PATIENT ALIGNED CARE TEAM AT The va sierra nevada health care system

Uche S. Uchendu, MD. Associate Chief of Staff, Ambulatory Care

Goals set at the PACT Summit - Met

To all the Veterans, we hear you

and we salute you!

Future PlansSustain Specialty spreadStay Tuned…

BackgroundVASNHCS has 69,000 square miles of mostly rural area of 31 countiesWith 116,000 veteran residents and 26,000 unique patientsPrimary care provided at the main facility is in Reno Nevada andFour CBOC’s : Auburn & Susanville CA; Minden & Fallon NV Outreach clinic in Winnemucca, NV

ACP Home builder

Patient Aligned Care TeamPatient Aligned Care TeamAccess

Offer same day appointments^ shared medical appointments^ non-appointment care

Care Mgt & CoordinationFocus on high-risk patients

Improve care for:oPrevention & Chronic disease

Improve transitions between PACT &: Inpatient ; Specialty; Broader Team

Practice RedesignRedesign team: oRoles & Tasks

Enhance: oCommunication& Team

Improve Processes:oVisit & Non-visit work

Patient Centeredness: Mindset and ToolsPatient Centeredness: Mindset and ToolsImprovement: Systems Redesign, VA TAMMCSImprovement: Systems Redesign, VA TAMMCS

Resources: Tech, Staff, Space, CommunityResources: Tech, Staff, Space, Community

In reality all PACT items should be standard operations : Plan, operation, directive ,execution = success. Phone calls should be returned timely.

D OMINANCE

I NFLUENCE

S TEADINESS

C ONSCIENTIOUSNESS

The DiSC will help you:Identify your behavioral “comfort zoneCapitalize on your behavioral strengthsIncrease your appreciation of others’behavioral “comfort zones” andbehavioral strengthsBe more effective when working with others

People are always courteousGood People

No complaints

Auburn CBOC Minden CBOCFallon CBOC

Susanville CBOC

Medical Home + VHA = PACT

ACP scoring methodology on 127 questions:0-33%: Weak Performance34%-67%:Average performance 67%-100%: Strong Performance

You Guys are good to me

PACT collaborative Goals – Met/Exceeded

PACT COMPASS Same Day Appt. with PCP

PACT COMPASS 2 day Contact Post Hospital

PACT COMPASS Ratio of Telephone to all Encounters

PACT COMPASS PCP Continuity

Challenges Staff turnover Buy-inCompeting demands Continuity and Space

MSA

LPN

RN

PCP

10/8/2010

Voice of the CustomerVoice of the Customer

FEB 2012≥ 10

<10 and ≥ 5

< 5

TOTAL POINTS (MAX

14)Facility 10Reno PC 9

Auburn 12

Minden3

Fallon 14

Susanville 8

PACT Fairs at all sites

PACT Recognition for 5 Teams 2011!

Winnemucca

TEACH training-All PACT staff