VA257-17-R-0506-A00004001.pdf

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Department of Veterans Affairs Veterans Health Administration Washington, DC 20420

VHA DIRECTIVE 1406

Transmittal Sheet

June 20, 2017

PATIENT CENTERED MANAGEMENT MODULE (PCMM) FOR PRIMARY CARE

1. REASON FOR ISSUE: This Veterans Health Administration (VHA) directive establishes the guidelines and business rules for use of the Patient Centered Management Module (PCMM) (formerly known as “Primary Care Management Module”). PCMM is an enterprise application that enables users to (1) set up and define health care teams, (2) assign staff and their associated full-time equivalent (FTE) staff to positions within each team, (3) assign patients to the team, and (4) assign patients to specific team members. Following these guidelines and business rules will ensure that the data entered into PCMM is reliable and consistent across VA. For primary care (PC) this will enhance the ability of the Patient Aligned Care Team (PACT) to optimally manage health care for patients assigned to PACT, including all VHA PC clinical sites of care to include VHA owned, leased and contracted locations. PCMM capabilities include the management of PC (as defined by VHA Handbook 1101.10, Patient Aligned Care Team (PACT) Handbook), non-primary care (e.g., mental health, Operation Enduring Freedom-Operation Iraqi Freedom-Operation New Dawn (OEF- OIF-OND), etc.) and community care (non-VA) populations, in support of current or future program office guidance.

2. SUMMARY OF MAJOR CHANGES: This VHA directive provides updated guidance on the utilization of PCMM to support a team-based, patient centric approach to patient care. This directive:

a. Highlights the enhancement from a Veterans Health Information Systems and Technology Architecture (VistA) Graphical User Interface (GUI) software program to a VHA web-based GUI application to include a name change from Primary Care Management Module to Patient Centered Management Module, utilizing the same acronym “PCMM”.

b. Mandates the assignment of a National PCMM Coordinator and a Principal Facility Coordinator for PCMM.

c. Ensures data validation occurs so the output is as refined as possible for executive decision making purposes.

d. Identifies capabilities for PCMM utilization for managing non-primary care and community care (non-VA) populations.

e. Describes the conversion of PCMM PACT assignment from pending to active when a qualifying teamlet encounter has been completed.

f. Establishes PCMM as the authoritative source for PACT staffing, capacity, panel size, and exam room space.

https://www.va.gov/vhapublications/index.cfm

June 20, 2017 VHA DIRECTIVE 1406

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g. Enables the entry of PCMM surrogates who are routinely responsible for the PACT patient population during staff absences.

h. Replaces the term “dual assignment” with “multi-PACT assignment” when referring to a primary care panel assignment status where a patient has been approved for assignment to more than one PACT.

3. RELATED ISSUES: VHA Handbooks 1101.10 and 1101.11(2).

4. RESPONSIBLE OFFICE: The Office of Patient Care Services (10P4) is responsible for the content of this directive. Questions may be directed to the Chief Consultant, Primary Care Services at 202-461-4158 or VHA10P4FStaff@va.gov.

5. RESCISSIONS: VHA Handbook 1101.02, dated April 21, 2009, is rescinded.

6. RECERTIFICATION: This VHA directive is scheduled for recertification on or before the last working day of June 2022. This VHA directive will continue to serve as national policy until it is recertified or rescinded.

Poonam Alaigh, M.D.

Acting Under Secretary for Health

DISTRIBUTION: Emailed to the VHA Publications Distribution List on June 22, 2017.

mailto:VHA10P4FStaff@va.gov i

CONTENTS

PATIENT CENTERED MANAGEMENT MODULE (PCMM) FOR PRIMARY CARE

1. PURPOSE

2. BACKGROUND

3. DEFINITIONS

4. POLICY

5. RESPONSIBILITIES

6. REFERENCES

APPENDIX A

PCMM USER PERMISSIONS .....................................................................................A-1

APPENDIX B

PACT TEAM AND STAFF ROLES IN PCMM ..............................................................B-1

APPENDIX C

PACT FTE DATA ENTRY IN PCMM ........................................................................... C-1

APPENDIX D

PRO-RATED ROOM AVAILABILITY DATA ENTRY IN PCMM .................................. D-1

APPENDIX E

PACT PANEL CAPACITY ............................................................................................E-1

APPENDIX F

PACT PATIENT ASSIGNMENTS IN PCMM ................................................................ F-1

APPENDIX G

PATIENT ALIGNED CARE TEAM (PACT) PATIENT CENTERED MANAGEMENT

MODULE (PCMM) INACTIVATION ............................................................................. G-1

APPENDIX H

NON-PRIMARY CARE AND COMMUNITY CARE (NON-VA) ASSIGNMENTS IN

PATIENT CENTERED MANAGEMENT MODULE (PCMM) ....................................... H-1

APPENDIX I

EXAMPLE SCENARIOS FOR IDENTIFYING PATIENT ALIGNED CARE TEAM (PACT)

TEAMLET FULL-TIME EQUIVALENT (FTE) ................................................................ I-1

APPENDIX J

QUALIFYING ENCOUNTERS ..................................................................................... J-1

PATIENT CENTERED MANAGEMENT MODULE (PCMM) FOR PRIMARY CARE

1. PURPOSE

This Veterans Health Administration (VHA) directive establishes the guidelines and business rules for use of the Patient Centered Management Module (PCMM) (formerly known as “Primary Care Management Module”). PCMM is an enterprise application that enables users to (1) set up and define health care teams, (2) assign staff and their associated full-time equivalent (FTE) staff to positions within each team, (3) assign patients to the team, and (4) assign patients to specific team members. Following these guidelines and business rules will ensure that the data entered into PCMM is reliable and consistent across VA. For primary care (PC) this will enhance the ability of the Patient Aligned Care Team (PACT) to optimally manage health care for patients assigned to PACT, including all VHA PC facilities of care to include VHA owned, leased and contracted locations. PCMM capabilities include the management of PC (as defined by VHA Handbook 1101.10, Patient Aligned Care Team (PACT) Handbook), non-primary care (e.g., mental health, Operation Enduring Freedom-Operation Iraqi Freedom-Operation New Dawn (OEF-OIF-OND) and community care (non-VA) populations, in support of current or future program office guidance. AUTHORITY:

Title 38 United States Code (U.S.C.) 7301(b).

2. BACKGROUND

a. Over time, VHA has developed a primary care system that balances productivity with quality, access, and personalized, proactive, patient-driven health care.

Management of patient panels in PC through mandatory and consistent use of PCMM has supported this care delivery system, and allows facilities to track patients and their assigned PACT across the system. Additionally, PCMM allows for specific data entry of PACT teamlet FTE and their allocated exam room space. When data are entered in a standardized manner, the information is used to analyze Primary Care capacity, staffing, space and workload nationally, by Veteran Integrated Service Network (VISN), by VA medical center, and community-based outpatient clinic (CBOC). PACTs manage the overall care provided to a majority of Veterans in the Department of Veterans Affairs (VA) Health Care System. PACT workload capacity is an important factor in determining the total number of patients that can be cared for in the system. In response to the growing number of Veterans using VA health care services, there is a need to quantify the primary care capacity that is available, so that supply and demand can be aligned.

b. The PCMM application supports automated data collection for management metrics and analysis related to access, workload, and panel management.

c. PCMM management and oversight requires a national PCMM Coordinator, a VISN PCMM point of contact (POC), and a Principal Facility Coordinator (PFC) for PCMM to ensure adherence to policy and business rules, and for data management, education and training. These staff members will serve as subject matter experts (SME) to VHA staff members and ensure accuracy and data integrity of PCMM.

3. DEFINITIONS

a. Actual PACT FTE. Actual PACT FTE is the portion of the full-time equivalent employee available to support the PACT.

b. Administrative Associate. The Administrative Associate is the teamlet member who provides administrative support for the delivery of primary care services and operations management to a PACT (e.g., medical clerk (MC), health technician (HT)).

c. Associate Provider. Associate Provider (AP) is a designation in PCMM intended primarily for trainees who require supervision from a physician or faculty provider who is associated with academic affiliates. Health professionals in training (e.g., physician residents, Nurse Practitioner (NP) and Physician Assistant (PA) residents) are APs when they provide ongoing and comprehensive primary care in collaboration with a supervising practitioner for an assigned panel of patients (see VHA Handbook 1400.01, Resident Supervision, and VHA Handbook 1400.04, Supervision of Associated Health Trainees). Staff PAs and NPs may be designated as APs as determined by local facility policy or when assigned shared responsibility for a panel of patients with a supervising or collaborating physician, NP or PA. See VHA Handbook 1101.10, VHA PACT Handbook.

d. Available Capacity. Available capacity is the difference between the actual panel size and the defined panel capacity (modeled capacity or modeled capacity override).

e. Clinical Associate. A Clinical Associate is a Licensed Practical Nurse (LPN), Licensed Vocational Nurse (LVN) or unlicensed assistive personnel (e.g., certified nursing assistant (CNA), medical assistant (MA), HT). The Clinical Associate is a teamlet member. See VHA Handbook 1101.10, Patient Aligned Care Team (PACT) Handbook.

f. Designated Women’s Health Provider (DWHP). A designated Women’s Health Provider (DWHP) is a Primary Care Provider who is proficient in women’s health.

A designated WH PCP is preferentially assigned women Veterans within their primary care patient panels. See VHA Directive 1330.01 Health Care Services for Women Veterans.

g. Discipline-Specific Team Member. A discipline-specific team member is a health care professional designated to a PACT position who provides direct discipline-specific patient care, either in-person or through telehealth, to one or more panels of patients, but not to all primary care patients at the facility. Examples of discipline-specific team members are: Clinical Pharmacy Specialists, Registered Dietitian Nutritionists, Social Workers, Physical Medicine and Rehabilitation Services Therapists, Lead Coordinators, Primary Care-Mental Health Integration staff members. See VHA Handbook 1101.10, Patient Aligned Care Team (PACT) Handbook. NOTE: Discipline-specific team members may also be referred to as expanded team members and may be included as part of a larger interdisciplinary team for complex care coordination and should be assigned in PCMM as appropriate.

h. Encounter. An encounter is a professional contact between a patient and a provider with responsibility for diagnosing, evaluating, and treating the patient’s condition. Encounters occur in outpatient and inpatient settings (including Residential Rehabilitation Treatment centers). See VHA Directive 1082, Patient Care Data Capture.

i. Examination Rooms. Examination rooms are fully-equipped rooms in which providers and other staff prepare and examine patients.

j. Expected FTE. Expected FTE is a field in PCMM that allows the user to identify the expected FTE associated with the team position being established. It is to be used to identify the portion of a full-time equivalent employee required to support the team.

k. Full-Time Equivalent. An FTE is the hours worked by one employee on a full-time basis in a normal 80 hour pay period. The value usually ranges from 0.0 to 1.0.

For example, a 1.0 FTE would work 80 hours in a pay period, while a 0.5 FTE would work 40 hours per pay period.

l. Managerial Cost Accounting. Managerial cost accounting (MCA) (formerly known as Decision Support System (DSS)) is an activity based cost allocation system that generates estimates of the cost of individual VA hospital stays and health care encounters. See VHA Directive 1750, Managerial Cost Accounting System (Decision Support System (DSS)).

m. Modeled Panel Capacity. The modeled panel capacity is the maximum number of patients a PACT is expected to care for when the baseline capacity, which is currently 1200, is adjusted by a formula that takes into account the current teamlet support staff, rooms, female veterans, intensity score, and PCP type.

n. Modeled Capacity Override. Modeled capacity override is the panel capacity set locally if primary care leadership chooses to use a panel capacity different than what the modeled panel capacity specifies.

o. Multi-PACT Assignment. A multi-PACT assignment (previously known as “dual assignment”) is a primary care panel assignment status where a patient has been clinically approved for assignment to more than one PACT. For more information see VHA Handbooks 1101.10, VHA PACT Handbook and 1101.11(2), Coordinated Care for Traveling Veterans.

p. Panel Management. Panel management is the administrative process of using the PCMM application to assign and un-assign patients to a team, and to calculate, adjust, and monitor PACT panel capacity and size.

q. Patient Aligned Care Team. The PACT is a team of health care professionals that provides comprehensive primary care in partnership with the patient (and the patient’s personal support person(s)) and manages and coordinates comprehensive health care services consistent with agreed upon goals of care. PACTs for special populations are designated by a specific indicator. See VHA Handbook 1101.10.

r. PACT Assigned Total. PACT assigned total is the sum of PACT assignments with an active and pending status.

s. PACT Staff. PACT staff is VHA staff designated in PCMM to a position in a PACT. See VHA Handbook 1101.10, Patient Aligned Care Team (PACT) Handbook.

t. Panel Management. Panel management is the administrative process of using PCMM software to assign and un-assign patients to a PACT, and to calculate, adjust and monitor panel size. NOTE: Panel management is often confused with population management. Panel management refers to management of assigning patients to a panel and managing the panel size. Population management refers to the use of data to address the health status of a cohort of patients defined by specific parameters. See definition for population management.

u. Panel Size. Panel size is a field in PCMM that displays the total number of currently assigned patients. For all PACTs, panel size is the total number of pending and active PCMM PACT assignments. For non-primary care and community (non-VA) populations, panel size is the total number of active assignments.

v. Patient Centered Management Module. PCMM is a VHA Web-based application that allows input of facility specific and PC panel specific data, and allows national roll up of this data for tracking, case finding, and comparison purposes.

w. Population Management. Population management is a data-driven process for proactively defining a cohort of patients who might benefit from a health care plan or intervention. This approach allows the PACT to contact individual patients in the cohort to offer the right service at the right time, rather than waiting for the patient to self-identify and seek out health care. Population management activities enable identification of gaps in clinical care and use strategies for improving health care outcomes for the defined patient cohort. NOTE: Population management is often confused with panel management. Population management refers to the use of data to address the health status of a cohort of patients defined by specific parameters.

Population management of a patient panel means that population management strategies are used to assess and address the care needs of all patients assigned to the panel. Panel management refers to management of assigning patients to a panel and managing the panel size. See definition for panel management.

x. Principal Facility Coordinator. The principal facility coordinator (PFC) is the facility’s designated staff member who manages and maintains the access, data entry, and accuracy of PCMM.

y. Primary Care Direct Patient Care FTE. Primary Care Direct Patient Care (PCDPC) FTE is the time to prepare for, provide, and follow-up on the clinical needs of PC patients. This includes all time spent in reviewing patient data; discussions about the care with colleagues; contacting the patient, family or other surrogate decision-makers, or caregivers to discuss their concerns or needs; and collaborating with potential and actual community care (non-VA) health care institutions on patients’ behalf.

z. Primary Care Intensity Score. Primary care intensity score is a measure that predicts primary care workload. The intensity score allows PCMM software to adjust primary care panel capacity to allow equilibration of PACT workload among teams despite differences in medical complexity of their patient panel. The primary care intensity score is computed at least yearly and typically explains over 40 percent of the total variation in PACT workload (including both face-to-face and telephone care). The model for determining the intensity score evaluates a wide-range of demographic variables including patient age, gender, priority group, insurance status, and number and severity of diagnoses to determine those factors most highly correlated with workload. These factors reflect a combination of complexity of illness and reliance on

VHA.

aa. Provider. For the purposes of this directive, the term provider is interchangeable with the PCP.

bb. Primary Care Provider. Primary Care Provider’s (PCP) are physicians, NPs, and PAs who provide primary care to an assigned panel of patients and in accordance with licensure, privileges, scope of practice or functional statement. The PCP is a teamlet member. See VHA Handbook 1101.10, Patient Aligned Care Team (PACT) Handbook. NOTE: Other PACT teamlet or discipline-specific team members provide health care services, but are not considered to be providers for the purpose of this directive.

cc. Qualifying Encounter. A qualifying encounter is an encounter by a PACT team member that triggers a PCMM status change from pending to active or maintains active status. See definition for encounter and appendix J for a list of qualifying encounters and stop codes.

dd. Registered Nurse Care Manager. The Registered Nurse Care Manager (RNCM) is a teamlet member who provides comprehensive and coordinated nursing care to an assigned panel of patients. The RNCM collaborates with both VA services and community services as appropriate to effectively meet the health promotion or disease prevention, acute, chronic, and long-term needs, based on the Veteran’s goals and plan of care with a focus on self-management. See VHA Handbook 1101.10.

ee. Pro-Rated Room Availability. Pro-rated room availability is the total count of available exam space to provide patient care when clinic is in session. The total count should include the proportional amount of time the space is available for patient care.

For example, if one exam room is equally shared by primary care and specialty care, primary care’s pro-rated exam room count would be 0.5.

ff. Station Modeled Capacity. The station modeled capacity represents the total number of patients that should be assigned to a team based on its station, care type, intensity score and rooms available at the station.

gg. Surrogate. A surrogate is a specific individual in a similar role that is assigned to cover for the corresponding PACT staff-member during short-term or unplanned absences.

hh. Teamlet. A teamlet consists of a PCP, RNCM, clinical associate, and administrative associate who provides patient care, either in-person or through telehealth, to one entire panel of patients as assigned in PCMM. Generally, teamlet members are designated in PCMM to the following positions: PCP, Registered Nurse (RN), LPN/LVN/HT, and Clerk. Trainees may also participate in teamlets. Special population PACTs may have additional or other designated teamlet positions in PCMM.

See VHA Handbook 1101.10.

ii. Trainee. A general term to describe undergraduate, graduate, and post-graduate students, interns, residents, fellows, and VA advanced fellows; and pre- and post-doctoral fellows whose time at a VA medical facility is spent in clinical or research training experiences to satisfy program or degree requirements. See VHA Directive 1400.09, Education of Physicians and Dentists, VHA Handbook 1400.08, Education of Associated Health Professions, and VHA Handbook 1400.07, Education of Advanced Fellows.

jj. Trainee Full-Time Equivalent. Although trainees are not considered employees for this purpose, trainee activities for supervised practice and other learning in primary care can be estimated assuming an 80-hour pay period. The estimated value usually ranges from 0.0 to 1.0. For example, a 1.0 trainee FTE would be present in the primary care setting for 80 hours in a pay period, while a 0.5 trainee FTE would be present in the primary care setting for 40 hours per pay period.

kk. Traveling Veteran Coordinator. A Traveling Veteran Coordinator (TVC) is a RN, PA, or NP who coordinates necessary or ongoing health care for Veterans on extended travel. See VHA Handbook 1101.11(2), Coordinated Care for Traveling Veterans.

ll. User Permissions. User permissions determine the actions an authorized PCMM user is allowed to perform within the PCMM application.

mm. Vacancy FTE. Vacancy FTE is the difference between PCMM expected and actual PACT FTE.

4. POLICY

a. It is VHA policy that PCMM be utilized by all PACTs for panel management.

PCMM is used to identify the PACT assigned to care for each PC patient. Current primary care panel capacity can be measured using PCMM by determining the number of active primary care patients assigned to a PACT. Entry of PCMM assignments is done in a standardized way throughout the VA health care system in order to ensure accurate and meaningful network and national analysis of this information.

b. It is the expectation that Veterans will receive primary and/or specialty care at VA medical facilities, regardless of a PACT assignment in PCMM. Assignment to a PACT is not a prerequisite for receiving episodic care at a VA facility or VA-owned or contract community-based outpatient clinic (CBOC).

5. RESPONSIBILITIES

a. VHA Executive Director for Primary Care Operations. The VHA Executive Director for Primary Care Operations is the business owner of the PCMM application and is responsible for:

(1) Ensuring the overall technical functionality, development, and future enhancements of the PCMM application.

(2) Developing national guidelines for PCMM use for PACT.

(3) Developing and implementing the PCMM business rules for PACT to monitor data validity, reliability and variances to include, but not limited to panel sizes, actual capacity, modeled capacity, staffing, and examination rooms.

(4) Reviewing PCMM metrics for outliers or excessive data variability that require further evaluation to determine if PCMM business rules are being correctly implemented in conjunction with the national PCMM Coordinator.

(5) Appointing a national PCMM Coordinator.

b. VHA Office of Academic Affiliations. The VHA Office of Academic Affiliations is responsible for policies regarding trainee engagement in clinical care and education.

c. National PCMM Coordinator. The National PCMM Coordinator is responsible for:

(1) Serving as the technical authority of PCMM and its utilization throughout VHA.

(2) Overseeing the PCMM application to ensure expected functionality is optimized.

(3) Communicating PCMM business rules, operational impact, and functional development to VISN and facility coordinators and others, as needed.

(4) Providing technical support to field users through virtual mentoring, teaching, and instruction.

(5) Analyzing and evaluating the accuracy of PCMM data and working with VISNs to address compliance with PCMM business rules and variation in PCMM generated data which raises the possibility of data inaccuracy.

(6) Providing feedback to facility leaders regarding PCMM metrics, in conjunction with officials from VHA Primary Care Operations.

(7) Assigning PCMM user permissions to National and VISN staff.

d. VISN Director. The VISN Director is responsible for:

(1) Ensuring implementation of this directive at all VA medical facilities in the VISN where Veterans receive primary care.

(2) Ensuring that the VHA Web-based PCMM application is utilized within all primary care facilities across the VISN and the data is accurate and valid.

(3) Implementing the PCMM business rules for PACT, as described within this Directive, and monitoring data validity, reliability, and variances to include, but not limited to panel sizes, actual capacity, modeled capacity, staffing, and examination room space.

(a) Developing corrective action plans in collaboration with VHA Office of Primary Care Operations to address inappropriate variances or deficiencies.

(4) Identifying a staff member to serve as the VISN PCMM Coordinator with the following knowledge and skills:

(a) In-depth understanding of PCMM business rules, functionality, and clinical impact;

(b) Ability to validate PCMM utilization and data integrity across all VISN locations;

and

(c) Ability to communicate with staff across all levels of the organization.

(5) Ensuring that the VISN PCMM Coordinator is actively involved with VISN-level PACT activities.

e. VISN PCMM Coordinator. The VISN PCMM Coordinator is responsible for:

(1) Completing VISN PCMM training activities and participating in national PCMM conference calls and discussion as needed.

(2) Participating in periodic conference calls with the National PCMM Coordinator to discuss the VISN PCMM Coordinator’s role and to coordinate and support PCMM training for facility PCMM coordinators.

(3) Facilitating monthly and routine collaboration and communication with PFCs.

(4) Delegating PCMM user permissions for VISN and PFCs.

(5) Ensuring that PCMM expectations and business rules are communicated with VISN PACT leaders and PFCs, as needed.

(6) Ensuring that all VISN users and PFCs are familiar with this PCMM directive, the PCMM user guide, and other applicable reference materials.

(7) Ensuring accuracy and timeliness of PCMM utilization through analysis and evaluation to ensure compliance with VHA PCMM and PACT policies, guidelines, and business rules throughout the VISN.

(8) Serving as the VISN technical expert for PCMM with the ability to troubleshoot and resolve user issues.

(9) Reviewing PCMM metrics at facilities within the VISN to identify outliers or excessive data variability. Concerns will be shared with appropriate VISN and facility leaders, as well as the National PCMM Coordinator.

f. VA Medical Facility Director. The VA medical facility Director, or designee, is responsible for:

(1) Identifying a PFC, and a back-up PFC, who are organizationally aligned under Primary Care clinical leadership, with the following knowledge and skills:

(a) In-depth understanding of PCMM business rules, technical functionality, and clinical impact;

(b) Ability to ensure that PCMM is fully utilized at parent and all division locations where Primary Care is provided;

(c) Ability to validate PCMM utilization and data integrity throughout all facility Primary Care locations including timely data entry and oversight management; and

(d) Ability to communicate with staff across all levels of the organization.

(2) Ensuring the FTE allocation of the discipline-specific PACT members in PCMM accurately reflects PACT responsibilities (see VHA Handbook 1101.10) and is in alignment with MCA labor mapping (see VHA Directive 1750, VHA Managerial Accounting System (Decision Support System)).

(3) Ensuring that the data in PCMM accurately reflects the business rules for PACT, as described in this Directive, and monitoring data validity, reliability, and variances to include, but not limited to panel sizes, actual capacity, modeled capacity, staffing, and examination room space.

(4) Developing action plans to evaluate and correct unexplained deviations in PCMM data, as described above, in conjunction with the VISN Director.

g. Facility Chief of Staff. The facility Chief of Staff is responsible for:

(1) Determining the time allocation for each PCP dedicated to patient care and maximum panel expectations.

(2) Reviewing PCMM data related to efficiency, capacity, and staffing. The Chief of Staff may delegate this responsibility to service level officials accountable for PACT. At larger facilities where PC teams are in more than one clinical service (e.g., PC and SCI

Service), the Chief of Staff may designate this responsibility to more than one primary care clinical leader and/or practice manager.

(3) Overseeing PCMM multi-PACT approval/denial clinical review process to include the identification of approving POCs who are RNs or PCPs.

(4) Ensuring allocated PACT examination room space is identified.

h. Service Level Officials Accountable for PACT. The service level officials accountable for PACT (i.e., designated facility PC, nursing, and administrative leader(s)) are responsible for:

(1) Ensuring service-level implementation of this Directive at all facilities of care administered by the VA medical facility where Veterans receive primary care. This includes special population PACTs, as defined in VHA Handbook 1101.10.

(2) Ensuring assignment of PACT team members and staffing are consistent with PACT staffing as outlined in VHA Handbook 1101.10, Patient Aligned Care Team (PACT) Handbook and are entered into PCMM accordingly.

(3) Ensuring that the PFC is notified of the required PCMM roles and identified staff during team setup in PCMM and as changes occur.

(4) Ensuring that validation of PCMM data is completed at least monthly and on a regular basis to ensure that definitions and decisions are subjected to ongoing evaluation and consistent interpretation.

(5) Identifying teamlet PCMM surrogates to enable the identification of PACT staff members who are responsible for covering the PACT teamlet when staff member absences occur.

(6) Identifying and validating the accuracy of the data related to number of rooms entered for each PACT.

(7) Validating the accuracy of the PCDPC FTE and maximum PACT capacity.

(8) Collaborating with the facility MCA Coordinator to ensure accuracy of teamlet PCMM FTE entry.

(9) Identifying PCMM positions, staff, and other information as needed for other non-primary care programs.

(10) Communicating any changes to staffing, staffing FTE, and pro-rated room availability to the PFC as they occur.

(11) Establishing local process/protocol to ensure PCMM PACT pending assignments are entered as soon as possible following the creation of the patient’s first PACT appointment. NOTE: Timely assignment of the patient allows for system-wide tracking of the patient’s care, which is optimal for care coordination and in the best interest of the patient. It is also beneficial to the organization, as it allows for better tracking and monitoring of patient assignments, panel capacity, and staffing demands.

i. Principal Facility Coordinator for PCMM. The PFC for PCMM is responsible for:

(1) Ensuring the integrity of the VA medical facility’s PCMM application, its functionality, utilization, and resulting data.

(2) Serving as the facility’s technical expert for PCMM with the ability to troubleshoot and resolve user issues.

(3) Participating in monthly national calls with the national PCMM Coordinator to ensure alignment with national policy, receive updates, and share strong practices.

(4) Meeting regularly with facility primary care leadership and group practice managers to review provider panel management data, including access for face-to-face and telephone care.

(5) Delegating PCMM user permissions for facility staff members.

(6) Ensuring accuracy of PCMM through analysis and evaluation to ensure compliance with VHA PCMM and PACT policies, guidelines and business rules throughout the facility.

(7) Establishing and managing PCMM PACT position set up, staff and FTE assignment, as well as patient assignments for all primary care locations. Specifically, the PFC will electronically create or modify team and position settings, assign staff to positions, assign FTE to positions, identify set maximum panel capacity, program clinical notification levels, and establish preceptor to associate provider links.

(8) Ensuring that PCDPC data is entered for each PACT teamlet member in PCMM and entered as a portion of a FTE employee and is kept current and accurate.

(9) Completing multiple assignment/reassignment to move large groups of PACT populations to different teams, when changes become necessary.

(10) Managing automatic inactivations to ensure appropriateness and communication to PACT members.

(11) Maintaining oversight of the Multi-PACT approval disposition to ensure timely completion of active assignments.

(12) Assisting operating officials in implementing identified improvement actions and plans through participation in organizational improvement work through station programs such as Systems Redesign projects.

(13) Ensuring facility PCMM standard operation procedures (SOP) or Directives are in place and current; meeting all local requirements and stakeholder concurrence to meet VHA PACT PCMM goals and objectives.

(14) Completing comparative analysis of VSSC reports or data sets with local PCMM data to identify data variance and ensure data integrity.

(15) Participating in PCMM training activities and in national and/or VISN PCMM conference calls and discussion as needed.

(16) Ensuring that PCMM users are knowledgeable in PCMM functionality and utilization.

(17) Ensuring that PCMM PACT pending assignments are entered prior to the patient’s first PACT appointment and no later than 24 hours from the creation of the patient’s first PACT appointment.

(18) Collaborating and coordinating throughout all levels of the organization, including executive leadership and program leaders.

(19) Actively participating in PACT committees, workgroups, improvement projects and process development.

6. REFERENCES

a. VHA Handbook 1101.10, Patient Aligned Care Team (PACT) Handbook

b. VHA Handbook 1101.11(2), Coordinated Care for Traveling Veterans

c. VHA Handbook 1140.07, Geriatric Patient Aligned Care Team (GeriPACT)

d. VHA Directive 1330.01, Health Care Services for Women Veterans

e. VHA Handbook 1400.01, Resident Supervision

f. VHA Handbook 1400.04, Supervision of Associated Health Trainees

g. VHA Directive 1082, Patient Data Capture

h. VHA Directive 1063, Utilization of Physician Assistants

i. VHA Handbook 1400.07, Education of Advanced Fellows

j. VHA Handbook 1400.08, Education of Associated Health Professions

k. VHA Directive 1400.09, Education of Physicians and Dentists

l. VHA Directive 1750, Managerial Cost Accounting System (Decision Support System (DSS)) https://www.va.gov/vhapublications/index.cfm https://www.va.gov/vhapublications/index.cfm https://www.va.gov/vhapublications/index.cfm https://www.va.gov/vhapublications/index.cfm https://www.va.gov/vhapublications/index.cfm https://www.va.gov/vhapublications/index.cfm https://www.va.gov/vhapublications/index.cfm https://www.va.gov/vhapublications/index.cfm https://www.va.gov/vhapublications/index.cfm https://www.va.gov/vhapublications/index.cfm https://www.va.gov/vhapublications/index.cfm

m. VHA Directive 2012-003, Person Class File Taxonomy, or subsequent policy issue.

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APPENDIX A

PCMM USER PERMISSIONS

Access to Patient Centered Management Module (PCMM) will be granted by National and Veterans Integrated Service Network (VISN) PCMM Coordinators and Principal Facility Coordinators (PFC) through the PCMM User Permission option.

a. Required PCMM User Permissions are as follows:

(1) VISN PCMM Coordinator;

(2) PFC; and

(3) Traveling Veteran Coordinator.

b. PCMM is designed to help implement VA policy and will work best when access is limited to a small number of users. This assures data integrity. User access that allows PACT data entry to teams, staff, full-time equivalent (FTE), rooms, and patient assignments is to be limited to the PFC and their back-up. NOTE: The PFC is responsible for the functionality, management and oversight of PCMM throughout the facility and its divisions; however, community-based outpatient clinics (CBOC) may also identify a local PCMM Coordinator or a PCMM Clerk to assist the PFC.

c. PCMM users must be assigned a permission role based on expected PCMM utilization. For example, staff members who need to utilize PCMM’s reporting functionality only, should be assigned a user permission role of “PCMM Reports Only”.

And executive leaders or staff members who need to view all PCMM data should be assigned the user permission role of “PACT Administrator – View ALL”. NOTE: Staff must be granted real Social Security Number (SSN) access by National Data Systems for viewing Veterans Health Administration (VHA) Service Support Center (VSSC) reporting in order to utilize the “PACT Administrator” permission.

d. PCMM user permissions for contract CBOC staff members must be limited to patient assignment data entry only. Contract CBOC staff members should not be allowed access to enter or modify Patient Aligned Care Team (PACT) teams, staff, FTE, or room data in PCMM.

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APPENDIX B

PACT TEAM AND STAFF ROLES IN PCMM

Patient Aligned Care Team (PACT) teamlet and teamlet surrogate roles for the Primary Care Provider (PCP)/Associate Provider (AP), Registered Nurse Care Manager (RNCM), Clinical Associate, and Administrative Associate must be designated in Patient Centered Management Module (PCMM) for all PACTs. Discipline-specific team members may assigned as appropriate to include Clinical Pharmacy Specialists, Registered Dieticians, Social Workers, Primary Care-Mental Health Integration staff.

See VHA Handbook 1101.10, VHA PACT Handbook.

a. PACT teamlets are identified as staff that are located in the same primary care clinic location, or collaborating through telehealth, and are responsible for the same assigned panel of patients. The PCMM team entries for PACT teamlets have the following requirements:

(1) Each PACT is allowed only one PCP, even if the PCP is part-time.

(2) Several part-time PCPs cannot be combined to form one full-time PACT PCP.

(3) Multiple APs are allowed on one PACT.

b. PCMM designations for each PACT teamlet role have the following requirements:

NOTE: PACT teamlet members must be assigned to one or more patient panels in

PCMM.

(1) Primary Care Provider (PCP):

(a) PCPs are physicians, Nurse Practitioners (NP), and Physician Assistants (PA) who provide primary care to an assigned panel of patients and in accordance with licensure, privileges, scope of practice, or functional statement.

(b) Department of Veterans Affairs (VA) Trainees, such as Fellows or Advanced Fellows, may be designated as PCPs if they are licensed, have completed all required professional preparation, can be successfully appointed as a licensed independent practitioner or staff practitioner, and do not have a learning plan for their educational experience that includes advancement of clinical primary care skills.

(c) Locums providers may be designated as a PCP.

(2) Associate Providers (AP):

(a) All physician residents must be designated as an AP.

(b) Physicians who are not residents cannot be designated as an AP.

(c) Staff NPs and PAs may be designated as APs.

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(d) NP and PA residents in primary care shall be designated as an AP when they are in residency or fellowship programs approved by VHA Office of Academic Affiliations.

(3) Registered Nurse Care Manager (RNCM):

(a) Registered Nurses (RN) must be designated as RNCMs.

(b) NPs cannot be designated as RNCMs.

(4) Clinical Associate: A teamlet member assigned in PCMM to one or more patient panels; trained and credentialed as a Licensed Practical Nurse (LPN), Licensed Vocational Nurse (LVN) or unlicensed assistive personnel including certified nursing assistant (CNA), medical assistant (MA), or health technician (HT).

(5) Administrative Associate: A medical clerk, patient services assistant, health technician or a medical assistant may be designated as an administrative associate.

c. Surrogate teamlet positions are to be populated with a specific individual in a similar role that is assigned to cover for the corresponding PACT staff-member during short-term or unplanned absences.

d. Discipline-specific team positions are not automatically created and can be added to a PACT by creating a position and identifying the specific team role (e.g., Clinical Pharmacy Specialist, Social Worker, Registered Dietitian Nutritionist, etc.).

(1) Clinical Pharmacy Specialists assigned to a PACT to provide comprehensive medication management services and team based care should be assigned appropriately in PCMM as PACT Clinical Pharmacist.

(2) Clinical Pharmacy Specialists who provide anticoagulation therapy management in a centralized anticoagulation clinic servicing one or more PC patient panels must be assigned appropriately in PCMM as Anticoagulation Clinical Pharmacist.

e. PACTs with a Designated Women’s Health Provider (DWHP) should be designated as a Women’s Health (WH) PACT, even if the assigned panel of patients is mixed in gender. See VHA Handbook 1101.10, PACT Handbook.

f. The following staff must not be entered in PCMM for PACT teamlet roles:

(1) Centralized telephone staff;

(2) Staff who are not consistently assigned to the same PACT or do not have regular engagement with other team members or patients on the panel; and

(3) Administrative staff (e.g., managers, supervisors, coordinators, etc.) or others for the purpose of administrative or clinical oversight.

APPENDIX B

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g. Adding staff members to PCMM to support VHA Support Service Center (VSSC) access (i.e., Primary Care Almanac) is not permitted. NOTE: Please refer to the VSSC home page to request social security number (SSN) and Protected Health Information (PHI) specific access requirements.

h. Staff member names or initials must not be included in team names.

https://vssc.med.va.gov/ https://vssc.med.va.gov/

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APPENDIX C

PACT FTE DATA ENTRY IN PCMM

Patient Centered Management Module (PCMM) requires an expected and actual full-time equivalent (FTE) be entered for each teamlet position. This is determined by calculating the portion of a full-time, 40-hour FTE employee that each teamlet member spends in managing care, known as Primary Care Direct Patient Care (PCDPC) FTE.

PCMM will identify vacant FTE by calculating the difference between the expected and actual PACT FTE values.

a. PCDPC FTE is the time utilized by staff to prepare for, provide, and follow-up on the clinical needs of primary care (PC) patients. In the Managerial Cost Accounting (MCA), this time is allocated to PC departments in proportion to the time spent in each of these activities. See VHA Directive 1750, VHA Managerial Cost Accounting System (DSS). Trainee FTE is not counted in PCDPC FTE. The PCDPC activities will vary based on teamlet roles (e.g., PCP, AP, RNCM, etc.) and include, but are not limited to:

(1) Time with the patient, family, or other surrogate decision-makers or caregivers, in clinic and over the phone, to discuss their concerns or needs;

(2) Reviewing patient records and data;

(3) Documentation of patient care;

(4) Telephone care group clinics;

(5) Discussion of patient care issues with consultants and other staff members (e.g., care coordinators, etc.)

(6) Communicating and collaborating with community (non-VA) professionals, agencies, and facilities involved or potentially involved with patients’ care;

(7) Time spent in patient care delivery with students in medicine, nursing and associated health professions;

(8) Precepting medicine, nursing, and associated health profession trainees while they deliver PC;

(9) Precepting or supervising staff NPs or PAs while they deliver PC.

b. Activities that are not considered PCDPC are the provision of specialty care to patients who are not assigned to the Patient Aligned Care Team (PACT) panel, inpatient hospital care (even for patients assigned to the PACT panel), administrative activities (including staff meetings), research activities, and educational activities. NOTE:

Administrative staff members do not have clinical time and therefore cannot be allocated PCDPC FTE.

c. The data entry requirements for PACT FTE in PCMM are as follows:

APPENDIX C

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(1) PACT FTE must not exclude annual leave (AL), sick leave (SL), work breaks or incidental time off.

(2) PACT FTE must be validated with the MCA to ensure accuracy and must be updated as changes occur.

(3) Expected FTE is the portion of time required to support a PACT patient panel.

The requirements for expected FTE for PCMM data entry are as follows:

(a) Expected FTE for a full-time PACT is 1.0 and may be adjusted for part-time PACTs.

(b) Expected FTE will default to 1.0 in PCMM.

(c) Adjustments to expected FTE require a value greater than 0.00 but cannot be greater than 1.0.

(d) Total teamlet FTE is expected to reach a PCP support ratio of 3:1.

(4) Actual PACT FTE is the portion of time dedicated to providing care to the assigned PACT patient panels.

(a) Time spent performing the following activities are included in the actual PACT

FTE:

1. Actions necessary to provide PACT-related clinical care;

2. Phlebotomy performed by the PACT on their own patients in the primary care clinic or in assigned exam rooms;

3. PACT huddles and meetings to discuss the care and management of specific patients;

4. Vital signs;

5. Primary Care appointment management check in/check out processes;

6. Patient education;

7. Nursing evaluations, procedures or injections;

8. Non-face-to-face-visits;

9. Population Management activities in support of care delivery;

10. Telephone, Secure Messaging, and other activities in support of non-traditional care delivery; and

11. PCMM surrogate coverage.

APPENDIX C

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(b) Time spent performing the following activities must not be included in the actual

PACT FTE:

1. Specialty or Inpatient care (non PC);

2. Administrative functions in support of specialty or inpatient care (non PC);

3. Responsibilities in support of PACT administrative, management, or oversight functions, medical center or VISN committees, or any activities not related to PACT care delivery;

4. Centralized, remotely-based, and non-PACT located telephone duties including clerk, nursing, or pharmacy;

5. Centralized phlebotomy;

6. Support for health care providers not assigned to a PACT; and

7. Business office enrollment functions.

(5) Associate Providers FTE is required.

(a) Trainee FTE is not included in PCDPC expected, actual and vacancy FTE reporting nor is it included in the modeled capacity formula.

(b) Non-physician staff AP FTE is included in PCDPC expected, actual, and vacancy FTE reporting and is included in the modeled capacity adjustments.

(6) Surrogate FTE is not required.

(7) PCMM will identify vacant FTE from the difference of Expected and Actual PACT FTE values.

(8) Validation of FTE is required during team and position creation, staff assignments, and when changes occur.

NOTE: For additional guidance on PACT FTE data entry in PCMM, see Appendix I, “Example Scenarios for Identifying PACT Teamlet Full-Time Equivalent”.

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APPENDIX D

PRO-RATED ROOM AVAILABILITY DATA ENTRY IN PCMM

Pro-rated room availability consists of the total count of exam rooms utilized by Patient Aligned Care Team (PACT) for the provision of patient care. The data entry requirements for pro-rated room availability in Patient Centered Management Module (PCMM) are as follows:

a. Pro-rated room availability must be listed in the “Room” section of PCMM.

b. Individual rooms are to be identified by a unique room number and name.

c. Expected use of rooms is entered by identifying the portion of time the room is utilized.

d. Several PACTs may use a portion of the room during regular and extended hours.

e. PACTs that rotate through generic space should be assigned to each room for the average amount of time utilized.

f. Examination room counts used for calculating modeled panel capacity will be automatically prorated based on the team expected FTE.

E-1

APPENDIX E

PACT PANEL CAPACITY

The baseline capacity for a full-time Patient Aligned Care Team (PACT) is 1,200 patients. Panel capacity for general PACTs will vary from facility to facility depending on patient characteristics and level of system support. For PACTs with a patient population reflecting the norms for disease severity and reliance on VHA and who have current norms of 3.0 teamlet support staff and 2.0 exam rooms per Primary Care Direct Patient Care (PCDPC) full-time equivalent (FTE) provider, an average panel would be 1,200 patients. After adjustment for the factors identified, panels for PACT providers largely fall in the range of 1,000 to 1,400. Associate Providers’ capacity and assignments are considered subtotals of the PCP’s capacity and panel size.

a. Special Population PACTs may have a smaller panel, as they serve a patient population with specific, substantial health care complexity, including Geriatrics, Home Based Primary Care, Homeless, Post-Deployment Care Program, Serious Mental Illness, Spinal Cord Injuries and Disorders, and Women’s Health (see VHA Handbook 1101.10, VHA PACT Handbook). Academic PACTs may also have smaller panel sizes, as they include trainees operating under the supervision of PACT providers.

b. PCMM will automatically display the Station Modeled Capacity (aggregate), Modeled Team Capacity, PACT Assigned Total and Available Capacity. Modeled capacity adjustments at the team level is based on 1) teamlet support staff, 2) examination rooms, 3) primary care intensity score, 4) women Veteran population, and