Patient Aligned Care Team (PACT) Intensive Management (PIM) Project

Patient Aligned Care Team (PACT) Intensive Management (PIM) Project

Purpose: Implement a Patient Aligned Care Team (PACT) model that identifies and proactively manages Veterans at the highest risk for hospital admission and death while the patient is still in the ambulatory care setting.

Goal:

• Reduce emergency department and urgent care utilization, hospitalization, and mortality in complex, high risk patients
• Improve Veteran and staff satisfaction

Objectives:

• Maintain the patient in the home setting as much as possible
• Secure appropriate home environment to facilitate health and well-being
• Utilize comprehensive team-based care
• Engage appropriate Veteran Health Administration (VHA) programs to provide interdisciplinary, coordinated, and timely management of complex medical issues

Inclusion Criteria:

• selected for intensive management

Exclusion Criteria:

• enrolled in other intensive case management at VA