Aleda E. Lutz VA Medical Center, Saginaw, Michigan
Patient Aligned Care Teams (PACT)
PATIENT ALIGNED CARE TEAMS (PACT)
On August 18, 2010 our first PACT Team began seeing patients. This PACT Team (called a Teamlet) consists of two primary care providers and their staff, which includes one patient services assistant (PSA), one registered nurse (RN), and one licensed practical nurse (LPN). The PACT is responsible for providing for all of a patient’s health care needs or appropriately coordinating care with other qualified professionals. Each PACT Teamlet is a highly functional team led by a provider, working collaboratively with the patient on the patient’s goals and needs to provide enhanced access to quality care that is whole-person oriented.
- Patient charts are reviewed prior to the visit to make sure that:
1. The patient needs to be seen (could the patient’s needs be met by a phone call)
2. All needed lab testing is ordered so that the patient can come in and have labs drawn prior to the appt.
3. All needed information is available to the provider for the visit (i.e. medical records from a private hospitalization or private physician’s office, etc.)
- All patients get a phone call from their PACT team to remind them of their appointment to come in for labs, bring home blood sugar and blood pressure readings as appropriate, and any other information required for a successful visit.
- Patients who have an acute care admission are seen during their admission and then receive a follow-up within two days of discharge by their PACT Team RN who coordinates post hospitalization care and needs.
- Patients who are seen in the Urgent Care are contacted by their PACT RN the next day, or on Monday if seen in UC on Friday or the weekend. The Team RN coordinates any follow up care needed and makes sure that the patient is doing well.
- PACT RNs see patients for care management rather than the Veteran seeing the provider. The RN helps them with self-management of their chronic diseases like diabetes, hypertension, or congestive heart failure and other conditions that may warrant additional attention. The RN focuses on patient education and uses motivational interviewing techniques to help the patient meet his or her goals.
- PACT RNs collaborate with providers for patients triaged by the call center RN to be seen. Often the patient’s needs can be met over the phone or another venue.
- Patients can call and talk with a member of their PACT Team whenever they have questions or concerns about their health.
- Patients cared for by PACT Teamlets can use secure messaging through the Myhealthevet program to communicate with their team as well.
- Patients who have not had prevention testing (i.e. mammogram, PAP, PSA, etc.) are contacted and an apptointment scheduled.
PACT Training provided:
- Saginaw had eleven employees attend the PACT Summit in April 2010
- Eight employees attended the 1st PACT Collaborative Learning Session
- Eight employees attended the 2nd PACT Collaborative Learning Session
- Saginaw sent two trainees to the PACT Facilitator Training in November 2010
- Two staff from Health Promotion and Disease Prevention (HPDP) attended National Training
- PACT was the topic of a Grand Rounds in November 2010, where medical, nursing, and administrative staff throughout the medical center were given an overview of the PACT concepts and implementation plan for Saginaw, including data outcomes of pilots at the facility.
- PACT Collaborative Attendees provided Teach-Back training at unit staff meetings and to ancillary services (Pharmacy, Acute Care, FMS).
- Staff are educated weekly through articles in the Employee Weekly Newsletter
- Staff and patients are educated through monthly displays in the main lobby at the VA Medical Center in Saginaw.
- PACT is a standing agenda item for staff meetings for Medical, Nursing, and Patient Administration services where Teamlet members give updates to their peers.
- Monthly Care Management Webinars are accessed by RN staff.
- Monthly Webinars from National, Veterans Integrated Service Network (VISN), and Collaborative Initiatives are accessed by PACT Teamlets, PACT Collaborative Team, and the PACT Home Team.
- PACT Teamlets received team and role specific orientation
- Twenty-five Teamlet staff and expanded team members attended sixteen hours of Motivational Interviewing (MI) training by a certified trainer.
We have successful PACT Teamlets on the Green Team at the Saginaw VA Medical Center and the Bad Axe Community Based Outpatient Clinic (CBOC). Primary care at the VA Annex, also located in Saginaw, will be implementing PACT concepts in January 2011.