Re-designing primary care

Understanding the needs, preferences, and goals related to their health is essential for doctors and other health care professionals to support and achieve their version of optimal health.   The Department of Veterans Affairs (DVA) is the largest integrated health care system in the United States, with 8.3 million Veteran patients cared for across 152 hospitals and 1400 primary care outpatient clinics or community living centers each year. In addition, there are over 53,000 licensed health care practitioners working across these clinics providing care. Given the large number of locations and the large number of employees, changing the way of doing things can be very challenging.

In April 2010, the VA began efforts to make changes to the way health care teams were caring for their patients, by establishing primary care teams (which included a doctor, nurses, and a clerk) whose goal was to fully understand the needs and preferences of their patients and to focus on providing care to the patient that will support them in achieving goals.

In this study, we focused on understanding things that were preventing doctors from delivering patient-centered care (PCC) and also things that were helping them to achieve it. We spoke with leaders in the health care system as well as doctors, nurses, and others to learn about planning for these changes, the process that occurred when making the changes, as well as any remaining challenges or changes that are still needed.

Fig. 1. 12 Principles of Patient-Centered Care. Source: Department of Veterans Affairs, Report of the Universal Services Task Force. April 2009.

Fig. 1. 12 Principles of Patient-Centered Care.
Source: Department of Veterans Affairs, Report of the Universal Services Task Force. April 2009.

A primary challenge during the course of this change was that many members of the health care community did not clearly understand what the goals of the new program were; as a result, some individuals were slower to want to make change and were slower to make changes. This suggested that better ways to communicate changes (such as through multiple levels of leadership) might facilitate better awareness and understanding of the changes occurring and encourage people to participate in the changes.

Our findings suggest that working as a team; including doctors, nurses, and others and providing everyone with a clear role and clear goals was essential for supporting the shift to PCC. Working as a team allowed members to share their experiences with one another, incorporate feedback and perspectives from multiple members of the team, and support one another to ensure the patient is receiving the best care possible.

We also found that members of the health care team felt that there was some clarification needed around what the role and goals of each team member should be. Some individuals, especially nurses, felt that on a daily basis their role seemed to include tasks that might be more appropriate for other team members. The lack of clearly defined tasks and roles contributed to some frustration among some team members. Participants suggested that with clear roles and goals, successes and needs for improvement in performance can be clearly identified and communicated to the health care team or the team member.

The study is a good example of how efforts to make change across many facilities and many health care team members need careful planning, evaluation at each step of the process to make changes as needed/possible along the way, and engagement by all members of the team so that everyone is familiar with and contributes to the vision and goals of the program and understands the importance of their role in that change.



Re-designing primary care: Implementation of patient-aligned care teams.
LaVela SL, Hill JN
Healthc (Amst). 2014 Dec


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