the expanded team final nov2010

The Expanded PACT

Team:

Care Management

Resources for the

Patient Aligned Care

Team (PACT)

PACT Teamlets will:

• Identify station specific

PACT Expanded Team

resources available to

support the PACT Teamlets

• Identify and clarify methods

of communication and

collaboration with PACT

Expanded Team resources

Module Objectives

Module Objectives

(con’t)

• Understand the importance

of accurately assessing

Veteran’s needs

• Understand the importance

of involving PACT Expanded

Team Members into the plan

of care

Pillars of the Patient

Aligned Care Team

•The primary care team is focused on the whole person

•Patient-preferences guide the care provided to the patient

Patient-Driven

•Primary care is delivered by an interdisciplinary team led by a primary care provider using facilitative leadership skills

Team-Based

•Veterans receive the care they need at the time they need it from an interdisciplinary team functioning at the highest level of their competency

Efficient

•Primary care serves as point of first contact for a broad range of medical, behavioral and psychosocial needs, fully integrated with other VA health services and community resources

Comprehensive

•Every patient has an established and continuous relationship with a personal primary care provider

Continuous

•The communication between the Veteran patient and other team members is honest, respectful, reliable, and culturally sensitive

Communication

•The PACT team coordinates care for the patient across and between the health care system including the private sector

Coordinated

What is the Expanded

Care Team?

Interdisciplinary Team Members

Team Members that are more

often involved with PACT

Integrated into the plan of care

May be embedded in Primary

Care

What is the Expanded

Care Team?

Interdisciplinary Team Members

Nutrition, Pharmacy, Care

Management/Social Work,

Primary Care Mental Health

Integration (PC-MHI), Specialty

Mental Health, Health Behavior

Coordinator, Health Promotion

Disease Prevention Program

Manager, MOVE! Coordinator

What is the Expanded

Care Team?

VHA Programs

VA Programs that address

Veteran needs outside of

Primary Care

Non-Institutionalized Care

Programs/ Geriatric and

Extended Care(i.e. Adult Day

Healthcare, respite, Palliative

Care/ Hospice, Community

Health Nurses, Homemaker

Home Health Aide, Medical

Foster Home)

What is the Expanded

Care Team?

More VHA Programs:

Community Living Center, Contract

Nursing Home, GRECC, Geriatric

Evaluation and Management

Homeless Programs

Specialty Mental Health (i.e.

MHICM, Suicide Prevention

Coordinator, MH RRTP)

Blind Rehabilitation (VIST)

Center for the Treatment of

Addictive Disorders (i.e. substance

abuse programs)

What is the Expanded

Care Team?

Free Standing Patient Aligned

Care Teams

Spinal Cord Injury (SCI)

Home Based Primary Care

(HBPC)

OEF/OIF Clinic

Geriatric Primary Care

Polytrauma

What is the Expanded

Care Team?

Free Standing Patient Aligned

Care Teams

ID/HIV

Dialysis

CBOC Teams/Teamlets

Specialty Mental Health

Women’s Health

What Does the

Expanded

Care Team Provide?

Direct patient care

Training and coaching (for staff

and patients)

Consultation

Shared decision making

Decision support systems

Access to tools and resources

Referral Process

How do the Teamlets identify and

refer a Veteran for intervention?

Expanded Team

Resources

Contact Person CPRS

Consult

Phone Vista

Gui

In

Person

Pager Secure

Messaging

Telemedicine

Medical Center

CBOC

Nutrition

Social Work

Dialysis

PC-MHI

HBC Health

Behavior

Coordinator

GEC Programs

Non-

Institutionalized

Care Programs

Accurate Assessment

PACT implementation in each

Medical Center should

ensure that PACT Expanded

Team resources are

identified and standards of

care are equal across all

PACT teams

Accurate Assessment

What does the Veteran need

outside of what the Primary Care

Teamlets can provide?

Where do I access that resource?

How to I communicate the needs

of the Veteran to the PACT

Expanded Team resource?

How do I incorporate PACT

Expanded Team interventions

into the Veteran’s treatment plan?

Communication is the

key

Teamlet Exercise

Objectives

What are the identified needs

of the Veteran?

What PACT Expanded Team

members should be involved?

How will the Teamlets

coordinate care with the PACT

Expanded Team?