A PACT Nurse is a Registered Nurse (RN) or Licensed Practical Nurse (LPN) who functions as a core member of a Patient Aligned Care Team (PACT) within the Veterans Health Administration (VHA). This specialized nursing role delivers team-based, whole-person primary care to Veterans. The PACT Nurse is central to managing a specific group of patients, focusing on continuous health management rather than episodic treatment. The role requires a comprehensive approach to patient health, spanning from acute illness management to long-term wellness planning.
Understanding the Patient Aligned Care Team Model
The Patient Aligned Care Team model represents how the VA delivers primary care, adapting the concept of the patient-centered medical home. This framework was launched around 2010 to shift healthcare delivery from a traditional doctor-centric model to a patient-centered approach that places the Veteran at the center of their care. PACT aims to improve the Veteran’s access to care, the coordination of services, and the overall continuity of health management.
The PACT philosophy is built on four core components: partnership with the Veteran, enhancing access through multiple communication methods, coordinating care across the health system, and utilizing a team-based structure. This model emphasizes proactive health promotion, wellness, and disease prevention. The goal is to provide personalized care that aligns with the Veteran’s specific health goals and lifestyle.
Core Duties and Clinical Focus of the PACT Nurse
The PACT Registered Nurse (RN) functions as a care manager for a designated panel of Veterans and is the consistent point of contact for ongoing health concerns. This involves care coordination, ensuring timely follow-up for test results, specialist referrals, and hospital discharge instructions. The nurse handles patient communication via telephone and secure electronic messaging, providing triage and determining the urgency of medical concerns.
The PACT nurse’s work is dedicated to chronic disease management for conditions like Type 2 diabetes, hypertension, and hyperlipidemia. Using evidence-based clinical protocols, the nurse monitors key biophysical markers, such as hemoglobin A1c (HbA1c) or blood pressure, to ensure treatment goals are met. These protocols may allow the nurse to perform tasks beyond the traditional scope, such as adjusting medication dosages under specific physician guidelines, to optimize a Veteran’s condition.
The PACT nurse provides patient education and specialized health coaching to empower Veterans to manage their own health. This coaching often employs Motivational Interviewing (MI), an evidence-based communication style designed to help patients strengthen their internal motivation for healthy lifestyle changes. Using techniques like open-ended questions, affirmation, reflective listening, and summarizing (OARS), the nurse helps the Veteran identify reasons and plans for behavior change, such as improving diet or increasing physical activity.
Interprofessional Collaboration within PACT
The PACT nurse operates within a “teamlet” that typically includes a primary care provider (physician, nurse practitioner, or physician assistant), a clinical associate (LPN or medical technician), and an administrative clerk. This core team meets frequently to discuss the status of their shared patient panel, ensuring a unified approach to care. The nurse’s role is to facilitate the flow of information and services among these members.
Beyond the core team, the PACT nurse leverages the expertise of an expanded interdisciplinary group to provide holistic care. This includes referring Veterans to embedded specialists like clinical pharmacists, dietitians, social workers, or mental health providers. The nurse acts as the liaison, coordinating these separate services into a single care plan for the Veteran. The PACT model ensures shared responsibility and seamless transitions of care, whether coordinating appointments or managing a Veteran’s transfer to a specialty clinic or a non-VA facility.