Background
PACT Principles*
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The primary care team is focused on the whole person
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Patient preferences guide the care provided to the patient
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Primary care is delivered by an interdisciplinary team led by a primary care provider facilitative leadership skills.
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Patients receive the care the need at the time thay need it from an interdisciplinary team functioning at the highest level of their competency.
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Primary care is the point of first contact for a range of medical, behavior, and psychosocial needs, and is fully integrated with other VA health services and community resources.
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Every patient has an established and continuous relationship with a personal primary care provider.
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The communication between the patient and the other team members is honest, respectful, reliable, and culturally sensitive.
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The PACT coordinates care for the patient across and between the health care system including the private sector.
Methods
Setting and participants
Data collection and analysis
Focus group questions for VHA stakeholders regarding scheduled telephone visits
Results
Characteristics of participants
Variable | Patients (n = 18) | Providers (n = 16) | Staff (n = 18) |
---|---|---|---|
Male (n (%)) | 18 (100) | 6 (38) | 3 (17) |
Age (n (%))†
| |||
25-34 | 0 (0) | 2 (13) | 2 (12) |
35-44 | 1 (6) | 6 (40) | 4 (24) |
45-54 | 2 (11) | 5 (33) | 4 (24) |
55-64 | 8 (44) | 2 (13) | 7 (41) |
65+ | 7 (39) | 0 (0) | 0 (0) |
White (n (%))†
| 8 (53) | - | - |
Chronic Health Conditions (n (%))‡
| |||
Hypertension | 16 (89) | - | - |
Diabetes | 9 (50) | - | - |
Coronary heart disease | 7 (39) | - | - |
Congestive heart failure | 2 (11) | - | - |
Chronic obstructive pulmonary disease | 2 (11) | - | - |
Have a home (land line) telephone (n (%)) | 14 (78) | - | - |
Have a mobile or cell (n (%)) | 14 (78) | - | - |
Drive self to VA appointments (n (%)) | 14 (78) | - | - |
Distance traveled (one-way) | |||
(Mean (SD)), (Min, Max) | 30.7 (17.1), (2–65) | - | - |
Degree/license (n (%)) | |||
MD | - | 11 (69) | - |
PharmD | - | 2 (13) | - |
PA | - | 2 (13) | - |
NP | - | 1 (6) | - |
RN | - | - | 5 (28) |
LPN | - | - | 8 (44) |
Other | - | - | 5 (28) |
Themes relating to VA PACT principles
PACT principles | Analytic themes | Patients | Providers | Staff |
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Comprehensiveness: Primary care as point of contact for range of patient needs, including mental and physical health |
Using scheduled telephone visits for routine physical and mental health issues
| Routine visits that do not require physical examination (eg, chronic disease monitoring or mental health check-in/follow-up); Determine need for in-person visit | Routine visits that do not require physical examination (eg, chronic disease monitoring); Determine need for in-person visit | Routine visits that do not require physical examination (eg, chronic disease monitoring) |
Defining scope of scheduled telephone visits- how focused should they be?
| General issues | Focused issues | General issues | |
Patient-centeredness: Focus on patient wants, needs and preferences |
Engaging patients in determining scheduled telephone visit usage
| For those who choose; want flexibility to change to in-person visits if not comfortable | For those who chose | Can improve patient satisfaction with more patient control over issues discussed |
Dealing with patients who have adherence or communication challenges
| Could be beneficial for patients anxious about facing provider | For those who are “compliant” and do not have cognitive/verbal difficulties | Concern about liability with higher risk patients (eg, unable to communicate well over the phone) | |
Continuity: Established and sustained relationship with primary care provider |
Ensuring availability of providers. | Maintain provider awareness of decisions or subjects discussed via telephone; concern about impersonal aspects of remote encounters | Better for patients with established provider relationships; | Maintain provider awareness of decisions or subjects discussed via telephone and some direct patient contact with providers |
Strengthening quality of patient-provider relationships
| Better for patients with established provider relationships and can help strengthen relationships with more frequent contact | Can help maintain relationships and improve care quality if patients use preferred mode |
Analytic themes | Patients | Providers | Staff |
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Concerns about time- potential time saver, but for whom?
| Less time with reduced travel and briefer visits. | Avoid increase in patient panel size. | Avoid increase in patient panel size. |
Block of time preferable for receiving call. | Provide designated time for calls. | Provide designated time for calls. | |
Use staff members to help make calls. | Need more staff support to cover calls. | ||
Concern about spending time on hard-to-reach patients. | Concern about spending time on hard-to-reach patients. | ||
Integrating telephone care with other modes of remote communication. | Tiered system, starting with email and then phone. | Has convenient features, for example surrogate message forwarding, but would not work for every patient. |
Comprehensiveness
“Two thirds of the time I’m down here because I got a letter from my care provider…but I feel fairly good and I may not have to see him…If you have a system where you can get through and you can talk, I think you can relieve a lot of this beaurocracy…if he deemed he had to see me then we could go from there.” -patient“Sometimes you can save visits. And if it’s a pretty simple thing, ‘Well, gosh, I didn’t need to see the person anyway. I’ll just postpone it for another two or three or four months or whatever makes sense.” –provider
“…A lot of the time when you do a patient call-back, they will address … most likely another issue, whether it be the paperwork or something else… So even though you called to check on …their blood sugar, they might say, ‘Well and I have to get the doctor to sign this paper”…Even though it might take a little bit longer on the phone call, …they don’t have to call back and say, ‘Oh by the way we were only talking about blood pressure or blood sugar but I had this too.’” -staff”I usually have patients come in and see me and then I assess their competence to follow up over the phone. And I actually find that my phone follow-ups are more focused than my visits. And sometimes there is an ‘Oh by the way’, but I usually just tell them that they need to be seen in clinic and they’re usually fine with that.” –provider
Patient-centeredness
“A lot of times…their visit is for one thing, but they’re so frustrated over something else that they’re wanting to discuss that and not why they’re here for their visit. And it will cut down on frustration and I think it would improve the patient satisfaction, because…it appears that you care by calling them back and saying, ‘Hey, I just want to touch base with you in between your visit and we just want to see how you are doing.’” –staff member“I want the flexibility to be able to change it if I suddenly decide…” –patient
“I always have so much guilt by the time I have my appointment. I’m her worst patient. I’ve got to be… I fret over it and I really do have some trouble with it mentally…And if it could be done over the phone, some rascal like me would like that.” -patient“What I chose to do with this particular patient was give him a blood pressure machine, ask him to check it twice a day and to call back within a week to tell me what the blood pressure readings were…I mean, this was a patient that had vested interest in being healthy and no pattern of non-compliance before…I think it…saved not only him having to have that extra hour for a nurse blood pressure check…or even another gap appointment to have it checked. So I think it saved everybody.” -provider
Continuity
“Well in the past,…my provider has been on the ball. He had suggested I go to another clinic for another procedure and two days later he called and said, ‘Did you get that appointment?’…So he does follow up on me. I don’t have anything but good praise…” -patient“Some of the telephone care the patients want from the physician, not from the nurse. And so I just think we need to make sure the physician’s available and willing and has the time in their schedule also to make some of these calls.” –staff member
“… [a Veteran] who’s been with his primary provider for some time- I think it would be a lot easier for him to do that than a new person coming in, because…there’s just too many things that could go wrong with somebody just starting their care under the VA.” -patient“I think it could be beneficial in maintaining the relationship that we have with our patients, also….So in theory it could work; it would give them an opportunity to say, my clinic cares about me…”- provider
Logistical considerations for implementation
“…this model has to address the time that we have and right now it’s already over-utilized, with patient care, along with other things, and addressing telephone encounters. So I think in the end it ultimately has to come from ancillary support to make it successful.” – provider“Right now, with the staffing that we have, it does not fit at all. So it would have to definitely be set up with more staff and a blocked out time.” –staff member
“The sort of email or secure messaging thing may be the savior of telephone medicine…I can do it more easily on my own time…It may be that if we do more emailing…bumping it up to telephone care if things clinically warrant it and then from there…to an office visit if it seems warranted beyond that…” –provider“Secure messaging looks more and more attractive, because you actually can assign a surrogate. We just had experience with that here recently…but…a certain number of patients who either can’t use it for whatever reason or who are not going to use it, don’t have access to it. So they still need the telephone.” –staff member