Many outpatient clinics where health professionals train will transition to a team-based medical home model over the next several years. Therefore, training programs need innovative approaches to prepare and incorporate trainees into team-based delivery systems. To address this need, educators at the San Francisco Veterans Affairs (VA) Medical Center included trainees in preclinic team "huddles," or briefing meetings to facilitate care coordination, and developed an interprofessional huddle-coaching program for nurse practitioner students and internal medicine residents who function as primary providers for patient panels in VA outpatient primary care clinics. The program aimed to support trainees' partnerships with staff and full participation in the VA's Patient Aligned Care Teams. The huddle-coaching program focuses on structuring the huddle process via scheduling, checklists, and designated huddle coaches; building relationships among team members through team-building activities; and teaching core skills to support collaborative practice. A multifaceted evaluation of the program showed positive results. Participants rated training sessions and team-building activities favorably. In interviews, trainees valued their team members and identified improvements in efficiency and quality of patient care as a result of the team-based approach. Huddle checklists and scores on the Team Development Measure indicated progress in team processes and relationships as the year progressed. These findings suggest that the huddle-coaching program was a worthwhile investment in trainee development that also supported the clinic's larger mission to deliver team-based, patient-aligned care. As more training sites shift to team-based care, the huddle-coaching program offers a strategy for successfully incorporating trainees.
Interprofessional case conferences (ICCs) offer an interactive, practical way to engage members of two or more health professions in discussions that involve learning and working together to improve patient care. Well-orchestrated ICCs provide opportunities to integrate interprofessional (IP) education into routine clinical practice. The authors provide 12 tips to support the conceptualization, planning, implementation, facilitation, evaluation, and sustainability of ICCs. They draw from extensive experience as IP educators and facilitators of ICCs and from literature on IP education, case-based learning, small-group facilitation, peer-assisted learning, and learner engagement - all of which offer insights into ICCs but have not been integrated and applied to this context.
Health care systems expect primary care clinicians to manage panels of patients and improve population health, yet few have been trained to do so. An interprofessional panel management (PM) curriculum is one possible strategy to address this training gap and supply future primary care practices with clinicians and teams prepared to work together to improve the health of individual patients and populations. This paper describes a Veterans Administration (VA) sponsored multi-site interprofessional PM curriculum development effort. Five VA Centers of Excellence in Primary Care Education collaborated to identify a common set of interprofessionally relevant desired learning outcomes (DLOs) for the PM and to develop assessment instruments for monitoring trainees' PM learning. Authors cataloged teaching and learning activities across sites. Results from pilot testing were systematically discussed leading to iterative revisions of curricular elements. Authors completed a retrospective self-assessment of curriculum implementation for the academic year 2015-16 using a 5-point scale: contemplation (score = 0), pilot (1), action (2), maintenance (3), and embedded (4). Implementation scores were analyzed using descriptive statistics. DLOs were organized into five categories (individual patients, populations, guidelines/measures, teamwork, and improvement) along with a developmental continuum and mapped to program competencies. Instruction and implementation varied across sites based on resources and priorities. Between 2015 and 2016, 159 trainees (internal medicine residents, nurse practitioner students and residents, pharmacy residents, and psychology post-doctoral fellows) participated in the PM curriculum. Curriculum implementation scores for guidelines/measures and improvement DLOs were similar for all trainees; scores for individual patients, populations, and teamwork DLOs were more advanced for nurse practitioner and physician trainees. In conclusion, collaboratively identified DLOs for PM guided development of assessment instruments and instructional approaches for panel management activities in interprofessional teams. This PM curriculum and associated tools provide resources for educators in other settings.
Health professionals must demonstrate competencies in quality improvement (QI) and interprofessional (IP) practice. Yet few curricula are designed to address these competencies in an integrated, longitudinal way. Our experiential IP QI curriculum addresses this gap.The IP QI curriculum was part of a San Francisco VA Health Care System training program for second-year internal medicine residents and adult gerontology primary care nurse practitioner students, pharmacy residents, and postdoctoral psychology fellows. Trainees worked in mentored IP teams to select, design, implement, evaluate, and present a project as part of a 9-month curriculum. Teaching methodologies included didactics and project-based skills application. Curriculum evaluation included trainees' QI knowledge and skills self-assessments, trainee satisfaction, mentor appraisals, and project results and impact assessments.From 2011-2012 to 2017-2018, 242 trainees completed the curriculum and 41 QI projects. Trainees reported high satisfaction with the introductory sessions (M = 4.4, SD = 0.7). They also reported improvement in comfort with QI knowledge and skills by the curriculum's completion. QI mentors (n = 23) observed growth in trainees' QI knowledge and skills, felt confident in trainees' ability to orchestrate a QI initiative, and believed their mentored QI projects added value to the organization. Thirty-eight projects resulted in system modifications.This IP QI curriculum offers team-based, workplace experiences for trainees to learn and apply QI knowledge and skills. Leading factors for successful implementation included attention to team-building and faculty development. Challenges included reliably collecting evaluation data, accurately measuring ongoing systems changes, and variable trainee engagement.
ABSTRACT Background Providing a robust continuity clinic experience is difficult due to uneven distribution of resident time. Immersion experiences early in training may improve residents' learning experiences. Objective We designed and implemented a continuity immersion experience to improve internal medicine interns' satisfaction and confidence with their outpatient skills, and we evaluated the timing of the experience and its benefits for learners. Methods Two cohorts of interns at 1 academic institution participated in a 3-week immersion block (during the first or second quarter of the intern year). Interns were surveyed twice about satisfaction and confidence. Analysis included independent and paired sample t tests to compare interns' responses pre- and postimmersion, and to evaluate effects over time. Results A total of 124 interns completed the immersion, with a survey response rate of 61%. Interns' self-rated confidence on a 5-point Likert scale improved significantly compared with preimmersion in the areas of medical knowledge and confidence with their electronic health record and communication skills (P ≤ .010 for all assessments). Interns reported high satisfaction with continuity clinic following immersion (cohort 1: 4.5 ± 0.54; cohort 2: 4.3 ± 0.68; on a 5-point scale with 5 = very satisfied). Improvements in knowledge, skills, and satisfaction in cohort 1 were sustained over 3 months. Conclusions A 3-week immersion experience in the first 6 months of residency improved interns' confidence in ambulatory content areas and satisfaction with clinic.
Abstract Background Although residency programs must prepare physicians who can analyze and improve their practice, practice improvement (PI) is new for many faculty preceptors. We describe the pilot of a PI curriculum incorporating a practice improvement module (PIM) from the American Board of Internal Medicine for residents and their faculty preceptors. Methods Residents attended PI didactics and completed a PIM during continuity clinic and outpatient months working in groups under committed faculty. Results All residents participated in PI group projects. Residents agreed or strongly agreed that the projects and the curriculum benefited their learning and patient care. A self-assessment revealed significant improvement in PI competencies, but residents were just reaching a “somewhat confident” level. Conclusion A PI curriculum incorporating PIMs is an effective way to teach PI to both residents and faculty preceptors. We recommend the team approach and use of the PIM tutorial approach especially for faculty.
In response to the national epidemic of prescription opioid misuse and related adverse outcomes, two clinical pharmacists developed a telephone risk assessment clinic to promote safe opioid prescribing through a monthly assessment of patient medication use, aberrant behaviors, and side effects.A pilot group of five primary care providers and their patients with chronic nonmalignant pain on chronic opioid therapy, defined as having received prescription opioid medications for ≥90 days in the last 120 days, were identified. A risk assessment evaluation based on Veterans Health Administration/Department of Defense Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain was created. Factors assessed were receipt of non-San Francisco Veterans Administration Health Care System controlled substance prescriptions through California's prescription drug monitoring program, urine drug test (UDT) results, and aberrant behaviors. Pharmacist-recommended changes to regimen and provider response to recommendation were compiled. The pilot was conducted from December 15, 2014, to March 31, 2015.Among 608 patients on chronic opioid therapy, 148 were assigned to pilot providers and 447 assessments were completed. Twenty-five (16.8%) patients had non-VA controlled substance prescriptions, of which 14 (56.0%) patients filled a non-VA controlled substance within 3 months of the start of pilot. Seventeen UDT results inconsistent with their prescribed regimens were identified from 12 patients (8.1%). Pharmacists recommended 66 changes to chronic opioid prescriptions in 48 patients (32.4%), including decreasing quantity of opioid(s) (33.3%), discontinuing chronic opioid therapy (22.7%), and delaying a fill (19.7%). Sixty-one of 66 (92.5%) pharmacist recommendations for regimen change were implemented by providers. Chronic opioid therapy was discontinued in 14 (9.5%) patients over the course of the pilot study.A pharmacist-led telephone risk assessment clinic improved adherence to clinical guidelines and changed opioid prescribing practices in more than one third of assessed patients.
Teams are critical to managing the health care needs of patients with part-time trainee providers. High-functioning teams require trusting relationships among trainees and staff and opportunities to learn and practice skills together. Irregular trainee schedules, time-limited training programs, and lack of protected time for team development during clinic can hinder development of high-functioning teams.To provide time for team development, we created an annual half-day team retreat for interprofessional trainees and staff at three San Francisco Veterans Affairs primary care clinics. We used principles of high-functioning teams and relationship-centered communication to develop retreat content, then trained interprofessional faculty members to facilitate and role-model this content. Retreat objectives and content focused on building relationships, establishing team goals, clarifying roles, and learning communication skills. Postretreat surveys and qualitative content analysis of comments and team goals evaluated retreat objectives and opportunities for improvement.Between 2011 and 2017, 16 team retreats were attended by 232 interprofessional trainees and 77 unique staff (some attended multiple times). Thirty-seven faculty facilitated. Most participants strongly agreed that they knew their team members better personally and professionally after the retreat (M = 4.7 out of 5, n = 368); 78% of teams (n = 65) submitted SMART goals addressing high-functioning teams. Participants' comments consistently reflected the benefits of protected time for team building.This team retreat supports team development among trainees and staff on primary care teams by promoting relationship building, role clarity, communication, and team processes. It can be valuable for all interprofessional participants.
This project aimed to reduce the number of high-risk patients prescribed insulin and/or sulfonylurea with glycated haemoglobin (HgbA1c) <7% in San Francisco Veterans Affairs Health Care System Medical Practice Clinic (SFVAHCS MPC).
Diabetes is a common disease where tight glycaemic control as assessed by HgbA1c must be balanced with the inherent risk of hypoglycaemic events caused by medications like sulfonylureas and insulin.1–3 In a previous study conducted in US veterans, a lower HbA1c of 6.9% compared with 8.4% had minimal impact on improving health, while increasing risk of at least one hypoglycaemic event (8.5% vs 3.1%).4 Elderly patients, especially those with cognitive or renal impairment, are at highest risk of hypoglycaemic events, which often result in decreased quality of life, loss of consciousness, seizures and altered mental status.5 6 Insulin (13.9%) and oral hypoglycaemic agents (10.7%) were among the four most commonly implicated medications requiring hospitalisations for adverse drug reactions.5 Recently, the Veterans Affairs (VA) adapted recommendations from the American Diabetes Association and the American Geriatrics Society’s Choosing Wisely initiative to avoid using these medications in high-risk patients with HbA1c <7.0%.7 8 Unfortunately, healthcare systems lack clear guidelines on how to enact these recommendations.
A total of 62 patients were identified November 2016 using an internal VA clinical performance dashboard. Eligible patients received primary care at SFVAHCS MPC, had diabetes, were prescribed insulin and/or sulfonylurea, had an HgbA1c 7% (n=8), no longer receiving primary care at SFVAHCS MPC (n=3) and death (n=2). A total of 28 patients met inclusion criteria. Patients …
