CREATE:
Improving Quality and Safety through Better Communication in PACTs
Director: Laura A. Petersen, M.D., M.P.H.Primary Investigators:About the CREATEAs part of its mission to provide Veterans with the best possible healthcare, VA has adopted a patient-centered care model called the Patient Aligned Care Team, or (PACT). The PACT model involves a team of healthcare professionals—led by a primary care provider—who work collaboratively with patients. The studies funded under this CREATE seek to address gaps or missed opportunities for high-risk primary care populations (i.e., patients who might be at risk for adverse health outcomes resulting from communication and coordination breakdowns in the outpatient setting.) The goal of funded projects within this CREATE is to study the development and implementation of point-of-care interventions in PACT that improve healthcare quality and safety. The interventions are expected to deliver timely, meaningful information to the PACT team, and to provide them with tailored information that is understandable and actionable so that clinical outcomes can be improved. This approach is consistent with VA's vision of providing high-quality patient-centered care. |
Partner Offices
Each CREATE works closely with operational partners throughout the VA System. The partners associated with this CREATE are: VA Primary Care Program Office VISN 12: Great Lakes VA Healthcare System |
Projects
This CREATE initiative includes three funded projects:
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Identifying and Delivering Point-of Care Information to Improve Care Coordination
This project will use the Productivity Measurement and Enhancement System (ProMES) to systematically identify organizational objectives and develop clear, accountable measures of coordination, which in turn should help identify care coordination needs in PACT settings. ProMES is a performance measure development method based on more than 30 years of work in motivation, feedback, participation in decision-making, and goal-setting. The project will utilize three high-risk clinical conditions as test cases: care for uncontrolled diabetic patients, timeliness of cancer diagnosis, and beta blocker titration post-discharge for Veterans with chronic heart failure.
(PI: Laura A. Petersen, M.D., M.P.H.) -
Automated Point of-Care Surveillance of Outpatient Delays in Cancer Diagnosis
This study will evaluate the accuracy of a "real-time" automated surveillance system to identify Veterans at risk for missed or delayed diagnosis of common cancers. Key aspects of the study include: identifying and transmitting data on potentially missed abnormal test results in near "real time;"allowing PACT team members to review specific patient data to confirm whether follow-up actions need to be initiated; and enhancing timeliness of care by identifying patients who are lost to follow-up, and bringing them back into the VA healthcare system for further diagnostic evaluation.
(PI: Hardeep Singh, M.D., M.P.H.) -
Automating Heart Failure Data for Patient Treatment Goals at the Point of Care.
Investigators will build from prior work developing automated data extraction systems to develop a process that uses automation to identify and deliver patient-specific data regarding guideline-concordance treatment for congestive heart failure to PACT providers. The project's key goals are to: provide a communication aid to the PACT team about beta-blocker titration for Veterans with CHF following hospital discharge; determine optimal attributes of the communication aid in partnership with PACT teams; and improve provider delivery of guideline concordant care and decrease patient readmissions and mortality.
(PI: Jennifer Garvin, Ph.D., M.B., R.H.I.A.)