Primary care at the Providence VA Medical Center: challenges, opportunities and innovations.

Almost one out of ten Rhode Island residents is a US veteran. About 30,000 of them get their care at the VA. Their needs reflect both the aging demographic of World War II and Korean War veterans now in their 80s and younger men and women returning from the Iraq and Afghanistan wars. The veteran population also tends to be sicker, with more medical conditions, overall poorer health, and to use more medical resources than the US general population.1 From a primary care perspective, caring for today’s veteran requires a focus in three core areas: (1) chronic disease management including early detection, reducing the risk of disease progression and preventing/treating acute exacerbations; (2) the interface between public health and clinical medicine which encompasses everything from universal screening for post traumatic stress disorder, depression and substance abuse to implementing a firstline response to the H1N1 pandemic and promoting weight reduction and smoking cessation; and (3) the capacity to address health disparities and the needs of vulnerable populations disproportionately represented in veteran populations. To address these areas, primary care within the VA began a major transformation about 15 years ago in its organization.23 VA-based care is organized around the Patient-Centered Medical Home (PCMH) Model. Every veteran is assigned a primary care provider and clinical team. Comprehensive care is coordinated within an integrated medical system model that promotes continuity along with population and patient-based disease management and health promotion. A comprehensive electronic medical record system allows for timely communication across services as well as care planning, population tracking, and clinical feedback. It also allows the provider to have access to records of all care across all VA facilities nationwide. Together the medical home model and electronic medical record provide the capacity and tools needed to apply the Chronic Care Model within a primary care setting: promoting patient self-management, engaging community resources, use of decision supthe on-site management of patients presenting with depression or anxiety disorders. Monthly clinical reports drawn from the electronic medical record are provided to each clinician, RN and team that includes aggregated chronic disease management measures (most recent blood pressures, LDL and hemoglobin A1C) and a listing of all outlier patients in that team. These data are used in bi-weekly team meetings to both promote effective care planning and serve as the benchmark for team-based quality improvement initiatives. Since implementing this care structure in 2006, we have seen a significant improvement in chronic disease management performance and the proportion of patients at target for blood pressure, lipid and diabetes control, exceeding both national VA targets and community standards.