Implementation of a novel population panel management curriculum among interprofessional health care trainees

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.

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.

Five ways to get a grip on grouped self-assessments of competence for program evaluation

Self-assessments conducted by individuals when taken together (grouped) provide valid and accurate measures of learning outcomes of the group. This is useful for program evaluation. Grouped self-assessments are simple to understand and construct, easy to implement, relatively accurate, and do not require extensive and complex pre-post testing measures. However, group self-assessments have the potential to be misused. To examine how group self-assessments have been used in medical education, we conducted a search of journal articles published in 2017 and 2018 from eight prominent medical education journals. Twenty-seven (n = 27) articles that used self-assessments for program evaluation were selected for data extraction and analysis. We found three main areas where misuse of self-assessments may have resulted in inaccurate measures of learning outcomes: measures of "confidence" or "comfort", pre-post self-assessments, and the use of ambiguous learning objectives. To prevent future misuse and to build towards more valid and reliable data for program evaluations, we present the following recommendations: measure competence instead of confidence or comfort; use pre-test self-assessments for instructional purposes only (and not for data); ask participants to do the post-intervention self-assessments first followed by retrospective pre-intervention self-assessments afterwards; and use observable, clear, specific learning objectives in the educational intervention that can then be used to create the self-assessment statements.

The Effects of Continuous Care Model of Information-Based Hospital-Family Integration on Colostomy Patients: a Randomized Controlled Trial

The purpose of this research was to examine the effects of continuous care model of information-based hospital-family integration on colostomy patients. Miles' operation is a major operative method for treating low rectal cancer, and this operation results in a permanent colostomy. It is difficult for patients to adapt to their colostomy. Previous studies have applied generally conventional nursing models to colostomy patients. This was a single-blind randomized controlled trial study. The sample of 155 patients who met the inclusion criteria was randomly assigned to either the experimental (n = 81) or control group (n = 74). The control group was provided with a routine standard of care. The experimental group was provided with an experimental treatment that consisted of an information-based (WeChat, blog, QQ, telephone, etc.) hospital-family integration continuous care model. Study variables were collected and instruments were selected as follows: basic information, State-Trait Anxiety Inventory (STAI), a self-efficacy scale, a colostomy complication assessment table, a quality of life scale, and a table of the degree of satisfaction. No statistically significant differences were found in demographic information between the experimental and control groups. In comparison with the control group, subjects in the experimental group had less anxiety and could better cope with anxiety, had a better self-efficacy and quality of life scores, and had fewer complications. The patients in the experimental group were shown to be more satisfied with the care model. In addition, the most useful and popular service is the online social tools WeChat and QQ, because they can communicate with video, and they are more real-time, efficient, and cheap. The continuous care model of information-based hospital-family integration significantly strengthened patients' self-efficacy and confidence, which decreased colostomy complications, ultimately improving the quality of life.

Perspectives of specialists and family physicians in interprofessional teams in caring for patients with multimorbidity: a qualitative study

BACKGROUND

Patients with multimorbidity often require services across different health care settings, yet team processes among settings are rarely implemented. We explored perceptions of specialists and family physicians collaborating in a telemedicine interprofessional consultation for patients with multimorbidity to better understand the value of bringing physicians together across the boundaries of health care settings.

METHODS

This was a descriptive qualitative, interview-based study. Physicians who had previously participated in the Telemedicine Interprofessional Model of Practice for Aging and Complex Treatments (Telemedicine IMPACT Plus [TIP] Program) were invited to participate and asked to describe their experience of being a member of the program. Interviews were conducted from March to May 2016. We conducted an iterative and interpretive process using both individual and team analysis to identify themes.

RESULTS

There were 15 participants, 9 specialists and 6 family physicians. Three themes emerged in the analysis: creating new perspectives on care for patients with multimorbidity by sharing knowledge, skills and attitudes; the shift from a consultant model to an interprofessional team model (allowing a window into the community, extending discussions beyond the medical model and focusing on the patient's health in context); and opportunities for learners, including learning about interprofessional collaboration and gaining exposure to a real-world model for caring for people with multimorbidity in outpatient settings.

INTERPRETATION

Family physicians and specialists participating in a TIP Program believed the program improved their knowledge and skills, while also serving as an effective care delivery strategy. The findings also support that learners require more exposure to nontraditional consultant models in order to care for patients with multimorbidity effectively.

Interprofessional Academic Patient Aligned Care Team Panel Management Model

The panel management model brings together trainees, faculty, and clinic staff to proactively provide team-based care to high-risk patients with unmet chronic care needs.

Internal Medicine Resident Experiences With a 5-Month Ambulatory Panel Management Curriculum

BACKGROUND

Panel management is emphasized as a subcompetency in internal medicine graduate medical education. Despite its importance, there are few published curricula on population medicine in internal medicine residency programs.

OBJECTIVE

We explored resident experiences and clinical outcomes of a 5-month diabetes and obesity ambulatory panel management curriculum.

METHODS

From August through December 2016, internal medicine residents at the University of Vermont Medical Center reviewed registries of their patients with diabetes, prediabetes, and obesity; completed learning modules; coordinated patient outreach; and updated gaps in care. Resident worksheets, surveys, and reflections were analyzed using descriptive and thematic analyses. Before and after mean hemoglobin A1c results were obtained for patients in the diabetic group.

RESULTS

Most residents completed the worksheet, survey, and reflection (93%-98%, N = 42). The worksheets showed 70% of participants in the diabetic group had appointments scheduled after outreach, 42% were offered referrals to the Community Health Team, and 69% had overdue laboratory tests ordered. Residents reported they worked well with staff (95%), were successful in coordinating outreach (67%), and increased their sense of patient care ownership (66%). In reflections, identified successes were improved patient care, teamwork, and relationship with patients, while barriers included difficulty ensuring follow-up, competing patient priorities, and difficulty with patient engagement. Precurricular mean hemoglobin A1c was 7.7%, and postcurricular was 7.6% (P = .41).

CONCLUSIONS

The curriculum offered a feasible, longitudinal model to introduce residents to population health skills and interdisciplinary care coordination. Although mean hemoglobin A1c did not change, residents reported improved patient care. Identified barriers present opportunities for resident education in patient engagement.