(VA, 2012a). Among those Iraq and Afghanistan war veterans who have sought care at VHA facilities, about 94% have used only outpatient services and about 6% have been hospitalized at least once (VA, 2012a).

VHA has substantial experience in treating patients who have chronic illnesses. Its patients have a higher prevalence of the eight most common chronic health conditions than do patients who are using TRICARE and private plans (Gibson et al., 2009), not including CMI. As indicated above, information is not available on the number of veterans who have CMI and receive their care from VHA or elsewhere.

Postdeployment Patient-Aligned Care Team Program

Gulf War veterans have begun to enter the VHA system by being assigned to a postdeployment patient-aligned care team (PD-PACT) (Hunt, 2012). A PD-PACT serves as a veteran’s medical home in VHA. The move to a medical-home model is relatively recent in VHA and implementation is ongoing (Reisinger et al., 2012). VHA’s implementation of this model of care compares favorably with implementation in most civilian practices and systems, in which the transition to patient-centered medical homes is still in the early stages of implementation. VHA has established principles and guidelines for the implementation of PACTs, educated its clinicians about the principles, and assigned champions to lead the implementation effort (VA, 2012j). It is important to note that this pathway to care did not exist when military personnel were returning from the 1991 Gulf War and entering the VHA system. The 1991 Gulf War veterans are now being served by PD-PACTs, but their enrollment rates have been highly variable among settings (VA, 2012e). The plan is for assignment to a PD-PACT to begin after a postdeployment comprehensive health examination and a postdeployment disability determination. At some sites, the wait time for the two steps is extremely long, sometimes more than a year. That is frustrating for veterans, who sometimes seek care elsewhere; it also compromises PACT primary care clinicians’ ability to render high-quality care.

Each PD-PACT is overseen by a project manager. Other team members can include primary care clinicians, nursing-care managers, mental health clinicians, social workers, and others who have expertise in such subjects as brain injury and physical rehabilitation. The number, specialty types, relative availability, and extent of integration into the primary care team of specialty-team members vary widely from clinic to clinic; VHA currently assigns behavioral-health clinicians to PACTs in VA medical centers (VAMCs) and outpatient clinics that have more than 5,000 primary care patients, and many smaller clinics also have behavioral clinicians on PACT teams. A veteran being cared for is considered a member of the team. The goal of the PD-PACT model is to provide comprehensive, integrated care,



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