Factors affecting primary care implementation for older veterans with multimorbidity in Veterans Health Administration (VA)

Abstract

Objective

To identify factors affecting implementation of Geriatric Patient‐Aligned Care Teams (GeriPACTs), a patient‐centered medical home model for older adults with complex care needs including multiple chronic conditions (MCC), designed to provide them with comprehensive, managed, and coordinated primary care.

Data Sources

Qualitative data were collected from key informants at eight Veterans Health Administration Medical Centers geographically spread across the United States.

Study Design

Guided by the Consolidated Framework for Implementation Research (CFIR), we collected prospective primary data through semi‐structured interviews with GeriPACT team members (e.g., physicians, nurses, social workers, pharmacists), leaders (e.g., executive leaders, middle managers), and other staff referring to the program.

Data Collection

We conducted in‐person, semi‐structured interviews with 134 key informants. Interviews were recorded with permission and professionally transcribed. Transcripts were coded in Nvivo 11. We used directed content analysis to identify key factors affecting GeriPACT implementation across sites.

Principal Findings

Five key factors affected GeriPACT implementation—five CFIR constructs within two CFIR domains. Within the intervention characteristics domain, two constructs emerged, namely, (1) the structure of the GeriPACT model and (2) design, quality, and packaging. Within the inner setting domain, we identified three constructs, namely, (1) available resources (e.g., staffing and space, and infrastructure and information technology), (2) leadership support and engagement, and (3) networks and communications including teamwork, communication, and coordination.

Conclusions

Older veterans with MCC have complex primary care needs requiring high levels of care management and coordination. Knowing what key factors affect GeriPACT implementation is critical. Study findings also contribute to the growing implementation science literature on applying CFIR to evaluate factors that affect program implementation, especially to aging research. Further studies on MCC‐focused specialty primary care will help facilitate patient‐centered care provision for older adults' complex health needs while also leveraging synergistic work across factors affecting implementation.

What is known on this topic

• Over one in four US adults have multiple chronic conditions (MCC) negatively affecting their health and quality of life over time.

• Because older adults, 65 years and older, are at a higher risk for MCC, managing MCC is increasingly important to improve health outcomes.

• The Veterans Health Administration has implemented the Geriatric Patient‐Aligned Care Teams (GeriPACT) program nationwide to meet the needs of older veterans with complex needs like MCC.

What this study adds

• We identified several key factors for GeriPACT program implementation including features of the GeriPACT model, characteristics of the program team, patient needs, enacted administrative processes, resources made available to the program (e.g., staffing, space, information technology), leadership support and engagement, and networks and communication channels in place.

• Hospitals looking to implement care models for older adults with MCC can pay attention to these factors as they develop their own programs.

• These key factors can be utilized to develop implementation strategies to overcome identified challenges.

1. INTRODUCTION

Over the past decade, the patient‐centered medical home (PCMH) model has aimed to strengthen the health care system by reorganizing primary care for more effective service to patients with complex health needs. ¹ , ² , ³ At the core, PCMHs (1) use a comprehensive, team‐based approach to addressing patients' various needs (acute, chronic, mental, and physical alike), (2) give a person‐centered orientation that involves the patient in care plans, (3) deliver coordinated care across a complex care system and connect to resources (e.g., medical, social, community), (4) offer access to care that meets patients' needs and preferences, and (5) commit to system‐based quality and safety. ² , ⁴ Hence, the PCMH has been proposed as an ideal setting for caring for individuals with multiple chronic conditions (MCC) (i.e., multimorbidity). ⁵ , ⁶

Multimorbidity occurs when a patient has two or more diagnosed chronic conditions. MCC is associated with poorer quality of life, increased health care utilization, greater health care costs and out‐of‐pocket expenditures, and higher mortality risk. ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹ According to a 2018 prevalence study, 27.2% of noninstitutionalized US adults of age 18 years or older live with MCC. ⁸ Older adults are more likely to experience MCC than younger adults. ⁸ , ¹¹ , ¹² The estimated prevalence of MCC is 63.7% among people older than age 65 years compared to 33% for adults 45–64 years old. ⁸ Given the aging population, longer life span due to modern medicine, and ongoing role of risk factors such as smoking and lack of exercise, it is expected that individuals with MCC will continue to be prevalent, requiring health care systems to find innovative cost‐effective ways to provide care. ¹³ Yet, adoption of PCMH models has been slow because of the lack of financial incentives especially when focused specifically on older adults, a group with a median range of 5–7 MCCs. ¹⁴

Starting in 2010, the Veterans Health Administration (or VA), the largest US integrated health care system with over 150 medical centers, initiated a specialized PCMH for older adults called Geriatric Patient‐Aligned Care Team (GeriPACT). GeriPACTs emerged in response to VA's commitment to provide coordinated services for older patients with complex care needs and also were a rebranding of preexisting geriatric primary care programs. The VA Office of Geriatrics and Extended Care (GEC) assisted GeriPACT growth in various ways, including monthly conference calls, creation of a GeriPACT community of practice for GeriPACT team members, consultation with GEC leaders, and the issuance of the GeriPACT Handbook in 2015 with guidance for GeriPACT implementation. ¹⁵ Although guidance was provided at the national level, GeriPACT implementation occurred at the local level, resulting in variable resources from site to site. GeriPACT implementation occurred in both VA Medical Centers (VAMCs) with preexisting Geriatric Primary Care programs and also at other sites new to the model. In about 7 years, the number of VAMCs offering GeriPACT almost doubled, such that by 2016, GeriPACT programs were present at 71 sites nationally. ¹⁵

About 46% of VA patients are older than 65 years of age, ¹⁶ and 95% of GeriPACT patients experience MCC, with a median range of 4–5 chronic conditions in 2016. ¹⁷ Through an interdisciplinary team approach, GeriPACTs offer enhanced expertise for managing patients with MCC whose health care needs are particularly complex. For example, GeriPACT patients have heightened vulnerability due to progressing functional impairment and one or more geriatric syndromes such as failure to thrive, frailty, delirium, falls, disorders of gait and balance, incontinence of bowel or bladder, dementia and other causes of impaired cognition, depression, polypharmacy, and malnutrition. ¹⁸ GeriPACTs are characterized by interdisciplinary teams of trained staff including geriatricians, registered nurses, social workers, clinical pharmacists, mental health providers, and dieticians (see Figure 1). ¹⁹ In comparison to general population PCMHs, GeriPACTs have a smaller panel size (i.e., two‐thirds of a general primary care provider's panel capacity) and longer appointments times. ¹⁵ , ¹⁸ Further, the team‐based care model that characterizes GeriPACT can be implemented in other health systems by integrating lessons learned from GeriPACT implementation in VA. ¹⁵ , ¹⁹ Figure 1 provides an overview of GeriPACT composition. ¹⁹ A 2016 survey of GeriPACT programs found that a majority incorporated common care practices for individuals with complex needs, including coordinated care with outside health care providers and incorporated non‐VA care records into the VA electronic health record; shared community resources for self‐management with patients; and identified patients in need of additional case management. ¹⁵

FIGURE 1.

Illustration of Geriatric patient‐Aligned Care Team (GeriPACT) team. ¹⁹ A GeriPACT is comprised of six core members who share interprofessional knowledge, psychological safety, and a shared sense of urgency to meet the needs of older adults with complex comorbidity in near real time. GeriPACT core members (illustrated in gray) augment their expertise with that of extended team (illustrated in green) specialty provider members. Source: Reprinted with permission from Reference 19 [Color figure can be viewed at wileyonlinelibrary.com]

To best care for individuals with MCC, the US Department of Health and Human Services' strategic framework outlines that programs should be person‐centered, incorporate chronic disease management, and provide high levels of care coordination and care management across care settings. Despite guidance for the creation of programs focused on the needs of individuals with MCC, there have been challenges to program implementation. To date, few fee‐for‐service care models incorporate these care provision tenants for patients with MCC due to lack of financial incentives. ¹³ Literature on care model provision and program implementation is sparse. Additionally, more traditional disease management programs have not been optimally effective and have not always linked up well with primary care. ²⁰ , ²¹ Thus, GeriPACT provides a useful setting to learn about program implementation.

Guided by the Consolidated Framework for Implementation Research (CFIR), ²² which was created to help translate research findings in real‐world settings, our study's objective was to identify key factors affecting the implementation of GeriPACTs. This evaluation can help target implementation strategies and fine‐tune GeriPACT functioning to better allocate resources and care provision. Further, findings can inform other health care institutions beyond VA about factors to consider when implementing a PCMH program focused on older adults with complex care needs.

2. METHODS

2.1. Study design and setting

As part of a larger sequential explanatory mixed‐methods evaluation designed to examine the effectiveness of GeriPACT model in VA, we conducted eight in‐person site visits. The study was reviewed and classified by VA Boston Healthcare System Institutional Review Board as a nonresearch operations program evaluation. Thereafter, the Research and Development Committee provided oversight for the work.

2.2. Site selection

For this evaluation, we worked with the VA GEC to identify active GeriPACT programs in the VA. To assure, we selected programs which met criteria for being considered a GeriPACT, we administered a survey to GeriPACT physician leaders to gather information about program characteristics. Based on VA's GeriPACT Handbook criteria, a GeriPACT should have dedicated space, appropriate core team members, served patients with specific geriatric conditions, and appropriate provider full‐time employee equivalent, given the panel size. ¹⁸ GEC provided us with a list of 71 VAMCs with GeriPACT programs that were eligible to participate in the survey. Of the 71 physician leaders who received the survey link, 44 participated. From the 44 GeriPACT sites responding to the survey (62% response rate), 22 sites met at least 50% of Handbook criteria for GeriPACT consistency ¹⁸ and were eligible for participation in this study. Survey findings from these 22 sites enabled us to select eight geographically diverse GeriPACT program sites (two sites at 50% consistency, four sites at 75% consistency, and two sites at 100% consistency with the Handbook guidelines) for our evaluation. See Solimeo et al. ¹⁹ for more information regarding site characteristics.

2.3. Sample of participants

Our goal was to interview key informants in specific roles/positions at each of the eight sites to obtain a variety of perspectives including (a) GeriPACT team members (see Figure 1), (b) providers coordinating care with GeriPACT from other primary care and specialty care (e.g., women's health), and (c) leaders (e.g., middle managers, executive leadership team members).

2.4. Data collection

2.4.1. Semi‐structured interview guide

We developed a semi‐structured interview guide based on CFIR. ²² , ²³ , ²⁴ , ²⁵ Although our interview guide contained questions about each of the five CFIR domains (characteristics of individuals, intervention characteristics, inner setting, outer setting, and process of implementation), we further refined the extensive framework to 24 (out of 39) constructs that were most applicable to our study based on GEC partner feedback. Our final interview guide emphasized the inner setting, given the literature about the organizational contextual factors that can influence GeriPACT implementation (e.g., organizational culture, structural characteristics, networks and communications, supportive leadership, provider attitudes and beliefs). ²⁵ Sample questions mapped to CFIR constructs with operational definitions can be found in Table 1. The interview guide was piloted with GeriPACT providers outside of our sample and refined.

TABLE 1.

Sample interview questions by CFIR domain and construct

Domain	Construct	Construct operational definition	Sample questions
Characteristics of individuals	Knowledge and beliefs	Individuals' attitudes toward and value placed on GeriPACT as well as familiarity with facts, truths, and principles related to GeriPACT.	What has been going well with your GeriPACT program to date?
Intervention characteristics	Design quality and packaging	Perceived excellence in how GeriPACT is bundled, presented, and assembled.	What is GeriPACT? How have you come to understand it?
	Relative advantage	Stakeholders' perception of the advantage of implementing GeriPACT versus general population primary care.	Why was GeriPACT implemented in your setting?
Inner setting	Available resources	The level of resources dedicated for GeriPACT implementation and on‐going operations, including IT, infrastructure, money, training, education, staffing, physical space, and time.	Did GeriPACT staff receive any training when they were brought together as a team? Were any infrastructure changes needed to accommodate your GeriPACT team(s) (i.e., space, staffing, IT)? Do you feel you have sufficient resources to administer GeriPACT?
	Leadership engagement	Commitment, involvement, and accountability of leaders and managers with the implementation and/or operation of GeriPACT (e.g., strategic planning, joint commission, etc.).	How supportive do you feel senior leaders have been of GeriPACT? How supportive do you feel middle managers have been of GeriPACT?
	Networks and communications	The nature and quality of webs of social networks and the nature and quality of formal and informal communications within and outside of an organization, including communications with patients in the context of direct care	How does your GeriPACT team communicate with each other regarding work/patient issues? How would you describe the level of teamwork on this team?
Outer setting	Patient needs and resources	The extent to which GeriPACT patient needs are accurately known/identified, prioritized, and acted upon (i.e., putting something into place) by the organization (or not).	How well do you think GeriPACT meets the needs of patients served in your organization? Do you feel patients face any barriers participating in GeriPACT?
Process of implementation	Planning	The degree to which a scheme or method of behavior and tasks for implementing or running GeriPACT are developed in advance, and the quality of those schemes or methods (e.g., training for GeriPACT implementation, desire or plans to do a process improvement or QI project). It applies to past, ongoing, and future GeriPACT implementation.	When did GeriPACT start at your facility? Has your GeriPACT team(s) done any informal process improvement or quality improvement or other more formal systems redesign projects? How do you monitor your goals?

Abbreviations: CFIR, Consolidated Framework for Implementation Research; GeriPACT, Geriatric Patient‐Aligned Care Team; IT, information technology; QI, quality improvement.

2.4.2. Site visit procedure

Site visit teams conducted 1‐hour, in‐person, semi‐structured interviews with key informants over two consecutive days at each site between October 2016 and February 2017. During each site visit, a team of two interviewers conducted interviews with these key informants. Interviews were audio recorded with participants' consent and professionally transcribed.

2.5. Data analysis

Verbatim interview transcripts were utilized to conduct a directed content analysis. ²⁶ For the analyses in this article, four experienced qualitative analysts, all of whom had participated in site visits, coded the 80 transcripts using a deductive approach to identify key factors affecting GeriPACT implementation. Figure 2 displays the multiple steps in our qualitative data analysis. ²⁷

FIGURE 2.

Qualitative data analysis steps [Color figure can be viewed at wileyonlinelibrary.com]

First, the analytic team developed a codebook of the CFIR constructs. Next, all analysts jointly coded one transcript to identify the CFIR constructs affecting GeriPACT implementation and then met to reach consensus on codebook definitions. Using a qualitative coding software (NVivo 11), ²⁸ the team repeated this process with three additional transcripts, ²⁹ , ³⁰ refining and expanding the codebook, and repeatedly ensuring a high level of consensus in coding practices. The team iteratively reviewed coded transcripts to refine the codes and reach consensus on how to apply the constructs to the transcripts. In doing so, this team identified redundancies among the CFIR implementation leader, opinion leader, and champion constructs reducing the number of constructs from 24 to 22. Once finalized, teams of two analysts coded each of the remaining 76 transcripts to ensure maximum saturation. Team members involved with data collection during the site visits did not code transcripts from those sites to reduce biases. Consistent with guidance regarding data saturation for key informant implementation studies, we reached data saturation for each site after reviewing five transcripts per site. ³¹

Upon completion of coding, analysts used site‐specific coding reports to create a site‐specific summary of CFIR constructs for each of the eight sites. Cross‐site matrices were then populated. ³² , ³³ Each matrix had eight columns where each column represented a site, and rows listed identified CFIR constructs. Matrix‐analysis techniques enabled us to compare factors and identify commonalities and differences across sites. This article reports on common factors when at least four out of eight sites had evidence of a factor affecting implementation.

3. RESULTS

We interviewed 134 key informants, who were knowledgeable about GeriPACT, across eight VAMCs through 80 in‐person interviews—44 individual and 36 group interviews. Table 2 summarizes key informants' roles.

TABLE 2.

Key informants interviewed by role

Role	N
GeriPACT core team members
Physicians and fellows	10
Nurse practitioners	10
Registered nurse care managers	9
Clinical care associate (e.g., licensed practice nurse)	8
Social workers	12
Pharmacists	9
Administrative/support staff (e.g., clerk, medical support analyst, program analyst)	8
GeriPACT extended team members
GeriPACT mental health providers (e.g., psychiatrists, neuropsychologists)	9
GeriPACT dieticians	5
Other providers coordinating with GeriPACT
Physicians (e.g., from primary care, emergency department, memory clinic, women's health)	23
Leadership
Executive leadership (e.g., medical center director, chief of staff)	6
Middle managers (RNs, MDs, and other service‐line level)	25
Total	134

Abbreviations: GeriPACT, Geriatric Patient‐Aligned Care Team; MD, medical doctor; RN, registered nurse.

We identified five key CFIR constructs related to GeriPACT implementation (i.e., the GeriPACT model; design, quality, and packaging; available resources; leadership support and engagement; and networks and communications) within two CFIR domains (intervention characteristics and inner setting). Table 3 provides quotes illustrating these findings.

TABLE 3.

Exemplar quotes on factors affecting GeriPACT implementation by CFIR construct

CFIR construct	Exemplar quotes
The GeriPACT model	“I think having a small panel size, we're able to spend more time with the veterans. I think having speech audiology, occupational therapy, physical therapy within our same area gives us quick access and support. GeriPACT improves veteran care and when we improve veteran care, we improve morale and when we improve morale, we improve customer service.”—Site A “GeriPACT serves [patients with] heart failure, kidney failure, liver failure and they are really better managed in a comprehensive GeriPACT because age matters, functionality matters, and multiple comorbid chronic conditions matter”—Site B
	“[Patients] get into GeriPACT for case management, multi‐medical care…we have one gentleman that's fifty years old and has frontal temporal lobe dementia. He would definitely get lost in the system in a [general primary care] environment where [here] we look after them, we make sure that they're routinely seen, and we follow their case. The patient care comes first, our management understands that, and they do provide for us if we need to work overtime.”—Site D
Design, quality, and packaging	GeriPACT team characteristics
	“It's a team that takes on all the responsibilities for the management of primary care patients but for a patient population with unique needs, increased needs relative to our general primary care teams… I think some of the unique services that we're able to provide through GeriPACT is intimate interaction between the clinicians and the social workers as well as pharmacy services to better manage both the social needs of the patient and additional supports in the home and provide support for polypharmacy that is a danger to all of us as we get older”—Site B “Our social worker came to the VA from the [state] Council on Aging… they coordinate a lot of the community services for older adults so she was a great resource when she came to the VA and that worked out very well”—Site E “The difference that I see between the GeriPACT clinics and the regular primary care clinics is just kind of more of the team and interdisciplinary approach. It's really nice to have our social workers right here as well as the physician, the geriatricians that work with the fellows, the fellows so it's really nice to have kind of a team‐based approach and be able to work with everyone all at the same time versus when I'm over at our primary care clinic.”—Site H
	Patient needs
	“There are some patients who have been very resistant to um well…not just participating in their own care. I think they're resistant to receiving care which just kind of gives you this ‘why are they coming here if they're not going to take any of the medicine,’ and you try to figure out why, [and] what's going on?”—Site A “GeriPACT patients can sit out in parking lot and call to get one of the volunteers to drive out there and pick them up but they don't all have cell phones so getting into the clinic from the parking lot is a huge barrier. A lot of these people are short of breath, have [chronic obstructive pulmonary disease] …our eighty‐year‐old, short of breath guy [is] having to trek all that way in because he doesn't own a cell phone.”—Site F
	Administrative processes
	“Sometimes the system of negotiating new primary care appointments for patients with geriatric syndromes can be difficult. We have to locate someone in primary care to come schedule it for us or the patient has to call and do it.”—Site A “You need to fill out that paperwork and you're running behind because there's no time …it's getting worse…with too many patients. If we can get a nurse practitioner or somebody just to work on those scheduled visits that would be a big help”—Site G
Available resources	Staffing
	“We have an executive meeting where we discuss staffing needs and anytime that someone from the GeriPACT say that they need something and they provide a good justification for that, the position has been approved.”—Site G “Staff got split and spread… it's competing priorities so depending on who the administrator is, the short‐term goals, the medical center priorities, geriatrics is not always…the resources aren't always there. In fact, we have experienced a resource reduction.”—Site B “We have a wonderful social worker, but she is covering way too many responsibilities…she's constantly being pulled to other places and spread way too thin for the kind of issues that we have in geriatrics”—Site C
	Spaces
	“A lot of patients like [our clinic] because it's a one stop shop. Radiology is downstairs, laboratory is on second floor, there is surgical clinic, there's [intensive care unit], there's an [emergency room]—everything is in one building, they love it.”—Site A “We have been identified as one of the services that has a serious space deficit because of the way the clinics are designed…I remember The Joint Commission came for one of the accreditation visits and said, “You have a very inefficient flow,” …I mean the design of the clinic doesn't help”—Site G
	Infrastructure and information technology
	“We get a lot of secure messaging, we go back to them and respond right away, and they know our name”—Site D “Travel within the facility is never easy…the place is big, and it's pretty spread out. It's certainly not designed to be easy to negotiate if you're an older person.”—Site C “We don't have a geriatric service line here so…all these different geriatric functions are scattered in different departments and I've, I started you know a year ago trying to sort of bring some of [those programs] … I said I never have been able to discuss that with the chief of staff”—Site F
Leadership support and engagement	“We have been very fortunate to have a leadership team especially locally that's been incredibly supportive of what we do. We have benefited from consistency in leadership and I think that's a big benefit.”—Site H “I'm not sure sometimes they realize how complex it is to perform the duties we perform. We are not [general] Primary Care. And like I said, a lot of our patients have multiple issues, concerns, and I don't think that they are really aware of that. But I never hardly deal with senior leadership. I just deal with knowing when I go home that we've done the best we could.”—Site C
Networks and communications	Teamwork
	“I think we do a really good job of making sure that things work really nicely, especially giving each other the heads‐up. A lot of times we're able to coordinate our schedules to get the patient seen, to minimize the number of visits that they have to make and things of that nature. That seems to work out pretty nicely…and I think that it works to the extent that it does because we care.”—Site A “The difference that I see between the GeriPACT clinics and the regular primary care clinics is just kind of more of the team and interdisciplinary approach. It's really nice to have our social workers right here as well as the physician, the geriatricians that work with the fellows, so it's really nice to have kind of a team‐based approach and be able to work with everyone all at the same time versus when I'm over at our primary care clinic.”—Site H “It's a pretty high functioning team. Everybody gets along. Everybody cooperates. Everybody tries to make sure clinic runs smoothly and that we really get the job done and take care of the veterans the best that we can…you have people…that are really working to their capacity, which is not true throughout the medical center.”—Site C
	Communication and coordination
	“We have very open communications… we have morning huddles… I always put in a note and co‐sign either the nurse or the provider… and notes don't always convey the essence so I will frequently communicate… I feel very fortunate in that we have an excellent working [team]”—Site F “I'd like to see more communication between the inpatient hospital teams at the [GeriPACT] clinic…their discharge summaries usually can take weeks to show up if they don't sign them. So, I have to piece together [information] from the progress notes which increases the complexity and time of the visit.”—Site A

Abbreviations: CFIR, Consolidated Framework for Implementation Research; GeriPACT, Geriatric Patient‐Aligned Care Team; VA, Veterans Health Administration.

3.1. Intervention characteristics

In this CFIR domain, participants across the sites discussed two key constructs to GeriPACT implementation—GeriPACT model and GeriPACT design, quality, and packaging.

3.1.1. GeriPACT model

Participants at many sites shared that facets of the GeriPACT model enabled caring for older adults with complex needs including MCC. Participants mentioned GeriPACTs were designed with smaller provider panels to enable longer appointments with patients resulting in closer patient/team relationships. Thus, the model enables patients who needed more time (e.g., due to impaired mobility, hearing, or cognition) to have their complex care needs addressed. In addition, participants highlighted that GeriPACT provided patients with a team‐based, patient‐centered, and interdisciplinary approach for their comprehensive health needs; care is coordinated and continuous to help these frail patients obtain preventative and proactive care rather than reactive care. The existence of the GeriPACT Handbook and collaborative interdepartment agreements had helped sites in building greater cooperation and mutual expectations across services.

3.1.2. Design, quality, and packaging

Themes that emerged in this construct included GeriPACT team characteristics, patient needs, and administrative processes.

GeriPACT team characteristics: Participants across the sites noted that skills, expertise, experiences, and attitudes of GeriPACT staff and providers can help to facilitate care for older adults with complex needs such as MCC. Team members were trained in geriatrics (e.g., geriatricians) and were knowledgeable about their patient population. They were willing to work up to the top of their abilities and licensure (i.e., “high functioning” nurses) and were knowledgeable about patient needs (e.g., registered nurse case managers who “keep the team together”). In addition, team members' buy‐in to the GeriPACT team approach made them committed to and passionate about understanding and providing care for geriatric patients with complex needs and MCC.

Patient needs: Participants at many of the sites perceived that patients faced barriers in their efforts to receive GeriPACT care and services. Although these barriers may not be unique to GeriPACT patients, they pose a greater challenge to GeriPACT patients already managing multimorbidity. Patient accessibility was a barrier. Patients faced both transportation and commute challenges (i.e., limited availability of hospital's transportation resources and long‐distance travel for care) as well as difficulty in finding parking spaces and navigating from the VAMC parking lot to the GeriPACT clinic. The second type of barrier was that some patients were resistant to care or noncompliant with self‐management (e.g., refusing to take their medications). Language and communication were the third type of barrier (e.g., Spanish‐speaking patients could not understand documents they received in English). Lastly, ill‐suited equipment in clinics hindered patients' care (e.g., inadequate scale for patients in wheelchair, limited access to Hoyer lift and oxygen).

Administrative processes: Participants at some sites identified barriers related to processes in their clinic's operations. The first type of processes was staff ability to handle incoming consults to GeriPACT from other departments (i.e., general primary care). This situation resulted in delays in care and services as consults were required for new patients' initial visits. Scheduling patients was the second type. There were challenges in scheduling patients' appointment when providers had to go through support staff instead of having direct scheduling access; staff also felt it was challenging to balance walk‐ins with scheduled appointments. The third type pertained to recognition that in a short‐staffed clinic, there can be communication challenges. For example, phone calls would sometimes remain unanswered or not all team members would be able to attend huddles.

3.2. Inner setting

Participants across the sites identified three key CFIR constructs related to GeriPACT implementation (i.e., available resources, leadership support and engagement, and networks and communications) in the inner setting domain.

3.2.1. Available resources

Participants noted the importance of having access to several types of resources, such as staffing, space, infrastructure, and information technology (IT); all were essential to GeriPACT program implementation and operation.

Staffing and space: Many teams were able to get necessary training, dedicated clinic space including co‐located space with other referral services. Participants mentioned they were able to acquire additional staffing (e.g., new hires, residents/learners) when requested from leadership. Yet, participants also discussed barriers related to insufficient staffing and space that negatively impacted GeriPACT implementation. For staffing, teams experienced lack of access to geriatric training for staff and providers, provider/clinician shortages (e.g., need for a psychiatrist, pharmacist, social worker, or geriatrician on the team), as well as providers' time not being solely dedicated to GeriPACT. Lastly, some GeriPACT team members reported to services where priorities or expectations did not always align (i.e., nursing, social work). In terms of space, some sites had small or shared clinic space that made team functioning difficult or had clinic space not set‐up to accommodate GeriPACT patients' needs (e.g., no Hoyer lifts or oxygen tank in exam rooms) which hindered care provision.

Infrastructure and IT: Features of infrastructure and IT that enabled GeriPACT operations at sites included the following: obtaining additional computers, using a video teleconferencing system to see patients who lived in remote areas, and using software for efficient completion of notes. In addition, providers were able to track patient care and services and co‐sign notes for care coordination in the computerized patient record system. Because GeriPACT was often embedded in the primary care service, staff and providers were able to take advantage of these tools and resources.

Key informants also discussed challenges associated with infrastructure and IT that affected GeriPACT implementation. First, a centralized calling system with many automated prompts made it difficult for patients to reach team members. Second, patients had lack of access to transportation to the GeriPACT limiting timely access to care. At times, staff reported limited wheelchair availability hindering timely access to GeriPACT care. Finally, sites experienced several IT challenges including navigating older forms in the electronic health record, check‐in kiosk malfunctioning, which lengthened check‐in processes, and lack of access to phones or cell signals impeding timely communication.

3.2.2. Leadership support and engagement

Team members in many sites expressed that leadership across multiple levels within the organization (e.g., national, regional, local levels) facilitated GeriPACT program implementation. Key informants mentioned there was national‐level support for geriatric programs serving older adults (e.g., GEC engagement with sites) and buy‐in from regional leadership. Local executive leadership supported GeriPACT model components such as lower panel sizes because they saw the value in GeriPACT for better management of patients with complex care needs. Sites also noted that the support of service line leaders (e.g., primary care, nursing) and strong collaborative relationships (e.g., sharing resource allocations) among middle managers supportive of GeriPACT programs were helpful, due to GeriPACT interdisciplinary innerworkings.

However, participants also mentioned barriers tied to leadership support that negatively affected implementation. For example, some regional leadership did not understand why GeriPACT needed a smaller panel size to meet patient needs. In addition, high turnover among local executive leadership resulted in unclear priorities and lack of guidance or follow through with GeriPACT implementation (e.g., having a policy in place that did not reflect GeriPACT patients' needs such as longer medical appointments). This situation created ongoing tensions between the length of appointment slots and expectations for provider productivity. At the middle management level, GeriPACT leadership turnover resulted in staff not knowing who to report to or go to for guidance. GeriPACT leadership turnover also influenced the lack of program visibility and recognition at the medical center, which undermined GeriPACT implementation efforts. For example, executive leadership at one program avoided visiting the clinic or middle managers at another site acknowledged efforts of all clinics but GeriPACT in their nurses' meetings.

3.2.3. Networks and communications

Within this CFIR construct, participants shared their perspectives about teamwork in addition to communication and coordination.

Teamwork: Because GeriPACT used an interdisciplinary team‐based and patient‐centered approach with strong support from trained geriatricians, registered nurses and social workers, staff at all sites felt it enhanced teamwork. Positive teamwork translated into a sense of belonging among accountable and valued team members who worked together cohesively. Team members enjoyed working together and felt the team was respectful even in disagreement and helpful to one another. GeriPACT teamwork resulted in strong relationships across services (e.g., mental health) and with patients. Teamwork also enabled GeriPACT to manage their patients' health and provide continuity of care.

Communication and coordination: Several sites highlighted communication and coordination—internal and external to the GeriPACT team—as a factor that affected implementation. Many explained that open, frequent or ongoing communication within their GeriPACT teams facilitated successful program implementation. Team members were easily accessible to one another and interacted in a mutually supportive environment. They communicated together through several modes, such as in‐person and facilitated through technology (e.g., phone, email, secure messaging, instant messaging).

Conversely, all sites discussed challenges with communication and coordination either within and/or across teams. For instance, coordination among GeriPACT team members reporting to different departments was challenging because there was little control over shared workload. There were also communication issues across teams, such as untimely or inadequate referrals, issues in getting completed and signed discharge summaries, and difficulties in accessing pharmacy services. Sites also noted resistance and tensions because other specialties/services misunderstood GeriPACT's mission and operation (i.e., smaller panel size and longer appointments for more complex patients than general primary care) and co‐management challenges with community hospitals and services (e.g., VA bureaucracy, issues with timely documentation for care transitions).

4. DISCUSSION

The goal of this article is to understand the factors affecting implementation of GeriPACT programs for older veterans with complex care needs in VA. Patients with MCC need person‐centered and highly coordinated care for the management of their chronic diseases ¹³ through team‐based specialty PCMH that involves patients in care plan development and provides patients with multilevel access to care, services, and resources. ² , ⁴ Consistent with PACT resource framework‐based findings from Solimeo et al., ¹⁹ results from our study show that GeriPACTs are organized specifically to serve older veterans with complex care needs such as MCC by providing patient‐centered care in a cohesive multidisciplinary, experienced team approach.

Our study found that several factors affected GeriPACT model implementation and the role that these factors played at the eight sites varied. Implementation research has shown that the identified factors are critical to program implementation success in health care. ²³ , ³⁴ , ³⁵ , ³⁶ , ³⁷ In particular, a synergy between consistent leadership support and engagement, networks and communications (i.e., communication and coordination among staff and providers through multidisciplinary teamwork), and links to senior management and resources (where senior management provide needed infrastructure, staffing, communicate expectations, reward accountability to staff system‐wide) improves health care clinical practices at the organizational level. ³⁷ , ³⁸ These identified factors should be considered deliberately and managed strategically for optimal impact when implementing programs for patients with complex needs or MCC. In particular, inner setting constructs in our study (e.g., available resources, leadership support and engagement, networks and communications) align with the literature as critical to program implementation success.

Elements of the design, quality, and packaging construct emerged as barriers, which highlight the importance of focusing on administrative processes and patient needs for accessing the GeriPACT program, given that older adults with complex care needs have to navigate large health care systems with intricate and time‐consuming administrative processes. These findings are particularly critical considering the known adverse health impact of MCC that may be exacerbated by patient barriers, such as challenges in engaging with the very system designed to facilitate access to health care services and management of multimorbidity. Specialty PCMH teams could focus on educating and supporting patients on adherence to self‐management routines to help improve their health outcomes with MCC.

There are several noteworthy strengths of our study. To our knowledge, little is known about factors affecting GeriPACT implementation in VA. ¹⁹ Understanding these factors is key, especially given program heterogeneity across VA. ¹⁹ Our study fills a critical need and gap in knowledge about how contextual factors can affect the implementation of a specialty PCMH (i.e., GeriPACT) for older adults with complex care needs and MCC. We used robust qualitative research methods (e.g., in‐person site visits) to identify several key factors that affect implementation for this study. In addition, our study results contribute to the growing implementation science literature on applying CFIR to evaluate factors that affect program implementation, specially to aging research. We interviewed a representative, cross‐section of participants, which included not only GeriPACT team leaders and team members, but also staff less directly involved in GeriPACT implementation, such as primary care physicians and referring providers (e.g., home‐based primary care physicians, emergency department physicians). This allowed us to obtain a wide range of perspectives about GeriPACT implementation within each VAMC.

Our study has some limitations. Only VAMCs were included in this evaluation; however, many of the identified factors are applicable to organizations implementing PCMH for older adults as well as more generally to health care program implementation. There is potential for selection bias as only 44 of 71 physician leaders responded to the survey used to assess site eligibility. Thus, we may be underestimating the number of factors related to GeriPACT implementation at sites struggling with program implementation and unable to participate in the survey. The participating sites were diverse in terms of other characteristics (e.g., region, number of teams) and provide insight into GeriPACT implementation in various contexts. Although our study reports on the ways that GeriPACTs function, we did not focus on how GeriPACT care was provided specifically to veterans with MCC. More research is needed to explore whether variations in GeriPACT care processes for patients with MCC are associated specifically with factors affecting implementation. In addition, we could only conduct eight site visits, given the scope of the larger project. However, the sites included in this evaluation were geographically diverse, representing regional differences in health care provision and patient needs. Finally, we were unable to prioritize the importance among the five constructs identified in this study to understand the ways these factors interact, which requires additional research.

5. IMPLICATIONS

This study strengthens the notion that a specialty PCMH model focused on older adults with complex care needs strongly supports person‐centered care in VA. We found positive teamwork practices were established among trained, skilled, and experienced multidisciplinary staff and providers. While available resources, leadership support and engagement, and networks and communications are factors capable of both facilitating and hindering care delivery with specialty PCMH, barriers associated with design, quality, and packaging pose a bigger challenge to providing care to older patients with complex care needs. Knowledge of these barriers presents an opportunity to find actionable strategies to help overcome challenges and improve implementation approaches in GeriPACT. For example, a clinic with inefficient administrative processes may look to system redesign to not only problem‐solve issues but also review and improve overall clinic flow and operations for the benefit of staff, providers, and MCC patients alike.

Future studies on specialty PCMH focused specifically on MCC will help to provide insights on how to facilitate patient‐centered care provision for older adults' complex care needs, while also leveraging synergistic work across factors affecting implementation. Additional research is also needed to find ways to overcome administrative processes and minimize barriers to make patient care as accessible as possible. With the growing population of older adults with MCC, successful implementation of specialty patient‐centered medical care and management becomes even more critical. Care management like that provided in GeriPACTs offers a useful model beyond VA to serve patients with complex care needs such as MCC.

CONFLICT OF INTEREST

There are no financial or personal conflicts of interests.

AUTHOR CONTRIBUTIONS

Concept, design, data collection, analysis, interpretation, and preparation of the article: Omonyêlé L. Adjognon and Jennifer L. Sullivan. Data collection, analysis, and preparation of the article: Marlena H. Shin and Melissa J. A. Steffen. Data collection and preparation of the article: Samantha Solimeo and Jennifer Moye.

DISCLAIMER

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.

Adjognon OL, Shin MH, Steffen MJA, Moye J, Solimeo S, Sullivan JL. Factors affecting primary care implementation for older veterans with multimorbidity in Veterans Health Administration (VA). Health Serv Res. 2021;56(S1):1057‐1068. 10.1111/1475-6773.13859