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Burnout is a prevalent issue among healthcare providers affecting up to 54% of physicians and 35% of nurses. Patient Aligned Care Teams (PACT) is a team-based primary care delivery model designed to assure the delivery of high-quality care while improving clinicians' well-being. Limited studies evaluated the relationship between work environment variables and PACT members' burnout and the relationship between PACT members' burnout and patient-centered care. This cross-sectional study is based on the 2018 Veterans Health Administration (VHA) national web-based PACT survey. Burnout was measured using a single-item question that was validated in previous studies. Descriptive statistics and logistic regression were used to analyze the data. Fifty-one percent of primary care providers and 40.12% of nurses reported high burnout. PACT members with a work environment characterized by high-quality team interaction, leadership support, and psychological safety experienced lower levels of burnout. PACT members' burnout explained 6% of the variance in PACT members' ability to deliver patient-centered care. Burnout among PACT members is attributed to multiple personal and occupational variables. This study identified modifiable work environment variables that can be used to inform burnout interventions., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objective: To examine the extent to which Veterans Health Administration (VHA) Patient-Aligned Care Team (PACT) members have a shared understanding/ agreement upon and enact responsibilities within the team., Background: The PACT model focuses on team-based care management. However, lack of a shared understanding of team-based care management roles and responsibilities makes system-wide implementation a challenge., Methods: Quantitative and qualitative analysis of national survey data collected in 2022 from primary care personnel working in a VHA-affiliated primary care facility., Results: Significant discrepancies exist in responses about what core team members say they do and what others perceive they should be doing, indicating either a lack of agreement, knowledge, or training about what core team members should do., Conclusions: Successful implementation of a team-based model requires adequate support and training for teamwork including shared mental models to work according to their clinical competency. Clear guidance and communication of expectations are critical for role clarity., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The aim of this study was to analyze perceptions and experiences of clinicians implementing the patient-centered medical home (PCMH)., Background: The PCMH model focuses on several important concepts, including team-based care management as well as care coordination and continuity among providers and across settings of care., Methods: A qualitative analysis of data collected in 2016 from primary care personnel through a national survey was conducted., Results: Four themes were found consistent with care management and care coordination: the importance of teamwork and optimized team member roles, need for adequate prioritization of care management and care coordination, need to refine tools and resources supporting care management and care coordination, and challenges with managing and coordinating care with and across complex systems., Conclusions: Successful implementation requires adequate support for teamwork and ensuring team members can work according to their clinical competency. Nurses practicing in expanded roles need clear role guidelines and adequate time to function in these roles.

Purpose: Patient engagement has been broadly defined as the process of actively involving and supporting patients in health care and treatment decision making. The aim of this study was to identify organizational factors that are associated with greater use of patient engagement care practices in Veterans Health Administration primary care clinics., Methods: We conducted a cross-sectional analysis of data from the 2016 Patient-Aligned Care Team (PACT) national survey of direct care clinicians (primary care clinicians, registered nurses, and clinical associates). Exploratory factor analysis was used to group conceptually related patient engagement survey items into 3 subscales: planning and goal setting; motivational interviewing; and organizational strategies to promote self-management. Our independent variables included literature-based factors reported to promote team-based care and interdisciplinary collaboration in primary care. We used generalized estimating equations with multivariate logistic regression analysis to identify independent correlates of high performance on each patient engagement domain (top 25th vs bottom 25th percentile)., Results: A total of 2,478 direct care clinicians from 609 clinics completed all patient engagement items in the PACT survey. For all patient engagement sub-scales, respondents at high-performing clinics were more likely to report having regular team meetings to discuss performance improvement and having leadership responsible for implementing PACT. For 2 of 3 patient engagement subscales, high performance was also associated with having fully staffed PACT teams (≥3 team members per primary care clinician) and role clarity., Conclusions: Several desirable organizational and contextual factors were associated with high performance of patient engagement care practices. Strategies to improve the organizational functioning of primary care teams may enhance patient engagement in care., (© 2020 Annals of Family Medicine, Inc.)

International implementation of the patient-centered medical home (PCMH) model for delivering primary care has dramatically increased in the last decade. A majority of research on PCMH's impact has emphasized the care provided by clinically trained staff. In this article, we report our ethnographic analysis of data collected from Department of Veterans Affairs staff implementing PACT, the VA version of PCMH. Teams were trained to use within-team delegation, largely accomplished through attention to clinical licensure, to differentiate staff in providing efficient, patient-centered care. In doing so, PACT may reinforce a clinically defined culture of care that countermands PCMH ideals. Such competing rubrics for care are brought into relief through a focus on the care work performed by clerks. Ethnographic analysis identifies clerks' care as a kind of emotional dirty work, signaling important areas for future anthropological study of the relationships among patient-centered care, stigma, and clinical authority., (© 2016 by the American Anthropological Association.)

Research evaluating the effectiveness, function, and implementation of patient-centered medical homes (PCMHs) has found major socioprofessional transformations and contributions of primary care physicians and, to a lesser degree, nurses. Our longitudinal ethnographic research with teams implementing PCMH in Veterans Health Administration (VHA) primary care identifies the important but largely underutilized contributions of clerks to PCMH outcomes. Although the relationship of high-performing clerical staff to patient satisfaction is widely acknowledged, PCMH can be further enhanced by enabling clerks to use administrative tasks as conduits for investing in long-term personalized relationships with patients that foster trust in the PCMH and the broader health care organization. Such relationships are engendered through the care-coordination activities clerks perform, which may be bolstered by organizational investment in clerks as skilled health care team members., (© 2016 Annals of Family Medicine, Inc.)

Objective: The experiences of RNs and licensed practical nurses (LPNs) implementing a patient-centered medical home (PCMH) in the Department of Veterans Affairs (VA) primary care clinics were examined to understand model implications for nursing practice and professional identity., Background: National implementation of the PCMH model, called patient-aligned care teams (PACTs) in VA, emphasizes areas of nursing expertise, yet little is known about the effect of medical homes on the day-to-day work of nurses., Methods: As part of a formative evaluation to identify barriers and facilitators to PACT implementation, we interviewed 18 nurses implementing PACT., Results: Challenges to nurse's organizational and professional roles were experienced differently by RNs and LPNs in the following areas: (1) diversified modes of care and expanded clinical duties, (2) division of labor among PACT nurses, and (3) interprofessional status in the team., Conclusions: Healthcare managers implementing PCMH should consider its inherent cultural and practice transformations.

Background: The patient-centered medical home (PCMH) relies on a team approach to patient care. For organizations engaged in transitioning to a PCMH model, identifying and providing the resources needed to promote team functioning is essential., Objective: To describe team-level resources required to support PCMH team functioning within the Veterans Health Administration (VHA), and provide insight into how the presence or absence of these resources facilitates or impedes within-team delegation., Design: Semi-structured interviews with members of pilot teams engaged in PCMH implementation in 77 primary care clinics serving over 300,000 patients across two VHA regions covering the Mid-Atlantic and Midwest United States., Participants: A purposive sample of 101 core members of pilot teams, including 32 primary care providers, 42 registered nurse care managers, 15 clinical associates, and 12 clerical associates., Approach: Investigators from two evaluation sites interviewed frontline primary care staff separately, and then collaborated on joint analysis of parallel data to develop a broad, comprehensive understanding of global themes impacting team functioning and within-team delegation., Key Results: We describe four themes key to understanding how resources at the team level supported ability of primary care staff to work as effective, engaged teams. Team-based task delegation was facilitated by demarcated boundaries and collective identity; shared goals and sense of purpose; mature and open communication characterized by psychological safety; and ongoing, intentional role negotiation., Conclusions: Our findings provide a framework for organizations to identify assets already in place to support team functioning, as well as areas in need of improvement. For teams struggling to make practice changes, our results indicate key areas where they may benefit from future support. In addition, this research sheds light on how variation in medical home implementation and outcomes may be associated with variation in team-based task delegation.

Background: The Veterans Health Administration (VHA) is changing its primary care delivery by implementing the patient-centered medical home (PCMH)., Objectives: To evaluate PCMH implementation among 22 newly formed teams working in the VHA., Study Design: Longitudinal formative evaluation of team members' role transformation during the first 18 months of implementation., Methods: We used 3 sequential, semistructured focus groups to gather data from 4 different groups representing the principal team member roles: primary care providers, registered nurse care managers, licensed practical nurses, and clerical associates., Results: Team members identified within-team role and interpersonal conflict, as well as discordant administrative leadership styles, as key implementation challenges., Conclusions: Our results suggest that, in addition to technological and fiscal infrastructure, healthcare leaders implementing the PCMH model must take into account interprofessional issues associated with changes in leadership and the adoption of team-based structures.

Purpose: To assess differences in Patient Aligned Care Team (PACT) performance between rural and urban primary care clinics within the Veterans Health Administration (VHA). Methods: An Explanatory Sequential Mixed Methods design was conducted using VHA administrative data to assess performance of a national sample of 891 VHA primary care clinics. Generalized Estimating Equations with repeated measures were used to estimate associations between rurality and process‐oriented endpoints including: chronic disease management through telehealth; use of telephone visits, group visits or secured messaging; same‐day access; continuity with primary care provider; and postdischarge follow‐up. Qualitative data collected during on‐site visits with 5 clinics were used to provide insights into PACT processes from the perspectives of staff in rural and urban clinics. Findings: After adjusting for patient‐ and practice‐level characteristics, clinics located in large rural or small/isolated rural areas demonstrated difficulty enhancing access through use of telephone visits, group visits, or secured messaging and completing postdischarge follow‐up calls, compared to urban clinics. Qualitative analysis indicated that staff from both rural and urban clinics reported similar barriers implementing these PACT processes. Both patient and staff behaviors and preferences impact implementation of these processes. Distance to care and access to high‐speed Internet were also reported as barriers. Conclusions: This study contributes to the understanding of PACT performance in rural settings by highlighting ways contextual and behavioral factors relate to performance. Increasing implementation of patient‐centered medical home (PCMH) models, such as PACT, will require additional attention to the complex relationships between the practice and surrounding context. [ABSTRACT FROM AUTHOR]

BACKGROUND: The patient-centered medical home (PCMH) relies on a team approach to patient care. For organizations engaged in transitioning to a PCMH model, identifying and providing the resources needed to promote team functioning is essential. OBJECTIVE: To describe team-level resources required to support PCMH team functioning within the Veterans Health Administration (VHA), and provide insight into how the presence or absence of these resources facilitates or impedes within-team delegation. DESIGN: Semi-structured interviews with members of pilot teams engaged in PCMH implementation in 77 primary care clinics serving over 300,000 patients across two VHA regions covering the Mid-Atlantic and Midwest United States. PARTICIPANTS: A purposive sample of 101 core members of pilot teams, including 32 primary care providers, 42 registered nurse care managers, 15 clinical associates, and 12 clerical associates. APPROACH: Investigators from two evaluation sites interviewed frontline primary care staff separately, and then collaborated on joint analysis of parallel data to develop a broad, comprehensive understanding of global themes impacting team functioning and within-team delegation. KEY RESULTS: We describe four themes key to understanding how resources at the team level supported ability of primary care staff to work as effective, engaged teams. Team-based task delegation was facilitated by demarcated boundaries and collective identity; shared goals and sense of purpose; mature and open communication characterized by psychological safety; and ongoing, intentional role negotiation. CONCLUSIONS: Our findings provide a framework for organizations to identify assets already in place to support team functioning, as well as areas in need of improvement. For teams struggling to make practice changes, our results indicate key areas where they may benefit from future support. In addition, this research sheds light on how variation in medical home implementation and outcomes may be associated with variation in team-based task delegation. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The aim of this study was to analyze the perceptions of core team members implementing patient-centered medical home (PCMH) within the Veterans Health Administration regarding delegation of work. BACKGROUND: Significant overlap exists in the performance of work tasks among PCMH team members (primary care providers, RNs, clinical associates, clerks), and scant literature exists on appropriate delegation within PCMH teams. METHODS: This study conducted used a quantitative and qualitative analysis of 4254 respondents to a 2018 survey. RESULTS: Primary care providers rely heavily on team members, and nurses report being relied upon at high levels. Lack of role clarity and a perceived need for a team leader were concerns voiced by participants. CONCLUSIONS: Findings indicated a need for clear guidance on roles and responsibilities within the team. Patient-centered medical home team members need information about the scope of practice of each professional group to allow providers to function at the top of their scope of practice and ensure effective delegation. [ABSTRACT FROM AUTHOR]