The move is towards transitioning to a patient-centered model according to the Department of Veterans Affairs publication “VAnguard” (March-April 2012). The agency is moving away from problem-based disease care toward patient-centered care that is based on relationships referred to as “Patient Aligned Care Teams (PACT).
By utilizing PACT, patients are their own number one healthcare advocate and get to make decisions to help direct their care. The doctors work closely with the patients to help them reach their optimal health, operate as a team and work with nurses and others to provide the right direction to patient care.
For example, PACT enables:
- The RN care manger to work with patients with two or three high-risk diagnoses, such as congestive heart failure or diabetes and is able to manage the medical situation through patient education, medication, or lifestyle changes
- Doctors can order the medications for the patients with the pharmacy closely monitoring the patient’s vital signs or blood sugars, and other lab results. Depending on the results, the pharmacist can adjust the medications
- Social workers to help with home care needs or a Care Coordination Home Telehealth nurse may follow vital signs or other readings that the patient is able to input via the telephone
- A dietitian to educate patients on nutrition or mental health services and helps patients establish strategies to help achieve their goals
- Admitting the patient as an inpatient more efficiently. The patient’s PACT will be alerted and if appropriate, visit them in the hospital, and if needed follow up with the patient after their discharge
- Patients to be able to communicate with their team with in-person visits, telephone calls, home telehealth, or secure messaging via “MyHealtheVet.”
Go to www.va.gov/opa/publications/vanguard/vanguard_12Marchapr.pdf to read the article published in “VAnguard” magazine.
