**Transcript of Cyberseminar**

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

**PACT Implementation: Findings from primary care surveys**

**Presenters: Christian Helfrich, PhD, MPH; Michelle Lempa, DrPH**

**January 16, 2013**

**PACT Implementation: Findings from primary care surveys**

**January 16, 2013**

Moderator:We are at the top of the hour; I would like to introduce our speakers now. Speaking first we have Dr. Christian Helfrich. He is the Chair of the Organizational Function Workgroup for the PACT Demonstration Lab Coordinating Center at VA Puget Sound Healthcare System. Joining him today is Dr. Michelle Lempa. She is the Administrative Director for VISN 4 Center for Evaluation of PACT, known as CPACT at the Philadelphia VA Medical Center. At this time, I'd like to turn it over to Dr. Helfrich. Are you are ready to show your screens?

Dr. Helfrich:Yes. I sure am.

Moderator:All right. 

Dr. Helfrich:Thanks, everybody for joining us today. I want to orient folks to this series. We have two Cyberseminars. This is the first one talking about survey findings from Patient-Aligned Care Team initiative evaluations by PACT Demonstration Labs, and then, the PACT Demonstration Lab Coordinating Center which I'm a part of. Today we're talking about some survey findings related to PACT implementation. In a month, we're going to talk about provider and staff experience, in particular, burnout, and we'll have a couple of other folks: Sandra Joos, and Lisa Meredith from the PACT Demo Labs in VISNs 20 and 22, respectively. We're covering today, just some findings on PACT implementation. I wanted to make sure, I don't know with our audience, how familiar folks are with the PACT Initiative, but I thought I'd just go over very briefly some of the broad outlines. 

The Patient-Aligned Care Team initiative, as I’m sure the vast majority of you know, is the VA's patient-centered medical-home model. It was formally launched in April 2010, and it includes multiple components, an emphasis on team based care with a formation of what are being called PACT teamlets comprising of a primary-care provider, nurse care manager, clinical associate, such as a med-technician or LPN, and clerical assistant, or clerk. These team members, in principle, share responsibility for a defined panel of patients. They're working together as a team on a single panel of patients. The initiative also entails changes to scheduling, scrubbing the PCP's schedule of cases, and providing alternatives to in-person visits such as telephone access and secure messaging. It also involves the use of nurse-care managers, the members of the teamlets, in addition to other healthcare staff in the primary-care clinic, mental-health providers, social workers, nutritionist, dieticians, to provide additional support in particular for care management; doing proactive care management of patients. 

The initiative also entailed providing some resources to support PACT implementation, in particular a significant amount of funding to the VISNs to support the expanded staffing model, the formation of these teamlets, and training, notably regional learning collaboratives that were co-organized by The VA Office of Systems Redesign, System Engineering Group in the VA. The initiative also entailed the funding of five PACT demonstration laboratories in VISNs 4, 11, 20, 22, and 23. 

My colleague Michelle, who will be talking in just a little bit, is from the VISN 4 Demo Lab, and these demo labs were funded to study particular aspects, or to develop particular aspects of the PACT model. And then there was the formation of the National Demonstration Lab Coordinating Center which I'm a part of that was placed in the role of helping the labs coordinate in particular on measures and methodology to make sure that we were consistent across labs on areas where we could have the opportunity to synthesize learning and findings, and to also make sure that we weren't unnecessarily duplicating activities. The Demo Lab Coordinating Center also had the further task of conducting an overall evaluation of the PACT initiative, and it's in that latter role that I'm going to be talking today. 

What I'm going to present to you on is a survey that the Demo Lab Coordinating Center put together, and fielded in 2012 to VA primary-care personnel. This is work that I did with the Organizational Function Working Group which is a group of largely researchers, but also some operations folks in the VA including representatives from all of the demo labs, and from some operations groups including the National Center for Organizational Development, and the Employee Education Service. We fielded this survey with the help of the Healthcare Analysis and Information Group or HAIG. They're actually the ones who got the survey in the field for us. 

Overall, the survey data that I'm going to be talking about was something that we went into the field with this past summer, and the goal of that survey was to help answer three broad questions which were really the three broad questions of the national evaluation, and that's to what extent has PACT been implemented, what factors foster or hinder PACT implementation, and what's the effect of PACT, what are the outcomes of PACT, and in particular in my role with the Organizational Function Working Group, I'm interested in PACT’s effect on employees, notably burnout and staff satisfaction, but also, in terms of what their perceptions are of changes in care. For today's talk, I'm mainly going to be speaking to you about this second question. What factors foster or hinder PACT implementation? In particular, we were interested in a set of barriers and facilitators, and in team functioning. We were interested in team functioning because PACT entailed this move to team-based care, and we know from broad literature that changing team roles, negotiating new team roles can be quite challenging. This survey was a web-based survey, and it was fielded via email through the Office of Operations through 10N. 10N sent the survey link out through leadership, leadership in primary care, nursing, pharmacy, social work, and nutrition. We asked the leadership in those groups to distribute the survey link down through their chain of command to all of their employees who work in primary care. The exception and actually I apologize that I don't have this on a slide, the exception being a group of demo lab sites in VISNs 22 and 20. Those two demo labs were fielding surveys with very similar content at a similar point in time, and so we did not duplicate. We wanted to not duplicate efforts. So the survey data that I'm presenting to you today omit, do not have data from VISNs 23 and the demo lab sites, or VISN 22, excuse me, and demo lab sites in VISN 20. 

The survey was in the field from May 21st to June 29th. We had a total of 6,400 respondents, 5,400 of whom were in the teamlet occupations: primary care providers, nurse care managers, clinical associates, and admin associates. Because of the way we fielded the survey, we don't have a denominator. We don't know ultimately who got the survey. Our best guess based on the response rate to the all-employee survey which is a larger VA survey that goes out to a census of employees, and for which there is a much more sophisticated tracking system. Our best guess based on all-employee-survey figures is that we probably got a 30% response rate, but it's just an approximation. 

Our respondents almost, these are just some basic demographics. Our respondents almost half of them were over 50 years old, and over a third of them had been with the VA for longer than ten years. Not quite two-thirds of them were not in a supervisory position. Over a third did have some supervisory responsibility, and again, 78% were in those four teamlet occupations. Our respondent demographics are very, very similar to the respondent demographics to the all-employee survey for respondents from primary care. So we feel in most respects we have a representative sample. The one exception was in supervisory level. We have a higher proportion of respondents to our survey that are in supervisory positions than primary care employee respondents to the all-employee survey.  

Just as a preface before I get into slides on barriers and facilitators to PACT implementation and team functioning, we asked some questions about just some basic PACT implementation questions, whether or not the respondent had been assigned to a teamlet. As you can see in that first column, over 90% of providers and nurse care manager respondents to our survey reported being assigned to a teamlet. Almost 90% of the clinical associates did, and we also asked how many hours on average per day they spent in teamlet-huddle activities, and a huddle being a meeting of teamlet members, these four members to plan out the day's activities, and we distinguished that from other meetings to either do team building, or coordination about teamwork, and communication in general. This was specifically about planning out the day's schedule for patients coming in, and handoffs, and things like that. 

The main questions that I want to talk with you about today are related to, again, to factors fostering or hindering PACT implementation. We asked a series of questions about barriers to delivering optimal patient-centered care, facilitators of PACT implementation, and then we asked a series of questions about team functioning including communication around difficult topics, participatory decision making, how chaotic the work environment is, and their history of making successful changes in the past. We also asked respondents about their perceived self-efficacy in implementing PACT, both as an individual and as a team. Did they feel like they were capable of implementing PACT, and outcome expectancy? If they implemented PACT, do they feel like they would see improvements in quality? 

Those are the questions that I want to focus on today. The questions about barriers and facilitators are a series of structured questions. Those were developed by the VISN 22 Demonstration Lab based on their work with their demo lab sites. The questions focused on barriers to delivering optimal patient-centered care, not barriers to PACT implementation, the reason why we did that was because in some cases, especially at the outset, we anticipated that they may not have implemented PACT and may not know all that much about PACT, and would be in a difficult position to respond to questions about what barriers there were to actually implementing PACT, but some of the key barriers to implementing PACT would also be general barriers to delivering patient-centered care in the type of model that PACT was intended to produce.

This first question is about facilitators. We asked these questions on a Likert scale from not at all helpful to very helpful. So, how for these ten structured items, how helpful were they? Not at all helpful, or very helpful, and this is the percentage of respondents who reported very helpful. As you can see, there was no facilitator that was reported by a majority of respondents. Teamlet huddles had a plurality of respondents saying they were very helpful at 44%, followed by regular teamlet meetings that are not huddles to discuss process and performance improvement, again, huddles being meetings about planning out the day. What work are we going to do today? Regular teamlet meetings to discuss how do we work, in general? How do we work as a team? 

You'll notice, at the bottom, there are a number of specific PACT support activities, so the regional or national learning collaboratives. There were a series of six of those organized in different regions, nationally. There is a PACT toolkit by the Office of Systems Redesign. And then more generally, there are quality improvement methods. This is not specific to PACT, but quality improvement methods including System Redesign's TAMMCS Model. I'm unfortunately, not going to be able to remember what the acronym stands for, but it's very similar to the LEAN or six-sigma approach where it's a process, a team-oriented process, for identifying and tackling a work issue. As you see, those were identified by our minority respondents. One of the things that we will be exploring in future analyses is just to what extent are these rated low because respondents haven't been exposed to them. They don’t know about them. Didn't participate in the learning collaboratives and to what extent those who participated are not finding them helpful. 

In terms of differences among the teamlet members in how helpful they found facilitators, these are the top six facilitators identified by primary care providers. You can see how they fell in the rankings for the other teamlet members, and the proportion of respondents who found them again, very helpful. Teamlet huddles are again, identified by a plurality across the groups, but it's lower for PCP's 10%. It was 37% of PCP's found teamlet huddles very helpful versus 48% of nurse care managers. The differences across these groups are all highly significant. In part that’s just because of the number of respondents, over 1,000 PCP's and nurse care managers and clinical associates. We have big numbers, and so a lot of these comparisons are going to be significant. In terms of barriers to delivering optimum patient-centered care, there was no single barrier that was identified by a majority of respondents, but a plurality identified clinical reminder volume followed by recruiting and retaining providers. Difficulty in accessing specialty care was at 37%, so 48% for clinical reminder volume being a problem that limits their ability a great deal, their ability to provide optimal patient-centered care. 

Interestingly, down at 17% is a lack of responsiveness to requests for assistance from my team members which was definitely a concern with a move to team-based care, and lack of support from clinical leadership, which was another item which we were very keen to understand. I would interpret it as middling, with a third of respondents saying it limits a great deal. That's a high response, a high proportion of respondents who think that their lack of support from their clinical leadership limits their ability to provide optimal patient-centered care. On the other hand, it is still a minority of respondents. Again, when we looked across the teamlet occupations at the top barriers, these are the top barriers identified by the PCP's, and not surprisingly some of the barriers identified by PCP's are not barriers for some of the other folks: Delivering opiate therapy. That's a problem for PCP's, not a problem for admin associates, because they're not involved in doing that, time and effort to input notes. Clinical reminder volume for PCP's: 64% of PCP's reported clinical reminder volume limits their ability to deliver optimal patient-centered care a great deal; 49% of our end-care managers, and similarly the CPRS view alert, so notification about labs, that sort of thing. 

Across the board, recruiting and retaining providers was high with a majority of PCP's reporting that limits their ability a great deal, and over a third, nearly a third or higher of nurse care managers and clinical associates saying that was a significant problem. 

We rated team functioning using a survey scale called the Survey of Organizational Attributes of Primary Care, and it measure four dimension of team functioning. Communication, so that's communication around difficult topics or conflict. Decision Making is about participatory decision making. Chaos is how chaotic the work environment is, and then history of change is whether or not they feel like their team has previously made successful changes, so chaos is a higher score. It's rated on one to five, a higher score is worse, on the other a higher score is better. This survey was used by Group Health Cooperative in their Patient-Centered Medical Home Demonstration Project, and it was previously used in the Ultra-Trial which is a primary-care-based trial, and we fielded a pilot survey of this survey in 2011, so we have scores from then. 

Overall, the scores among respondents, among the different occupations, are similar. Communication is rated a little bit higher by providers and care managers. Decision making is rated a little bit higher by admin associates; chaos a little bit higher by providers and nurse care managers. History of change, a little bit lower among clinical associates, admin associates, but largely the same. The scores are a bit lower, on average, than in our 2011 pilot because we had a small number of respondents to the 2011 survey that is not a comparison, we have little confidence that that reflects an actual change, but just for interest we do see what appears to be a decrease. It is lower on average also than the Group Health baseline data, so at baseline, what Group Health's providers were reporting was their team functioning. Our providers, care managers, clinical associates were reporting lower team functioning. Except on history of change where it's very similar. Our providers and primary care employees are reporting higher team functioning, though than in the Ultra-trial which was the original trial that used this instrument. 

We also asked these questions about self-efficacy. Actually this first row is about whether or not they feel like they understand PACT, and three-quarters of PCP's and nurse care managers said they do. Then, we asked how confident are you that you were capable of implementing PACT, so the individual, a majority of respondents, but a little higher for nurse care managers and clinical associates, majority of respondents, but still less than two-thirds. How confident are you that your teamlet clinic team is capable of implementing PACT? These are lower, and in particular for providers it's somewhat lower, and then, in terms of confidence that PACT will improve VA primary care smaller again with providers being significantly lower than our end-care managers, clinical associates, and admin associates. 

We also tested to see if barriers and facilitators differed for respondents at a hospital-based primary care clinics, versus community-based primary care clinics. They were not. The one exception was a slightly higher proportion of CBOC respondents, Community Based Outpatient Clinical respondents reported problems accessing and communicating with specialists, not surprising, but otherwise, not different. A couple of quick limitations, with response there is a significant threat of response bias. We don't have a true denominator; we don't know who got these surveys. We relied on the clinical leadership to distribute the surveys. Comparison to the AES, the All-Employee Survey demographics, give us confidence that we got a representative set of respondents, but we cannot discount the threat of response bias, in fact, I'm certain there's response bias, the question is what direction it goes. It's not possible to link these observations to teamlets. The lowest identifiers we have is a clinic-level identifier that limits our ability to test for convergence at the teamlet level. So, for example, in terms of teamlet functioning.

Conclusions from this survey, we find evidence that PACT is being implemented, that our respondents said they understood PACT, they were confident they could implement it, and factors like being assigned to a teamlet, a high proportion of respondents reported in the affirmative. Factors that seem to be influencing the implementation of PACT and quality of patient-centered care overall, relate to the business. The volume of clinical reminders was reported as the greatest barriers. Teamlet huddles were reported as the greatest facilitator in the teamlet functioning scores. The chaotic work environment sets of questions were very high, higher in the VA than at Group Health Cooperative, and higher than our previous pilot work. Then PACT specific training has been very helpful for some, but it's a minority of folks, and again, that will be an area for us to do further research on. Our next steps are developing an overall measure of PACT implementation, and assessing that relationship with utilization patient experience, and also assessing correlates of primary care personnel burnout and turnover. As you all will see in the slides that are available, my contact information's there. Also, my colleague Emily Dolan, who again, was a key person in developing and analyzing the survey data, we're happy to answer questions and thanks very much. I really appreciate the opportunity to talk with you about these survey findings. I'll hand it over to Michelle. 

Moderator:Excellent! Thank you very much Dr. Helfrich and I will turn it over to Dr. Lempa, now. 

Dr. Lempa:Hello everyone, before we begin, I just want to give everyone fair warning that we've had a mouse situation here in our office suite for the past couple of weeks, and this morning, I heard some activity in my office. I've tried to do a lot of banging and slamming, and making of noise, and stomping, but if you hear me scream like a little girl, and the line goes silent, you know now why. This presentation is the results of a primary care provider survey that we implemented, asking providers in VISN 4 about the quality improvement climate at their facilities, and the Director of C-PACT is Rachel Werner, and she, along with Judith Long, the Associate Director, and Judy Shea, who is the director of our qualitative core, designed the survey, and wanted to get it out pretty quickly after the implementation of PACT, and the rest of the folks here are our core team who implemented the survey. So, what we wanted to do was we wanted to look at the quality improvement environment within the clinics in VISN 4, so we could understand what the barriers were from the providers’ perspective to quality improvement, and to what degree change efforts are supported within their clinics. We were also interested in looking at change over time as PACT matures. 

These items do not specifically ask about PACT. Rather, they were adapted from existing instruments that were assessing different aspects of the quality improvement environment, so we looked at improvement processes such as taking time to plan activities, to what extent are sites using data to help with decision making around quality improvement. We asked about a variety of potential barriers which we will get to, and we also asked items around their practice setting experience which are looking at how stressful the primary care providers perceive the work environment to be, how chaotic it is, etc. Some of those items are similar or the same items to what you heard in Christian's presentation around chaos, and some of those other things, and then we also looked at communication between the teams, or among the teams in primary care, and then some communication and cooperation outside of primary care, such as with other departments. 

Primary care providers for us were anyone identified in a variety of sources as a primary care provider, so those were MD's, CO's, PA's, and nurse practitioners. We have administered the survey twice, first at the start of PACT in 2010, and again this past summer in 2012. We invited all VISN 4 primary care providers to participate. Because we were interested in seeing how opinions changed over time, our survey was not anonymous, but rather it was confidential. This way we were able to link responses from 2012 back to the same respondent in 2010. Our overall response rate actually is very, very good, and this is in part due to my fabulous persistent staff, but mostly because VISN 4’s primary care staff have been just amazingly generous with their time. The leadership in VISN 4 as well as the local leadership at the different stations has been also very generous with their time, so that's why you see such a fantastic response rate here. 

We did have some changeover in our provider pool between 2010 and 2012. We had about 22% attrition from this original pool of 347, and then in this 360, about 25% of the providers that were surveyed were actually new since 2010. Out of both surveys, we had 104 who responded to both of them. We'll be talking about this subset in some of the results today. VISN 4 has ten stations which includes ten VA medical centers, as well as about 46 CBOC's, and you can see the responses ranged from 42% to 70%, and response rates were the same regardless of whether they were at the main facility, or within a community-based outpatient clinic. 

What we're presenting here today are the results of the 2012 data collection, and we'll be reporting the two top boxes from the frequencies. For example, if we asked them on a five-point scale how much they agreed or disagreed with a statement, we've combined agree and strongly agree here in the results that you're going to see. We did some comparisons within the 2012 data. We looked CBOCs versus main facilities, and there were no statistically significant difference in any of the items on the survey. We also compared two groups of primary care providers. We looked at MD’s and DO's, and PA's and NP's together, and there were no statistically significant differences with the exception of one item which I will point out later, but I don't want to spoil it for you right now. We did do a comparison on that subset who answered the survey back in 2010, and again in 2012. I'll share those findings as we go along. 

Just before we do that, I want to give you a handful of highlights from the baseline survey in 2010, just to give you little bit of grounding in where we were at that time. In the rest of the presentation we'll dive into the 2012 results. Back in 2010, primary care providers were reporting that insufficient staffing and competing demands were their largest barriers. They did not believe that staff resistance to change was a barrier. Providers also said that they and other staff were overworked and stressed, but they didn't think that the work environment was chaotic, or that it was changing so fast that they couldn't keep up. Internal communication between doctors and nurses was reported to be effective, highly effective, and cooperation with departments outside of primary care and with senior administrators was quite low. 

Onto 2012, the first two items here have somewhat low, but not tragically low agreements. We asked providers to say how much they agreed or disagreed with these statements here. In relation to PACT, it is worth noting that this first item we make sure that we regularly take time to figure out ways to improve our work process, saw no significant changes from 2010 to 2012. This is a bit disappointing given that part of PACT implementation and the change process is supposed to involve protected time for teams for precisely this reason, to figure out new ways to do their work. We know from some of our other studies that we have going on that teams are struggling with maintaining their protected time. This is just one area to watch out for. On a high note, an overwhelming majority of providers feel that staff promptly resolved patient complaints. There may be some lessons here that can be adapted in terms of how they're resolving patient complaints, and perhaps they can adapt that to other processes within their clinics. 

I’m going to move onto a set of questions looking at how much providers say that their sites are using patient data to improve quality. These items, this is another area with some room for improvement. The numbers are sort of hanging there in the middle. What we hear though our qualitative interviews is that many of primary care staff don't know what data are available, or how to access them. Sometimes they know of a data source, but can't get access to it for some reason, or their facility doesn't have a person, for example, someone in the Systems Redesign Position that could help them with pulling data to help them do some decision making on quality improvement. 

This is all understandable that the front-line staff’s main job is to see patients, and they're not necessarily trained in data analysis, and they don't necessarily have the time to be poking around in analyzing data, but if there is a person at their facility, then it would be great if they could get linked to that person. I will say that this item here, we use data from patients to improve services. There was actually a significant decrease from 2010 to 2012 in that group of respondents in how much they agreed with that statement, so this is just an area for caution because we want to make sure that we're not slipping further behind in using some of the data, and the evidence to make decisions. 

We looked at barriers to improving quality, and we looked at these different groups, staffing, financial, financial barriers, resistance from staff, and competing demands. In terms of staffing, we asked to what extent was there sufficient personnel support to implement mandated QI changes, and the choices here were not at all, very little, some, great, and very great. Only 16% said that personnel support existed to a great or a very great extent. Just like the highlight that I showed you on 2010, in 2012 we're seeing a perception of lack of staffing here. We asked about specific staff roles, and whether or not there were sufficient numbers of staff in these roles, so to what extent were each of these items a barrier to improving performance? In this case, the choices were no barrier, small barrier, moderate, or large barrier. Here we are reporting the percent that answered moderate or large. A majority was reporting insufficient primary care providers, specialists, and nurses, and slightly less, but almost half of providers, were reporting that lack of administrative support staff was a barrier, and an overwhelming majority said limited personnel, in general, was a barrier. 

Coupled with this is agreement that not being able to shift resources is a barrier, and we've heard this from different staff in other venues, so other surveys or through qualitative interviews and site visits. We know that sometimes medical centers can't shift their dollars around to where it might benefit PACT implementation. These all were high in 2010, and we're seeing that they're fairly high again in 2012. We have a couple of items looking at those financial resources, and to what extent the lack of finances was a barrier. So our generic administrative officer or perhaps, fiscal person here seems to be a little bit worried about this. Fifty eight percent of primary care providers agree with him that limited financial resources is a barrier to quality improvement. Looking at this from another angle, only 20% of providers said that they had financial resources to a great or very great extent, in order to support quality improvement changes. 

This has changed up a little bit from the top-box reporting because it was important to see. We asked if resistance from various kinds of staff members was a barrier to quality improvement. For the most part, this is not a barrier. In fact, you can see no barrier, the majority of providers across all of these different saying if there was resistance from PCP's, or subspecialists or local managers and support staff. They're really saying that this is not a barrier to improvement, so this is really an area of strength that can be built upon to see additional quality improvement changes. Here's our last barrier: 73.4% of providers really feel that there are too many competing demands. This is the same in 2012, just like it was in 2010. There hasn't been a lot of movement here. 

I want to move on to communication. I want to move on to communication and cooperation. These items, we asked to what extent were any of these items a barrier to improving performance. You can see that primary care providers, the overwhelming majority really feel that there is effective communication between physicians and nurses. This is high just like it was back in 2010. Not so many are feeling that there is cooperation between departments, or between the physicians and senior administration, and even though these are low, there is a significant increase in the number of providers who were reporting great or very great cooperation between departments. 

That's been really good news that this is really moving in the right direction, then just as a side note, on this item with cooperation with the senior administration. We've had about half of our medical centers have had director changes since the beginning of PACT implementation in 2010. We did an analysis where we looked at the sites that had a change in leadership versus no change in leadership at that station, and the stations with no change were significantly more likely to report great or very great cooperation. This just tells us that it takes some time to establish a relationship, and build that trust, and so we perhaps may see some increases in those other sites as time goes on, and those relationships are built. 

Last, I want to take a look at how stressful the primary care providers perceive their work environment to be. From this gentleman's reaction here, I think you know what's coming. Just as in 2010, low numbers of providers are really reporting that their environment is chaotic, and that things are changing so fast that they can't keep up. However, a large majority is feeling stressed and overworked, and believe that other staff are feeling the same way. They all are feeling like they're too busy to make changes which brings us back to that first item about taking time to improve performance. Again, this is another reflection of providers not really experiencing that protected time which PACT is supposed to afford them to be making process changes, and process improvements. Our VISN leadership here in VISN 4 is aware of this, and has been working on strategies to improve protected time or to create more space for protected time, so we may see this item and the first item moving in a positive direction in future years. 

For these two items here, the providers in 2012 for that subset that answered both surveys are feeling significantly more stressed and overwhelmed by work demands than they were back in 2010. As you'll recall, in the beginning I said that there was one difference between MD's and DO's and PA's and nurse practitioners. Here is the item right here in the green box. PA's and NP's are feeling significantly more like it is hard to make any changes in the practice because they're so busy seeing patients, and I don't really have a good answer for what that's about, it could be a reflection of the difference in their job descriptions or their duties. We would have to look at that through some other study to try and get at the why behind we're seeing a significant difference in how they respond to this item. 

The last item that I want to leave you with is that along with our providers feeling stressed and overwhelmed, they're also feeling unrecognized for their efforts. We asked providers if they felt that they were adequately recognized non-financially for improving quality, and only about a third of them said that they were, so here is a fantastic opportunity for local leaders and national leaders to find ways to recognize QI efforts among providers and staff within primary care.

Our takeaway message, the biggest area for caution is that the providers are really feeling stressed and overwhelmed, and we really need to find ways to alleviate this. Based on this particular survey, which is a narrow slice, there is room for opportunity to find more ways to recognize quality improvement efforts, to give teams time, protected time to make changes, and perhaps to figure out some win/win situations with some of those other competing demands. There may be areas of alignment with other initiatives where they can find some efficiency and meet the goals of both PACT and some of the other initiatives that are in primary care, and throughout the VA. 

Again, staffing, funding, and competing demands remain barriers. There is less control at the local level somewhat for alleviating the funding situation and staffing, but perhaps there are ways that either local or national leaders can start making some changes that will benefit providers not feeling so stressed. There's also room for improvement in using data for quality improvement. This again, is another area of caution because we did see a slip in one of those items, and they weren't terribly high to begin with, so we want to make sure that we're not creating some losses and that we want to move towards making gains in this area. In order to do a lot of these things, we can build on the strengths that we have. There is really great effective communication between the doctors and nurses. There's low or no resistance among staff to make changes, and then there are some processes in place such as addressing patient complaints to create even more gains, and also we can harken back to some of the facilitators in Christian's presentation that primary care staff said that they found helpful. Here are other places where we really can make some improvements, and build from our areas of strength. 

I just want to again, thank the primary care providers, and the other staff in VISN 4 for being so incredibly generous with us in sharing their time and their thoughts. The VISN 4 leadership and staff, in particular Dr. McPherson and Jen Sooc for their continued support of all of our efforts and everyone at our Demo Lab Coordinating Center, and our partner labs, as well as Primary Care Services. Thank you very much!

Moderator:Thank you, Dr. Lempa. We do have several pending questions, so we'll get right to it. I just want to mention to anyone that joined after the top of the hour, to submit a question or a comment, simply type it into the question section on the dashboard on the right-hand side of your screen, and press send. The questions are directed at each presenter individually, so we'll just go ahead and alternate back and forth. This first one is for Dr. Helfrich. How much of teamlet huddles being the top facilitator is due to salience? For example, if it's the most common strategy, it is also perceived as the most useful, just because it is the most used?

Dr. Helfrich:That is a great question, one of the things that we don’t know. That is entirely possible, and one of the things we don't know yet is these facilitators, are they associated with indicators of PACT implementation, other indicators of PACT implementation, and that's something that we are going to be looking at in the near future to try and understand what facilitators are actually empirically associated with higher levels of PACT implementation. The challenge is getting reliable, valid data, and like, with a survey, we've got measure of PACT implementation. We've got barriers and facilitators in that same survey, and there the challenge is the survey, we're measuring all of these things with the same instrument, and there's a real threat of bias, what they call method bias, from measuring these things in the same survey, and then trying to assess relationships. They're going to be correlated. One of the things that we're working on right now with the demo labs and with the Office of Primary Care is looking at some of these different sources of data, administrative data. Data on staffing, for example, in trying to triangulate different data sources and my hope is that we'll be able to identify some of these facilitators that maybe are actually associated with hard evidence of higher levels of implementation.

Moderator:Thank you for that reply. The next question came in during Dr. Lempa’s portion, but either of you may be able to address it. Is there an overall estimate of the number of VA staff and providers who are actively engaged in PACT in the VA? I've looked around, but cannot find an estimate.

Dr. Helfrich:Yes, and actually, Michelle, I can respond to that. The answer is yes and no. In terms of, in principle, PACT is being implemented nationally, right, so in principle all VA primary care clinics are involved. The numbers of primary care staff, those estimates actually vary. The one group that we have a really pretty good beat on is primary care providers, because they're in the Primary Care Management Module PCMM. There we know who those folks are. The physicians, nurse practitioners and PA's, but for other staff it's more difficult to get a solid figure on the numbers of staff. That's one of the reasons why we did this survey was to try to get a better sense of the proportion of folks out there who again, are, have been assigned to teamlets, who are actually engaged in team-based care. So, the answer is yes and no. We can get a number of PCP's they all in principle should be implementing PACT, and in terms of national number of folks assigned to a PACT teamlet, our survey, and then another survey by the Office of Primary Care, the PACT Recognition Survey, those are probably the best bets. I don't know if that answers the question.

Moderator:Thank you for that reply. The submitter can always ask for further detail, if needed. This next question is in reference to one of Michelle's slides. In the practice setting experience slide, and related to the high levels of stress and lack of protected time, how much of this variance do you think could be attributed to work demands in general versus PACT-specific?

Dr. Lempa:These could be work demands, in general. We did not ask specifically about PACT. PACT may be influencing some of the increases that we see because it's just the growing pains of a new initiative. It could be the downturn in the economy, and levels of funding being flat, or not increased for some reason. There are a lot of reasons. We can't necessarily attribute this directly to PACT. What we wanted to do is just get a sense of where people were throughout these initial years of PACT implementation, and get a sense of their opinion of how they're experiencing the climate within their practices.

Moderator:Great, thank you. This next one is for Dr. Helfrich: 78.2% of the respondents were designated teamlet occupation, within this group, what the response rate by type of teamlet member.

Dr. Helfrich:That's also a great question, and that we don't have. We don't have a response rate by teamlet members. That is actually something we are working on, again, this goes back to one of the previous questions. With PCMM, we have a figure on providers and we've been working on a response rate for providers. We haven't finished that yet. The response rate for providers is much lower. It's over 20%, but not by much. That's something that we're still working on. For nurse care managers, for clinical associates, for admin associates, we don't have a denominator, unfortunately. I'd be happy to explain how we arrived at the approximately 30% if folks want to follow up offline. I just have to stress, again, that it's an approximation, and it's our best guess.

Moderator:Thank you very much. I'm going to go ahead and combine a couple of questions here. Are these surveys published? If so, what are the references, and would you be willing to post the survey questions so we can use them as a basis for discussion with our PCP's?

Dr. Helfrich:Michelle, do you want to?

Dr. Lempa:Our survey is published in the sense that we actually pulled from existing surveys, but I am certainly happy to share a copy of our survey items, our questionnaire with you, yes.

Dr. Helfrich:Yes, and parts of our survey are from published validated scales like Michelle said, we're happy to share the survey; we're happy to share the citations. We're actually working on a paper, just a descriptive paper to describe the survey, basic results from the 2012 survey findings, and the purpose of the survey, all that. We're hoping to have that submitted to the Journal of General Internal Medicine, probably next month, and once that’s available, that's also something that we're happy to, folks who are interested, email me, and I'll put you on the mail list, and we'll make sure to get that out to you when it's available.

Moderator:Great, thank you both for making yourselves available offline.  The next questions we have: What type of personnel is included in the category, clinical associates? 

Dr. Helfrich:I'm happy to answer that. Nancy Sharp, who's on the Demonstration Lab Coordinating Center Team, just reminded me that we have a Sharepoint site that's open to all VA employees. A Sharepoint site for the PACT Demo Lab Coordinating Center, and maybe, and Molly I don't know if we could post that, or send it out or something. That will be a great place for us to direct folks. In terms of clinical associates, so that would include medical technicians, licensed practical nurses, licensed vocational nurses, and there was another group, and I apologize, I don't have it in front of me, but there were four occupations there. These are the folks that work directly with the provider in bringing patients into the clinic, getting them settled in an exam room. It's those occupations.

Moderator:Excellent, thank you for that reply. The next question we have, and this is addressed to either of you: What strategies have you seen being used to improve PACT members’ sense of being overwhelmed, and not feeling their co-workers or leadership are supporting them?

Dr. Helfrich:Great question. Michelle? I bet you’re in a better position to answer that than I am.

Dr. Lempa:What I can do is refer folks to a publication that actually is hot off the presses in the last couple of months from our qualitative team that looked at some things I talked about here. So, looking at leadership and the ways in which leaders support, or don’t support PACT, and how that affects the team. For example, the protected time that I talked about was also a theme within our qualitative studies that we've done that says those sites, or those teams that are given that protected time, and it’s not taken away for some other reason, feel like they can function a little bit better. The other theme that is in there is around the data use, and data issues. What I can do is I can make that publication available, because it will be a good read, and give some good strategies that potentially could help alleviate some of the stress.

Moderator:Thank you. We do have about five pending questions. We are approaching the top of the hour. Are you both able to stay on, and answer the remaining questions?

Dr. Lempa:Sure. 

Dr. Helfrich:Certainly.

Moderator:Thank you very much. Okay, moving right along. The next question: Lack of administrative support for one-third of PACT teams is a major problem. How is this barrier going to be addressed within the system?

Dr. Helfrich:That's a really tough question, in part because it speaks to a number of different actors. From my perspective, the one thing I can say, and an omission in making my presentation, was mentioning the heavy involvement of the Office of Primary Care in our survey and in the National Evaluation, and just in general in the operation of the demo labs and the Demo Lab Coordinating Center. We worked very closely with Drs. Gordon Schectman and Rich Stark, and others. The issues of administrative support are going to be those are really going to be things that are going to take involvement of the leadership at a policy level, at a national level, and at a more local level. It's difficult for us from survey data; we can describe what we're seeing. We can feed that back to the policy makers. It's very difficult to use that data, and say here is the solution. It's going to take some dialogue. It may be different site-to-site, but for our part, our role is to describe what we're seeing as best we can, and to make sure that that information gets to national leadership, and to the extent possible, tailored information gets out to folks at a more local level.

Moderator:Thank you for that reply. This question is in follow up to the last one about protected time, protected time, how much, and how often?

Dr. Lempa:I don't really know. There were some guidelines around that. If I am recalling correctly, each team was supposed to have an hour per week of protected time to be able to do some planning. These are not the huddles that Christian mentioned. These are planning time. I'm pretty sure it's about an hour a week. That's pretty difficult to find in folks’ schedules, so there have been some difficulties with that and not being able to protect that time 

Moderator:Thank you for that reply. The next question, we have three remaining. How do we find out more information about the degree to which PACT has been implemented in the VA by VISN and within a facility for a particular VISN which is in reference to goal number one in slide six of Dr. Helfrich's presentation. 

Dr. Helfrich:That's also a great question. One of the things that we want to do, and have struggled to do, just because of competing demands on our end, we do want to make these data available to the extent we can. Part of sending out these surveys was that they were to be anonymous. We were going to maintain anonymity by not reporting data that were potentially identifiable to an individual or to a small group of individuals. We are hoping to provide some aggregated data, but at this point, and to post it someplace where anybody can get it. At this point we're still working to do that, and honestly, it is largely, right now, it's just our own staffing, and competing demands, but that's something that I'm hoping that we can do. We do want to; folks in the field gave us these data. We feel like those data belong to those folks in the field. We want to make it accessible, and hope to.

Moderator:The next question: Is a PACT mainly defined member provider, nurse, HT, clerk?

Dr. Helfrich:Yes. This again, is something Michelle may want to weigh in on. There's the ideal PACT teamlet which is the four members, but the Office of Primary Care, Patient Care Services, they very early on shied away from making that a requirement, saying that everybody has to form the same PACTs. This would be actually a good question to have someone from the Office of Primary Care respond to, but that definition of a teamlet is a recommendation, it is something that is an ideal, but the leadership recognized very quickly that it may not be possible, or appropriate in all circumstances. Michelle do you have, you're much closer to the ground.

Dr. Lempa:Yes. I agree with what you're saying that there were those official guidelines, and recommendations of that configuration of four different people, but we've seen here in VISN 4 that there are teams with alternate configurations that are functioning very highly. We've got teams that, for example, don't have an RN, but the primary care provider and the LPN are picking up the care-management duties, or for example, some of our larger facilities with academic affiliations where you have a lot of part-time FTE providers needing to figure out an alternate way of putting a team together when you've got multiple people who are working, let's say 10% or 20% time in a clinical capacity. There are lots of means to the end, here; lots of ways that teams can configure themselves using their existing resources.

Moderator:Thank you both for those replies. I seem to have left the most loaded question for the end. Is there a mechanism?

Dr. Helfrich:Times up! 

Moderator:Thanks for joining us everybody.

Dr. Lempa:I think I see that mouse. I think I need to go. 

Moderator:Yes. This is a doozy. Is there a mechanism to create improvements in PACT, for example, how to help providers deal with high volume of alerts, perhaps an RN could be trained to triage or process alerts?

Dr. Helfrich:That's an excellent question. Michelle do you have, let me punt it to you ... let me give you the tough one. 

Dr. Lempa:For us, the work that we're doing here in VISN 4 is mainly observational. We're not, C-PACT is not necessarily intervening, but we are seeing what a lot of different sites are doing, and examples that they have. I am not sure how to answer this; I need to think about it. 

Dr. Helfrich:There are a couple of resources, more than a couple of resources. There is not a simple answer to that. There is not a single solution. Some of the resources that are out there right now, actually in those facilitator slides, the Office of Systems Redesign has a toolkit, PACT toolkit, and this is of practices ostensibly best practices that they've identified. I do not know if it specifically has anything addressing the care manager, delegation to the care manager, or how best to work with a care manager in managing volume in cases. 

There is also the training support which is still being provided through Employee Education Services in the Office of Systems Redesign in addition to the regional collaboratives which have concluded. There were learning centers. I'm not certain, I believe those are still operating. That's something I am certainly happy to look into, and again, we can post to the Sharepoint that Nancy Sharp had mentioned. Finally, the demonstration labs like Michelle said, largely, some of the demonstration labs are doing, testing models. Oftentimes it's descriptive, but we will be increasingly seeing findings from the demo labs about what appears to be working. Some of that will be cyber seminars, presentations. Some of that'll be papers. Some of that is going to be policy documents, but that is something we anticipate seeing more of in the near future, like in the next year.

Dr. Lempa:Those regional collaborative also have their Sharepoints. They're still up, so you may be able to find resources within that. Here at VISN 4 we actually have a virtual collaborative that our VISN leadership created that really encourages teams and folks at different sites to share some of their successes, and some of their struggles with each other, so that's another way to maybe just even ask some other teams within your site, or at some of the other sites within your station what they're doing, and what they've found to be successful.

Moderator:Thank you both very much. I do want to plug our next PACT session which will be Wednesday, February 20th at 12:00 p.m. and that'll be on provider and staff experience with PACT, Results and Recommendations from national and regional primary care surveys. Also you can register for that by visiting the cyber seminar catalogue, and you can also go to the archive catalogue to view past PACT presentations. At this time, I'd like to thank our presenters for lending their expertise to the field, and thank our audience members for joining us. For our audience members, as you exit the presentation, please do wait just a moment while a brief survey populates on your screen. We do appreciate your feedback, and take it into consideration when scheduling for new topics. Would either of you like to give any concluding comments?

Dr. Helfrich:Just to say thank you for the opportunity to present. 

Dr. Lempa: Thank you so much for listening.

Moderator:Great! Thank you everyone. Have a nice day!

Dr. Helfrich:Take care everybody.

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