Infusing Gerontologic Practice Into PACT

The older adult population in the VA is growing. Adults aged > 85 years are the fastest growing segment of the older veteran population and many are afflicted with multiple medical problems and functional impairments.^1,2 The majority of older veterans (94.6%, or about 1.9 million veterans) who seek care at the VA obtain care through primary care providers (PCPs) who are often not formally trained in geriatrics.^1,3 With the increasing number of older patients, new models of care are needed to provide coordinated, comprehensive, efficient, and patient-centered care.^4,5

Common themes found in successful models of care for older patients include a team approach, care management (comprehensive and coordinated), and patients who are active partners.⁴ These themes are reflected in the VA Patient Aligned Care Team (PACT) primary care program. PACT, a model of care that was initiated in 2010 and is built on a foundation of patient-centered care, encompasses a team approach to provide comprehensive, coordinated, and personalized care.^6-8 The challenge for the VA is to integrate gerontologic principles and tools into the daily practice of all PACTs in order to improve care provided for older veterans.⁹

This article discusses current challenges in caring for older veterans in the VA system and recommends tools that can be used to infuse geriatric care principles into VA primary care by the PACT, to improve the quality of care provided to older veterans. In addition, the article also describes VA geriatric programs that PACT clinicians can access to supplement older veterans’ care.

Challenges of Caring for Older Veterans

One concern when caring for older veterans arises when the veteran accesses both VA and non-VA health care services to offset medication costs and obtain services not covered by Medicare or other insurance companies.^2,3 This “dual care” can exacerbate polypharmacy issues and increase confusion regarding plans of care. Problems may arise when multiple providers from different systems of care prescribe medications available only within their own formulary and/or order diagnostic and laboratory tests with results available only within their own health care system.

The VA is also challenged by health care delivery for rural veterans. Thirty-six percent of all veterans live in rural areas, and they often depend on non-VA services to meet their health care needs due to difficulty traveling to the nearest VA facility.¹⁰ Seasonal residency also presents challenges. An increasing number of older veterans are seen at different VA facilities when they “winter” in a different section of the country.

Fortunately, a VA provider in one facility can access a patient’s electronic medical records in another facility, using the VA Computerized Patient Record System (CPRS). However, it is unclear to what extent busy VA PCPs use this function when seeing patients. Although individual pilot programs have shown promise, integrated electronic health records between VA and non-VA health care have not advanced to the point of sharing data or reconciling care plans (R. Rupper, personal communication, March 1, 2013).

Many PCPs and other PACT staff are not formally trained in geriatrics and may have had limited exposure to geriatric principles.³ Clinic time pressures, multiple clinical reminders (eg, vaccinations), and panel management of specific diseases make it challenging to find time to focus on complex geriatric syndromes. Current PACT performance measures also do not routinely include geriatric-specific quality of care criteria or focus on patient function (K. Shay, personal communication, February 12, 2013), a hallmark of geriatric care.⁸ Furthermore, with increasing complexity of the health care system and limited availability of resources, it is often time consuming to identify and collaborate with non-VA resources to ensure patients’ needs are met in their communities.

Opportunities for Improvement in Care

The VA transformation to PACTs has led to process changes in clinic workflow that may aid in addressing the aforementioned challenges in caring for older veterans. Each patient is assigned to a PCP-led team that includes a registered nurse care manager, a clinical associate, and an administrative associate. The PACT model of care has increased access to care by redesigning face-to-face visits, increasingly moving toward open access, and through the increased use of virtual access via secured e-mail, telephone visits, and telehealth.⁸

In addition to process changes, the VA has created new tools to assist teams in patient management. One of these is the Care Assessment Need (CAN) score, a risk stratification tool available for use by PACTs to identify patients at highest risk for hospital admission and/or death for focused care management.¹¹ It is based on statistical prediction models of veterans enrolled in primary care, using patient characteristics and health care use information.¹¹ Although the CAN score looks promising, more research is needed to evaluate its effectiveness in improving care for older veterans and its association with better patient functioning—an important focus in quality geriatric care.