Interprofessional transformation of clinical education: The first six years of the Veterans Affairs Centers of Excellence in Primary Care Education

Interprofessional Curriculum Delivery: Experience of a Primary Care Education Program

Few post-graduate training programs offer a comprehensive curriculum that includes structured clinical experiences to teach interprofessional care. To address this need, the United States Department of Veterans Affairs, Office of Academic Affiliations funded the Centers of Excellence in Primary Care Education (CoEPCE) from 2011-2019 to provide interprofessional curricula for health profession trainees (HPTs), including physician residents, nurse practitioner residents, pharmacy residents, and psychology residents. We examined changes over time in curricular domains, system impacts, and program practices based on HPT survey data and the qualitative evaluation of narrative feedback. An annual survey was administered to participants. Indirect standardized ratios were calculated for interprofessional professional education (IPE) program domains, system impacts, and program practices. Qualitative responses were coded based on curricular domains and key program components. The study cohort included 369 HPTs. Site and profession standardized indirect ratios across all professions indicated improvements in curricular domains, system impacts, and program practices, with significant differences observed for associated health HPTs as compared to other HPTs for performance improvement. Qualitative data indicated that profession was associated with differences in perceptions of the curriculum. Although improvements occurred over time, our findings support the need for the thoughtful consideration of profession-specific identity characteristics when designing interprofessional curricula.

Culture change and lessons learned from ten years in the VA centers of excellence in primary care education

BACKGROUND

Team-based care is critical to achieving health care value while maximizing patient outcomes. Few descriptions exist of graduate-level team training interventions and practice models. Experience from the multisite, decade-long Veterans Affairs (VA) Centers of Excellence in Primary Care Education provides lessons for developing internal medicine training experiences in interprofessional clinical learning environments.

METHODS

A review of multisite demonstration project transforming traditional silo-model training to interprofessional team-based primary care. Using iterative quality improvement approaches, sites evaluated curricula with learner, faculty and staff feedback. Learner- and patient-level outcomes and organizational culture change were examined using mixed methods, within and across sites. Participants included more than 1600 internal medicine, nurse practitioner, nursing, pharmacy, psychology, social work and physical therapy trainees. This took place in seven academic university-affiliated VA primary care clinics with patient centered medical home design RESULTS: Each site developed innovative design and curricula using common competencies of shared decision making, sustained relationships, performance improvement and interprofessional collaboration. Educational strategies included integrated didactics, workplace collaboration and reflection. Sites shared implementation best practices and outcomes. Cross-site evaluations of the impacts of these educational strategies indicated improvements in trainee clinical knowledge, team-based approaches to care and interest in primary care careers. Improved patient outcomes were seen in the quality of chronic disease management, reduction in polypharmacy, and reduced emergency department and hospitalizations. Evaluations of the culture of training environments demonstrated incorporation and persistence of interprofessional learning and collaboration.

CONCLUSIONS

Aligning education and practice goals with cross-site collaboration created a robust interprofessional learning environment. Improved trainee/staff satisfaction and better patient care metrics supports use of this model to transform ambulatory care training.

TRIAL REGISTRATION

This evaluation was categorized as an operation improvement activity by the Office of Academic Affairs based on Veterans Health Administration Handbook 1058.05, in which information generated is used for business operations and quality improvement (Title 38 Code of Federal Regulations Part 16 (38 CFR 16.102(l)). The overall project was subject to administrative oversight rather Human Subjects Institutional Review Board, as such informed consent was waived as part of the project implementation and evaluation.

From the Nexus vision to the NexusIPE™ learning model

The Nexus vision of simultaneously transforming health professions education and healthcare delivery to achieve Triple (now Quadruple) Aim outcomes was first articulated in the 2012 proposal and funding of the National Center for Interprofessional Practice and Education (National Center). Over the past decade, the National Center has worked with over 70 sites implementing large scale and practice-based interprofessional practice and education (IPE) programs. Because what is needed to implement the Nexus to achieve Quadruple Aim outcomes was not well understood in 2012, the National Center took a social innovations and developmental evaluation approach. This iterative method led to the development of the National Center NexusIPE™ Learning Model that adapts the 3-P high-level stages (Presage, Process, and Product), proposed as a framework for IPE by Barr and colleagues. National Center collaborators' lessons learned about the Nexus vision are highlighted in this issue and provide real-world examples of elements of the NexusIPETM Learning Model. Reflecting on ten years of experience, the National Center leaders recognize the need for Nexus transformation and the relevance of the NexusIPETM Learning Model today as education and health systems grapple with mounting workforce challenges. The model provides opportunities to address growing workforce shortages, provide equitable care that leads to health, and support the well-being of practice teams in the face of challenges such as the COVID-19 pandemic.

Aims, development, and early results of an interdisciplinary primary care initiative to address patient vulnerabilities

Addressing substance use disorders and social determinants of poor health at a population level is a major national healthcare priority. One promising model to improve healthcare outcomes for patients with these conditions is the Vulnerable Veteran Innovative Patient-Aligned Care Team (PACT) Initiative, or VIP - an interdisciplinary, team-based primary care delivery model designed to address the needs of vulnerable patients in the Veterans Health Administration. VIP establishes a single, integrated primary care environment for the management of substance use disorders, mental illness, social determinants of poor health, and complexities in care resulting from the co-occurrence of these conditions. We describe the origination, goals, and evolution of VIP to provide an example of how clinics and health systems can address vulnerable patient populations within a primary care clinic framework. While ongoing evaluation will be essential to understand its impact on patient outcomes and its sustainability and scalability in the future, VIP holds promise as a novel model to improve care for patients with addiction and other vulnerabilities.

Experiences of Patient-Centered Medical Home Staff Team Members Working in Interprofessional Training Environments

BACKGROUND

Evidence is growing that interprofessional team-based models benefit providers, trainees, and patients, but less is understood about the experiences of staff who work beside trainees learning these models.

OBJECTIVE

To understand the experiences of staff in five VA training clinics participating in an interprofessional team-based learning initiative.

DESIGN

Individual semi-structured interviews with staff were conducted during site visits, qualitatively coded, and analyzed for themes across sites and participant groups.

PARTICIPANTS

Patient-centered medical home (PCMH) staff members (n = 32; RNs, Clinical and Clerical Associates) in non-primary care provider (PCP) roles working on teams with trainees from medicine, nursing, pharmacy, and psychology.

APPROACH

Benefits and challenges of working in an interprofessional, academic clinic were coded by the primary author using a hybrid inductive/directed thematic analytic approach, with review and iterative theme development by the interprofessional author team.

KEY RESULTS

Efforts to improve interprofessional collaboration among trainees and providers, such as increased shared leadership, have positive spillover effects for PCMH staff members. These staff members perceive themselves playing an educational role for trainees that is not always acknowledged. Playing this role, learning from the "fresh" knowledge imparted by trainees, and contributing to the future of health care all bring satisfaction to staff members. Some constraints exist for full participation in the educational efforts of the clinic.

CONCLUSIONS

Increased recognition of and expanded support for PCMH staff members to participate in educational endeavors is essential as interprofessional training clinics grow.

Realist approach to evaluating an interprofessional education program for medical students in clinical practice at a community hospital

Introduction: We examined the interrelationships between context, mechanism, and outcome using a realist approach following the introduction of interprofessional education (IPE) to clinical practice for medical students in the community.Methods: Through participant observation and interviews, a working hypothesis was developed. To evaluate IPE in clinical practice, medical students' reports were thematically analyzed, and configuration on contexts, mechanisms, and outcomes were identified using a realist approach.Results: Influential contexts were medical students' experience of clinical practice and learning characteristics, the capacity of other professionals, interprofessional relationships, and characteristics of the community hospital. One key mechanism was observational learning. Others were self-regulated learning, legitimate peripheral participation, experiential learning, contact hypotheses, awareness of social structure, and cognitive empathy. As faculties supported these key mechanisms, medical students became aware of the legitimacy of community-oriented primary care, noting the roles of physicians who support patients' and/or their family's life in collaboration with other professionals, and reflecting the necessity of shifting from physician-centered perspectives. As a result, medical students deepened their empathic understanding for other professionals.Conclusion: Faculties should develop IPE programs in clinical practice based on the 'mechanism', 'context', 'outcome' pattern and 'context-mechanism-outcome' configuration in primary care settings.

Association of a Multisite Interprofessional Education Initiative With Quality of Primary Care

IMPORTANCE

Studies have shown that interprofessional education (IPE) improves learner proficiencies, but few have measured the association of IPE with patient outcomes, such as clinical quality.

OBJECTIVE

To estimate the association of a multisite IPE initiative with quality of care.

DESIGN, SETTING, AND PARTICIPANTS

This study used difference-in-differences analysis of US Department of Veterans Affairs (VA) electronic health record data from July 1, 2008, to June 30, 2015. Patients cared for by resident clinicians in 5 VA academic primary care clinics that participated in the Centers of Excellence in Primary Care Education (CoEPCE), an initiative designed to promote IPE among physician, nurse practitioner, pharmacist, and psychologist trainees, were compared with patients cared for by resident clinicians in 5 regionally matched non-CoEPCE clinics using data for the 3 academic years (ie, July 1 to June 30) before and 4 academic years after the CoEPCE launch. Analysis was conducted from January 18, 2018, to January 17, 2019.

MAIN OUTCOMES AND MEASURES

Among patients with diabetes, outcomes included annual hemoglobin A1c, poor hemoglobin A1c control (ie, <9% or unmeasured), and annual renal test; among patients 65 years and older, outcomes included prescription of high-risk medications; among patients with hypertension, outcomes included hypertension control (ie, blood pressure, <140/90 mm Hg); and among all patients, outcomes included timely mental health referrals, primary care mental health integrated visits, and hospitalizations for ambulatory care-sensitive conditions.

RESULTS

A total of 44 527 patients contributed 107 686 patient-years; 49 279 (45.8%) were CoEPCE resident patient-years (mean [SD] patient age, 59.3 [15.2] years; 26 206 [53.2%] white; 8073 [16.4%] women; mean [SD] patient Elixhauser comorbidity score, 12.9 [15.1]), and 58 407 (54.2%) were non-CoEPCE resident patient-years (mean [SD] patient age, 61.8 [15.3] years; 43 912 [75.2%] white; 4915 [8.4%] women; mean [SD] patient Elixhauser comorbidity score, 13.8 [15.7]). Compared with resident clinicians who did not participate in the CoEPCE initiative, CoEPCE training was associated with improvements in the proportion of patients with diabetes with poor hemoglobin A1c control (-4.6 percentage points; 95% CI, -7.5 to -1.8 percentage points; P < .001), annual renal testing among patients with diabetes (3.2 percentage points; 95% CI, 0.6 to 5.7 percentage points; P = .02), prescription of high-risk medications among patients 65 years and older (-2.3 percentage points; 95% CI, -4.0 to -0.6 percentage points; P = .01), and timely mental health referrals (1.6 percentage points; 95% CI, 0.6 to 2.6 percentage points; P = .002). Fewer patients cared for by CoEPCE resident clinicians had a hospitalization for an ambulatory care-sensitive condition compared with patients cared for by non-CoEPCE resident clinicians in non-CoEPCE clinics (-0.4 percentage points; 95% CI, -0.9 to 0.0 percentage points; P = .01). Sensitivity analyses with alternative comparison groups yielded similar results.

CONCLUSIONS AND RELEVANCE

In this study, the CoEPCE initiative was associated with modest improvements in quality of care. Implementation of IPE was associated with improvements in patient outcomes and may potentiate delivery system reform efforts.

Developing Interprofessional Primary Care Teams: Alumni Evaluation of the Department of Veterans Affairs Centers of Excellence in Primary Care Education Program

PURPOSE

The Centers of Excellence in Primary Care Education (CoEPCE) is an interprofessional graduate training program within the Department of Veterans Affairs (VA). In this project, we describe career paths of CoEPCE graduates, their perceptions of CoEPCE program value, their overall satisfaction with the training, and suggestions for program improvement to enhance interprofessional education and workforce development.

METHODS

The Graduate Participant Survey was developed and administered in 2018 to CoEPCE graduates from 2012 to 2017. Quantitative data from closed-ended questions were analyzed through descriptive and non-parametric statistics to test for significant differences by profession. Qualitative data from the single open-ended question were analyzed using content analysis with inductive and deductive approaches.

RESULTS

The survey was completed by 180 graduates. Greater proportions of pharmacists and psychologists than nurse practitioners and physicians were employed in VA, and greater proportions of nurse practitioners and pharmacists than physicians and psychologists were employed in primary care. Although smaller proportions of physicians were currently employed in primary care (P < .0001), a greater proportion completed advanced training programs (P < .0001). Overall, graduates perceived that their CoEPCE training was highly valued by advanced training programs and employers and improved their chances of finding a job. They reported high levels of satisfaction (mean = 4.3 ± 0.9 out of 5 total) with the training program, continued to use skills they learned during training, and believe their CoEPCE experiences made them better health care providers.

CONCLUSIONS

Ninety-four percent of the CoEPCE graduates were employed at the VA and/or primary care at the completion of their training, although there were significant differences by profession. Graduates continued to practice interprofessional skills learned during their training and were highly satisfied with the program. Taken together, the findings indicate that continued enhancements to the interprofessional clinical learning environment are warranted.