Innovative, Interprofessional Models of Specialty Care Delivery & Education in the Department of Veterans Affairs (VA)

14th International Health Workforce

Collaborative Conference

May 8, 2013

VA

Health

CARE

Defining

EXCELLENCE In the 21st Century

Authors & Acknowledgments

• Office of Academic Affiliations, VA Central

Office staff:

Barbara K. Chang, MD, MA, Director of Medical &

Dental Education

Judy L. Brannen, MD, MBA, Clinical Director of

Graduate & Undergraduate Education, Medical &

Dental Education

Christy A. Howard, MSW, Specialty Care Project

Manager

David M. Latini, PhD, Health Systems Specialist

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Presentation Objectives

• Review of an innovative, inter-professional education initiative:

Patient-Centered Specialty Care Education Centers of Excellence (SCE COE)

• Focus:

Sites & innovations

Early outcomes & lessons learned

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Scope of Training in VA

• ~37,000 medical residents train in VA annually

– 30% total US medical residents

• 10,300 physician resident positions (AY 2012)

– 9% US positions funded by VA

• >2,300 ACGME-accredited programs

– 75 medical specialties & subspecialties; 7 combined programs

Health Professions Trainees Total

Physician residents 37,104

Medical students 21,502

Dental residents & students 1,231

Nursing 32,349

All other 24,608

Total 116,794

VA Primary Care System

• Largest integrated healthcare system in the US

• >850 sites of Primary Care

• 4.8 M primary care patients

• 12 M encounters annually

• 2-yr transition to Patient Aligned Care Teams (PACT) – VA’s version of patient-center medical home

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CoEs in Patient-centered Specialty Care Education (SCE COEs)

• 3 sites selected

• Criteria: Team-based, patient-

centered care

Physician (at least 1 medical & 1 surgical)

Associated health trainees

Affiliate support

Potential sustainability

• Up to $500K/yr x 3 years for ‘infrastructure’ +Trainee stipends

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Goals & Objectives

Overarching goal: … the transformation of clinical education and patient care by preparing [trainees] to work in and lead patient-centered interdisciplinary and/or interprofessional teams providing specialty care in the setting of coordinated longitudinal primary care.

Objectives: Development of exportable models of patient-centered care & education featuring

Interprofessional and interdisciplinary collaboration

Coordinated longitudinal care for patients requiring specialty care

Performance improvement

Patient-centered care

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Patient-Centered Specialty Care Education COEs

Salt Lake City VAMC –

Musculoskeletal Disease Center

Integrated

Healthcare

Team

• Rheumatology

• Orthopaedic Surgery

• Endocrinology

• Physical Therapy/Occupational Therapy

• Internal Medicine/Family Medicine

• NP, PA and Clinical Pharmacy

Trainees (55) • Rheumatology, Endocrinology, NP students, PA students,

& Physical Medicine and Rehabilitation Residents

Trainee

Experience

• Joint Injection Clinic

• Didactic Training

• Simulation

• Supervised Clinical Activities

Patient-

Centered

Patients with MSK disorders seen by specialty care

interprofessional team with Family Medicine Practitioner

Evaluation E*Value System, pre/post test, extraction & analysis of

clinical data

Cleveland VAMC – Transforming & Integrating

Medical & Surgical Expertise Cancer Center (TIE)

Integrated

Healthcare Team

• Surgical Oncology, Hematology & Oncology,

Interventional Radiology; Psychology, Nursing, Nurse

Practitioner, and Social Work

Trainees (25) • General Surgery, Family Medicine, Oncology, Nurse

Practitioner Students, Psychology Fellows, and Social

Work Interns

Trainee

Experience

• Integrated Supervised Clinical Activities

• Case Conferences

• Tele-Health

Patient-Centered • >312 patients served in the TIE center. Family

integration into patient care. Main focus – Nurses

(Patient Navigation, Cancer Survivorship) and Mental

Health (Distress Management)

Evaluation • Patient Perception of Patient Centeredness; 360o-

evaluation; Didactic session evaluation tool;

• Templated notes for patient data collection

Atlanta VAMC – Women’s Health Center

Integrated

Healthcare Team

Current: Family Medicine, Psychiatry, Ob-Gyn,

Cardiology, Dermatology, and Ophthalmology

Planned: Nursing, Clinical Pharmacy, Social Work, PA,

and Nutrition

Trainees (9) • Family Medicine, Internal Medicine Residents,

Psychiatry, and OB-GYN (Planned: PA, Pharmacy,

Social Work and Nursing)

Trainee Experience NEW location will open summer 2013. Trainees

working in temporary CBOC location with integrated

team.

Patient-Centered Family Medicine integration with same day specialty

appointments; OB/GYN, Cardiology, Psychiatry, Derm

Evaluation • Post/Pre Testing Evaluations

• Interviews; Working with PACT Eval Team

Models of Care & Highlights

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Site Salt Lake City - MSK

Disorders

Cleveland –

Cancer

Atlanta –

Women’s Health

Models of

Care

Pt-ctr’d, disease-specific

team, incl. primary care

practitioners, specialists in

MSK, & trainees.

Proactive risk factor

screening & intervention

Pt.-ctr’d collaborative

cancer care via

huddles. Sequential

same day appts.

Shifting from

expedited appts to

pt. centered,

collaborative

interprofessional

team approach

Highlights 1-week intensive mini-

residency

Practitioners available

immediately

Risk factor follow-up

Reduction in co-pays,

pt. visits, & travel costs

’d quality of care

Pt. Navigation.

Distress screening

w/ interventions

’d timeliness of

appts & access to

multiple specialties

X-training of

trainees

Bi-weekly team

meetings w/

Program Director &

faculty to outline &

strengthen model &

curriculum

Dual affiliation

participation

Evaluation Across SCE COE Sites

• Team Development Measure (TDM)

• Annual Site Report Template

• Semi-structured interviews/site visits

• Corporate Data Warehouse Access

Utilization

Clinical Outcomes

Challenges/Lessons Learned

• Space/hiring issues – all sites are limited by available space!

• Budget challenges (slow to spend)

• Vigilance needed RE:

Physician-centric practice

Parallel vs. collaborative practice

• Need for local ‘marketing’ to ensure sustainability

External accreditation standards assist

Summary

• Improvement in education & clinical systems is interdependent & iterative

• IPE requires changes in education, faculty relationships, infrastructure, & attention to communication & culture

• Evaluation is challenging

• Critical role of coordinating center

• Trainees are overwhelmingly enthusiastic!!!

Specialty Care Education COEs: Barbara K. Chang, MD, MA Director, Medical & Dental Education, OAA Tel. (502) 287-4722 e-mail: barbara.chang@va.gov

Judy L. Brannen, MD, MBA Clinical Director, Undergraduate & Graduate Medical Education Tel. (804) 675-5481 e-mail: judy.brannen@va.gov Web: http://www.va.gov/oaa

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Questions?