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Connecting the Dots

Interprofessional Health Education and Delivery System Redesign at the Veterans Health Administration

Gilman, Stuart C., MD, MPH; Chokshi, Dave A., MD, MSc; Bowen, Judith L., MD; Rugen, Kathryn Wirtz, PhD, FNP-BC; Cox, Malcolm, MD

doi: 10.1097/ACM.0000000000000312
Perspectives
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Health systems around the United States are embracing new models of primary care using interprofessional team-based approaches in pursuit of better patient outcomes, higher levels of satisfaction among patients and providers, and improved overall value. Less often discussed are the implications of new models of care for health professions education, including education for physicians, nurse practitioners, physician assistants, and other professions engaged in primary care. Described here is the interaction between care transformation and redesign of health professions education at the largest integrated delivery system in the United States: the Veterans Health Administration (VA). Challenges and lessons learned are discussed in the context of a demonstration initiative, the VA Centers of Excellence in Primary Care Education. Five sites, involving VA medical centers and their academic affiliates in Boise, Cleveland, San Francisco, Seattle, and West Haven, introduced interprofessional primary care curricula for resident physicians and nurse practitioner students beginning in 2011. Implementation struggles largely revolved around the operational logistics and cultural disruption of integrating educational redesign for medicine and nursing and facilitating the interface between educational and clinical activities. To realize new models for interprofessional teaching, faculty, staff, and trainees must understand the histories, traditions, and program requirements across professions and experiment with new approaches to achieving a common goal. Key recommendations for redesign of health professions education revolve around strengthening the union between interprofessional learning, team-based practice, and high-value care.

Dr. Gilman is director, Advanced Fellowships and Professional Development, Office of Academic Affiliations, Veterans Health Administration, Washington, DC.

Dr. Chokshi is director of population health improvement, New York University (NYU) Langone Medical Center, and assistant professor of medicine and population health, NYU School of Medicine, New York, New York. At the time this article was written, he was White House Fellow, Office of the Secretary, Department of Veterans Affairs, Washington, DC.

Dr. Bowen is professor of medicine, Oregon Health and Science University School of Medicine, Portland, Oregon, and education consultant, Office of Academic Affiliations, Veterans Health Administration Centers of Excellence in Primary Care Education, Washington, DC.

Dr. Rugen is nurse practitioner consultant, Centers of Excellence in Primary Care Education, Office of Academic Affiliations, Veterans Health Administration, Washington, DC.

Dr. Cox is adjunct professor of medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. At the time this article was written, he was chief academic affiliations officer, Office of Academic Affiliations, Veterans Health Administration, Washington, DC.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Disclaimers: The views expressed in this article are those of the authors and do not necessarily reflect the policies or views of the Department of Veterans Affairs, the New York University Langone Medical Center, or the Perelman School of Medicine.

Correspondence should be addressed to Dr. Chokshi, NYU Langone Medical Center, 227 E. 30th St., Room 647, New York, NY 10016; telephone: (646) 754-5441; e-mail: dave.chokshi@nyumc.org.

It is no longer possible to describe the most important challenges facing health professions education without placing them in the context of the rapidly changing health care system. Implementation of the Affordable Care Act—with coverage expansion for approximately 25 million people and a shift to value-driven care delivery—has renewed interest in improving primary care. One approach to such transformation, the “patient-centered medical home” (PCMH), is gaining particular credence. This model emphasizes interprofessional, team-based practice to achieve improved access, care coordination, and patient communication. Federal agencies such as the Agency for Healthcare Research and Quality have devoted significant resources to support organizations wishing to implement the model.

The evidence demonstrating advantages of primary care using interprofessional team-based approaches is thin, reflecting both the challenge of evaluating complex system change and the heterogeneity of the models employed.1,2 Despite this paucity of evidence, many health systems are embracing new models of interprofessional practice in pursuit of better patient outcomes, higher levels of satisfaction among patients and providers, and improved overall value. At the same time, a variety of PCMH assessment, certification, and accreditation products are offered by organizations such as the American College of Physicians, the Joint Commission, the National Committee for Quality Assurance, and the Accreditation Association for Ambulatory Health Care.

Health professions education is inherently intertwined with care delivery because professionals in training must be educated in clinical environments and be prepared to lead and improve clinical care.3 As with the transformations toward interprofessional care well under way in clinical care delivery systems, educational transformations are being aggressively pursued despite conflicting evidence.4 The Institute of Medicine and Josiah Macy, Jr. Foundation have each called for increasing interprofessional collaboration in health care.5–7 A consortium of prominent professional organizations has joined forces to develop the Inter-professional Education Collaborative and has gone so far as to develop Core Competencies for Interprofessional Collaborative Practice.8

In this article, we offer initial observations from our experiences with a pilot focused redesign of health professions education at the largest integrated care delivery and health professions education system in the United States: the Veterans Health Administration (VA). Of note, the VA recently approved strategic goals for transforming primary care education across the entire organization, informed in part by the early results of the five-site demonstration project described here.9

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Challenges to Health Professions Education Redesign

Many existing health professions education strategies were developed in the context of care delivery strategies that are increasingly obsolescent, such as an almost exclusive focus on inpatient care settings.10 Failure to transform education will delay the development of the workforce needed to practice in a rapidly changing health system. It may also amplify the tendency to maintain the status quo as academic health centers find their transformation efforts hamstrung by conflicting incentives—for instance, fee-for-service versus value-based payment.

Given the long-standing emphasis on workplace learning in education for all major health professions,11 education leaders must be well informed about current and future systems of care so that a given curriculum is properly situated in clinical settings where trainees have meaningful roles.12 Likewise, it is essential for care delivery system leaders to be aware of health professions curricula in order to ensure that conflicts between such curricula and the desired performance of the system of care do not result in adverse consequences for patients.

Education and health system leaders share strategic responsibility to develop the nation’s future clinical workforce.13 Joint transformation of clinical and education systems that is properly managed can fuel mutual benefit; when not, transformation of either can impede the other. Such a result may have immediate implications for any specific patient’s experience, but it also has the potential to ripple across an institution, across the professions, and—as new professionals with mismatched attitudes or skills emerge into the workplace—across generations.

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Struggles Encountered in the VA Experience

In 2010, the VA committed to transforming primary care services enterprise-wide into Patient Aligned Care Teams (PACT), based on the PCMH model.14,15 A PACT “teamlet” collaborates to deliver health promotion, disease prevention, and acute and chronic disease management to a defined panel of patients. A teamlet is composed of a primary care provider (a physician, nurse practitioner, or physician assistant); a registered nurse (RN) care manager, a licensed practical nurse, and/or a health technician; and a medical clerk. Other clinicians, such as clinical pharmacists, social workers, and psychologists, supplement the teamlet, advancing sustained relationships between patients and the entire primary care team.

The system-wide PACT transformation was a daunting undertaking: Primary care at the VA serves about 4.8 million patients via 12 million annual encounters at over 850 points of care. Aside from its scope, this transformation challenged the VA’s statutory mission to provide health professions education to benefit both the VA and the nation. The VA’s health professions education activities, like many others in the United States, have been mostly hospital based and organized with an emphasis on training each profession in parallel rather than in a more integrated fashion.

The VA Centers of Excellence in Primary Care Education (CoEPCE) initiative was implemented in 2011 as a demonstration project to explore the interprofessional redesign of clinical education in concert with the transformation of the primary care delivery system. CoEPCE seeks to prepare graduates of health professions programs to work in and lead interprofessional primary care PACTs or other care teams that provide coordinated longitudinal care. Physician residents and nurse practitioner students are the primary learners, but other trainees are also incorporated.

The CoEPCE curriculum addresses four principal domains: interprofessional collaboration (including both team-based learning and care delivery), sustained relationships (between patients and providers and between faculty, staff, and trainees), shared decision making (between patients and providers and amongst team members), and performance improvement (including both individual and team-based performance). Curricular implementation occurs primarily in the clinical practice setting (workplace) where trainees collaborate to provide team-based care and engage in system redesign improvement activities. Learning in didactic sessions supports workplace learning. Case conferences generated from clinical practice experiences facilitate interprofessional learning from reflection.16,17

In early 2011, an interprofessional panel of VA health educators and leaders competitively selected five demonstration centers involving VA medical centers and their academic affiliates in Boise, Idaho; Cleveland, Ohio; San Francisco, California; Seattle, Washington; and West Haven, Connecticut. Educational program accreditations were the responsibility of the academic affiliates, with the VA serving as a participating institution. A national coordinating center was established to facilitate interaction between the approved sites and VA leadership, maintain fidelity to project goals, and foster collaborative learning across the approved sites.

Local implementation struggles largely revolved around the operational logistics and cultural disruption of integrating educational redesign for medicine and nursing and facilitating the interface between educational and clinical activities of the PACT programs. Although experienced as clinical training sites, VA practice leaders were unaccustomed to considering the impact of PACT implementation on education programs. Similarly, both VA and affiliate education program leaders rarely considered input from their clinical practice partners before implementing new clinical curricula.

Interprofessional team-based care and learning engages more trainees, faculty, and staff, which challenges existing resources and space configurations for team huddles, clinical supervision, and team learning activities. As a result of this initiative, clinical teamlet members have become key educators in work-based learning activities, such as team huddles where they coach trainees in their roles and responsibilities.18 Furthermore, education leaders collaborate with clinical administrators to design and implement quality improvement initiatives that include trainees.

Clinical faculty time must be apportioned in different ways, and supervision models must be reconfigured as faculty members from different professions engage in coteaching and coprecepting activities involving interprofessional trainees. For example, although VA policy has traditionally recognized the need for dedicated time for physician preceptors, the VA does not have a strong tradition of providing protected time to the clinical faculty of other professions, including nurse practitioner faculty.

To implement new models for inter professional teaching and supervision, faculty, staff, and trainees must understand the histories, traditions, and pro gram requirements of each other’s professions and experiment with new approaches to achieving a common goal. PACT clinical staff effort must also be recalibrated to support the program’s learning goals. For example, to support the goal of maximizing patient–trainee continuity while ensuring that the supervising practitioner is appropriately involved, the RN care manager must not only coordinate care for the team’s panel of patients as for a nonacademic team but must do so maintaining continuity of engagement between patients, trainees, and supervising faculty to ensure quality of care and patient satisfaction for the expanded academic team.

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Key Lessons

Regular telephone conversations with centers, site visits conducted by members of the coordinating center staff, site-submitted periodic progress reports, and personal reflections all contributed to longitudinal learning within CoEPCE. Four key lessons have emerged from the VA experience thus far. First, careful attention must be paid to the details of educational redesign. The development of a curriculum that recognizes trainees’ professional diversity, addresses different academic levels of preparation, and accommodates distinct educational schedules and prior clinical experiences is a complex and time-consuming exercise.

All five centers have struggled to engage trainees across professions in meaningful ways, uncovering underlying assumptions about students’ readiness for clinical learning. For instance, combining nurse practitioner students who have considerable bedside experience with newly minted physician residents has different consequences than combining novice nurse practitioner students with more advanced medical residents. In both cases, one group will be expected to outperform the other in terms of clinical knowledge and skills, but in neither case is psychological safety and team communication enhanced, potentially reinforcing stereotypes and hierarchies. A more blended approach, including novice and more advanced learners from both professions, may lead to more favorable learning experiences.

Second, interprofessional understanding is required not just on the learners’ side but also among faculty—and this requires active nurturing. For example, the creation of a robust interprofessional curriculum requires a good understanding of each profession’s core values, developmental models, and language. Likewise, interprofessional coprecepting must be preceded by faculty engagement to ensure that all understand the core values and practice roles of the professions involved. All five centers have discovered ways in which commonly used words have different meanings depending on one’s professional perspective. For example, the words “medical” and “medicine” are interpreted by many nurses to imply physician focus, and thus may undermine the interprofessional dimension. Likewise, although physician assistants are generally comfortable with the label of “midlevel provider,” nurse practitioners do not believe that accurately describes their role. Even with due preparation, faculty and staff must be prepared to learn in the workplace, deliberately and actively reflecting in the moment and on their shared experiences to improve collaborative interprofessional practice.

Third, eliciting feedback from learners and academic affiliates—in the spirit of continuous quality improvement—must be built into the process of educational redesign from its inception. Learner feedback allows for more appro priate balancing of learning modalities including participation in direct patient care, didactic sessions, and reflection in and on action. At one center, conversations during the planning stage between VA education leaders and academic affiliates about learning in workplace settings led to new commitments to trainee engagement that exceed the minimums established by accrediting bodies. As a result, nurse practitioner–physician trainee continuity in PACT teamlets was ensured.

Fourth, clinical settings must demonstrate excellence in the interprofessional practice of patient-centered primary care in order to provide an optimal learning environment for engaged learners.19 Among the five demonstration centers, those with more advanced PACT implementation and habits of team-based care have made more substantial progress integrating learners into the workplace as the primary locus of curricular instruction. In contrast, centers with less advanced PACT implementation rely more heavily on didactic instruction and simulation to achieve curricular goals. Regardless of the developmental state of the host site, however, learners of all participating professions are anxious to have more interactions with their counterparts. As such, they are a tremendous resource for transformation.

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The Way Forward

The CoEPCE demonstration project was not designed to assess the benefits of the overall PACT transformation; others are doing so, and reports about overall PACT outcomes are beginning to emerge.20 Rather, it is our intent to emphasize the inherent complexity of education redesign and the critical importance of close coordination and cooperation between the clinical and educational initiatives. The overall VA experience will add to a growing evidence base that health professions education redesign contributes to and benefits from transformation of the clinical practice environment.

Health professions education redesign will require substantive changes in both policy and culture. Professional organizations and health professions accrediting bodies must collaborate to develop a common understanding of professional development across the education–practice continuum of each profession. Without this, achieving interprofessional understanding on mutually interdependent scopes of practice may be haltingly slow. Academic health centers and other sites of clinical learning must begin to move beyond traditional paradigms and incorporate interprofessional education and advance team-based models of care.21

Rapid changes in the U.S. health care system provide new opportunities and significant risks to health professions education. Demonstration projects of the type described here are essential to better define issues and begin to find solutions. For example, the VA is expanding the primary learners for this project to include clinical psychology and pharmacy residents, with the ultimate goal of facilitating adoption of integrated models of learning and practice throughout the VA health care system.

Without new and expanded partnerships between health care delivery systems, the academic community, and the nation’s health professions and policy bodies, the vision of health professions education redesign may remain unrealized. These organizations and the diverse professions they span should collaborate to form a new team—a team able to lead the transformation of U.S. health care to a value-based system centered on improving patient experiences and individual and population health.

Acknowledgments: The authors wish to thank the codirectors of the sites of the Veterans Health Administration Centers of Excellence in Primary Care Education, including Laura A. Angelo, MS, ANP-BC; Rebecca Brienza, MD, MPH; Kameka Brown, MS, MBA, PhD, FNP; Mary Dolansky, RN, PhD; Jill Edwards, APRN, BC, NPI; Susan L. Janson, PhD, RN, ANP-BC, CNS, FAAN; Terry Keene, DNP, FNP-BC, ARNP; Melanie Nash, MSN, FNP, NP-C; Rebecca Shunk, MD; Mimi Singh, MD, MS; C. Scott Smith, MD; Sharon A. Watts, DNP, FNP-BC, CDE; Joyce Wipf, MD; and Susan A. Zapatka, MSN, ANP-BC. They also wish to thank Deborah Ludke, MHA, Laural Traylor, MSW, and Kimberly Uhl, MBA, for their many contributions without which this program could not be possible.

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