"We've not gotten even close to what we want to do": a qualitative study of early patient-centered medical home implementation.
BACKGROUND
The Veterans Health Administration (VA) Patient Aligned Care Teams (PACT) initiative is designed to deliver a medical home model of care associated with better patient outcomes, but success will depend in part on the model's acceptability and sustainability among clinic employees.


OBJECTIVE
We sought to identify key themes in the experience of primary care providers, nurse care managers, clerical and clinical associates, and clinic administrators implementing PACT, with the aim of informing recommendations for continued development of the model and its components.


METHODS
Observational qualitative study; data collection from 2010 to 2013, using role-stratified and team focus groups and semi-structured interviews.


METHODS
241 of 337 (72 %) identified primary care clinic employees in PACT team or administrative roles, from 15 VA clinics in Oregon and Washington.


METHODS
Data coded and analyzed using conventional content analysis techniques.


RESULTS
Overall, participants were enthusiastic about the PACT concept, but felt necessary resources for success were not yet in place. Well-functioning teams were perceived as key to successful implementation. Development of such teams depended on adequate staffing, training, and dedicated time for team development. Changes within the broader VA system were also seen as necessary, including devolving greater control to the clinic level and improving system alignment with the PACT model. PACT advocates from among clinic and institutional level leadership were identified as a final key ingredient for success. These themes were consistent despite differences in clinic settings and characteristics.


CONCLUSIONS
PACT implementation faced significant challenges in its early years. Realizing PACT's transformative potential will require acting on the needs identified by clinic workers in this study: ensuring adequate staffing in all team roles, devoting resources to in-depth training for all employees in communication and other skills needed to maximize team success, and aligning the broader VA hospital system with PACT's decentralized, team-based approach.
Portland VA Medical Center, Health Services Research & Development/ VISN 20 PACT Demonstration Laboratory, Veterans Health Administration, Mail code R&D63, PO Box 1034, Portland, OR, 97239, USA, anais.tuepker@va.gov.
Anaïs
A
Tuepker
Devan
D
Kansagara
Eleni
E
Skaperdas
Christina
C
Nicolaidis
Sandra
S
Joos
Michael
M
Alperin
David
D
Hickam
D006801:Humans; D010348:Patient Care Team / Q000592:standards* / Q000639:trends; D018802:Patient-Centered Care / Q000592:standards* / Q000639:trends; D011320:Primary Health Care / Q000592:standards* / Q000639:trends; D036301:Qualitative Research; D014481:United States; D014493:United States Department of Veterans Affairs / Q000592:standards* / Q000639:trends