Approaches to functional assessment differed between GeriPACT and PACT clinics. Consistent with the central role that functional status assessment plays in geriatrics practice, GeriPACTs tended to employ a routine, multidisciplinary approach to measuring functional status. This approach included standardized functional assessments by multiple primary care team members, including LPNs, SWs, and PCPs. In contrast, when PACTs completed standardized functional status assessment, it was generally carried out by a single team member (typically an LPN). The PCPs in PACTs used a nonroutine approach to assess functional status in which they performed detailed functional assessments for certain high-risk patients and referred a subset for further SW evaluation.
These processes are consistent with research showing that standardized functional status data are seldom collected routinely in nongeriatric primary care settings.11 Reports by PCPs that they did not always assess functional status also are consistent with previous research demonstrating that clinicians are not always aware of their patients’ functional ability.10
In addition to highlighting differences between GeriPACT and PACTs, the identified processes illustrate the variability in documentation, clinic workflow, and clinical reminder content across all clinics. Approaches to documentation included checkbox-formatted clinical reminders with and without associated nursing notes, patient questionnaires, and templated PCP and SW notes. Clinics employed varying approaches to collect functional status information and to ensure that those data were shared with the team. Clinic staff assessed functional status at different times during the clinical encounter. Clinics used several approaches to share this information with team members, including warm handoffs from LPNs to PCPs, interdisciplinary team huddles, and electronic signoffs. Finally, clinical reminder content varied between clinics, with differences in the wording of ADL and IADL questions as well as in the number and type of response options.
This variability highlights the challenges inherent in developing a routine, standardized approach to measuring functional status that can be adapted across primary care settings. Such an approach must be both flexible enough to accommodate variation in workflow and structured enough to capture accurate data that can be used to guide clinical decisions. Capturing accurate, standardized data in CDW also will inform efforts to improve population health by allowing VHA leaders to understand the scope of disability among older veterans and plan for service needs and interventions.
Whereas the larger qualitative study will identify the specific barriers and facilitators to developing and implementing such an approach, current clinic processes present here offer hints as to which features may be important. For example, several clinics collected functional status information before the visit by telephone or questionnaire. Therefore, it will be important to choose a functional status assessment instrument that is validated for both telephone and in-person use. Similarly, some clinics had structured clinical reminders with categoric response options, whereas others included free-text boxes. Incorporating both categoric responses (to ensure accurate data) as well as free-text (to allow for additional notes about a patient’s specific circumstances that may influence service needs) may be one approach.
Limitations
This study’s approach to identifying clinic processes had several limitations. First, the authors did not send process maps to clinic directors for verification. However, speaking with PACT members who carry out clinic processes is likely the most accurate way to identify practice. Second, the results may not be generalizable to all VA primary care settings. Due to resource limitations and project scope, community-based outpatient clinics (CBOCs) were not included. Compared with clinics based in medical centers, CBOCs may have different staffing levels, practice models, and needs regarding implementation of functional status assessment.
Although 46 participants from 9 clinics were interviewed, there are likely additional approaches to measuring functional status that are not represented within this sample. In addition, 3 of the 4 clinics included are affiliated with academic institutions, and all 4 are located in large cities. Efforts to include rural VAMCs were not successful. Finally, clinic-level characteristics were not reported, which may impact clinic processes. Although study participants were asked about clinic characteristics, they were often unsure or only able to provide rough estimates. In the ongoing qualitative study, the authors will attempt to collect more reliable data about these clinic-level characteristics and to examine the potential role these characteristics may play as barriers or facilitators to implementing routine assessment of functional status in primary care settings.
Conclusion
VA primary care clinics had widely varying approaches for assessing and documenting functional status. This work along with a larger ongoing qualitative study that includes interviews with veterans will directly inform the design and implementation of a standardized, patient-centered approach to functional assessment that can be adapted across varied primary care settings. Implementing standardized functional status measurement will allow the VA to serve veterans better by using functional status information to refer patients to appropriate services and to deliver patient-centered care with the potential to improve patient function and quality of life.