Consolidated Framework for Implementation Research (CFIR)

• PACT Model 
Consolidated Framework for Implementation Research (CFIR) 

• A compilation of common constructs from published implementation theories. 

• Provides a framework to understand contextual factors that affect 

implementation of new programs. 

CFIR Construct Definition 

Compatibility How the intervention fits with existing workflows and 

 

systems. 

The nature and quality of webs of social networks and the 

Networks & Communications nature and quality of formal and informal communications 

 within an organization. 

The level of resources dedicated for implementation and 

Available Resources on-going operations. 

 

Access to Knowledge and Ease of access to digestible information and knowledge 

about the intervention and how to incorporate it into work Information 

tasks. 

 

Damschroder et al., Implementation Science, 2009:4-50
PACT Model: Foundation and Pillars

•Building the foundation was necessary to create functioning teamlets 

“If [the] foundation 

isn’t built, then you 

can’t have anything on 

top of [the] 

foundation... and 

expect it to be 

functional...” 

Leadership
Compatibility: Existing Clinic Structure Not Highly 

Compatible with the PACT Model

LPN 

3.5 part-time

PCPs

RN LPN

Clerk

15 part-time 

PCPs

RN RN

Clerk

LPN 

4 Teams (3500 patients each) 20 Teamlets (1100 patients each)

“Every other site in our health care system has full-time providers. So...you’re linking up 

one nurse, one LPN with one doc, very different than linking up with at least two, or up 

to 5-6 docs that are on different half days...it’s a very different model...” Leadership
Available Resources: Staff --Hiring

• Staff needed to be more than doubled to meet the 3:1 staff to provider 

teamlet ratio and to keep up with growth in the patient population. 

• Hiring process was lengthy and resource-intensive: 

• “We’ve hired [a lot of people] this year...that’s working with HR, interviewing 

people, making final selections, doing the paperwork...to write them up to go to 

the Boards if it’s a nurse and things like that. That’s taken a...huge amount of 

time...” Leadership

• Rapid changes in roles and resulting stress made hiring and retention 

more difficult, even though most staff were positive about PACT:

• “...we all kind of think the concept’s good. It’s just how they execute it that’s 

going to be the big thing. Because like right now, pretty much the RNs are...really 

in an uproar...we have four [out of twelve]...leaving.” RNCM 

• Especially difficult for hires new to primary care:

• “We’ve hired some excellent [non-primary care] nurses...Two [of them] have 

both said very clearly, they didn’t realize how hard this work was, that, you 

know, this was not what they thought it was and it’s much harder.” Leadership
Available Resources: Staff – Effects of Shortage

• Delayed teamlet formation:

• “P: ...like I was talking to Dr. [Last Name PCP 1] this morning and her clerk’s iffy and her 

LPN’s about to go out on two week’s of leave and...her RN, Patient Care Services is 

sitting on. So you know, she, today’s her last day of having a full teamlet for at least 

two weeks. 

• I: Right, so what happens then in terms of functioning?

• P: It kind of falls apart” RNCM

• Required staff to cover vacancies in other teamlets: 

• “You need to be involved with just your teamlet only...the nurse tells [the doctor], ‘You 

have a cancelation...and so and so needs a pap smear and so and so needs blood work.’ 

We don’t do that. We don’t even know who [the doctors are] seeing...it’s 

unorganized.” LPN 

• LPNs spent most of their time checking in patients for many PCPs, 

not doing more advanced tasks and coordinating patient care within 

a teamlet: 

• “for right now, we check the patient in. All we do is take the vitals and go sit them 

down... If we have this all set up...the patient gets better contact with you, he knows 

you’re his nurse and he knows that’s his doctor and it’s more like a regular doctor’s 

office.” LPN
Available Resources: Space

• Leadership needed to “scavenge” for space.

• Not enough contiguous space for growing staff and co-location of 

teamlets: 

• “If you want teamlets to function well, you really should...have everybody 

consolidated in a similar area so you’re not wandering around the halls 

looking for each other.” RNCM

• Lack of co-location a barrier to bringing care to the patient:

• “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 we come back out and call them...the doctor 

could...just come and say, “...[this patient] needs an EKG...” I could just 

come right to the room...do the EKG and then let them continue on.” LPN

• No stable space for RNCMs:

• “I was just with somebody before I came to see you, and we’d already been 

kicked out of two rooms...” RNCM
Networks and Communications: In Clinic

• Lack of space and the need to schedule a changing roster of part-time 

PCPs and residents made co-location difficult and thwarted 

communication: 

• “In some instances we have so many docs from a given team in clinic that you 

may be 200, 300 feet from your nurse so that...direct...communication where 

you can just walk out of an office two feet away...to have a discussion about a 

patient care need is somewhat limited right now.” Leadership

• Staff had to deal with multiple modes of communication from multiple 

providers:

• “It’s challenging for nurses to have inputs from many different [doctors] who may 

have different practice styles. So one doctor always sends issues via a CPRS 

computer-based alert...some providers get on instant...the different ways of 

communicating really challenges the implementation of PACT.” Management

• Lack of stable space and telephones for nurses made them difficult to 

reach:

• “...because we don’t have a dedicated space for all nurses with a telephone and 

telephone number, nurses end up moving from room to room...it’s challenging to 

get calls directed to them...” Leadership
Networks and Communications: Residents Not Often in Clinic

• Communication often delayed when residents not in clinic:

• “...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... 

whenever I have to co-sign a resident to a note, I sign the mentor for that resident as 

well...” RNCM

• Residents deal with multiple and difficult-to-access communication 

systems: 

• “I have to check [the EMR system] to get alerts...if I’m at the University, I’m not to 

[do] that [more than 3 times a week]...I’m[also] doing CITRIX desktop but...I can’t 

get it at home.” Resident

• Residents often had no clear point of contact:

• “if I get a message from a nurse or somebody within the team through CPRS, I don’t 

always know who I’m supposed to direct that to...early on as a resident, it’s hard to 

identify...who you’re supposed to communicate with and you can’t do everything 

through your attending because they have, I don’t know how many residents they’re 

in charge of.” Resident
Access to Knowledge and Information: Residents

• Difficult to leverage the resident-mentor relationship for PACT 

education because many physician mentors themselves had limited 

hours in clinic:

• “...the model was built to educate residents on the clinical practice of medicine... 

The mentors...can educate them on [heart failure, lung disease, etcetera]...what 

they have a harder time doing is educating them on practice management, how 

do you...get involved in access for your patients, how do you actively identify 

patients who use resources out there...they don’t live those things themselves.” 

Leadership

• Occupied with clinical curriculum:

• “When we come here in July, our heads are spinning in terms of like trying to know 

what’s going on in terms of the residency program.” Resident

• Difficult to attend meetings:

• “...meetings between...attendings and clinic staff...usually occur you know, at 

noon or 12:30 which is...when we as residents have to be finishing up seeing our 

patients and...leaving usually for another site and for other responsibilities. So 

um, even though residents are welcome to go to those meetings, practically we 

don’t really go on any regular basis.” Resident
Access to Knowledge and Information: All Staff

• Challenging to train a large staff:

• “Because we’re an academic [medical center] and because we have so many 

people [who] are part-time that we almost have 2 or 3, 4 times as many 

people to educate about this program as...hospitals that are not academic.” 

Management

• Challenging to train many new staff in the midst of rapid change:

• “RN educator- I’m training them for the PACT model and it’s getting confusing 

when they come into the clinic and are told that’s not the way we do things.” 

Field Notes

• Challenging to train new nurses who came from outside primary care:

• “...I’m not saying they can’t hire anybody...without a strong background [in 

primary care] because they can, but not in a time where they’re making so 

many changes.” RNCM

• National teamlet training discontinued before most AAVA teamlets

formed
Fast Forward to 2013: Where are we now? 

• Teamlets and Staffing

• 20 Teamlets formed.

• Almost full staffing.

• Hired float nurses.

• Co-location and Communication

• Improved, but still a challenge, especially communication with residents.

• Heavy use of instant messaging.

• Training and “Living PACT”

• Coaching model tailored to local needs.

• Part-time PCP attendance and engagement important. Still difficult to include 

residents.

• Facilitates getting into the “pillars”

• Target access and continuity.

• Evaluation in process.
Audience Poll Question

• If you are implementing PACT in an academic medical center, 

what are the main challenges you face? (check all that apply)

• Staffing

• Space

• Communication

• Training

• Other 
Conclusions and Recommendations

• Large academic medical centers face special challenges in implementing the 

PACT model. 

• Building the foundation to support functioning teamlets was complicated by 

residents and PCPs with limited clinic hours. 

• More difficult to co-locate teamlets

• Few clear communication channels when not in clinic, especially for residents.

• Limited exposure to the PACT model. 

• Inadequate space and communication challenges were closely related.

• Recommendations:

• Important to focus on space and to establish technological means of communication.

• Develop strategies to engage part-time PCPs and residents in the PACT model, and to train all 

staff early in implementation. 

• Think creatively about staffing models.

• Need to better understand how clinics with chronic staffing shortages can successfully 

implement PACT. 

• Although the time it took to build the foundation was considerable, it has 

proven essential.

• With functioning teamlets in place and the coaching model implemented, the clinic is now 

seeing more rapid uptake of the work processes needed to provide true patient-aligned care, 

and improvement in access and continuity metrics.
Acknowledgements

Co-authors: 

• Molly Harrod, PhD

• Claire Robinson, MPH

• Ann Annis-Emeott, RN, MPH

• Jessica Ott, MPH

• Darcy Saffar, MPH

• Sarah L. Krein, PhD, RN, Co-Principal Investigator, PRIISM

• Clinton L. Greenstone, MD, Co-Principal Investigator, PRIISM, and Associate 

Chief of Staff for Ambulatory Care, VA Ann Arbor Healthcare System

Thanks to:

• Ann Arbor VA Primary Care Management, Providers, and Staff

• Eve Kerr, MD, MPH, Principal Investigator, PRIISM, and Director, Center for 

Clinical Management Research

Contact Jane Forman at jane.forman@va.gov 
Part-time Primary Care Physician 

Access and Continuity: 

Implications for PACT

Ann-Marie Rosland, MD MS

Research Investigator, VA Ann Arbor Center for Clinical 

Management Research

Assistant Professor, University of Michigan Medical School

June 19, 2013
Part-Time Physicians

• 22% of men and 44% of women physicians 

work part time

– More than 80% of academic departments have 

part time physicians

• pediatrics, family medicine, and internal medicine

– Associated with less burnout, higher job 

satisfaction, slightly greater productivity/hour, 

similar process performance

2011 Physician Retention Survey, Cejka / AMGA

Rayburn et al 2010; Lugtenberg et al 2006; Machaber 2008; Fairchild 2001; Parkerton 2003
VA Primary Care Physicians

Partial Availability in Primary Care Clinic Due to:

• Actually Part-Time

• Administrative Duties

• Non-Primary Care Clinical Duties (i.e. Urgent Care)

• Research 

• Teaching

• Trainees
Poll Question

• Primary Care providers work part-time in our 

primary care clinic for the following reasons: 

(check all that apply) 

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

Teaching/mentoring part of the time
Team

Based Care

• Teamlets

• Continuity 

CareManagement & 

Coordination

• Chronic illness

• High-risk patients

• Prevention

• Care Transitions

Patient 

Access

• Scheduling

• New 

Appointment 

Types

• Technology

Patient Centeredness

2010 

2014 
Teamlet: 

Assigned to 1 panel 

(1200 patients)

• Provider

• RN Care Manager

• Clinical Associate 

(LPN, Medical 

Assistant)

• Clerk

Patient

Other Team Members

Clinical Pharmacy Specialist ± 3 panels

Social Work: ± 2 panels

Integrated Behavioral Health

Psychologist ± 3 panels

Social Worker ± 5 panels

Care Manager ± 5 panels

Psychiatrist ± 10 panels

Actual panel size = 

120 patients per 

half-day session
VA PACT Access Measure

• Emphasized Access Measure

– Percent of requests for same-day appointments 

accommodated same-day or next-day 

WITH the patient’s assigned PCP
VA PACT Continuity Measure

• Percent of Appointments Completed with 

Patient’s Assigned PCP

• Emphasized Continuity Measure includes

– ED Visits

– Telephone Appointments

– Primary Care Mental Health visits
PACT Performance Measurement

PACT Recognition Score

• Continuity - % provider visits with Assigned PCP

• Same Day Access with Assigned PCP

• Telephone ratio - % of PC encounters by phone

• Post-Discharge follow-up - % contacted within 2 days
Study Research Questions

• How do part-time PCPs compare to full-time 

PCPs in VA PACT performance measures of 

access and continuity?

• Would alternate performance measures better 

reflect patient experience of 

access/continuity?

• Are patients’ experiences with access and 

continuity different for those with part-time 

vs. full-time PCPs?
Methods

• Setting

– One VA Healthcare System

• Hospital-Based Site with a co-located Urgent Care (UC)

– (51 providers)

• Community-Based Site with NO Urgent Care 

– (17 providers)
Methods – Encounter Data

• Data from Completed PC and UC Encounters

– In-Person encounters with physician-level provider

– Excluded encounters from Patients Assigned to a 

Resident PCP

– July 2010 – December 2012 

– Data Available:

• Date patient called to schedule

• Desired appointment date

• Date encounter was completed

• Assigned Provider

• Provider seen at the encounter
Methods - Predictor

• Physician Availability

– Assigned Panel Size as proxy

– 120 patients = 1 half-day session per week

– Continuous in models

– <5 sessions per week when used as dichotomous

• Full time is 8 patient care sessions

• Distribution of primary care docs with nadir at 4-5 

sessions per week
PCP-Months by Half Days in PC Clinic
Methods - Outcome 

• Access Measures

– Same-Day Request: Date Called = Desired Date

– % Same-Day Requests Accommodated

• Same-Day - Assigned PCP (Day 0 or Day 1)

• Same Day – Other PCP (Day 0 or Day 1)

• 2-7 Days - Assigned PCP

• Continuity Measures

– % Physician Appointments Completed with Assigned PCP

• PC + UC

• PC Only 
Modeling Methods

• Three-Level Nested Logistic Regression

– Predictor: PCP Panel Size Continuous

– Outcome: Encounter Meets Access or Continuity 

Measure

– Random Intercepts: patients and physicians

– Covariates:

• Time

• Site of Assigned PCP

• Patient: Age, Sex, Dx (CHF, DM, chronic pain, PTSD, SMI, 

SUD, Depression), Chronic Opioid User, OEF/OIF

• # of same-day requests by that patient in that month
Results

• 1375 total PCP-months of care

• 49% were from Part-Time PCPs

• 23,078 Encounters from Same-Day 

Appointment Requests Continuity

• 110, 454 Total PC Encounters

• 28,247 UC Encounters
Predicted Probability& of Accommodating

a Same-Day Appointment Request

0.17

0.19

0.42

0.2 0.21

0.43

0.27

0.24

0.45

0 

0.05 

0.1 

0.15 

0.2 

0.25 

0.3 

0.35 

0.4 

0.45 

0.5 

Same-Day with 

Assigned PCP

2-7 Days with 

Assigned PCP

Same Day with 

Non-Assigned PCP

Probability

Type of Encounter Resulting from Same-Day Request

2 

Sessions/Week

5 

Sessions/Week

10 

Sessions/Week

*

*=PCP Availability was significant predictor of outcome in MLM 
Predicted Probability& of Continuity with Assigned PCP

0.61

0.92

0.79

0.85

0.77

0.99

0.76

0.82

0.92

0.99

0.71

0.76

0 

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1 

Primary Care + 

Urgent Care Clinic

Primary Care 

Clinic Only

Primary Care+ 

Urgent Care Clinic

Primary Care 

Clinic Only

Probability

2 

Sessions/

Week

5 

Sessions/

Week

10 

Sessions/

Week

* 

* 

*=PCP Availability was significant predictor of outcome in MLM

Hospital Based Site Community Based Site
Patient Experiences Access and Continuity

• VA CAHPS-PCMH Patient Survey

– Consumer Assessment of Healthcare Providers 

and Systems – PCMH

– Now used for SHEP

– October 2012

– Mailed to those >=2 outpatient primary care visits 

in past year
Patient Experiences

Data/Methods

• 2881 respondents assigned to PCP at two 

examined sites

• 53% response rate

• Designated as assigned to part-time vs. fulltime PCP
Patients of 

Part-Time PCP

N=436 

Patients of 

Full-Time PCP

N=2066 

P value

For URGENT need, 

appointment as 

soon as needed

73% usually or 

always

81% usually or 

always 0.02* 

For URGENT need, 

days waited for 

appointment

 Same day or 1 day

 2-7 days

 >7 days

34% 

31% 

36% 

43% 

35% 

23% 

0.004* 

For ROUTINE need, 

appointment as 

soon as needed

87% usually or 

always

90% usually or 

always 0.11 

Patient Experiences - Access
Patients of 

Part-Time PCP

N=436 

Patients of 

Full-Time PCP

N=2066 

P value

% usually or always

How often PCP 

knew important 

medical history

95% 93% 0.07

How often PCP 

seemed informed 

about specialist 

care

91% 89% 0.41

Patient Experiences - Continuity
Results Summary

• High levels of same-day access and continuity 

overall

• Patients assigned to part-time PCPs had less same 

day access to assigned PCP

• Indications that part-time assigned patients at 

site with contiguous UC use UC more often

• Equally likely to get appointment with assigned 

PCP 2-7 days

• Patient experiences of access mirrored encounter 

data results – slightly less urgent access but 

similar routine access and continuity
Limitations

• Two health care sites

• No data on people who call with urgent 

problem and do not get a primary care 

appointment.

• No external data (comorbidities)


Implications 

PCMH Performance Measurement

• Are we capturing all important elements that 

reflect good access to urgent care?

– Appropriate Triage to UC / ER

– Telephone encounter**

– Nurse encounter*

– Visit with PCP on shared teamlet* 
Implications 

PCMH Performance Measurement

• When is it important to see the assigned PCP 

for an urgent clinical matter?

– Could measure at clinic level**

– Could change to 3 or 7 day measure** 

– What do patients prioritize (in what situations)?

– Can continuity reside in a Team or with the RN?
Conclusions

• Ideally good access ‘performance’ would 

reflect the urgency of the need and 

appropriateness of the mode and timing for 

meeting that need

• Ideally access measures would recognize and 

encourage the full use of PCMH approaches to 

improve access and continuity
Collaborators

• Sarah Krein

• Eve Kerr

• Clinton Greenstone

• Myra Kim

• David Ratz

• Darcy Saffar

• VISN 11 PACT lab
Questions

• Jane Forman, PhD

– Jane.Forman@va.gov

• Ann-Marie Rosland, MD MS

– Ann-Marie.Rosland@va.gov