Excellence in Healthcare Patient Aligned Care Teams


– WHEN THE IDEA OF
THE MEDICAL HOME WAS
INTRODUCED INTO THE VA, WE ALREADY WERE AT A
PRETTY HIGH LEVEL OF
FUNCTION OF PRIMARY CARE. AND SOME OF US
WERE WONDERING
WHAT THIS WOULD DO TO HELP US MOVE FORWARD. – WE’VE PROVIDED EXCELLENT
PRIMARY CARE FOR THE
LAST 15 TO 20 YEARS. THIS IS REALLY
TRYING TO MOVE US
TO EXCEPTIONAL CARE. – WE HAD TO SHAKE UP
THE BOX A LITTLE BIT AND PUT
THE PIECES BACK IN TOGETHER SO THAT WE COULD GET
A DIFFERENT OUTCOME. – PACT AND THE MEDICAL
HOME SEEM TO HAVE
TAKEN PRIMARY CARE FROM A REALLY
STRONG FOUNDATION,
THE BASELINE, UP TO AN EVEN HIGHER
LEVEL OF PLAY. – IT’S REALLY CRITICAL
FOR US TO MOVE FROM
AN ORGANIZATION THAT HAS BEEN
PROVIDING GOOD
HEALTH CARE TO ONE THAT PROVIDES
THE BEST HEALTH CARE. THE BEST HEALTH
CARE ANYWHERE. – WE HAVE THE
OPPORTUNITY TO TAKE
AN EXCELLENT SYSTEM AND MAKE IT
TRULY THE BEST. – SO, IT’S REALLY
ASPIRATIONAL IN NATURE. AND THAT MAKES IT
HARD, BUT WORTH IT. – MANY ORGANIZATIONS
DO NOT HAVE THE
INTERDISCIPLINARY CARE TEAM AVAILABLE IN ONE LOCATION TO TAKE CARE OF
THE PATIENTS’ COMPLETE
AND WHOLE NEEDS. SO, THAT IS JUST
THE BEAUTY OF PACT. – I’VE BEEN IN PRIVATE
PRACTICE FOR RIGHT
AT 20 YEARS, AND THIS IS DIFFERENT. IN PRIVATE PRACTICE,
IT’S STILL KIND OF A
PHYSICIAN-BASED PRACTICE WHERE THE PHYSICIAN
KIND OF TAKES
THE LEAD ROLE THERE AND EVERYTHING ELSE
KIND OF IS INTEGRATED
INTO THE PHYSICIAN. – MANY YEARS AGO, FOR
INSTANCE, IN OUR SPECIALTY
CLINIC, IN PULMONARY, WE MET ONCE A WEEK
ON A WEDNESDAY AND THE PATIENT
CHARTS WERE PILED
UP IN ONE AREA AND ALL THE PULMONARY
DOCS WENT IN AND GRABBED THE CHART
AND SAW THE PATIENTS. AND THERE WASN’T
REALLY MUCH CONTINUITY
OF CARE THERE EITHER BECAUSE THE PATIENTS
REALLY DIDN’T EVEN HAVE
THEIR OWN DOC, SO TO SPEAK. – THE PACT MODEL IS
DIFFERENT, BECAUSE
YOU ACTUALLY HAVE A TEAM OF PEOPLE THAT ARE
RESPONSIBLE FOR YOU. I’M JUST GOING
TO HAVE YOU DO
A PEAK FLOW. NOW, I KNOW
THAT YOU’VE DONE
THIS BEFORE. – I THINK THE PATIENTS
ARE DEFINITELY HAPPIER, BECAUSE THEY’RE DEALING WITH
THE SAME PEOPLE OVER AND
OVER AGAIN, THE SAME TEAM. THAT PROVIDES
A CONTINUITY THAT REALLY IS WHAT A LOT
OF PEOPLE PREFER RATHER THAN SEEING SOMEBODY
DIFFERENT EACH TIME. – ON OUR GREEN TEAM,
WE HAVE MYSELF, THE RN, WE HAVE AN LPN,
WE HAVE THE DOCTOR,
WE HAVE A CLERK. AND THAT’S THE BASIC
PEOPLE THAT SEE THE
PATIENTS DAY-TO-DAY IN THE CLINIC SETTING. – WE WORK AS A TEAM,
NOT ONLY THE CORE TEAM, BUT ALSO THE ANCILLARY
CARE PROVIDERS, SUCH AS THE NUTRITIONIST,
THE PHARMACIST, THE SOCIAL WORKER,
AND THE MENTAL
HEALTH PERSON. – THEY DELIVER CARE TO
THAT PATIENT, THE TOTAL
COMPREHENSIVE CARE. AND THE PATIENT IS
IN THE CENTER OF
THE DELIVERY MODEL. – I WORK AT ARKANSAS
NUCLEAR ONE, WHICH IS A NUCLEAR
POWER PLANT HERE IN
RUSSELL, ARKANSAS. I WORK AS
A SAFETY TECHNICIAN. I LOVE MY JOB. IT CAN BE VERY DEMANDING,
BUT I LOVE IT. THE THINGS THAT I FEEL
ARE IMPORTANT TO ME,
FIRST OF ALL IS MY FAMILY. WE’RE RIGHT HERE
ON THE WATER. WITHIN MINUTES
WE’RE OUT THERE
AND WE’RE FISHING, OR WE’RE PULLING THE KIDS
ON THE TUBE. – KRISTIE HAS
SOME CHALLENGING ISSUES. HER TOP 3 WOULD PROBABLY BE
SJOGREN’S SYNDROME, SHE HAS BILIARY
CIRRHOSIS, AND SHE
HAS FIBROMYALGIA. – THANK YOU.
– THANK YOU. – HER BLOOD WORK HAS
TO BE DONE REGULARLY. WE HAVE TO LOOK AT HER
IMMUNE SYSTEM, WE HAVE TO LOOK AT HOW
IT’S AFFECTING HER LIVER, AND THEN HOW IS
IT AFFECTING HER
MUSCLES AND HER PAIN. – WITH MY CONDITIONS, I DO HAVE
TIMES WHERE I’M NOT AT MY BEST AS FAR AS THE PAIN
LEVEL THAT I HAVE, AND, I MEAN,
SOMETIMES IT CAN GO
ON FOR A FEW DAYS, WHERE I JUST FEEL DRAINED. FOR THE PROBLEMS THAT
I HAVE, I HAVE TO GO TO
THE SPECIALTY CLINICS, WHICH ARE ACTUALLY LOCATED
IN LITTLE ROCK. THAT’S 84 MILES AWAY FROM HERE. – AND I’M AFRAID THAT IF
SHE HAD TO MAKE AS MANY TRIPS AS SHE’S HAD TO MAKE
FOR LAB AND STUFF SHE MIGHT NOT HAVE MADE THEM
BECAUSE OF THE DISTANCE. – I THINK THE PACT TEAM HAS
MADE A SIGNIFICANT DIFFERENCE
IN KRISTIE’S LIFE. I THINK IT HAS
TAKEN A WHOLE-TEAM
APPROACH TO GIVE HER A HOLISTIC VIEW OF HER
MEDICAL HOME. – GET YOU TO PUT
YOUR LEFT HAND RIGHT
IN THE CENTER OF THAT. – OK. – SHE STILL HAS
ALL THE ACCESS TO BIG-CITY
SPECIALIST MEDICINE
IF SHE NEEDS THAT. – HOLD REAL STILL. – SHE HAS A HOME BASE
AND, I THINK, FEELS MORE COMFORTABLE
WITH THAT, WHERE WE CAN COORDINATE
ALL OF HER CARE. – NOW SHE HAS THE ABILITY
TO COME HERE. SHE GETS HER LABS DONE
VERY QUICKLY. SHE GETS IN, SHE GETS OUT,
HER PRIMARY CARE’S RIGHT HERE. SHE GETS IN, SHE GETS OUT. IT’S MADE HER LIFE A LOT EASIER. – PATIENT-DRIVEN CARE
MEANS TO ME THE ABILITY FOR
PATIENTS TO PARTICIPATE
IN THEIR OWN CARE. – IT MEANS SPENDING
THAT EXTRA MOMENT TO FIGURE OUT WHO
VETERAN SMITH IS. WHAT DRIVES YOU?
WHAT MOTIVATES YOU? AND THEN BRINGING ALL
OUR RESOURCES, OUR STAFF, OUR SPECIALTY CARE,
ALL THE RESOURCES WE HAVE TO FIND OUT WHAT MOTIVATES THAT
VETERAN TO REACH HIS GOALS. – IT IS DRIVEN
BY THE PATIENT. THE PATIENT SETS
THEIR OWN GOALS. – IT MAY NOT BE
IMPORTANT TO HIM WHAT
HIS HEMOGLOBIN A1C IS, THAT SPECIFIC LAB, BUT
WHAT IS IMPORTANT TO HIM IS THAT HE’S ABLE TO GO OUT
AND FISH ON THE LAKE. – THEY GET TO DECIDE WHAT THINGS
ARE IMPORTANT TO THEM, WHAT THINGS THEY THINK
THAT NEED TO BE ADDRESSED. OF COURSE, YOU DO
HAVE TO GIVE
YOUR MEDICAL ADVICE AS TO WHAT YOU
THINK ARE THE MOST
IMPORTANT THINGS THAT NEED TO BE
ON THAT LIST. – THE DOCTOR OR
THE NURSE MAY HAVE
GIVEN YOU GUIDANCE, BUT IF YOU CHOOSE
TO NOT FOLLOW
THAT GUIDANCE, THEY KNOW THAT THEY’RE PART
OF THAT TEAM AND THAT’S PART
OF THEIR RESPONSIBILITY. – ONCE THEY UNDERSTAND THAT
THEY HAVE A STAKE IN THIS AND THAT IT’S
DRIVEN BY THEM, BUT WE’RE THERE
TO SUPPORT THEM
AND HELP THEM, THEN IT MAKES
A BIG DIFFERENCE, AS FAR AS COMPLIANCE
AND OVERALL SATISFACTION. – I’M A COMPUTER TECHNICIAN.
I SET UP COMPUTER NETWORKS, REPAIR SYSTEMS. I HAVE CUSTOMERS THAT ARE
AS FAR NORTH AS WISCONSIN AND AS FAR SOUTH AS FLORIDA. SO, I COVER A BIG AREA. I DON’T KNOW WHY,
BUT I HAVE THIS THING
WITH MY DIET. IT WASN’T THAT I WAS
EATING THE WRONG STUFF, IT WAS THAT MY
EATING HABITS WERE BAD. I HAVE DIABETES. MY A1C WAS HORRIBLE. IN FACT, IT WAS SO HORRIBLE
I CAN’T REMEMBER IF
IT WAS 11.7 OR 12.7, BUT IT WAS NASTY. – HI. THIS IS DENA
FROM THE DANVILLE VA. DIABETES IS A VERY
COMPLICATED DISEASE. YOU HAVE TO KEEP YOUR A1C
WITHIN A NORMAL RANGE, OR AT LEAST WELL
CONTROLLED, WITHOUT
THE FLUCTUATIONS, THE HIGH SUGARS,
THE LOW SUGARS. – CAN YOU GET SOME WEEDS
BACK THERE BEHIND ME? RIGHT, THERE’S ONE,
GET THAT ONE. – MR. COX WAS A LITTLE
DIFFICULT AT TIMES, JUST A LITTLE ON
THE STUBBORN SIDE. DIDN’T REALLY WANT
TO ADHERE TO HIS DIET,
TO HIS MEDICATIONS. – HE WAS JUST NOT READY TO
COME IN AND TALK TO US. WHEN WE’VE TALKED
TO HIM IN THE PAST
OR CALLED HIM, HE SAYS, “I KNOW WHAT I NEED TO DO,
I’M JUST NOT DOING IT.” – I WENT AT IT
THE WRONG WAY. I WEIGHED 247 POUNDS,
AND I DECIDED I WAS
GOING TO LOSE WEIGHT. AND THE WAY I DID THAT
WAS I JUST QUIT EATING. AND WHAT I DID WAS I
CAUSED MY BLOOD SUGAR
TO GO OUT OF WHACK, AND THEN WHEN I DID EAT,
I WOULD EAT ONE MEAL
EVERY TWO OR 3 DAYS, MY BLOOD SUGAR
WOULD GO UP. SO, IT WAS TERRIBLE. – HE DOESN’T TAKE
GOOD CARE OF HIMSELF. HIS HEMOGLOBIN A1C
WAS SKYROCKETING. – AND THERE’S SOME THINGS
THAT COME OUT OF THAT, THAT
SPROUT OUT OF THAT DIABETES. YOU KNOW, I HAVE NEUROPATHY
IN MY LEFT LEG AND I HAVE THE
SHOULDER PROBLEM WITH
MY RIGHT SHOULDER. – HE NEEDS SURGERY
ON HIS SHOULDER. AND HE WAS TOLD
THAT BEFORE ANY
SURGERY CAN COME, HE HAS TO GET
THAT A1C DOWN. – DR. DE PEDRO KIND OF
PUT IT IN MY OWN MIND THAT NO MATTER WHAT
THEY DID, IF I DIDN’T
TAKE CHARGE OF IT, IF I DIDN’T TAKE
RESPONSIBILITY FOR IT, IT WASN’T GOING
TO GET BETTER. – DR. DE PEDRO WAS
VERY PERSISTENT AND EVERY TIME HE CAME IN,
ONCE A YEAR, HE SAYS, “HEY, WOULD YOU LIKE
TO COME SEE OUR DIETITIAN?” – HE SAYS, “WE’RE
GOING TO HELP YOU
WITH SOME MEDICATION, “BUT I WANT YOU TO TALK
TO THE DIETICIAN.” GOOD MORNING.
– HELLO. – I HAVE AN APPOINTMENT. – OKAY, YOUR NAME?
– COX. I WAS INTRODUCED TO JACQUIE,
ON THE GREEN TEAM. JACQUIE SAYS,
“TOM, TO GET YOUR
BLOOD PRESSURE DOWN, “YOU’VE GOT TO,
YOU KNOW, CUT
THE SUGAR DOWN. “YOU’VE GOT TO GET EXERCISE.
YOU CAN’T BE A COUCH POTATO. “YOU’VE GOT TO
GET OUT AND MOVE.” – JUST TAKING HIS INSULIN, HE’S
HAD A SIGNIFICANT IMPROVEMENT. NOW WE’RE WORKING
WITH HIM WITH FURTHER
EXERCISE, DIET CHANGES, TO “CAN WE BRING HIS
A1C DOWN EVEN FURTHER?” JUST RECENTLY HE
SHOWED UP ON MY
DOORSTEP AND SAID, “HEY, I WANT TO JOIN
THE MOVE! PROGRAM.” – SO, I FEEL
LIKE I’VE GOT PEOPLE THAT
ARE MAKING IT POSSIBLE FOR ME TO DO
WHAT I NEED TO DO. – IT LOOKS GOOD TO ME. – HOW DOES THE
TEAM APPROACH WORK? NOW THAT I’VE
EXPERIENCED IT,
I DON’T SEE HOW YOU CAN TAKE CARE
OF SOMEONE AND NOT
HAVE THAT APPROACH. – YOUR DIABETES,
AS YOU KNOW, HAS BEEN
COMPLICATING YOUR HEALTH. – THAT TEAM WAS ABLE TO
ENGAGE HIM AT A TIME THAT HE WAS READY
TO BE ENGAGED. THAT’S PERSONALIZED,
THAT’S PATIENT-DRIVEN, AND HE ENDED UP
MAKING THOSE CHANGES. – WHEN I SEE A 5-POINT DROP
IN MY A1C IN 60 DAYS AND 1,500 POINTS
IN MY TRIGLYCERIDES, IT MAKES A BELIEVER
OUT OF YOU. – FRANKLY, IT’S AN ENORMOUS
ACHIEVEMENT, WHAT HE DID. IT TOOK AN ENORMOUS
AMOUNT OF WORK OVER A
PROLONGED PERIOD OF TIME, AND I THINK HE’S RIGHTFULLY
PROUD OF THAT. – SO, HIS QUALITY
OF LIFE IMPROVED THROUGH HIS ENGAGEMENT WITH
THE PATIENT-ALIGNED CARE TEAM. THAT IS WHAT PACT IS ALL ABOUT. – HEALTHCARE THROUGHOUT
OUR WHOLE NATION HAS ALWAYS
BEEN VERY DISEASE-BASED. YOU HAVE DIABETES,
WE’RE GOING TO TREAT
YOUR DIABETES. AND WHAT WE’RE
TRYING TO DO AT
PATIENT-ALIGNED CARE IS MOVE THAT
FROM FOCUSING
ON THE DISEASE TO FOCUSING ON HEALTH
AND WELL-BEING, AND THE PREVENTION
OF DISEASE. – AND YOU NEED
THIS PREVENTION. FIRST OF ALL IS, IF WE SEE
THAT SOMEBODY IS
OVERWEIGHT, RIGHT, AND WE KNOW WHAT’S
GOING TO HAPPEN
IN THE FUTURE, OR IF SOMEBODY HAS
THE SUGARS THAT ARE
A LITTLE BIT ELEVATED, WE KNOW WHAT’S
GOING TO HAPPEN. BUT, IF WE START
MODIFYING THE DIET AND MAKE THEM
EXERCISE, RIGHT, WE’RE GOING TO
PREVENT DISEASES. AND I THINK THAT’S
WHAT WE NEED TO DO AND THAT’S WHAT
THE PACT MODEL IS DOING. – IT’S DESIGNED TO
THINK BEYOND KIND OF
A CHECKBOX APPROACH. BECAUSE ALL THE BOXES
ARE CHECKED, YOU BELIEVE
THAT THE CARE IS OPTIMAL. – WE WANT TO MOVE IT SO THAT
WE NEVER HAVE TO WORRY
ABOUT THE DIABETES. WE WANT TO WORRY ABOUT,
“HOW DO WE PREVENT? “HOW DO WE HELP YOU
TO BE MORE ACTIVE? “HOW DO WE HELP
YOU TO EAT BETTER? “HOW DO WE START
ESTABLISHING GOOD
HABITS EARLY?” – SO, YOU GET
A WIN-WIN SITUATION. THE PATIENT GETS
TAKEN CARE OF SOONER, PROBLEMS GET
ELIMINATED BEFORE
THEY’RE MAJOR PROBLEMS, AND IT’S MUCH MORE
COST-EFFECTIVE. – SO, WE’VE BEEN WORKING TO
REALLY IMPROVE THE COORDINATION OF PERSONALIZED
SERVICES THAT FOCUS NOT ONLY ON THE MANAGEMENT
OF DISEASE, BUT ON THE PHYSICAL,
PSYCHOLOGICAL, SOCIAL, AND SPIRITUAL
WELL BEING OF THE
VETERAN POPULATION. – I WAS A PLUMBER
FOR 35 YEARS AND A CERTIFIED WELDER. – WHEN I
FIRST STARTED SEEING HIM, HE WAS WORKING
IN CONSTRUCTION
AND WELDING, AND WAS GENERALLY
QUITE WELL. I WAS JUST TREATING HIM FOR
HYPERTENSION AND PRE-DIABETES. – AND I GUESS BEING IN
CONSTRUCTION, PUTTING UP
HIGH-RISE BUILDINGS, WELDING, BLACK PIPE,
GALVANIZED PIPE,
STAINLESS STEEL PIPE, AND THE FUMES FROM
THE WELDING RODS, I THINK,
PLAYED A GREAT, GREAT,
BIG DEAL IN MY HEALTH. – HI, MR. WARD,
HOW ARE YOU DOING? – FINE, THANK YOU. – WE HAD FOUND EARLY ON,
BECAUSE HE’D BEEN EXPOSED TO SOME WELDING
CHEMICALS, AND ASBESTOS,
AND AGENT ORANGE, THAT HE HAD
SOME ABNORMALITIES
IN HIS CAT SCAN, AND I HAD BEEN FOLLOWING
THOSE ALONG WITH DR. SCHILERO,
HIS PULMONOLOGIST. – AND IT DID REVEAL SOME SUBTLE RETICULATIONS OR STRIATIONS
AT THE LUNG BASES THAT WERE SUGGESTIVE OF AN
INTERSTITIAL LUNG DISEASE. – INTERSTITIAL LUNG
DISEASE IS PROGRESSIVE. MEDICAL TREATMENT IS
NOT EFFECTIVE IN ANY
WAY FOR THE PATIENT, SO, HE WAS TREATED
SYMPTOMATICALLY. – IN HIS CASE, WE TALKED
ABOUT TRANSPLANT, BECAUSE TREATMENT
WITH PHARMACOTHERAPY OR MEDICINES IS
NOT VERY GOOD. WE SAID, “LET’S GET
ALL THE TESTS WE NEED, “AT LEAST UP FRONT HERE THAT
ARE GOING TO BE REQUIRED AS PART OF A
TRANSPLANTATION EVALUATION.” – IN ABOUT 2011, HE REALLY BEGAN TO DEVELOP
RESPIRATORY DISTRESS. IT WAS BECOMING DIFFICULT
FOR HIM TO EVEN DO
NORMAL ACTIVITIES. – IT’S ALMOST LIKE
HAVING A SPONGE THAT INSTEAD OF BEING
WET AND VERY COMPLIANT AND MOVING IN AND OUT
IS NOW STIFFENED. – SO, WHERE YOUR LUNG EXPANDS
LIKE A BALLOON, MINE DOESN’T. – I WAS SCARED TO DEATH. YOU COULD SEE HE WAS
GETTING WORSE AND WORSE. IT WAS GETTING MORE
AND MORE DIFFICULT
FOR HIM TO BREATHE. – TO WALK FROM HERE TO
THE ELEVATOR I’D PROBABLY
HAVE TO STOP TWICE. YOU KNOW, IT WAS
VERY SHORT SPURTS IN DISTANCE, WALKING,
WITHOUT HAVING TO STOP. – HE WAS ON OXYGEN FULL-TIME, NOT JUST WITH
AMBULATION OR EXERCISE, AND THE AMOUNT OF
OXYGEN NEEDED WAS GOING
HIGHER AND HIGHER. IT’S A DARN GOOD
THING THEY LISTED
HIM WHEN THEY DID, BECAUSE I DON’T
THINK HE HAD A LOT
OF TIME ON HIS HANDS. – ULTIMATELY, HE WAS
SUCCESSFUL IN OBTAINING A SINGLE LUNG
TRANSPLANT IN JANUARY. – THE DAY AFTER SURGERY,
HE CALLED TO SAY, “YOU KNOW, I CAN
BREATHE WELL, I’M
BREATHING AGAIN, “AND JUST WANT TO
THANK THE TEAM FOR
ALL THEIR HELP.” – IT’S BETWEEN NIGHT AND DAY. IN OTHER WORDS, I CAN
BREATHE, I CAN WALK, I DON’T NEED THE OXYGEN ANYMORE, YOU KNOW, SO, I HAVE
A NEW LEASE ON LIFE. – MR. WARD STOPS BY,
LIKE, I WOULD SAY
ALMOST EVERY DAY I SEE HIM. HE COMES IN,
IF IT IS MAYBE JUST
A MEDICATION REFILL THAT HE NEEDS TO BE DONE,
OR IF HE HAS QUESTIONS
ABOUT HIS MEDICATIONS. SO, I PRINTED OUT
A LIST OF ALL YOUR
NEW MEDICATIONS… OR IF HE JUST WANTS
TO STOP BY JUST TO LET
DR. SHERMAN OR I KNOW OF ANY CHANGES THAT
ARE TAKING PLACE. – NOW HE’S BACK TO HIS OLD
SELF, DEMANDING, YOU KNOW, NO PATIENCE
WITH CERTAIN THINGS. BUT, YOU KNOW, HE’S
BACK TO NORMAL, ALMOST. – ALL RIGHT, BABY,
THANKS A LOT. – SO, IT’S BEEN A JOURNEY. BUT IT’S ONE
THAT WE SURVIVED, AND WITH THE GRACE OF
GOD WE’LL GO FORWARD. – IF I HAVE 1,000
PATIENTS IN MY PANEL, PRIOR TO IMPLEMENTATION
OF THE PACT MODEL, IT’S PRETTY MUCH UP
TO ME TO KIND OF SORT OF
REMEMBER THE 1,000 PATIENTS, KNOW WHAT THEY ARE HAVING,
WHO’S DOING WHAT. IT’S VERY, VERY DIFFICULT. – WITH THE IMPLEMENTATION
OF PATIENT-ALIGNED CARE, THE ROLES OF EACH
MEMBER OF THAT TEAM, THE PROVIDER,
THE RN, THE LPN, THE MEDICAL SUPPORT ASSISTANT,
AND THE VETERAN, THEY HAD TO CHANGE,
BECAUSE YOU WERE GOING
TO EMPOWER EACH ROLE TO WORK TO THE TOP
OF THEIR SCOPE. – MY NURSES COORDINATE
JUST AS MUCH MEDICAL CARE
FOR MY PATIENTS AS I DO. THEY HELP ARRANGE
A LOT OF CONSULTS, THEY HELP ARRANGE
SOCIAL WORK, THEY HELP ARRANGE
TRANSPORTATION TO GET
THE PATIENT THERE. – I DEFINITELY THINK THAT
IT’S A TEAM EFFORT. EACH PERSON HAS, YOU KNOW,
HAS A ROLE THAT THEY PLAY. THEY ALL WORK TOGETHER. – IT’S A TEAM APPROACH
EVERY DAY. THE BURDEN JUST DOESN’T
LIE ON YOUR SHOULDERS. – YOU KNOW, THEY HAVE
MY RECORDS, AND THEY KNOW ME
ON A FIRST-NAME BASIS. AND, YOU KNOW, ONCE YOU SEE
THE SAME PERSON OVER AND OVER, YOU GET MORE FAMILIAR
AND YOU FEEL MORE
COMFORTABLE AROUND THEM. SO, IT’S KIND OF
LIKE A FAMILY AFFAIR. – I COULD TELL THEM ANYTHING. I’M NOT EMBARRASSED
TO ASK THEM ANY QUESTIONS OR ANYTHING LIKE THAT
OR HAVE ANY CONCERNS. THEY MAKE YOU FEEL
VERY, VERY COMFORTABLE, JUST LIKE I’VE KNOWN
THEM FOR 20 YEARS. – I REALLY LIKE THE IDEA
OF WORKING AS A TEAM. IT’S GREAT TO DISCUSS PATIENTS AND TO GET IDEAS FROM
A VARIETY OF PERSPECTIVES. – I JUST THOUGHT, WOW,
THIS IS LIKE BEING
BACK IN RESIDENCY, WHEN YOU PRESENT A PATIENT
AND EVERYBODY GETS INPUT AS TO WHAT NEEDS TO BE DONE. AND IT BECOMES MORE OF
A LEARNING EXPERIENCE FOR EVERYBODY IN
THAT PACT TEAM. – EVERY MORNING,
THE PACT TEAMS HAVE WHAT
THEY CALL A HUDDLE. AND YOU GET TOGETHER WITH
YOUR DOC, YOUR CLERK, YOUR LPN AND THE RN,
AND WE ALL SIT DOWN AND WE KIND OF
PLAN OUT THE DAY. – WHEN I FIRST CAME HERE,
I WAS AMAZED THAT MY NURSE HAD ALREADY LOOKED AT MY
SCHEDULE FOR THE NEXT DAY AND HAD TAKEN NOTES,
AND THE NEXT MORNING WE DISCUSSED EACH
PATIENT INDIVIDUALLY, WHAT THEIR NEEDS ARE,
IF THEY’RE GOING TO
NEED LAB, X-RAY, EKG, AND WHAT SOME OF THEIR
MAJOR DIAGNOSES ARE THAT NEED TO BE
ADDRESSED THAT DAY. – WE HAVE
OUR MONTHLY HUDDLE WITH
THE GREEN TEAM MEMBERS, THE ANCILLARIES, LIKE
SOCIAL WORKER, NUTRITION, AND THOSE ARE TIMES WHEN WE
DISCUSS DIFFERENT PATIENTS, TROUBLESOME PATIENTS THAT
WE NEED TO WORK TOGETHER TO GET SOMETHING
ACCOMPLISHED ON. – IF I HAVE A QUESTION, I
USE THE OTHER HALF OF MY
BRAIN, WHICH IS MY LPN, AND I WILL EITHER
INSTANT-MESSAGE HER OR GET UP, WALK
OUT OF MY OFFICE, AND WALK OVER
AND TALK TO HER. – THEY’LL SEND ME
A LITTLE COMMUNICATION. WE HAVE THE LITTLE
COMPUTER COMMUNICATION. THEY’LL SEND ME A
LITTLE NOTE, “WE NEED
YOU FOR 5 MINUTES,” OR “DO YOU HAVE TIME?”
OR “THE VETERAN IS HERE “AND WOULD LIKE
TO SEE YOU, WHAT IS
YOUR TIME FRAME LIKE?” AND IF I CAN, I SAY,
“BE RIGHT THERE.” – MY OFFICE IS CENTRALLY
LOCATED TO ALL THE
PROVIDERS’ OFFICES, AND IT’S JUST A MATTER
OF A FEW STEPS DOWN TO THE CLINIC AREA
TO SEE A PATIENT. – SPECIALTY CARE IS
A LOT MORE SEAMLESS
IN THIS SYSTEM IN THAT YOU HAVE MOST OF
ALL THE MAJOR SPECIALTIES AT YOUR FINGERTIPS,
IF YOU NEED THEM. – WE ALSO HAVE FACILITATED
ELECTRONIC CONSULTS. SO, IF SOMEBODY HAS
A QUESTION OR A PROBLEM THAT DOESN’T NECESSARILY REQUIRE
A FACE-TO-FACE ENCOUNTER WITH THE VETERAN, THAT’S
SOMETHING WE COULD EASILY
ADDRESS ELECTRONICALLY. – YOU KNOW, WE HAVE
GREAT CARE. SOME OF THE BEST
CARE ANYWHERE, BUT WE HEAR REPEATEDLY
THAT IT’S NOT VERY
EASY TO ACCESS. – WE’RE LEVERAGING OTHER TYPES
OF NON-TRADITIONAL APPOINTMENTS FOR VETERANS, SO THAT WE
CAN HAVE BETTER ACCESS. NOT EVERY PATIENT NEEDS
A 30-MINUTE APPOINTMENT. SOME MAY NEED AN HOUR
AN APPOINTMENT, BUT SOME MAY ONLY
NEED A PHONE CALL. IT’S REALLY LEVERAGING
WHAT IS THE RIGHT ACCESS FOR THAT VETERAN ON
THAT SPECIFIC SCENARIO. – OVER 25% OF THE VISITS
ARE BY TELEPHONE, AND THAT’S A REAL BOON
TO OUR PATIENTS THAT WORK OR HAVE LIMITED MOBILITY. – WE REALLY ARE TRYING
TO ENCOURAGE THAT VETERAN TO REACH OUT AND MAKE
CONTACT WITH THEIR RN OR THE MEDICAL
SUPPORT ASSISTANT
AND LET THEM KNOW, “HEY, I HAVE A PROBLEM TODAY. “HOW’S THE BEST WAY
I CAN HANDLE IT?” – FOR EXAMPLE, IF THEY
ARE SICK AT HOME, AND THEY DON’T HAVE
AN APPOINTMENT, THEY CAN CALL ME AND SAY, “NURSE, I NEED TO COME
IN TODAY, I’M HAVING
THESE SYMPTOMS.” – SOME OF IT IS PROACTIVE. IF PATIENTS DON’T SHOW
UP FOR APPOINTMENTS, OR I KNOW THEY’RE
ILL AND I JUST NEED
TO CHECK ON THEM AND FIND OUT HOW
THEIR DIABETES IS DOING, OR THEIR INFECTION, OR
THEIR MALIGNANCY WORK-UP, I HAVE THE ABILITY TO CALL
THEM BETWEEN APPOINTMENTS. – FOR THE FIRST TIME
IN MY LIFE, I HAD A DOCTOR THAT CALLED ME TO ASK
HOW MY MEDICATIONS
WERE WORKING OUT, IF I WAS HAVING ANY PROBLEMS. AND, FRANKLY, AT THAT TIME,
IT SCARED ME. I THOUGHT I WAS
DYING, BECAUSE SHE WAS GIVING ME
SO MUCH ATTENTION. AND I LOVED IT. – AND THEN THE VETERAN
THAT RECEIVES THE TELEPHONE CALL ON HIS LAB
AND FOLLOW-UP DOESN’T HAVE TO COME ALL
THE WAY TO THE CLINIC, HE GETS HIS CARE,
IT’S QUICK, IT’S EASY, IT’S
ACCESSIBLE FOR HIM, AND YET, WE’RE DEVELOPING
ACCESS FOR OTHER VETERANS WHO REALLY DO NEED TO
BE SEEN FACE-TO-FACE. I THINK, PROBABLY ONE
OF THE BIGGEST BARRIERS RELATED TO PATIENT-ALIGNED
CARE TEAM IS JUST THE CULTURAL CHANGE
AND THE ACCEPTANCE OF CHANGE. MANY OF THE STAFF HAD
BEEN WITHIN THE SYSTEM
FOR A LONG TIME, AND THAT CAN CAUSE… WE’VE ALWAYS DONE
IT THAT WAY. WELL, JUST BECAUSE
WE’VE ALWAYS DONE
IT THAT WAY DOESN’T MEAN THAT’S
THE RIGHT WAY. – IN THE BEGINNING,
AS WITH ANY CHANGE, THERE’S ALWAYS
THAT LITTLE BIT OF UNKNOWN IN THE BEGINNING AS TO
WHAT PACT IS GOING TO BRING AND HOW IT’S GOING TO
IMPACT WITHIN THEIR
WORK ENVIRONMENT. – AS YOU KNOW,
CHANGE IS NOT EASY. AND WE ENCOUNTERED MANY
BARRIERS, ESPECIALLY
WITH THE SPECIALISTS. AT THE BEGINNING THEY SAY,
“NO WE CANNOT DO THAT.” – WE HAVE TO REALLY
ROCK THIS BOAT. WE HAVE TO CHANGE IT UP. WE HAVE TO DO SOMETHING
DIFFERENT IF WE’RE GOING
TO GET A DIFFERENT OUTCOME. – IT’S A LITTLE BIT
LIKE A VETERAN WHO
NEEDS TO CHANGE IN TERMS OF IMPROVING
THEIR HEALTH. THE VETERAN, AT
ONE POINT OR ANOTHER, WILL MAKE THE DECISION THAT
THEY’LL INVEST THE EFFORT
TO MAKE THAT CHANGE. IT MAY BE TOMORROW, IT
MAY BE 5 YEARS FROM NOW. I THINK TEAMS ARE
IN THE SAME DYNAMIC. – IT TAKES ENERGY,
IT TAKES EMPOWERMENT, IT TAKES COLLABORATION, IT TAKES A TRUST
IN YOUR TEAM MEMBERS, AND IT TAKES CHANGING THE WAY
THE VETERAN VIEWS US. – I BELIEVE THAT ONCE
THEY STARTED TO HEAR
MORE ABOUT PACT, WHAT IT IS, THEY
RECEIVED THE TRAINING, THEY GOT ACCUSTOMED
TO THE VERBIAGE, THEN THEY GOT MORE
COMFORTABLE IN REALIZING THAT THIS IS WORK
THAT THEY ALREADY KIND OF DO. – EVERYONE HERE IS WILLING
TO CHANGE AND TO LEARN, AND THAT MAKES
IT A LOT EASIER. – ONCE THEY LEARN OR
THEY SAW ANOTHER GROUP COMING ALONG AND SAYING, “YEAH, IT’S DOABLE,”
THEY GOT INTO IT. – THIS IS A JOURNEY.
WE HAVE A LONG WAYS TO GO. THERE’S NO FINITE END POINT, BUT I THINK
WE’RE GETTING BETTER
AND BETTER EVERY DAY. – BECAUSE PACT IS
EVOLVING, AND WE WANT
TO STAY RIGHT WITH IT, AND IT’S WORKING
GREAT FOR US. – WE WERE CONCERNED ABOUT… INVESTING $2 MILLION AT THE SITE FOR
THIS PACT PROGRAM, AND WILL WE BE ABLE
TO MAKE THE RETURN
ON THIS INVESTMENT? – IF WE DO OUR WORK WELL,
AND THIS IS A CONTINUED
IMPROVEMENT ACTIVITY, TOO, WE COULD KEEP
MORE PEOPLE OUT
OF THE HOSPITAL, WE CAN KEEP THEM
AWAY FROM EXPENSIVE
EMERGENCY ROOMS. – WE’VE SEEN THE BED DAYS
OF CARE DECREASE OVER THE
COURSE OF THE PAST TWO YEARS BY TWO OR 3 DAYS,
ON AVERAGE, FOR EACH VETERAN
THAT’S ENROLLED INTO
THE RUSSELLVILLE CBOC, AND THIS IS SIGNIFICANT. – WE ALSO LOOK AT
ER UTILIZATION, SO THEY’RE NOT VISITING
THE ER AS OFTEN. NOW THEY KNOW THAT
THEY HAVE AN RN
CARE COORDINATOR, THEY HAVE A TEAM THAT
THEY CAN CALL DIRECTLY
IF THEY NEED SOMETHING. – AN ADMISSION
TO OUR HOSPITAL, FOR INSTANCE, COSTS $20,000 TO $30,000. ONE BREAST CANCER ADMISSION MAY COST THE VA $300,000. IF YOU HAVE IDENTIFIED
ONE COLON CANCER
BY COLONOSCOPY AND PREVENTED IT,
THAT SAVES $60,000. SO, IF WE PREVENTED
10 SUCH CASES, THAT’S ALREADY
HALF A MILLION. [LAUGHS] AND ETCETERA, AND THEN
ONE HEART ATTACK, ONE STROKE, ONE
AMPUTATION PREVENTED, YOU KNOW, ONE HIP
FRACTURE PREVENTED. IT JUST ADDS UP, EVEN
IN THE FIRST YEAR, AND 10 YEARS DOWN
THE LINE, IT’S JUST
GOING TO PAY FOR ITSELF OVER AND OVER
AND OVER AGAIN. – I’VE NOT MET
A VETERAN WHO SAYS THEY WOULD CHOOSE TO
GO TO THE HOSPITAL BECAUSE IT’S A
FUN PLACE TO BE. I THINK THE HOSPITAL IS
MUCH BETTER THAN IT USED TO BE IN TERMS OF PLEASANTNESS,
BUT IT’S STILL NOT A VERY PLEASANT EXPERIENCE
FOR MOST FOLKS. – WE’RE GETTING THE
VETERAN HEALTHIER,
KEEPING HIM AT HOME, KEEPING HIM IN AT WORK,
KEEPING HIM WITH HIS FAMILY. – PATIENTS SEEM TO BE
VERY HAPPY HERE. THE RUSSELLVILLE
CBOC HAS… SOME OF THE HAPPIEST
PATIENTS, PROBABLY. THEY’RE SO THRILLED
WITH THIS MODEL
THAT IT’S AMAZING. – WHEN YOU TAKE A MORE
HOLISTIC APPROACH, A TEAM
APPROACH TO THE PATIENT, THE PATIENT’S HAPPIER,
AND I THINK THE PHYSICIAN AND THE HEALTH CARE TEAM’S
HAPPIER, BECAUSE YOU SEE HOW IT IMPACTS THEIR LIVES. – THEN, THAT’S WHAT WE WANT.
WE WANT IMPROVED PATIENT SATISFACTION, PATIENT SAFETY,
THE QUALITY OF LIFE. AND I THINK WE HAVE BEEN
ABLE TO ACCOMPLISH THAT. – PATIENT-ALIGNED CARE, WHEN WE LOOK AT
THE DATA THAT COMES
OUT, IS SUCCESSFUL, AND VETERANS ARE HAPPY
WITH THE RESULTS. THEREFORE, THE
PROVIDERS THAT ARE
GIVING IT ARE HAPPY. – WELL IT’S ABOUT
RELATIONSHIPS, RIGHT? WE TALK ABOUT
RELATIONSHIP-BASED CARE. IT’S ABOUT HAVING RELATIONSHIPS, AND YOU CAN SEE IT IN
ALL 3 OF OUR PATIENTS. I MEAN, THE THING THAT
REALLY DELIGHTS THEM ABOUT THEIR CARE IS THE
PEOPLE THAT THEY CONNECT
WITH BACK AT THE VA, BECAUSE THOSE PEOPLE
CARE ABOUT THEM. – I COULD GET MY CARE
AT ONE OF THE OTHER
CLINICS IN RUSSELLVILLE, BUT WITH THE PACT TEAM
AT THE VA HERE, I LIKE THEM. I’M COMFORTABLE WITH
THEM, THEY KNOW ME, IT’S JUST WE WORK
REALLY WELL TOGETHER. – IT’S MADE HER A HAPPIER
PATIENT, AND I THINK
SHE’LL TELL YOU THAT IT’S MADE
A BIG DIFFERENCE
IN HER LIFE. – IT’S A CHOICE FOR THEM.
CBOC IS A CHOICE. FORTUNATELY FOR US,
WE’VE BEEN CHOSEN A LOT,
AND WE ARE GRATEFUL FOR THAT. – I LOVE MY PACT TEAM.
LOVE THEM.
THEY’RE AWESOME. I DON’T KNOW WHAT ELSE
TO SAY ABOUT THEM,
BECAUSE THEY’RE GREAT. – I GUESS MY
OVERALL IMPRESSION ABOUT
SELF-DIRECTED CARE IS, THEY’RE WILLING TO TELL
YOU WHAT YOU NEED TO DO. THEY’RE WILLING TO RIDE YOUR
HIND END IF YOU DON’T DO IT. IF YOU DO DO IT,
THEY’RE WILLING TO
HELP GET THE JOB DONE. – MR. COX HAS REALLY
TAKEN RESPONSIBILITY
IN HIS HEALTH CARE. I’M VERY PROUD OF HIM. SO, HE GETS PRAISES FOR
HIS ACCOMPLISHMENTS. – I REALLY
OWE THE VA BIG TIME. I COULDN’T ASK FOR BETTER CARE
NO MATTER WHERE I WENT. – IF THE GOAL OF THE
PATIENT-CENTERED CARE IS TO EMPOWER
THE PATIENT TO BE IN CHARGE OF
THEIR OWN HEALTH, I CAN’T THINK OF
A BETTER EXAMPLE OF IT THAN MR. WARD’S CASE. – I WOULDN’T BE THIS HEALTHY
WITHOUT THE PACT TEAM. YEAH, I FEEL LIKE
I’M THE ASSISTANT
COACH, YOU KNOW, AND DR. SHERMAN
IS THE HEAD COACH. SO, SHE GIVES ME
THE PLAYS AND I RUN
THEM, YOU KNOW? – HE’S BEEN DOING FANTASTIC. HE’S GAINING STRENGTH,
AND HIS SHORTNESS OF BREATH
IS IMPROVING BY THE DAY. HIS WHOLE OUTLOOK
ON LIFE HAS CHANGED, BECAUSE HE FEELS
SO WELL NOW. – I THINK EVERY DAY FOR HIM
IS A GREAT DAY, YOU KNOW. YOU CAN SEE IT IN HIS FACE.
[LAUGHS] – AND I’M GETTING BETTER
AND BETTER EVERY DAY. AND LOVING EVERY
MINUTE OF IT. EVERY MINUTE OF IT.

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