Improving chronic illness care for veterans within the framework of the Patient-Centered Medical Home: experiences from the Ann Arbor Patient-Aligned Care Team Laboratory.
While key components of the Patient-Centered Medical Home (PCMH) have been described, improved patient outcomes and efficiencies have yet to be conclusively demonstrated. We describe the rationale, conceptual framework, and progress to date as part of the VA Ann Arbor Patient-Aligned Care Team (PACT) Demonstration Laboratory, a clinical care-research partnership designed to implement and evaluate PCMH programs. Evidence and experience underlying this initiative is presented. Key components of this innovation are: (a) a population-based registry; (b) a navigator system that matches veterans to programs; and (c) a menu of self-management support programs designed to improve between-visit support and leverage the assistance of patient-peers and informal caregivers. This approach integrates PCMH principles with novel implementation tools allowing patients, caregivers, and clinicians to improve disease management and self-care. Making changes within a complex organization and integrating programmatic and research goals represent unique opportunities and challenges for evidence-based healthcare improvements in the VA.
VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 300 N. Ingalls Bldg., Room 7E10, Ann Arbor, MI 48109-5429 USA ; Department of Internal Medicine, University of Michigan, Ann Arbor, MI USA.
John D
JD
Piette
Bree
B
Holtz
Ashley J
AJ
Beard
Caroline
C
Blaum
C Leo
CL
Greenstone
Sarah L
SL
Krein
Adam
A
Tremblay
Jane
J
Forman
Eve A
EA
Kerr
Access-to-care; Chronic disease; Health system change; Information technology; Self-management; Telehealth; Veterans