by (photos from left) Bridget O’Brien, PhD, Rebecca Shunk, MD, Susan Janson, DNSc, RN, ANP-BC, CNS, AE-C, FAAN, Maya Dulay, MD (no photo) Shalini Patel, MD, and Jessie Coty, RN, BSPH, MEM (no photo)
Mr. Parks is a Vietnam War Veteran who was diagnosed with diabetes five years ago. On a Thursday morning at 10am, he receives a call from his nurse, Debbie. She knows this is the best time to catch him and she keeps him accountable for checking his glucose and taking his insulin regularly. Today she also orders his HGA1C and fasting lipids and reminds him about his appointment in three weeks with Dr. Alvarez, his resident physician, and Gary, the clinic dietician. One week prior to his appointment Mr. Parks receives a call from Ella, his LVN, who asks his agenda for the visit and reminds him to get his fasting labs beforehand. The day of the visit the teamlet briefs Dr. Alvarez about Mr. Parks’ agenda at the morning huddle.
Mr. Parks' experience may sound unusual if you are accustomed to “traditional” primary care in which a busy group of providers handle all follow up care and, as a result, important messages sometimes fall through the cracks. In fact, Mr. Parks' example reveals a whole new way of doing primary care in the VA.
In less than one year the VA Medical System has embraced the patient-centered medical home (PCMH) as both a concept and, more impressively, as an up-and-running system of patient care in its primary care clinics nationwide. By the summer of 2011, Patient Aligned Care Teams (PACTs) and teamlets were ‘huddling’ on a regular basis to improve coordination and continuity of care for their assigned panels of patients. These teamlets consist of primary providers (MDs and NPs), Registered Nurses (RNs), Clinical Associates (LVNs, LPNs), and Clerical Associates. In addition, teams of associated health professionals (social workers, mental health providers, nutritionists/dieticians, podiatrists, clinical pharmacists) were providing integrated services in VA primary care clinics and working closely with teamlets to support patient care.
Often major system redesign efforts such as PCMH and PACT have implications for the education of trainees in the health professions, but rarely is there an explicit effort to incorporate the trainees into the change process. For example, it would not be uncommon in a VA primary care clinic for teamlets to huddle every morning with attending physicians and nurse practitioner primary care providers to review the schedule for the day and discuss any important patient concerns or needs. Although residents and NP students are the primary provider for their panel patients, they would not be asked to huddle with a teamlet because the process is new and changing, trainee panels are small, and the trainees and teamlets are pressed for time. This is a missed opportunity for the residents to learn experientially about systems-changes and practice-based improvement.
Fortunately, VA leadership recognized PACT as a golden educational opportunity. VA primary care clinics around the country provide training sites for a substantial number of residents, NP students, and trainees from associated health professions. Rather than allowing these trainees to be bystanders or passive recipients of PACT, the VA envisioned new models of education, aligned with the goals of PACT/PCMH, that would engage trainees as active participants in the change effort.
One example of the VA’s commitment to aligning excellence in primary care and excellence in ambulatory education occurred in January of this year. Through a competitive process, the VA Office of Academic Affiliations selected five Centers of Excellence for Primary Care Education (Boise, Cleveland, Puget Sound/Seattle, San Francisco, and West Haven). At the San Francisco VA we have created an Educational Program called EdPACT (Education in Patient Aligned Care Teams) in which teams of NP students and Internal Medicine residents work collaboratively within a teamlet to provide care for a panel of patients. The NP students and medical residents also cover each other’s patients when absent from clinic due to university breaks, inpatient rotations, and vacations.
In addition to immersion in this interprofessional, team-based model of care, trainees participate in weekly educational sessions addressing core topics of PACT/PCMH such as patient-centered communication, interprofessional collaboration and teamwork, performance improvement, and continuity of care. Activities range from video tape review and discussion of communication skills during patient visits, a day long team-building retreat for teamlets, complex case conferences with a multidisciplinary team of professionals, and dedicated time to work on panel management and performance improvement projects. For residents and NP students, this explicit attention to and participation in interprofessional, team-based care, performance improvement and engagement in systems redesign is typically not a major component of clinical training.
We have received several positive reports on EdPACT within the first few months.
From a sub-specialist:
During the first week of the program Dr. Pat Cornett, an attending in Hematology-Oncology, sent a note about one of our EdPACT NP student-providers: "I saw a new oncology patient who must have been one of the first new patients... seen by an NP student. He (the patient) couldn't have been more effusive with praise and was quite complimentary towards the care provided by the student."
From an EdPACT preceptor:
Dr. Maya Dulay shared her observations of team huddles, noting that the huddles allow her to do “anticipatory precepting.” Knowing what patients the trainees would see allowed her to suggest skills for trainees to work on during the visit and ways they can utilize their team better. By the end of the first two months she was very pleased to see the residents appropriately delegating tasks to other members of the teamlet rather than doing everything themselves and to see the NP students suggesting ways to improve team-based care by proposing improvements in the LVN's pre-visit planning phone calls and other changes to make the huddle run more smoothly.
From Jessie Coty, an EdPACT NP student:
My first weeks in the EdPACT program seem a blur of many images.
Images of charismatic patients with heart wrenching military stories and their lives since unfolded. Mental snapshots that mark lightening-paced introductions to a diverse set of care providers. These introductions then needed a more deliberate untangling of how to best work together. Process diagrams of how to wrestle (and win!) with CPRS (the VA’s electronic health record), never mind negotiate many administrative procedures. Yet, perhaps the clinic’s pace was most responsible for the rush of images. While slow for an experienced practitioner, or even my resident partner, I regularly ran for the finish line well after all others had left the clinic!
Yet, if I take a breath and a few steps back, a very definite theme appears. I absolutely love this program! I understand its vision and see where it’s headed. My immediate immersion smack dab into the “thick” of providing patient-centered primary care, along with a team of bright and passionate professionals, moves me despite tiring weeks. I hope it moves my patients too.
We are eagerly watching as Jessie and all of our EdPACT trainees develop core skills in quality primary care over the course of the year. The successes and opportunities for improvement of our program will be identified through a variety of mechanisms including: trainee satisfaction with the program, attitudes towards teams and primary care, skills in communication and performance improvement, and impact on clinical process and outcome measures for patient panels. If you would like more information about our EdPACT program, please contact or visit our website at http://www.sanfrancisco.va.gov/education/edpact.asp
Bridget O’Brien, PhD, is an Assistant Professor in the Department of Medicine and the Office of Medical Education at the University of California, San Francisco. She directs evaluation for the San Francisco VA Center of Excellence for Primary Care Education (EdPACT). She was one of the three primary researchers for The Carnegie Foundation’s national study of medical education and is a co-author of "Educating Physicians: A Call for Reform of Medical School and Residency."
Rebecca Shunk, MD is as an Associate Professor of Medicine at the University of California San Francisco (UCSF). She is currently the Director of the Center of Excellence in Primary Care Education and the Associate Director of the PRIME Program at the San Francisco VA Medical Center . Her academic interests are in teaching the concepts of the Patient Centered Medical Home, resident education and in teaching the cardiac physical exam. Her favorite projects have included the new Center of Excellence in Primary Care Education and teaching the Introduction to the Cardiac Physical Exam Lecture to all first- year UCSF medical students.
Susan Janson, DNSc, RN, ANP-BC, CNS, AE-C, FAAN is a Professor of Nursing and Medicine at the University of California San Francisco and Co-Director of the SFVA COE. Previously she was Co-Director of the UCSF Center for Primary Care. As an NP faculty leader she has a strong commitment to the development of interprofessional educational models in the context of the Patient-Centered Medical Home.
Maya Dulay, MD is an Assistant Professor of Medicine at the at University of California San Francisco ( UCSF). She is the Associate Director of Clinical Care and Education for the SFVA COE as well as the Assistant Director of Medical Practice and the Residency Clinic Site Director at the SFVAMC. She was a graduate of the UCSF Primary Care Residency. Her current interest are in medical education and the implementation of PACT.
Shalini Patel, MD is an Assistant Clinical Professor of Medicine at the University of California San Francisco (UCSF). She is currently the EdPACT Community Based Outpatient Clinics (CBOCs) Site Director and the Medical Education Site Director at the VA San Bruno and Downtown San Francisco CBOCs. Her interests are education and mentorship in primary care as well as community and underserved medicine.
Jessie Coty, RN, BSPH, MEM works as an Environmental Scientist and is also an Adult Nurse Practitioner student at the UCSF. Her interests lie at the nexus of environmental and public health. The unique clientele of the VA allow Jessie to work at this interface with many VA patients that have had diverse and multiple environmental exposures that impact their health.