Session # E5
Innovations in Interprofessional
Workplace Learning
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India C. King, PsyD, Associate Director for Evaluation and Performance Improvement and
Psychology Faculty, Boise VAMC Center of Excellence in Primary Care Education
Amber K. Fisher, PharmD, BCACP, Co-Director, Boise VAMC Center of Excellence In Primary
Care Education; Pharmacy PGY 2 Ambulatory Care Residency Program Director
William G. Weppner, MD, MPH, FACP, Co-Director, Boise VAMC Center of Excellence in Primary
Care Education; Assistant Professor, University of Washington Department of Medicine
Elena Speroff, DNP-C, WHNP-BC, Associate Director for NP Education, Boise VAMC Center of
Excellence in Primary Care Education
CFHA 18th Annual Conference
October 13-15, 2016  Charlotte, NC U.S.A.
Faculty Disclosure
The presenters of this session have NOT had any relevant
financial relationships during the past 12 months.
Learning Objectives
At the conclusion of this session, the participant will be able to:
• Identify opportunities to use interprofessional
workplace learning activities to meet the
educational and patient care needs of training
clinics.
• Describe shared educational goals across
different healthcare professions.
• Acquire information on the process of
implementation for three workplace learning
programs.
Bibliography / Reference
1.
Kitto, S., Goldman, J., Schmitt, M., & Olson, C. (2014). Examining the intersection between continuing education, interprofessional education and workplace learning.
Journal of Interprofessional Care, 28, 183-185.
2.
Nisbet, G., Lincoln, M., & Dunn, S. (2013). Informal interprofessional learning: an untapped opportunity for learning and change within the workplace. Journal of
Interprofessional Care, 27I, 469-475.
3.
Kuipers, P., Ehrlich, C., & Brownie, S. Responding to health care complexity: Suggestions for integrated and interprofessional workplace learning. Journal of
Interprofessional Care, 28, 246-248.
4.
Weppner, W. G., Davis, K., Sordahl, J., Willis, J., Fisher, A., Brotman, A., Tivis, R., Gordon, T., Smith, C. (2016). Interprofessional care conference for high-risk primary
care patients. Academic Medicine, 91, 798-802.
5.
Wang et al. (2013). Predicting risk of hospitalization or death among patients receiving primary care in the veterans health administration. Medical Care, 51, 368-373.
6.
Grant et al., (2011). Defining patient complexity from the primary care phsycian’s perspective: A cohort study. Annals of Internal Medicine, 155, 767-804.
7.
Bitton, A., Pereita, A., Smith, C., Babbott, S., & Bowen, J. (2013). The EFECT framework for interprofessional education in the patient centered medical home. Health
Care, 1, 53-68.
8.
Edelman, D., Gierisch, J, McDuffie, J., Oddone, E., & Williams, J. (2014). Shared medical appointments for patients with diabetes mellitus: A systematic review. Journal
of Internal Medicine, 30, 99-106.
9.
Kirsh, S., Watts, S., Pascuzzi, K., O'Day, M., Davidson, D., Strauss, G., Kern, E., & Aron, D. (2007). Shared medical appointments based on the chronic care model: A
quality improvement project to address the challenges of patients with diabetes with high cardiovascular risk. Quality & Safety in Health Care, 16(3), 349-353.
10.
Watts, S., Strauss, G., Pascuzzi, K., O’Day,M., Young, K., Aron, D., & Kirsh, S. (2015). Shared medical appointments for patients with diabetes: Glycemic reduction in
high-risk patients. Journal of the American Association of Nurse Practitioners, 27(8), 450-456.
11.
King, G., Shaw, L., Orchard, C. A., and Miller, S. (2010). The interprofessional socialization and valuing scale: A tool for evaluating the shift toward collaborative care
approaches in health care settings. Work, 35(1), 77‐85
Learning Assessment
A learning assessment is required for CE credit.
A question and answer period will be conducted
at the end of this presentation.
Outline
Context
Highlight Three Workplace
Learning Activities
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Overview
Training Objectives
Barriers & Facilitators
Evaluation Status
Conclusion
Questions
Context: Boise VAMC Center of
Excellence in Primary Care Education
Organizational Support for Team-Based
Care
Shared Training Clinic
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Psychology Postdocs & Interns
Internal Medicine Residents
Pharmacy Residents
Nurse Practitioner Residents & Students
Nursing Students & VALOR trainees
Relatively new training programs
CoEPCE Grant Funding
Community Size & Location
It is the mission of the Boise CoEPCE to
bridge professions, bringing people
together to create, teach, evaluate and
improve trainees’ experience and Veterans’
health.
Workplace Learning
Challenging to Define
Interprofessional Working1
• Implicit activities  Explicit knowledge2
• Training based in complexity3
Training Tensions
• Patient care/productivity & education/training experiences
Foster organizational Development & Growth1
Area of Focused Innovation
Innovations in IP Workplace Learning
For Each Activity:
Trainee-Led SMA
Population Health/Panel
Management
Number of Patients
Maturity
Patient Acuity
PACT-ICU
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Overview
IP Training Objectives
Barriers & Facilitators
Evaluation Status
Patient Aligned Care Team
4
Interprofessional Care Update
Training Objectives:
1. Improve care coordination for complex patient needs
2. Increase understanding of interprofessional team member roles
3. Develop the language to speak between professions
4. Learn the skills necessary to participate on an interprofessional
team
PACT ICU Case conference
Overview
• Bimonthly meeting of involved primary care faculty, staff & trainees
• Internal Medicine & Nurse Practitioner PCPs, Pharmacy, Psychology,
RN Care Managers, Social Work services
Coordination
• One RN coordinates patient selection
◦ PCP reviews & selects one patient from highest risk patients from risk registry5 6
• All professions - worksheet for patient review
• Psychology PD pre-calls patient
,
Conference Facilitation
• EFECT model7 as practical approach
• Rotating faculty to facilitate
E licit narrative
F acilitate group
meeting
E vidence-based
gap analysis
C are plan
T rack changes
Results: Educational impacts
Trainee survey question (n=30)
Pre
Post
P-value
“How helpful was the conference in developing a treatment plan?” (1-5)
n/a
4.7
n/a
“My understanding of all the elements (biological, social, psychological) that
must be considered in the patient’s care” (1-5)
2.9
4.5
p<0.001
“My understanding of the roles that each of the team can play in hard to
manage patients like this one.” (1-5)
3.0
4.4
p<0.001
PACT ICU Helpful?
5
80
Changes in Understanding
4
60
3
Before
20
2
After
0
1
40
1 - Not
helpful
12
2
3 Somewhat
helpful
4
5 - Very
helpful
0
Elements
Roles
Results: Behavior change
Total Primary care provider visits over time adjusted
per 100 patients (p=ns)
3
1.5
2.5
2
1
1.5
0.5
1
0.5
0
0
High CAN control
PACT-ICU
Total PACT team visits over time adjusted per
100 patients (p=0.0002)
PACT-ICU: Evaluation Status
Educational outcomes following conference exposure:
• Satisfaction,* self-reported knowledge of interprofessional roles,*
• Consult behavior change(?)
Quality of care:
• Improved hypertension control*
• Trend towards improved glycemic control (?)
Utilization outcomes at 6 months:
• Increased team engagement/encounters with patient;* no increase in primary care visits
• Decreased hospitalizations,* trend towards decreased urgent care/ER visits
Dissemination
• Qualitative study of implementation at 4 other academic PACT settings; other non-training sites
within VA and beyond
* statistically significant compared to high risk controls matched by propensity scores
PACT-ICU: Barriers & Facilitators
Facilitators:
• Focus on appropriate patients
• Relevance to attendees
• Initially weekly, then bimonthly
• Proactive, profession-specific
(but standardized) chart review
• Timing – stage & schedule
• Supervisor/trainee pairing Zone of proximal development
• Continuity & follow-up
• Socialization matters
Barriers:
• Risk prediction
• Resource utilization
• Billing – CCM vs. medical team
conference?
• Frequency & scheduling
• Profession & Staff buy-in
• Facilitation approach
Trainee-Led Shared Medical
Appointments (SMA) Overview
1. Popular in Patient Centered Medical Homes and can show positive
patient and health system outcomes8,9,10
2. The Boise version has a dual focus: patient and trainee learning
outcomes
3. Our product is relatively well-developed, is expanding this year, and
nearly ready for wide dissemination
SMA: Training Objectives
After the conclusion of the SMA series, patients will:
1. Learn about their chronic disease enabling them to improve their selfmanagement skills
2. Set SMART goals for themselves
After the conclusion of the SMA series, trainees will:
1. Help patients develop SMART goals
2. Provide meaningful and useful education to a group of patients in living room
language
3. Be able to manage all aspects of SMA in another setting
SMA: Barriers & Facilitators
Facilitators:
Barriers:
•Excellent learning experience for
IP trainees
•Consumes most of a clinic half
day for multiple clinicians
•Trainees receive an
interprofessional continuity
experience
•Patient recruitment
•Take all patients with diagnosis
who have been engaged by their
primary care provider
•Patients expected to attend all 5
visits
•Pt. decline after visits stop
SMA: Evaluation Status
Interprofessional Socialization and Valuing Scale11
ISVS showed a non-significant trend in positive improvements in the value
participants place on interprofessional work
Working with others
6
5
4
Pre
3
Post
2
1
0
Ability
Value
Comfort
SMA: Evaluation Status
Trainee Focus Group Interviews
1. What did you learn or wish you learned from the SMA experience?
2. What was different about your interactions with patients in the SMA vs. usual
clinic care?
3. What was it like having multiple profession participate in the SMA?
4. How was the training class helpful or not as helpful as you would’ve liked?
5. What general feedback do you have about your SMA experience?
Population Health/Panel
Management (PH/PM)
Quarterly Interprofessional Sessions
• Brief tutorial on registry use + Population Health activities
Primary Care Provider Trainees
• Develop two individual-based interventions
• Create one population-based invention for primary care panel utilizing interprofessional
team
Non-Primary Care Provider Trainees
• Utilizing the registry information, rank primary care providers in order of “greatest need to
population-based intervention”
• Develop and share one population-based intervention with a primary care provider trainee
All Trainees
• Collaboratively discuss population-based interventions
PH/PM: Training Objectives
1. Access and understand disease-specific registry
2. Sort populations based upon various data points
3. Identify current and upcoming gaps in care
4. Differentiate between population and individual based interventions
5. Understand how to utilize an interprofessional team to improve population
health
PH/PM: Barriers & Facilitators
Facilitators:
• Interprofessional Collaboration
• Proactive Care
• Population Health postgraduate accreditation
requirements
Barriers:
• Pre-work & Data-base access
• Scheduling & Productivity
• Engaging both PCP and nonPCP trainees
• Trainee comfort saying “no” to
inappropriate referrals
PH/PM: Evaluation Status
Newest Innovation
Survey responses:
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“That panel management data exists”
“How to use data tool”
“Great way to find patients who have been lost to follow up”
“A little training goes a long way”
“It is valuable to have time to do panel management!”
Future Directions
• Database access tracking
• Changes in panel health markers (A1c)
• Knowledge increase
Conclusion &
Questions
Session Evaluation
Please complete and return the evaluation form
before leaving this session.
Thank you!
Bonus slides
Results: Participation by Profession
Profession
Percent
attended
(N=41)
Medicine
Nurse
Practitioner
Pharmacy
Psychology
Social
Work
Nursing
Chaplain
Other
82%
39%
87%
87%
57%
74%
48%
13%
Participation
100
80
60
40
20
0
Medicine
28
NP
Pharm
Psych
SW
Nursing
Chaplain
Other
Evaluation approach
Prospective observational trial
◦ Team behavior outcomes
◦ PCP encounters – face to face, telephonic and secure messaging
◦ Team encounters – face to face, telephonic and secure messaging
◦ Patient level outcomes
◦ Quality outcomes related to diabetes (BP) and hypertension (Ha1c)
◦ Urgent Care and ER visits, Hospitalizations
◦ 6 months pre/post-PACT ICU conference, 2 month segments to look for trends
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◦
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VA Clinical Data Warehouse
Data collection July 2012 to October 2015
SAS, proc mixed; repeated ANOVA, t-test, Chi2
IRB approved via VA (Puget Sound/Boise VAMC)
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Evaluation sample
128 PACT ICU Patients presented
1/2013 to 8/2015
Died (n=51, 9.1%)
Eventually presented in PACTICU (n=114)
Propensity score – PCP panel,
closest CAN, age, gender
Control pts
n=562
PACT-ICU pts
n=128
Died (n=4, 3.1%)
Controls pts
n=403
PACT-ICU pts
n=124
PACT-ICU
n=105
Controls
n=105
Total for analysis
n=210
30
Repeat presentations
(n=19)
Table 1 - Population
PACT ICU
High Risk Controls
Notes
Number (n)
105
105
Fewer patients with 6
month data
Male (%)
86%
89%
p=0.40
67.1 [12.3]
69.2 [12.6]
p=0.51
22% [14]
21% [14]
p=0.89
Age (mean [SD])
Baseline risk estimate*
(mean [SD])
*Care Assessment Needs score, estimating risk of death/hospitalization in 90 days.
31
Results – PCP & Team visits
Total Primary care provider visits over time adjusted
per 100 patients (p=ns)
3
2.5
2
1.5
1
0.5
0
High CAN control
32
PACT-ICU
3
2.5
2
1.5
1
0.5
0
Total PACT team visits over time adjusted per
100 patients (p=0.0002)
Results – Quality measures – BP
Blood Pressure
(average 60 days prior vs average 60-120 after)
130
120
110
100
90
80
70
60
Systolic PACT-ICU
Systolic Control
Diastolic PACT-ICU
Diastolic Control
33
p=0.004
p=0.06
Pre
125.5
119.9
74.5
67.3
Post
122.6
121.4
73.2
69.1
Results – Quality measures – DM
Hemoglobin A1c
(120 days prior vs 60-180 days after)
9.0
8.5
8.0
p=ns (?)
7.5
7.0
6.5
6.0
PACT-ICU
High Can control
34
Pre
8.5
7.2
Post
7.9
7.6
Results – Urgent Care/ED visits and
Hospitalizations
Urgent Care and ER visits, (p=0.19)
Hospitalizations, (p=0.04)
1
0.5
0.8
0.4
0.6
0.3
0.4
0.2
0.2
0.1
0
0
35
High CAN control
PACT-ICU
Evaluation of IPE interventions
1. Institute of Medicine. Measuring the impact of interprofessional education on
collaborative practice and patient outcomes. April 22, 2015 http://nap.edu/21726