Infusing Gerontologic Practice Into PACT

To address this limitation in access, VA programs have begun using telehealth technology to increase competencies of PCPs in caring for older veterans. For example, the VA Geriatric Scholars Program is a national educational program with different avenues to “geriatricize” VA primary care services and improve knowledge and care provided to older veterans.²⁸ It consists of several subprograms: Geriatric Scholars Program for Rural Community Based Outpatient Clinics; Geriatric Scholars Program for Primary Care Providers; Rural Interdisciplinary Team Training; and the Geriatric Assessment Pocket Guide.²⁹ These components may include didactics both face-to-face and online, clinical experience with performing common geriatric screening tools, and a quality improvement project.

Some local VAMCs have also developed programs to address this need to improve care provided to older veterans in PACT. The VA Greater Los Angeles Healthcare System (GLA) GRECC, for example, has started several programs to infuse geriatrics into PACTs, including the Geri Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO). VA SCAN-ECHO was developed to increase access to specialty care in rural/underserved areas. The PCP presents a case and a specialty provider gives guidance in the assessment and/or management of a specific clinical problem.³⁰ Unlike many other SCAN-ECHO programs, the GLA Geri SCAN-ECHO program encourages not only PCPs, but also nurses and social workers to submit consults for discussion and encourages team management (a hallmark of quality geriatric care). Another important GLA GRECC project is the Veterans Cognitive Assessment and Management Program (V-CAMP), which uses videoconferencing to assess and manage veterans with cognitive impairment/dementia who reside in underserved areas in the GLA region. The program provides dementia care management and access to neuropsychological examinations—services that are often not available in rural areas.³¹

Various VA program offices have also published useful resources to help PACT clinicians infuse gerontologic principles into their practice. The VA Office of Nursing Services has a Geriatrics and Extended Care Field Advisory Committee, which recently produced on-demand lectures in the virtual VA eHealth University (also known as myVeHU campus) on improving the PACT’s management of progressive chronic diseases and dementia recognition and initial evaluation. They also produced a resource guide for VA clinicians (nursing and non-nursing), based on a team consensus of what the workgroup thinks a clinician would find helpful in clinical practice to improve care of older veterans. The VA Office of Geriatrics and Extended Care Service also identified a list of clinical and educational resources to help PACT clinicians. These include the Geriatrics Evaluation and management (GEM) Tools Booklet (http://geriatricscareonline.org) and a SharePoint site to improve dementia care in all settings.

The VA Office of Geriatrics and Extended Care provides additional geriatric-specific programs (http://va.gov/geriatrics). These programs may be useful for consultation and collaboration for patients whom the PACT teams have found to be more challenging and require more assistance to meet performance measures and patient needs. A recent evidence synthesis notes that direct involvement of geriatricians (as opposed to indirect care with limited contact) is more likely to result in positive patient outcomes and should be considered for those patients who are the most frail and/or high utilizers of services.³²

Conclusion

The PACT initiative in the VA health care system may prove to be an important vehicle for improving and standardizing the care provided to older veterans. Use of reliable and valid tools in the identification and assessment of geriatric syndromes, provision of quality standards, and use of innovative telehealth practices are promising enhancements for the primary care of older veterans.

Acknowledgements
We would like to thank the following contributors for their thoughtful review of the initial drafts of this article: Dr. Balmatee Bidassie; Dr. Kathryn Corrigan; Dr. Gail McNut; Dr. Linda Kinsinger, chief consultant for preventive medicine in the Office of Patient Care Services; Dr. Theodore Hahn, GRECC deputy director from VA Greater Los Angeles Healthcare System; Dr. James Hallenbeck, associate chief of staff, Extended Care at VA Palo Alto Health Care System; Ms. Storm Morgan, VA Office of Nursing Services PACT program manager; and Dr. Kenneth Shay, director of Geriatric Programs for the VA Office of Geriatrics and Extended Care.

The authors also would like to express their gratitude to the VA Office of Nursing Services, Clinical Practice Program, Geriatrics and Extended Care Field Advisory Committee for the opportunity to work on this manuscript.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
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