the expanded team final nov2010
DESCRIPTION
The Expanded PACT Team: Care Management Resources for the Patient Aligned Care Team (PACT) Module Objectives 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 (con’t) •Understand the importance of accurately assessing Veteran’s needs •Understand the importance of involving PACT Expanded Team Members into the plan of careTRANSCRIPT
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?