Over time, the VHA has developed a Primary Care (PC) system that balances productivity with quality, access, and patient service. Management of patient panels in PC through mandatory and consistent use of the Patient-Centered Management Module (PCMM) has supported this system redesign. In a PC setting and in the Patient-Aligned Care Team (PACT) model, patients are assigned a Primary Care Provider (PCP) who is responsible for delivering essential health care, coordinating all health care services, and serving as the point of access for VA care. The PCP works together with a team of professionals which includes nurses, pharmacists, social workers, health care professions, trainees, clerks, etc.

The PCMM software is considered to be an important component in measuring patient demand and PCP capacity to meet that demand, as well as reduce wait times. It allows users to set up and define treatment teams, assign positions to the team, assign staff to positions, assign patients to the team, and assign patients to a PCP. PCMM was developed to assist VA facilities in implementing PC. PCMM supports both PC and non-PC teams. Teams are groups of staff members organized for a certain purpose.

In order to fully support a team-based, patient-centric approach to healthcare delivery, enhancements to the current PCMM functionality are being requested that will allow a team to be formed and aligned around a patient, including providers across multiple VA sites and in non-VA settings to enable care coordination and communication. The software must also support automated data collection for management metrics and analysis related to access, workload, and panel management. This functionality would be ideally integrated into the future Clinical Practice Environment (CPE) versus being a separate and distinct module or application. VHA’s model of team-based care is known as the PACT. The goal is to evolve or replace existing PCMM software application with functionality that identifies all team members and specialists (VA and non-VA) involved in the care of the patient, as well as their contact information and provide modalities to facilitate provider-to-provider communication.

When PCMM data is entered in a standardized manner, it can be used to analyze the system and PACT workload nationally by Veterans Integrated Service Network (VISN), and by a facility and its substations, as well as at the team level. PACTs manage the overall care provided to a majority of VA health care systems, and their 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 wanting to use VA health care services, there is a need to quantify the PC capacity that is available so that demand and supply can be better aligned. PCMM allows users to set up and define a healthcare team, assign staff and health professions trainees to positions within the team, assign patients to the team, and assign patients to practitioners, including trainees. Data regarding PCMM team setup and assignments is used to calculate recommended panel size for PC teams and providers. The PCP and PC team information captured in PCMM is transmitted and stored at the Austin Corporate Franchise Datacenter (CFD), is available in the Corporate Data Warehouse (CDW), and is used for national reporting and performance measurement.
PMAS Increment 1 of the PCCM Re-host/Reengineering project develops a basic prototype based in the HP Lab environment. The Prototype will demonstrate limited PCMM functionality that is representative of the business functionality that can be designed and developed collaboratively during short iterative development cycles using the Agile SDLC.

PMAS Increment 2 & 3 of the project will deliver the remaining functionality necessary to meet Initial Operating Capability (IOC).