The VA Ann Arbor Healthcare System was awarded resources to establish a Patient Aligned Care Team (PACT) laboratory in order to develop and evaluate innovative patient-centered programs that help veterans adopt healthy behaviors and manage chronic diseases. Key innovations in the PACT system include: (1) a population-based registry; (2) a Navigator system that matches veterans to programs based on their preferences and needs; and (3) a menu of low-cost self-management support services including several technology-facilitated self-managemen programs. A number of these programs build on those designed by Dr. Piette and other CMCD-affiliated investigators, and focus on using accessible, mobile phone-based services to improve care across the continuum for patients who are recently discharged, receiving ambulatory care, or managing their condition in the community. PACT programs include the following resources developed by CMCD:
- The CarePartner Program uses automated telephonic assessment and self-management support calls to provide tailored patient education and facilitate structured communication between patients, informal caregivers, and care managers.
- The Peer-to-Peer Program uses a telephonic platform to link veterans living with similar conditions so that they can give and receive mutual support for self-management.
- An Adherence Intensification Program (AIM) uses clinical pharmacists and technology-based follow-up including refill-based adherence measures to improve medication adherence and appropriate medication intensification among chronically ill patients.
For more information, contact Nicolle Marinec at firstname.lastname@example.org
Informal Caregivers, Interactive Voice Response (IVR), Internet, Telephone, Veterans