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Next-generation primary care, coming to a VA clinic near you

VA researchers studying the 'patient-centered medical home'

Army Veteran Gena Van Camp has been using VA health care for 30 years. She's more satisfied nowadays than she was a few years ago, especially with her primary care.

In the past, says Van Camp, she would often be seen by a medical resident. Now, it's the same nurse practitioner every visit. To Van Camp, that means someone who knows her and her medical history, without needing to look through her VA electronic health record.

"Before, it was a new doctor every few months," says the Coatesville, Pa., resident, who served in military communications. "By the time someone got to know you, he was gone."

Van Camp also likes the practice's accessibility. When she calls on the phone, a triage nurse listens to her concern and either provides appropriate advice or recommends an appointment. When Van Camp does need to leave a message, she gets a return call promptly.

The changes Van Camp is seeing are part of a shift in VA to a new way of doing primary care. It's called the patient-centered medical home (see box). Actually, the model isn't new—it's been around since the 1960s—but it's receiving renewed attention, both in and outside VA. This spring, VA researchers began evaluating how it can be best applied in VA's health system, the nation's largest.

Transformation already under way

A handful of VA clinics began moving to the new model a year or two ago. VA policymakers say at least 80 percent of VA clinics will follow suit by 2012. The rollout is a huge effort—even by VA standards—that is costing some $250 million. It's expected to pay long-term dividends, though, both for patients and the system. Among the core features: team-based care that emphasizes continuity; a bigger role for nurses in coordinating care; email, secure messaging and other alternative forms of contact with patients; and more attention on behavioral health issues.

The makeover across all VA sites should be complete by about 2015.

"It will take that long because it's also a culture change," says Joanne Shear, MS, FNP-BC, who worked as a nurse practitioner in VA and is now helping to oversee the transition for VA's Office of Patient Care Services.

The culture change, she explains, has to do with the mindset at the philosophical core of the medical home.

"It's about being more patient-centered," says Shear. "In reality, we've always tried to accommodate what the patient wanted. But we're now placing more emphasis on that. We want to focus on what the patient wants, not what the facility wants them to have."

Beyond that general principle and some others, there's a lot of discussion about what exactly the medical home should look like in VA. That's where VA researchers come in.

Major study will probe medical home model

Five teams of top VA health-services researchers in five different regions have begun a wide-reaching study of the medical home model. The effort will take three to five years. The teams will address a complex array of issues, drilling down to the details of day-to-day care. But they also hope to shed light on overarching questions: How should the model be structured in VA? Which features work best for VA patients? Is it economically viable? Are patients—and providers—happier?

David Atkins, MD, MPH, associate director for VA's Health Services Research and Development Service, worked with Patient Care Services to develop and select the research sites. He says the five so-called demonstration labs will "provide a sophisticated, robust platform for critical evaluation of the patient-centered medical home."

Atkins adds that VA is "setting a great example of forward thinking" by building research into the process from an early stage. "Too often, health systems decide to do something new without investing in making sure they do it the most effective and efficient way, and in learning how to do it even better."

The medical home concept has been studied outside VA, mainly in small pilot projects, by systems such as Kaiser Permanente and Group Health Cooperative. But no prior research has been on the scale of VA's new initiative. So outside experts—many of whom talked with VA to help the agency plan its implementation—are now eager to learn from VA's nationwide experiment.

"They're watching us very closely," says Shear.

Stephan Fihn, MD, MPH, who co-chaired the committee that developed the research program and is now heading a coordinating center overseeing the five independent labs, agrees that VA's study results could be of wide interest.

"They're all keen to see our results," says the longtime VA physician-researcher, based at the VA Puget Sound Health Care System. "Can a system with more than 1,000 care sites do this? There's great heterogeneity in our system. How do you retain the flexibility to adapt the patient-centered medical home to settings as diverse as a small rural clinic and a large, academically affiliated primary care clinic that's got 150 providers and medical residents?"

Demo labs span the nation

Answers will take shape as the five labs—themselves based in diverse VA settings—begin compiling data. All the groups will be looking at certain core questions; additionally, each will test its own set of theories or interventions.

For example, a team in a Midwest VA region that spans parts of Iowa, Minnesota, the Dakotas and Nebraska will explore how the medical home serves rural patients. Four in ten patients in that region live in rural or "highly rural" areas.

Another demo lab, based in southern California, will home in on care-team structure and processes. The group will also test a telemedicine program for formerly homeless Veterans with chronic physical or mental illness who found housing through VA. Enhanced access to care is a pillar of the medical home, and researchers and clinicians are aggressively seeking ways to connect with Veterans who have not had a history of regular medical care.

A third demo lab is based in a mid-Atlantic VA region that spans parts of Pennsylvania and five other states. The network serves a racially and economically diverse mix of Veterans, from inner-city Philadelphia to the farmland of West Virginia. As part of their study, researchers here, led by Rachel Werner, MD, PhD, will look at how the medical home can help high-need patients such as those with pain, dementia or serious mental illness.

Medical homes, ideally, feature excellent communication between primary care providers and other pieces of the health care system, such as specialty clinics or home-health services. That aspect of the model can be critical for vulnerable patients, says Werner.

Teamwork is another cornerstone of the medical home. In VA's model, this typically means a physician, nurse practitioner or physician assistant; registered nurse; clinical associate such as a licensed practice nurse or medical assistant; and clerical support person. Such a team will typically care for up to 1,200 Veterans. Support is provided by a pharmacist, social worker, mental health therapist and dietician, all of whom work closely with the primary team members.

Shear: "We did a lot of research a year and a half ago to come up with this model. We scoured the literature and talked with a lot of sites, both external partners and sites within VA that were more progressive."

Long-term relationship with one provider

Notwithstanding the team approach, the goal is for each patient to forge a relationship with one provider—namely the doctor, nurse practitioner or physician assistant—who gets to know him or her over time, even as other team members play a role in the care plan.

Says Shear: "The literature really demonstrates that a primary care system that's based on a longitudinal relationship with a patient, someone who knows the patient and helps to guide that person through both chronic and preventive care, increases quality in terms of health care outcomes, is less costly for countries and health systems, and increases both patient and provider satisfaction."

She adds that the formula works especially well for older patients with chronic health problems, noting that Veterans over age 65 make up some 44 percent of VA's patient population. "Generally, the longitudinal relationship is a good thing for them, and it's something they really want."

Shear says that over the long term, such care results in better patient outcomes. "Think about the patient whose diabetes is better controlled who won't end up needing dialysis or an amputation."

Her assertion jibes with data from VA sites that been early adopters of the medical home. For example, in the Midwest region that is home to one of the demo labs, the proportion of medical-home patients whose blood pressure was under 140/90 went from 82 to 86 percent between July 2008 and August 2009. In a comparison group of Veterans in the same region who received conventional primary care, the proportion stayed at 80 percent.

Fihn acknowledges the value of long-term, one-to-one relationships between patients and providers. At the same time, he asserts that coordination of care is just as important.

"This isn't about a specific type of practitioner—it's about teams," he says. "As a consumer and a patient, I'm happy when the people providing whatever services I need are working in concert. So when I talk to a nurse, I can be confident that person is actively involved with the larger team. So this isn't just a visit to my nurse practitioner, it's a visit to my health care team."

At the Philadelphia VA Medical Center, the model includes a physician as well as a nurse practitioner, along with the other members. The physician handles the higher-level needs, while the nurse practitioner handles more routine visits. "Patients may not always see a primary care doctor," says Werner. "They may see a nurse practitioner for routine things like adjusting a medication for a chronic illness, and they may see the physician for more acute or complex issues."

Fihn extols the virtues of this approach: "The physician suddenly feels, now I can spend an hour with a patient who is really sick, if I need to do that. On the other hand, I don't have any incentive to see the patient with the cold, the urinary-tract infection, the sprained ankle. Other team members can take care of those problems, and they are delighted to do so. My patients are happy, because they have better access. I'm happier because I'm able to practice more like a physician." Provider satisfaction is one of the variables that will be measured by the five demo labs.

Werner says that even if some patients don't immediately like the idea of being seen by someone other than a physician during a routine primary-care visit, they tend to warm up to the idea once they see that it actually increases their access to appropriate care and to professionals who can answer their questions.

Many elements of medical home already in place in VA

Fihn says VA was in the forefront of using non-physician providers and team-based models decades ago, well before the medical-home movement gained steam. For example, he says, "We were one of the first to enthusiastically embrace nurse practitioners. I've worked side by side with nurse practitioners in the clinic since 1982."

Another VA example: anticoagulation and diabetes clinics where pharmacists and nurses, not physicians, take the lead in providing care. This aspect of the medical home, says Fihn, "isn't necessarily a sea change for us."

In fact, many elements of the medical home that are now being studied have been familiar ingredients in VA care for some time. Electronic health records and telemedicine are two prime examples.

The challenge now is blending the pieces into a cohesive, integrated whole. Fihn: "We've known some of the pieces, but no one's understood how to assemble the whole. The demonstration labs are evaluating which pieces matter most. How are they best constructed? What are the effects of variations in that construction? How should they vary according to types of patients and practice settings? How do we ensure that coordination occurs?"

VA will benefit, cost-wise, by having so many of the pieces already in place. Other health systems that have piloted the medical home model have had to pour money into infrastructure—for example, extra staff or new computer systems. On the other hand, these same organizations have been able to recoup much of the initial cash outlay as fewer patients end up at the emergency room and in the hospital.

There's a research benefit also, says Werner, to the fact that so many pieces of the medical home puzzle are already in place in VA.

"It frees us up to go a step further and think about what we can do to make the care more patient-centered and more team-based," she says. "We can move beyond the structural elements—information technology, electronic health records, performance measurement—and work on the culture of care."

Move to medical home on par with VA shift in 1990s

Parallel to the sweeping changes that transformed VA in the 1990s into a first-rate medical system, the move to the medical home is being seen as the next critical transformation for the nation's largest health care system.

"Everybody who understands how medical care needs to be delivered in this era agrees we have the potential to go there," says Fihn. "But we need to go there to maintain our position as one of the leading health care systems in the world. If we don't aggressively and successfully pursue the medical home model, our future is at stake."

For longtime patients like Gena Van Camp, who enrolled in VA in 1980, the changes happening in VA primary care clinics are positive ones. She's convinced the medical home is a winning idea, long before the results from the demo labs are in. "I hope it continues," she says. "This is a great improvement."