Integrating Post-Combat Care into the Patient Aligned Care Team (PACT)

1. Integrating Post-Combat Care into the Patient Aligned Care Team (PACT) Lucile Burgo, MD National Co-Director Post Deployment Integrated Care Initiative Associate Primary Care Director VA Connecticut

2. Disclosure Statement • I have no conflicts of interest to disclose

3. OUTLINE • Some primary care history and facts • PACT as a framework for “best care” • Post deployment care in the PACT • How can the WRIISC align with PACT?

4. IOM Definition of Patient Centered Care Healthcare that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions • superb access to care • patient engagement • clinical information systems • care coordination • integrated and comprehensive care • smooth transfer of information • ongoing public information

5. Veteran Centered Care Physical Psychological Veteran Psychosocial

6. VHA Primary Care Milestones

7. Primary Care in the VHA

8. VHA Primary Care Providers7371 Providers, 5008 FTE (Avg. 0.69 FTE) (5% Trainees) 8

9. VHA Primary Care by Age & Gender 44% 6.1% Female 25% 21% had encounter in Mental Health

10. VHA Primary Care

11. PATIENT ALIGNED CARE TEAMS Replaces episodic care based on illness and patient complaints with coordinated care and a long term healing relationship THE PRIMARY CARE CORE TEAM

12. Pillars of PACT

13. Population Health Model Patient Complexity, Health Status, Needs Medical Home Team Specialty Care RN Care Manager Teamlet Specialty Certified RN Specialist Clinical Nurse Specialist Clinical Nurse Leader, Case Managers, Clinical Pharmacists Coordination of Care Disease/Cohort Management Management of Care

14. Other Team Members • Clinical Pharmacy Specialist: ± 3 panels • Clinical Pharmacy anticoagulation: ± 5 panels • Social Work: ± 2 panels • Nutrition: ± 5 panels • CaseManagers • Trainees • Integrated Behavioral Health • Psychologist ± 3 panels • Social Worker ± 5 panels • Care Manager ± 5 panels • Psychiatrist ± 10 panels For each parent facility Health Promotion Disease Prevention Program Manager:1 FTE Health Behavior Coordinator: 1 FTE My HealtheVetCoordinator:1 FTE Panel size adjusted (modeled) for rooms and staffing Monitored via Primary Care Staffing and Room Utilization Data The Patient’s Primary Care Team

15. Patient Aligned Care Team Veteran Centered, Team based, coordinated care PACT Care Coordination & Care Management Team Function and Culture Veteran VA (VHA and VBA)

16. Patient-Centered Perspective

19. Primary Care (PCMM) National Staffing Ratio

20. Primary & Specialty Care: Becoming True Partners

21. In the end we know… Primary care is best when it does these four things well:

22. If Primary Care does those things well, then patients who receive care in those practices….

23. Post Deployment Integrated Care Vision: • Comprehensive, Veteran-centered, team based care for returning combat Veterans • Health recovery oriented • Transitional in nature

24. Three Variations of the PDICI Model • Post Deployment Clinic Model • Dedicated space and staff • Full time if volume indicates • Part time, with shared space • Cohort Model • Specific Primary Care Provider or Providers identified to develop skills and experience • OEF/OIF patients assigned to these providers • Representatives from other professions similarly identified • Consultative Model • OEF/OIF veterans assigned to all Primary Care Providers; cared by usual staff • Medical/Mental Health/Social Work resources with specialized knowledge and skills identified to assist in consultative role

25. Post Deployment Care for Recent Combat Veterans RECOMMENDED ELEMENTS • Co-localization whenever possible for Polytrauma, Mental Health, Pain, and Physical Therapy clinics Same day access encouraged even when co-localization not possible • Collaboration as above, as well as with chaplain, CAM/WRIISC, VBA, community services/agencies • Extended hours availability • Seamless telephone access; provisions for secure e-mail and text messaging alternatives encouraged • When feasible identified space

26. Post Deployment Care for Recent Combat Veterans ESSENTIAL ELEMENTS FOR CARE • Comprehensive psychosocial and medical intake performed at initial visit by PCP, MH, SW • Integrated, de-stigmatized MH treatment • Resources aligned around Veteran • Active participation by OEF/OIF program staff and specialized teams in mental health, polytrauma, pain, SA featuring full integration of all post deployment services • Integrated team meets to formulate Veteran centered care plan • Extended hours availability

27. Post Deployment Care for Recent Combat Veterans • The PACT will have tools and training to accomplish comprehensive intake and provide ongoing support and coordination of post deployment care • Teamlet: Primary Care Provider(s), RN care manager and clinical associate, and clerk trained in combat Veteran’s unique needs • Extended team: PACT social worker, PC-MHI, pharmacist trained in combat Vet unique needs • OEF/OIF program : trains and supports PACT joining core team when needed • PDICI champions(PC,MH) assist with facility education and consultative support of PACT • Expanded Team: Polytrauma/rehab, Pain, SA, specialty mental health, OT,PT, vision, suicide prevention, chaplains, WRIISC, LMD, medical and surgical specialties, military case managers join the Veterans’ team when needed

28. TASKS FOR POST DEPLOYMENT CARE IN THE PACT ESSENTIAL ELEMENTS FOR CARE IN THE PACT • Risk assessment at each encounter F 2 F and non F 2 F • Proactive visit needs assessment by teamlet (prescreens?) to coordinate services on day of visit (MH, SW, 2ary TBI, specialty care, labs, xrays) • Orientation to team, roles understood, partnership with Veteran • Assist with MHV-IPA, discuss communication methods (secure messaging, telephone), demonstrate web resources • Weekly (extended) team huddles for complex cases • Assure knowledge of/connection to OEF/OIF program for each combat Vet. Key role of RN care manager

29. TASKS FOR POST DEPLOYMENT CARE IN THE PACT • Initiate appropriate assistance from OEF/OIF program manager and social worker, primary care champions, Consultative Team • Benefits, C+P • Legal assistance • Vet centers • Case management • Community resources and services • Schools • Assure coordination of care with specialty clinics and programs especially Polytrauma, pain, substance abuse, specialty mental health(PTSD), physical therapy, orthopedics, neurology(points of contact, service agreements) • Consider care provision via telehealth (telerehab, telepain, video conferencing), group visits for orientation, intake

30. Post-Deployment/PACT • Which features are different? • Younger population • fewer “disease management” needs and need for more psychosocial support/ case management

31. Post-Deployment/PACT • Who are the critical team members and their roles? • Central role of OEF/OIF/OND Program manager/case management • Need for behavioral health support and de-stigmatized MH tx for sub-threshold MH concerns

32. Post-Deployment/PACT • Major strengths of the model • “post-deployment” focus strengthens health recovery/reintegration goals for treatment • Strong history of Veteran centered, team based care in our Post-Deployment Integrated Care Clinics • “natural” fit with co-located, collaborative MH/PC clinics • High profile, high need cohort • “Veterans of the future”

33. Post-Deployment/PACT • Major challenges of the model • Psychosocial needs of the population easily overlooked (“low disease/high impairment) • OEF/OIF/OND Program Managers stretched thin

34. Post-Deployment/PACT • How might the model differ if: • This is a core mission of the VA • Institutional memory is essential to insure preparedness and optimal care for military personnel returning from future deployments • Need nascent capabilities (post-deployment care clinical champions) during times of peace • WRIISC can also insure ongoing attention to war related illnesses and injuries

35. Specialty PACT – Operations • Are there strong practices? • Designated post-combat care PACT (sees exclusively combat Veterans (Minneapolis) • Consultative model (VISN1) • Cohort models: • PDIC/PACTs (VISN1, VISN20)

36. Specialty PACT – Operations • What education and training is needed to launch? Sustain? • Rural health initiative trainings • Post-Combat Care • Military Culture • Environmental Agent Exposures • C&P/Benefits • WRIISC trainings • VHIs • NCPTSD/Polytrauma/Pain etc

37. Lessons Learned (cont’d) • How can we align the Specialty PACT and Primary Care PACT to assure that we best meet Veterans’ needs? • Strengthen the relationship of PM and PACT RN Care Manager • Strengthen case management assets • Bring Polytrauma, Pain,MH, SUDs assets into PACT • Integrate WRIISCs and Population approaches into process

38. Lessons Learned (cont’d) • How can we move in a direction of integration/communication and away from silos? • Reinforce “health recovery, reintegration” focus • Stay focused on Veteran centered care • Strengthen team processes • Expand “teamlet” based care notion to the idea of “core team” based care with Veteran at center of team, and all other team members brought into full team status

39. Patient Aligned Care Teamfor Returning Combat Veterans Patient centered, team based, integrated care Evidence based, continuously improving care Communication Combat Veteran Care/Case Manager Collaboration Coordination Post-Combat Care moves our PACTs forward The PACTs move our Post-Combat Care forward

40. Where do the WRIISCs fit in to PACT? PACT and the Veterans are your stakeholders. • PACTs need education and consultative support • Veterans with unresolved exposure concerns and MUS need expert opinion How do you best reach and serve both PACT and the Veteran? • Exposure conferences • WRIISC on site consultative service for MUS, exposure concerns • Telephone consults for exposure concerns • Virtual Consults with emerging telehealthpossibilities,e-consults, VA-SCAN( Specialty Care Access Networks)

41. PRIMARY CARE TEAM Case Manager Social Worker HOSPITALISTS PC Provider Clinical Associate NON-VA CARE TEAMLET Behaviorist RN Care Manager Administrative Clerk Polytrauma PATIENT Mental Health Pharmacist NCPTSD Dietitian Nursing WRIISC SPECIALISTS Family

43. Integrated Post-Deployment Care Wiki Post Deployment Integrated Care Initiative Lucile Burgo, MD and Stephen Hunt, MD Tri-WRIISC Meeting Washington, DC August 9-10, 2011

44. Caring for those who come home from war • Why a Wiki? • We have Veterans to serve today. • The Wiki aims to improve care for returning combat Veterans by creating an evolving, collaborative platform that consolidates the vast knowledge about post-combat care within the VA system. • 2. We have Veterans to serve tomorrow. • The Wiki will provide clinical and policy recommendations that help VA plan and deliver post-combat care for cohorts of Veterans returning home from future deployments.

45. An evolving resource Integrated Post-Deployment Care Wiki

46. Please join us! If you’re interested in contributing to the Wiki, please: • Email Rosie Hinojosa at rosie.hinojosa@va.gov to attend a Wiki training session and learn how to add content • Email content directly to Katie Berndtson at kathryn.berndtson@va.gov and she will add it for you

47. Thank you Thank you to all those who have contributed to and supported the Wiki so far: • Office of Health Information • Thad Abrams • Wes Ashford • Jeanette Akhter • Heather Belanger • Jean Bromley • John Chardos • Melinda Gentry • Sara Greenwood • Rosie Hinojosa • Linda Kleinsasser • Victoria Koehler • Elizabeth Manning • Becky Monroe • Tu Ngo • Heather Reisinger • Ilene Robeck • Alison Whitehead