Treating the Whole Patient: A Team Approach

The Oscar G. Johnson VA Medical Center (OGJVAMC)in Iron Mountain, Michigan uses teamwork to promote the health and wellness of the 20,022 Veterans they serve across 25,864 square miles. In 2010, the VA transitioned to a Patient Aligned Care Team (PACT) model to serve the health care needs of Veterans. The Veteran is assigned a health care team that includes a primary care provider, registered nurse, licensed practical nurse, and an administrative clerk. The PACT team may include other providers depending on the health care needs of the patient, such as a social worker, diabetic educator, and dietician.

Instead of delivering care only at the bedside, PACT teamlets partner with Veterans to deliver accessible and coordinated primary care. Here are the highlights of how and why PACTs work in Iron Mountain:

• PACT provides for an ongoing relationship between the patient and his or her health care team; enhances access to primary and specialty care; provides coordinated care across the health system, caring for the whole person physically, mentally, and emotionally.

• The PACT model increases shared medical appointments and improves transitions/coordinated care between primary care and any needed inpatient or any specialty care.

• Registered Nurses offer continuity for the Veteran and care team, even if the primary care provider changes. It’s not unusual for the RN to have two decades of experience at OGJVAMC.

• Primary care providers trust nursing, administrative and, ancillary team members in order to manage a 1,200-1,800 patient panel. When it takes 1-2 years to recruit a new provider to the community, team trust is even more important.

• Ancillary staff plug in to the PACT based on each Veteran’s needs. Since implementing PACT in 2011, OGJVAMC services offered by social workers, dietitians, pharmacists, mental health practitioners (including peer support specialists) and other professionals increased by 60%.

• Team members share a “do everything you can” attitude to care for the whole Veteran. That means the pharmacist may help identify resources to combat homelessness, while the licensed practical nurse listens at length to the Veteran in order to determine how his medication adherence may be negatively impacting his lab results.

• Care does not stop after a primary care visit or even after a telehealth appointment. Veterans living in rural areas with a mental health diagnosis receive intensive outreach from professional staff to create individualized recovery plans.

Read OGJVAMC’s latest annual report here to learn more about PACT (page 14).

Contact Drew Murray at the [email protected] if you want more information or have another example of how teamwork improves care.

Education to Practice is a service of the Michigan Health Council