Advancing Integrated Primary Care Education in

the VA Medical SystemKendra Campbell, Ph.D.

Assistant Professor of PsychologyUniversity of Alaska Fairbanks

Daniel Baughn, Ph.D.Staff Psychologist, PCMHI

James A. Haley Veterans’ Hospital

Rebecca Shunk, M.D.Co-Director, Center of Excellence in Primary Care Education,

Associate Director of PRIME Program, UCSF Internal Medicine Residency

Eleni Romano, Ph.D.Primary Care Psychology FellowSan Francisco VA Medical Center

Objectives for Today

• Provide overview of EdPACT• Educational domains

• Report preliminary outcomes• Challenges/Next Steps• Discussion/Q&A

Patient Aligned Care Teams (PACT)• Team-based patient-centered model of care

• 1200 patients per team • Teamlet- Primary Care Provider, Registered Nurse, Licensed

Vocational Nurse and Clerical Associate• Practice Changes

• Panel Management• Pre-visit planning• Huddles• Shared Medical Appointments/Group Clinics• Walk-in appointments• Telephone appointments• Secure Messaging• Health Coaching

Diabetes Shared Medical Appointments

VA Centers of Excellence (COE)• Criteria:

• Transformative, generalizable, sustainable, and interprofessional primary care training

• Must include MD & NP trainees• COE awards:

• Up to $1 M/yr x 5 years, exclusive of any new trainee positions

• 5 COEs• Cleveland, San Francisco, West Haven, Boise, and Seattle

Mission of EdPACT:To develop and implement an inspirational model of patient-centered, interprofessional education that will advance primary care within and beyond the VA

Joint effort with:• UCSF School of Nursing• UCSF School of Medicine • Office of Medical Education

StructurePrimary care training in a team-based, PCMH model• Practice partnership

model• Each trainee has

his/her own panel and cross-covers partners’ patients

• Interprofessional trainees support multiple trainee teamletsTeamlet

Dietetics

Social Work

Psychiatry

Pharmacy

NP student

Medicine

R2

Medicine

R2

Psychology

Health Professions Trainees

EdPACT ParticipantsCore EdPACT trainee teams:• Internal Medicine residents (two PGY-2 partners)• Adult NP students from UCSF (1 per pair of MD partners)• Additional interprofessional trainees:

• Clinical pharmacy, social work, psychology fellows, podiatry, nutrition, medical students, optometry, audiology, psychiatry

Teamlets:• LVN, RN, ClerkPreceptors & Educators:• Longitudinal MD & NP preceptors• Clinical psychology faculty & fellows• Experts in communication, teamwork, performance improvement• Additional health professionals– podiatry, social work, pharmacy,

nutrition

Educational Domains of EdPACT

• Shared Decision-Making

• Sustained Relationships

• Interprofessional Collaboration

• Performance Improvement

Curricular Content: Interprofessional Collaboration

DidacticsInteractive small group seminars:

HuddlingTeam Members Roles

Handoff communicationFeedback

Conflict ResolutionDebriefing

Workplace reinforcement:Huddling

Huddle Coaches

Preceptors reinforce skills and provide feedback during huddles

Teams engage in formative assessment processes

ReflectionHalf-day retreat:Team building

Opportunities to reflect

Identifying similarities and differences

Nuts & Bolts of MH Integration

• Didactics• Shared Decision Making

• Motivational Interviewing

• Case Conferences• Diabetes Board• Collaborative Care Conference

• Physical Proximity• Huddles/Huddle Checklist

• Shared Medical Appointments

• Team Development Retreat

• Groups (Stress Management, Pain, Tobacco)

Interprofessional Communication -Huddles

Barriers to PC-MH Integration• Limited facility space• Increasing MH trainees/staff contact in exam room

• Staff turnover and scheduling complexity• Cross discipline/specialty MH understanding of integrated care

• Culture change/ paradigm shifts

Measuring OutcomesProgram Component Data SourceCurriculum • Session evaluations

Learners • Learner Perception Survey (LPS-PC)• Interviews• Patient-Provider Continuity

Faculty / Preceptors • Interviews• Mid & End of year surveys

Staff • Maslach Burnout Inventory (MBI)

Teams • Team Development Measure• Interviews• Huddle Observations• Team-Patient Continuity

Patients • Patient Surveys (CAHPS)• Interviews

Systems • QI project status

Team Development Results: Years 1 & 2

STAGE SCORE COMPONENTS SOLIDIFICATION

Pre-team 0-36 None to Building

1 1-46 Cohesiveness

In Place2 47-54 Communication

3 55-57 Role Clarity

4 58-63 Goals-means Clarity

5 64-69 Cohesiveness

Firmly In Place

6 70-77 Communication

7 78-80 Role Clarity

8 81-86 Goals-means Clarity

Fully Developed 87-100 Everything

www.peacehealth.org/about-peacehealth/medical-professionals/eugene-springfield-cottage-grove/team-measure/Pages/Default.aspx Last Accessed 1/12/2012.

Fall(Aug/Sept)

Spring(Mar/Apr)

Yr 1 - Trainee Teams: 59.4

Yr 1 - Trainee Teams: 64.6Yr 2 - Trainee Teams: 62.2

Yr2 - Trainee Teams: 70.3

Team Development Scores by TeamFall 2012 to Spring 2013

Team 1 Team 2 Team 3 Team 4 Team 5 Team 6 Team 7 Team 8 Team 9 Team 100

10

20

30

40

50

60

70

80

90

100

5548

82

6369

6659 60

56

6460

56

76 74

88

55

8178

73

64

Aug/Sept 2012 Mar/Apr 2013R2-NP student Teams (Fall and Spring)

TD

M S

core

s (0

- 100

)

Outcomes: Patient Satisfaction, 2011-12

R2s NP StudentsSFVA Outpatient

Clinic FY12 YTD Qtrs1-3

  N % Usually or Always N % Usually

or Always N % Usually or Always

How often did this provider explain things in a way that was easy to understand?

241 95% 73 97% 304 89.1%

How often did this provider listen carefully to you? 241 94% 73 100% 304 90.0%

How often did this provider show respect for what you had to say? 242 96% 72 100% 299 91.7%

How often did this provider seem to know the important information about your medical history?

238 94% 72 94%

• Surveys returned by 244 R2 patients and 73 NP student patients • 18% Response Rate, on average, for R2s and NP students

Outcomes: Patient Satisfaction, 2011-12

R2s NP StudentsSFVA Outpatient

Clinic FY12 YTD Qtrs1-3

  N % 9 or 10 N % 9 or 10 N % 9 or 10

Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate this provider?

242 73% 74 76% 310 68.1%

  N % Definitely Yes N % Definitely

Yes    

Would you recommend this provider to your family and friends? 242 79% 74 89%    

Next Steps• Dissemination of our work/ Demonstrating benefit of EdPACT and PCMHI overall

• Implementation of PCMHI to VA Community- Based Clinics

• Americorps participants- health behavior coaches

• Increasing motivational interviewing/shared decision making/ other behavioral health topics into curriculum

Discussion

• Implementing change in primary care/ integrated health education within and outside of VA medical system

• Setting-based differences

• Directions for future growth/applications of current model

Thank You