Emergence of the patient-centered medical home (PCMH) has challenged medical educators to develop curricula addressing the skills and knowledge needed to work effectively in interprofessional (IP) health care teams.1 While descriptions of goals related to IP education exist, implementing opportunities for such collaboration in the actual workplace has been difficult.2 Given evidence of the efficacy of primary care education initiatives to improve services and delivery of care,3 the development of curricula addressing the needs of health care providers in IP settings is imperative. Additionally, training targeting the development of specific skills for team functioning and providing IP care to high-risk patients is rare.2
We believe that using “high-risk” patients as a conduit to focus the IP team on explicit, collaborative, team-based care is a novel way to teach trainees about the roles of others on IP teams. Care conferences that focus on such patients allow team members to take responsibility for their part in caring for complex patients and to work together collaboratively.
Recently, health care professionals have suggested the EFECT model (“Elicit the narrative of illness, Facilitate a group meeting, Evidence-based gap analysis, Care plan, and Track changes”) as a framework for IP education in the PCMH.4 The EFECT model focuses explicitly on the patient’s context and narrative of illness—both important aspects of care for high-risk patients.
To investigate the feasibility and initial educational impact of a high-risk patient care conference (based on the EFECT model) as a vehicle for improving opportunities for IP workplace learning opportunities for trainees, we developed the Patient-Aligned Care Team Interprofessional Care Update (PACT-ICU) conference. Here we describe the implementation of the PACT-ICU conference—an innovation to address the needs of high-risk patients while providing IP education for trainees—at the Boise Veterans Affairs Medical Center.
Setting and initiative
The Boise VA is one of five VA Centers of Excellence in Primary Care Education (CoEPCE) developing and testing educational programs to prepare health professions trainees to work together on an IP team in primary care.5,6
We developed the PACT-ICU in 2012 within the CoEPCE’s teaching clinic which serves as the training site for 32 physician residents, 4 nurse practitioner (NP) students and residents, 5 clinical psychology interns and postdoctoral fellows, 5 pharmacy residents, and other trainees annually. The teaching clinic serves approximately 2,400 patients each year. This clinic operates as an IP academic PACT (patient-aligned care team), which is the VA’s version of a teaching PCMH clinic.
The PACT-ICU conference is a regularly scheduled meeting designed to improve trainees’ knowledge of IP collaboration and to facilitate proactive, coordinated PACT-based care. On a weekly basis, two trainees from either the physician or NP program each present one patient (two total patient presentations). Physician trainees participate during a two-week clinic block, alternating with six weeks of wards or electives in a “6+2” clinic schedule. NP trainees are in clinic part-time each week throughout the year of their postgraduate training program, and present approximately every two to four months. All physician and NP trainees participate in the PACT-ICU, but new trainees (interns and NP students) do not present until the second half of the year, after they have participated as observers in the conference. Other participants include pharmacy residents, postdoctoral psychology fellows, nursing, and social work students. Trainees are typically accompanied by their supervisor to the conference.
A registered nurse (RN) care manager from the teaching clinic uses a Web-based7 schedule to organize selection and review of patients; the Web site provides worksheets, guidance, sample recommendations, and a participant survey. A week before the conference, the organizing RN gives each presenting trainee a list of their top-five highest-risk patients from the VA-based Care Assessment Needs registry, which predicts 90-day risk of death or hospitalization.8 From this list, the presenting trainee selects one patient whom they feel is appropriate for presentation based on current needs, risk of deteriorating status, and potential responsiveness to an IP care plan.
The patients to be presented are shared with members of the team who perform a standardized chart review prior to the conference. Others involved in the patients’ care outside of the PACT (e.g., subspecialist consultants, home health care providers, wound care or rehabilitation specialists) may also be invited to the meeting, based on presenter request. Participants are encouraged to use a standardized worksheet from the clinic Web site7 to identify the patients’ strengths, needs, and gaps in care; this worksheet is attached to a secure reminder e-mail with the patient identifier.
A typical PACT-ICU case presentation begins with agenda setting and review of the EFECT model by RN and physician facilitators. Each presenting provider trainee then provides a five-minute update on the patients presented the previous week, as well as those patients’ engagement in the proposed care plan (updates on patients are again presented approximately two months after their initial presentation to follow up on care plan recommendations). Next, the trainee presents the current patient. For example, a second-year internal medicine resident presented a relatively typical patient who had multiple chronic illnesses and difficulty engaging in his care:
Mr. X is a 68-year-old gentleman with a history of diabetes mellitus type 2, difficult-to-control hypertension, severe obstructive sleep apnea, hyperlipidemia with a history of rhabdomyolysis, bipolar disorder, and chronic pain from progressive diabetic neuropathy, which has prompted repeat [emergency room] visits. Based on our last clinic visit, I know that he wants to work on improving his mobility and dealing with the stress of his chronic illnesses; he is the caregiver for his wife who is on dialysis, and [he] often neglects his own care in support of hers. I would like help from the PACT ICU team in addressing the following issues:…
Following the brief patient presentation, the facilitator helps to clarify any jargon or complex medical conditions, and again reiterates the patient’s motivation for seeking care. The facilitator then starts a discussion, soliciting input from, in turn, nursing staff who may know the patient from clinic visits and phone calls; pharmacy trainees regarding the patient’s medication regimens and opportunities to facilitate adjustment of these; and psychology trainees regarding options for treatment and strategies for the primary care provider to elicit patient values and motivate meaningful change. Other service providers are welcome to provide input, and each trainee’s supervisor has the opportunity to refine suggestions and to discuss how care can be delivered from his or her profession’s point of view. This discussion allows supervisors to model not only conversations with the patient/caregiver but also approaches to holding effective dialogues with personnel from different professions to improve collaboration.
At the end of the conference, the physician facilitator assists the presenting physician or NP trainee in summarizing the care plan and identifying specific action items for each member of the team. In addition to physician or NP interventions, action items commonly address a full range of biopsychosocial needs and often include pharmacy, social work, and behavioral health referrals. Action items may entail coordinated future visits with “warm” (in-person) handoffs between caregivers, nurse care management coordination, and, when appropriate, nontraditional forms of care provision (e.g., home telemonitoring, telephone visits, secure messaging).
The PACT-ICU conference, including the action items, is summarized in a chart note, which participating members review and co-sign electronically. Appendix 1 shows the notes from the case presented above.
To assess the early outcomes of our PACT-ICU initiative, we recorded patient characteristics, plus trainees’ participation and satisfaction. We recorded attendance and (through a survey) asked trainees who participated in PACT-ICU how helpful they found the conferences in forming a treatment plan; possible responses ranged from 1 (“Not helpful”) to 5 (“Very helpful”). We obtained institutional review board (IRB) approval through the VA Puget Sound Health Care System IRB. The outcomes presented below include 16 months’ worth of data collected between the implementation of the initiative on January 24, 2013, and near the end of the following academic year on April 24, 2014.
Over the first 16 months of the PACT-ICU, 33 trainees (internal medicine resident physicians or NPs) presented 79 patients. Each trainee presented two or three times each academic year. The patients were 90% male; their mean age was 64.5 years (standard deviation [SD] 9.3, range 28–92), and their mean calculated 90-day risk of death or hospitalization was 22% (SD 14%, range 1%–45%).
Participation by supervisors and trainees of different disciplines was consistent; specifically, the core disciplines of internal medicine, pharmacy, psychology, and nursing were present at more than 70% of the PACT-ICU conferences. NP levels were lower because of a smaller number of NP trainees rotating less frequently through the PACT-ICU conferences. All of the trainees responding to the survey (n = 32 [97%]) reported that the conferences were either “very helpful” (69%) or “helpful” (31%) in developing a treatment plan.
Overall, according to the free-text comments provided on surveys, trainees expressed satisfaction with the PACT-ICU conference and appreciated the opportunity to leverage it to explore other means of improving patient care. Helping one another to facilitate patient behavior change was a particularly positive experience for trainees. To illustrate, one medical resident expressed difficulty in helping a patient modify his (the patient’s) lifestyle. During the conference, psychologists identified an opportunity to help the resident improve her (the resident’s) motivational interviewing skills. The PACT-ICU conference led to a patient visit during which the psychology fellow was able to demonstrate motivational interviewing techniques for the resident. Similarly, other conferences led to shared visits during which pharmacists and psychologists together helped patients with diabetes and depression.
The PACT-ICU provides a unique venue through which supervisors can counsel trainees from different programs on the roles and responsibilities of IP team members. The PACT-ICU model provides a structured approach to discussing each patient—that is, a template for careful, personalized analysis of each case. The model also suggests possible approaches for evaluating trainees’ knowledge, attitudes, and behaviors.
Through our implementation of the PACT-ICU, we learned several important lessons. First, involving co-leaders from different disciplines (in this case nursing and medicine) to coordinate and facilitate the group discussion is important—not only for better IP functioning but also for modeling IP behaviors to trainees (see Table 1). Next, taking the time to identify each conference participant by name, discipline, and academic level and allowing at least one representative from each discipline to report findings helps reinforce team roles and encourages meaningful review and participation. Following up on patients’ progress with a brief 5- to 10-minute update at one week and again at two months helps provide continuous feedback and accountability to care plans. Finally, and perhaps most important, we learned the importance of developing a transparent care plan that includes recommendations for specific action items by different members of the team (see Appendix 1). Such a plan allows trainees to “share the care” of complex patients in a coordinated manner, allowing representatives from different disciplines to have ownership from their own professional area of expertise.
The restructuring of the U.S. health care system has led to an increased demand for IP training to plan the care for high-risk patients.1 There is a need for IP education practices that teach health profession trainees why and how to work with one another as members of a comprehensive patient-centered care team.1–3 Augmenting didactic presentations about the roles and responsibilities with workplace learning experiences is vital. To address this gap in primary care education, we developed an innovation focused on an IP care conference, the PACT-ICU, which targets high-risk patients in primary care and emphasizes developing transparent, actionable care plans.
The results of our early evaluation demonstrate the effectiveness of an innovative patient-centered conference for enhancing trainees’ experience in IP care and, potentially, for producing more comprehensive patient care plans. While IP care conferences are of interest in academic internal medicine clinics and have shown improved trainee satisfaction9 and quality of care,10 implementation and evaluation can be difficult.
The results of our evaluation must be considered within the limitations of our small sample size, the use of a study-created satisfaction measure, and the single-site location. To address some of these limitations, we plan to continue the initiative, to extend it to other academic primary care clinics, and to evaluate the effects of the PACT-ICU on trainee knowledge and behaviors, quality of care, utilization patterns, and patient outcomes.
Overall, we feel that IP care conferences such as the PACT-ICU show much potential for improved educational outcomes, more IP collaboration, and improved patient care.
Acknowledgments: The authors wish to acknowledge the feedback from Dr. Stuart Gilman from the Coordinating Center for the VA Centers of Excellence in Primary Care Education, and their colleagues at the four other collaborating Centers of Excellence at the Cleveland VA, New Haven VA, San Francisco VA, and VA Puget Sound Veterans Health Care System.
1. Interprofessional Education Collaborative Expert Panel. Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. 2011. Washington, DC: Interprofessional Education Collaborative; http://www.aacn.nche.edu/education-resources/ipecreport.pdf
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2. Institute of Medicine. Interprofessional Education for Collaboration: Learning How to Improve Health From Interprofessional Models Across the Continuum of Education to Practice: Workshop Summary. 2013.Washington, DC: National Academies Press.
3. Hammick M, Freeth D, Koppel I, Reeves S, Barr H. A best evidence systematic review of interprofessional education: BEME guide no. 9. Med Teach. 2007;29:735751.
4. Bitton A, Pereira AG, Smith CS, Babbott SF, Bowen JL; Society of General Internal Medicine Patient-Centered Medical Home Education Summit. The EFECT framework for interprofessional education in the patient centered medical home. Healthc (Amst). 2013;1:6368.
5. Gilman SC, Chokshi DA, Bowen JL, Rugen KW, Cox M. Connecting the dots: Interprofessional health education and delivery system redesign at the Veterans Health Administration. Acad Med. 2014;89:11131116.
6. U.S. Department of Veterans Affairs, Office of Academic Affiliations. VA Centers of Excellence in Primary Care Education (CoEPCE). 2015. http://www.va.gov/OAA/coepce/index.asp
. Accessed January 21, 2016.
7. Center of Excellence Boise VA Medical Center. PACT ICU. 2016. http://boisevacoe.org/pact-icu/
. Accessed January 21, 2016.
8. Wang L, Porter B, Maynard C, et al. Predicting risk of hospitalization or death among patients receiving primary care in the Veterans Health Administration. Med Care. 2013;51:368373.
9. Dattalo M, Nothelle S, Tackett S, et al. Frontline account: Targeting hot spotters in an internal medicine residency clinic. J Gen Intern Med. 2014;29:13051307.
10. Janson SL, Cooke M, McGrath KW, Kroon LA, Robinson S, Baron RB. Improving chronic care of type 2 diabetes using teams of interprofessional learners. Acad Med. 2009;84:15401548.
Appendix 1 Example of Trainee Primary Care Provider Documentation From PACT-ICU Conference
Veteran was discussed in PACT-ICU by multidisciplinary conference. Issues explored were his history of psychiatric illness, impulsivity/inattention, current social stressors, and the impacts on management of his T2DM, HTN and OSA, and frequent ER visits. Lately he is making great progress with his blood glucose control with the help of the pharmacy insulin titration clinic, but has been inconsistent with blood pressure and did not follow through with consults for sleep medicine and screening colonoscopy. He continues to struggle with chronic pain in his feet which he attributes to inappropriate orthotics.
Called veteran today to discuss recommendations related to the above issues. He continues to be under a great deal of stress regarding his family relationships and doesn’t feel that he can attempt too many changes right now. However, he would like to focus on his mental health and agrees to the following plan below:
- #1. Determine appropriate plan for regular mental health follow-up: Veteran agrees to see psychiatrist as recommended by PACT-ICU; Dr. [Behavioral Health Provider] to facilitate referral.
- #2. Hypertension: Pharmacy suggesting starting amlodipine as next agent, potentially BID furosemide as next agent if leg swelling worsens. Veteran agrees to start amlodipine; I will order this for mail-out today. We will consider referral to pharmacy hypertension clinic to facilitate medication adjustment. Also, see OSA discussion below.
- #3. Case management consult for home health medication management: Veteran agrees to initial visit, RN care manager to facilitate.
- #4. Foot pain/neuropathy: Discussed chronic pain group as recommended by PACT-ICU; veteran is not open to this currently. I will refer to podiatry to review options.
- #5. Obesity: Discussed referral to clinic weight loss program; veteran not open to this now; reports making progress exercising independently.
- #6. Obstructive sleep apnea: veteran agrees to follow up with sleep clinic for updated equipment. Behavioral health to schedule visit to discuss strategies to tolerate mask, as recommended in PACT-ICU.
- #7. Colon cancer screening: lower priority; per patient request, will discuss at next clinic visit; consider motivational interviewing.
- #8. ER visits: Discussed strategies to better access clinic team; RN care manager will call in two weeks to follow up on care plan; veteran also instructed on how to sign up for secure messaging feature for nonurgent issues.
Abbreviations: PACT-ICU indicates Patient-Aligned Care Team Interprofessional Care Update; T2DM, type 2 diabetes mellitus; HTN, hypertension; OSA, obstructive sleep apnea; ER, emergency room; BID, twice-a-day medication dosing; RN, registered nurse.