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Improving Care Coordination for Older Veterans

The innovative Geriatric Patient-Aligned Care Team (GeriPACT) model was developed to provide interdisciplinary primary care to older Veterans with complex care needs in the VA healthcare system. GeriPACT is different from the usual VA Patient-Aligned Care Team (PACT) in that care is focused on meeting the needs of frail older adults (65+) who often require services in multiple clinics or settings. 

Care coordination is an integral feature of the GeriPACT patient-centric approach to primary care. Care coordination includes the “facilitation, management, and organization of services within the healthcare system, including specialty care, hospitals, home healthcare, long-term services and support, and other medical settings; within the community, including community-based organizations, community services, and governmental agencies; and between settings for transitions in care.”¹  To provide high-quality, proactive, and coordinated care, GeriPACTs include a pharmacist and social worker on the core team, as well as providers with advanced training in Geriatrics, and serve a panel size two-thirds the size of a standard PACT.² To date, more than 70 VA Medical Centers have implemented GeriPACTs .

Under the leadership of Jennifer Sullivan, PhD, GeriPACT QUERI has partnered with the Office of Geriatrics and Extended Care (GEC) to conduct an observational mixed-methods assessment of GeriPACT implementation in order to support the rapid translation of research findings into practice.  As part of this study, care coordination is examined in two ways, by:

• Assessing GeriPACT structural characteristics and the presence of PACT components, such as care coordination, and
• Examining the relationship of structural characteristics with patient utilization and cost.

Web-based surveys were administered to GeriPACT physician leaders and team members across 71 VA medical centers to collect relevant data needed to analyze care coordination and GeriPACT implementation.

Investigators found that about 70% of GeriPACTs had a designated case manager to coordinate across specialties or with providers outside of GeriPACT. In addition, of all PACT components assessed, care coordination practices were used most consistently. All or almost all GeriPACTs utilized nine practices, including:

• Planning for visits with patients requiring support for chronic conditions,
• Advance chart review to anticipate patient needs,
• Assessing barriers when patients do not move toward treatment goals,
• Sending/receiving information from other entities to support patients under care or transitioning settings,
• Reviewing information from other facilities to assess follow-up support for the patient,
• Contacting patients/families soon after discharge,
• Incorporating external records into the electronic record,
• Coordinating post-discharge care with other entities, and
• Providing help for patients in need of a subspecialist.²

The GeriPACT model offers a way to improve care coordination for frail older Veterans. This partnered GeriPACT evaluation will provide GEC leadership with information about the impact of care coordination on patient outcomes to better tailor implementation for improved effectiveness across the VA healthcare system.

For more information about GeriPACT QUERI or this project, in particular, please contact Dr. Jennifer Sullivan at Jennifer.Sullivan@va.gov.

1. Schreiber R. Patient-centered medical homes and the care of older adults. Public Policy & Aging Report. December 29, 2017;27(1):S7-S11.
2. Sullivan J, Eisenstain R, Price T, et al. Implementation of the Geriatric Patient-Aligned Care Team Model in the Veterans Health Administration (VA). The Journal of the American Board of Family Medicine. May 2018;31(3):456-465.