Improving chronic illness care for veterans within the framework of the Patient-Centered Medical Home: experiences from the Ann Arbor Patient-Aligned Care Team Laboratory

While key components of the Patient-Centered Medical Home (PCMH) have been described, improved patient outcomes and efficiencies
have yet to be conclusively demonstrated. We describe the rationale, conceptual framework, and progress to date as part of
the VA Ann Arbor Patient-Aligned Care Team (PACT) Demonstration Laboratory, a clinical care-research partnership designed
to implement and evaluate PCMH programs. Evidence and experience underlying this initiative is presented. Key components of
this innovation are: (a) a population-based registry; (b) a navigator system that matches veterans to programs; and (c) a
menu of self-management support programs designed to improve between-visit support and leverage the assistance of patient–peers
and informal caregivers. This approach integrates PCMH principles with novel implementation tools allowing patients, caregivers,
and clinicians to improve disease management and self-care. Making changes within a complex organization and integrating programmatic
and research goals represent unique opportunities and challenges for evidence-based healthcare improvements in the VA.