Headline

Nurses and members of fully staffed interdisciplinary care teams are more likely to use patient identification and care management tools.

Context

The majority of patients with complex health and psychosocial needs within the Veterans Health Administration (VHA) receive primary care in patient-centered medical homes (PCMHs), which emphasize coordinated care delivered by a multidisciplinary team. PCMHs in the VHA system have access to tools and resources within the electronic health record (EHR) for patient identification and population management. This study examines PCMH team member perspectives on the most highly-rated tools.

Findings

PCMH teams with full staffing were more likely to use care management tools. While many sophisticated prediction scores, dashboards, and care management tools are linked to the EHR, many VHA PCMH team members preferred simpler metrics related to utilization and illness. Team role significantly predicted the value placed on patient identification tools, as registered nurses (who often serve as care managers) were more likely than primary care providers to describe these tools as very important.

Takeaways

PCMH and other interdisciplinary teams may have access to patient identification and care management tools, but their use of these tools will be affected by whether they work within fully staffed teams. PCMH teams may need additional training and supports to use these tools.