With VA’s Care Team approach, your doctor is not alone; VA doctors have nurses and many others working closely with them to provide input and direction to your care.
Have you ever gone to an Urgent Care facility where you were unknown, and had to fill out multiple forms every time you visited?
Have you ever felt like you were a number in the health care system?
Have you ever felt like you were telling the same story over and over and over again to different health care providers?
If so, you are not alone.
Leading the Pack
Fortunately, there is change coming to the Department of Veterans Affairs as well as the private sector. In many ways, VA is leading the pack.
In fulfilling its responsibility to provide ‘the best care anywhere’ for every Veteran, VA is embracing an opportunity to move away from problem-based disease care toward something very different: patient-centered care based on relationships that are built gradually, over time, and committed to positive results over the Veteran’s lifetime. This new way of thinking regarding your health care is called PACT, or Patient Aligned Care Team.
“Reactive, physician-centered care will be a thing of the past as VA designs and delivers a 21st century health care delivery system that is based in lifelong planning and support, and centered on the Veteran patient,” explained Dr. Tracy Gaudet, director of VA’s Office of Patient Centered Care and Cultural Transformation.
“The 21st century VA will be a healthcare system that has the Veteran at the center, and begins with their vision of health and their goals.”
In order to understand PACT, you must first understand Primary Care. Primary Care is outpatient-centered health care that coordinates care of inpatient and outpatient services, specialty clinics and community resources. Primary Care is usually the entry point into health care for most patients.
“The whole key to PACT is relationships.”
— Dr. Steve Swearingen
The Patient Aligned Care Team takes this a step further by putting patients at the center of their own care. The care is person-oriented as opposed to disease-oriented. The person is just that: a person, not a group of diseases to treat.
PACT in Action
Kenneth Duncan, a Vietnam era Veteran, recently called the Charles George VA Medical Center http://www.asheville.va.gov in Asheville, N.C., complaining of shortness of breath.
The moment he picked up the telephone, he triggered a chain-reaction that may have saved his life.
“I talked with Mr. Duncan to find out what his symptoms were,” explained April Courson, a registered nurse who is part of Duncan’s Patient Aligned Care Team. “We call this ‘telephone triage.’ Based on what he told me, I knew he needed to come in right away.”
As soon as Duncan arrived, an initial evaluation was performed by another member of his Patient Aligned Care Team, Licensed Practical Nurse Linda Montgomery. She wasted no time in sending her patient directly to her Team Lead, Dr. Steve Swearingen.
“He has chronic pain, but he was in more pain than usual,” said Swearingen. “He was also more short of breath than usual. I sent him to X-ray. They called the report back to me and it wasn’t good: he had pulmonary edema. His lungs were filling up with fluid. It looked like he might be developing pneumonia, too, but it was hard to tell. I sent him directly to the emergency room so they could get started on his EKG, his blood work, and other medical tests.”
“While Linda was transporting the patient to E.R., I was calling in the report to the emergency room nurse,” Courson said. “They were ready for him when he got there.”
Duncan was not in the emergency room long. The decision was soon made to send him to the medical center’s Intensive Care Unit where he would be started on a regimen of diuretics and antibiotics.
“They were wonderful over there at the ICU,” Duncan said. “I was there for seven days. They were very good with my pain medication. They knew how to count pills over there. They did a fine job, as far as I’m concerned.”
“As soon as he was transferred from ICU to the medical ward, I went to see him,” Courson said. “He was very glad to see me. I was a familiar face.”
She added: “As soon as a patient is transferred from one part of the hospital to another, a member of their Patient Aligned Care Team goes to visit them.”
And Duncan’s care won’t stop when he leaves the hospital. His Patient Aligned Care Team will continue monitoring him.
“When he’s discharged, I’ll be calling him to follow up on how he’s doing, and to see what his needs are,” Courson said.
Your Team and You
With the Patient Aligned Care Team approach, you are your number one health care advocate! You and your family get to make decisions and help direct your care! Your doctor works closely with you to help you reach your optimal health, and stay there. But your doctor is not alone; they have nurses and many others working closely with them to provide input and direction to your care.
The Care Manager nurse, for example, may zero in on two or three high-risk diagnoses, such as congestive heart failure or diabetes that may be managed through patient education, medication, lifestyle changes, etc. Do you see a theme? Once you, the patient is educated, you have the choice of changing how you eat, exercise, take your medicine, etc. Your family can be intimately involved as well.
The doctor may order the medications you need to take, and the pharmacist may follow up with close monitoring of your vital signs or blood sugar and other lab results, and adjust those medications. You may have a social worker to help you with home care needs, or a Care Coordination Home Telehealth nurse who follows vital signs or other readings you input, via a phone system.
You may have a dietitian instruct you, or Mental Health services may help you establish goals and give you strategies to help achieve them, in order to live a more healthy lifestyle. If you are admitted as an inpatient, your Patient Aligned Care Team will be alerted to this and, if appropriate, visit you in the hospital. They will follow up with you after your discharge to ensure you get the care you need.
You may be involved in group appointments, telephone clinics, or appointments with someone other than your primary care provider, such as a nurse, mental health specialist, nutritionist, etc. And VA is providing more and more ways to communicate with your team, such as in-person visits, telephone calls, Home Telehealth, or secure messaging via My HealtheVet.
Additional information about PACT is available at: Patient Aligned Care Team