Clinical Review

Characteristics of High-Functioning Collaborations Between Primary Care and Podiatry in VHA PACTs

The key to high-functioning PACT/Podiatry teams rests with the quality of the communication between providers.

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The patient centered medical home (PCMH) concept was developed in response to the need to improve the overall health care system in the U.S.1 The episodic/acute care model has not provided high-value health services for the costs incurred. A 2010 Commonwealth Fund report indicated that the U.S. was near the bottom on quality measures of patient safety, care coordination, access, efficiency, overall quality, and healthy life expectancy compared with 6 other western countries.2 The U.S. spends an average of $7,960 per capita, 2.5 times more than the average of the 6 other western countries surveyed, on health care.1 The core principles that define the PCMH include (1) enhanced access; (2) continuity; (3) comprehensiveness; (4) team-based care; (5) care coordination; (6) a systems-based approach to quality and safety; and (7) reimbursement structures consistent with the added value of this system.1

The VHA adapted the PCMH concept to fit its unique integrated health care system. The development and implementation of the patient aligned care teams (PACTs) was designed to advance and expand primary care through increased access, continuity, and coordination of care for veteran patients.3 To accomplish the care coordination component, a set of principals was developed to define its structure, using the PCMH neighbor concept. Recognizing the importance of specialty and subspecialty collaboration with primary care, the American College of Physicians issued a white paper in 2010 to define policies and features of this relationship.4 Those characteristics include bidirectional effective communication, coordination, and integration; appropriate and timely consultations and referrals; efficient, appropriate, and effective information flow; comanagement responsibility; patient-centered care, enhanced care access and high levels of care quality and safety; and whole-person coordination and integration by primary care.5

The purpose of this study was to describe the PCMH characteristics within VHA centers that self-identified as centers with good or fair/poor communication between PACTs and Podiatry. The authors’ prior work showed that higher levels of coordination were associated with lower rates of diabetes-related lower limb amputations at VA centers.6


The podiatry service chiefs at 107 VHA hospitals were sent an online survey via e-mail on October 2, 2014. Two follow-up e-mails were sent to centers that did not respond after 1 week and then again after 2 weeks. Respondents were not offered rewards or inducements to participate. Centers were chosen at random and represented the diversity of facility complexity groups. The VHA Facility Complexity Model classifies VHA facilities at levels 1a, 1b, 1c, 2, or 3. Level 1a facilities are the most complex and level 3 facilities are the least complex.

The survey was designed to determine the characteristics of high-functioning teams as defined by the joint principles of the PCMH and to assess the operational theories that good functioning teams possess the following characteristics, based on the VHA Handbook 1101.10 PACT Handbook.7

  1. Good bidirectional communication between PACT and podiatry.
  2. A working care coordination agreement (CCA) that defines referral processes, e-consult conversion when appropriate, and successful coordination of care.
  3. Face-to-face meetings to discuss and adjust the CCA and other program components.

The audience for the survey was the chiefs of podiatry at 107 medical centers, representing a combination of medical center complexity groups 1, 2, and 3. The survey consisted of questions designed to assess the self-reported relationship between PACT and Podiatry Service at each reporting medical center (Appendix).

Statistical Analysis

A group level analysis was performed between centers identifying themselves by having good or fair/poor communication between PACT and Podiatry. The Fisher exact test (2-sided) was used to assess for associations. Significance was set at P ≤ .05.


The response rate for this survey was 54% (58/107). The Table describes the frequency of PCMH characteristics in good communicating and fair/poor communicating centers. Thirty-seven centers self-identified as having good communication between PACT and Podiatry, and 21 reported fair/poor communication (P = .015). Frequent bidirectional communication occurred in 68% of good communication centers and 10% in fair/poor communication centers (P < .001). There were no differences between good communicating centers and fair/poor communicating centers for having working care coordination agreements. In good communication centers, 69% of consults were appropriate at least 75% of the time compared with 40% of the time for fair/poor communication centers (P = .032). Active care coordination in most cases occurred in 53% of good communication centers vs 5% of fair/poor communication centers (P < .001).

In the survey, characteristics supported by the joint principles statement for developing a PCMH were assessed.3 Favorable characteristics included good communication between providers (PACT and Podiatry), a high percentage of consults considered appropriate (> 75%), and high levels of coordination. Unfavorable characteristics included poor communication between providers (PACT and Podiatry), low percentage of consults considered inappropriate (< 75%), and poor levels of communication. In the survey, 47% of good communicating centers had 1 or 2 favorable characteristics for a PCMH compared with 80% fair/poor communication centers that had 1 or 2 unfavorable characteristics (P = .025) (Figure 1).


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