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Veteran Affairs Centers of Excellence in Primary Care Education: Transforming nurse practitioner education
Abstract
To integrate health care professional learners into patient-centered primary care delivery models, the Department of Veterans Affairs has funded five Centers of Excellence in Primary Care Education (CoEPCEs). The main goal of the CoEPCEs is to develop and test innovative structural and curricular models that foster transformation of health care training from profession-specific "silos" to interprofessional, team-based educational and care delivery models in patient-centered primary care settings. CoEPCE implementation emphasizes four core curricular domains: shared decision making, sustained relationships, interprofessional collaboration, and performance improvement. The structural models allow interprofessional learners to have longitudinal learning experiences and sustained and continuous relationships with patients, faculty mentors, and peer learners. This article presents an overview of the innovative curricular models developed at each site, focusing on nurse practitioner (NP) education. Insights on transforming NP education in the practice setting and its impact on traditional NP educational models are offered. Preliminary outcomes and sustainment examples are also provided.
... In 2010, the Department of Veterans Affairs (VA) redesigned their model of primary care delivery for veterans by placing the patient at the center of care with an interprofessional team to engage and collaborate in healthcare decision-making. [23] The foundation of the VAMC Patient Aligned Care Teams (PACT) with primary care clinics requires that care is patient driven, team-based, coordinated, comprehensive, and continuous. [23] The PACT interprofessional team generally includes a primary care provider, a registered nurse (RN) care manager, a health technician, and a medical clerk. ...
... [23] The foundation of the VAMC Patient Aligned Care Teams (PACT) with primary care clinics requires that care is patient driven, team-based, coordinated, comprehensive, and continuous. [23] The PACT interprofessional team generally includes a primary care provider, a registered nurse (RN) care manager, a health technician, and a medical clerk. Other clinicians, such as clinical pharmacists, social workers, and psychologists, supplement the PACT to facilitate care coordination between patients and the primary care team. ...
... The Centers of Excellence in Primary Care Education (Co-EPCE) offered health professional trainees opportunities to work in PACTs with health professionals within five VAMC primary care facilities. [23,26] Nurse practitioner (NP) residents at one of the CoEPCE sites rated the value of the teaching and mentoring they received through their VAMC clinical experience higher than NP residents who did not receive this training. VAMC NP residents cited continuity of care, the knowledge and skills gained, and responsibility to patients, as pivotal to their educational training. ...
There is limited literature that specifically addresses how academic institutions and healthcare facilities effectively establish and manage clinical experiences for students. Since advanced practice nursing education (APRN) programs strive to provide appropriate clinical experiences as part of their students’ educational training, it is imperative that academic institutions and clinical facilities establish working relationships and protocols for productive collaboration. Barriers may exist in arranging student clinical placements, including scheduling conflicts and provider workload burden. Collaborative approaches for placing APRN students in primary care settings can be beneficial for student learning and the clinical care of patients. The purpose of this paper is to provide an initial roadmap for coordinating APRN and other health professional students’ placement in clinical rotations at a Veterans Health Administration Medical Center (VAMC) primary care clinic in the Midwest.
... [1][2][3][4][5][6] As a result, many programs include QI projects as part of a required curriculum during clinical placements. [7][8][9][10][11] There is a potential added benefit in interprofessional (IP), experiential QI learning. The Accreditation Council for Graduate Medical Education (ACGME) Clinical Learning Environment Review program noted that "IP, team-based quality improvement efforts... provide residents... with experiential learning that goes beyond basic QI methods to include developing skills and behaviors in shared leadership, communications, systems-based thinking, change management, and professionalism." 3 Despite this promoted ideal, most ACGME programs provide limited opportunities for residents to participate in IP QI teams. ...
... QI was a core curricular domain of the SFVAHCS CoEPCE program, established in 2011 to teach IP trainees how to deliver team-based, patient-centered care. 11,48,49 Prior to and throughout the QI curriculum, trainees participated in several learning activities related to team-building and IP collaboration to help them in the development of skills (building relationships, establishing team goals, clarifying roles, and learning communication skills) that support successful QI teamwork . 2,11,38,50,51 IP teams of trainees, staff, and mentors performed QI activities in the setting in which they worked, the main academic primary care clinic or one of two communitybased outpatient clinics. ...
... 11,48,49 Prior to and throughout the QI curriculum, trainees participated in several learning activities related to team-building and IP collaboration to help them in the development of skills (building relationships, establishing team goals, clarifying roles, and learning communication skills) that support successful QI teamwork . 2,11,38,50,51 IP teams of trainees, staff, and mentors performed QI activities in the setting in which they worked, the main academic primary care clinic or one of two communitybased outpatient clinics. ...
Introduction:
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.
Methods:
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.
Results:
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.
Discussion:
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.
... They should seek to develop a good understanding of the particular challenges and/or opportunities that the IPE will contribute. These may be demonstrated on a strategic level in relation to an overall improvement in health systems (Mann et al., 2009;Lennox and Anderson, 2012;Miller et al., 2014), on a community level in relation to local inequalities (Larivaara and Taanila, 2004;Ryan et al., 2015), on team level in relation to a particular service configuration (Rugen et al., 2014), and/or in relation to individual professional practice level (Meisinger et al., 2016). To understand the potential contribution of IPE, it is worth considering barriers related to collaboration, for example, siloed working within health and social care, poor team working, hierarchical and physician-centred culture, and professional (rather than person)-centred emphasis within care Meisinger et al., 2016). ...
... The more authentic the experiences the more students will learn (Schrader et al., 2016). Involving patients and family members as partners of an inter-professional team can demonstrate to learners that there is potential for new forms of professional-patient interactions (Crutcher et al., 2004;Rugen et al., 2014). Wider competences such as clinical leadership can be acquired through student-run inter-professional clinics (Meisinger et al., 2016). ...
... Practical activities were also a means to achieving wider impacts than improved competence of the participants. Supporting individual patients, for example, at a time of transition such as leaving hospital, enabled learners to experience many steps involved and secure a good discharge for the person and their family (Mann et al., 2009;Kent et al., 2014;Rugen et al., 2014;Sicat et al., 2014;Meisinger et al., 2016;Zaudke et al., 2016). Reflecting on the insights of an individual and/or group of people was used by a number of programmes as the basis for students to identify practical ways that services and/or collaboration could be improved in that local area (McNair et al., 2005;Delva et al., 2008;Lennox and Anderson, 2012;Ryan et al., 2015). ...
Inter-professional education (IPE) can support professionals in developing their ability to work collaboratively. This position paper from the European Forum for Primary Care considers the design and implementation of IPE within primary care. This paper is based on workshops and is an evidence review of good practice. Enablers of IPE programmes are involving patients in the design and delivery, providing a holistic focus, focussing on practical actions, deploying multi-modal learning formats and activities, including more than two professions, evaluating formative and summative aspects, and encouraging team-based working. Guidance for the successful implementation of IPE is set out with examples from qualifying and continuing professional development programmes.
... The key success characteristics of postgraduate NP residency/fellowship programs include communication with preceptors, mentoring consistency, building evaluation components to quantify program results, and identifying key stakeholders and funding sources to support implementation and sustainability of the programs (Brown, Poppe, Kaminetzky, Wipf, & Woods, 2016;Goudreau et al., 2011;Kells, Dunn, Melchiono, & Burke, 2015;Rugen et al., 2014;Sciacca & Reville, 2016). In a recent survey, Faraz (2019) found that facilitators of NP transition to practice include mentorship, social support, job satisfaction, and work-life balance. ...
... Previously, Graduate Nurse Education (GNE) Demonstration projects, which were funded by CMS, enabled the implementation of NP residency/fellowship programs. The same holds true for the Veterans Administration (VA) federally funded programs (Rugen et al., 2014;Wiltse Nicely et al., 2012). Innovative funding of NP residencies/fellowships is needed to explore diverse funding stream sources such as health systems to receive a return on investment on the NP workforce. ...
Background:
A current trend to address the increasing numbers of new graduate nurse practitioners (NPs) and the expanding scope of practice of NPs is the emergence of employer-based postgraduate NP residency/fellowship programs.
Purpose:
The purpose of this study was to conduct a comprehensive examination of postgraduate NP residency/fellowship programs in the United States, to gain an understanding of the facilitators, barriers, benefits, and funding of these programs, from the perspective of the program directors.
Methods:
This exploratory study used a quantitative design to conduct an online survey, developed by the researchers, of program directors of postgraduate NP residency/fellowship programs. Descriptive statistics were generated for continuous variables: the mean, SD, and minimum, and maximum values, and for categorical variables, frequency and percentage were reported.
Results:
More than 90% of program directors indicated that NP recruitment and retention were benefits to organizations implementing NP residency/fellowship programs. Decision makers in organizations support postgraduate NP residency/fellowship programs and few barriers exist to implement programs. More than 84% indicated that physician and administrative support were facilitators to program implementation. Less than 50% of program directors identified barriers to implementation. Less than half of programs received funding sources for program implementation.
Implications for practice:
This study provides data and insight into the emerging industry of postgraduate NP residency/training programs and informs regulators, educators, and employers about how to maximize the facilitators, reduce and decrease barriers, identify sources of funding, and appreciate the benefits of implementing programs.
... GME funding included in hospital Medicare payments for nursing and allied health education programs amounted to $270 million in 2012. However, the VA (Rugen et al., 2014) began primary care NP residencies in 2010, followed by four Psychiatric-Mental Health NP (PMHNPs) residencies in 2013 to assist in the delivery of primary care and mental health services. HRSA does provide Nursing Workforce Development for Advanced Nursing Education at the rate of $67 million in 2013 (Department of Health and Human Services, 2014). ...
... A notable effort in developing NP residencies is within the Veterans Administration (VA). NP residencies within the VA were initiated in 2010 with a focus on primary care (Rugen et al., 2014). In 2013, an innovative nurse-led residency model was proposed by the VA Office of Academic Affiliations (OAA) to meet the demand for PMHNPs. ...
Background:
The Doctor of Nursing Practice (DNP) degree positions nurse practitioners (NPs) and other advanced practice registered nurses, with clinical competencies similar to other disciplines requiring doctoral education (medicine, physical therapy, psychology, and pharmacy). In addition, all these disciplines also offer residencies. However, nursing is the only discipline that does not require a doctoral degree and/or have a systematic approach to residency training for advanced practice roles. The authors posit that there are critical policy issues to resolve within the nursing profession to clarify the role that clinical residencies should play in transition to DNP practice specifically related to NPs.
Purpose:
The purpose of this article was to (a) describe the context of NP residency models within NP curricula that strengthen the DNP Essentials with an emphasis on Essential VIII and a focus on distinctive clinical specialization, (b) describe the history and policy implications of NP residency programs as well as existing programs that assist transition to practice, and (c) recommend policies for consideration related to DNP NP residencies.
Methods:
Literature on nurse practitioner residencies was reviewed.
Discussion:
While nurse practitioner residencies continue to grow, research is needed regarding outcomes of job satisfaction, clinical competencies, and patient satisfaction.
Conclusion:
The first year of practice for nurse practitioners is a critical period of professional development. It is important to further clarify the need, direction, and program standards. Academically affiliated residencies will facilitate the development and standardization of curricula and competencies to enhance clinical rigor. The partnership between academic units and clinical agencies will pool resources and strengthen nursing in both settings.
... By 2010, 92 percent of all U.S. academic health centers offered IPE courses and 89 percent offered IPE clinical training experiences (Greer et al. 2014). However, IPE curricula vary by requirement (mandatory or elective), setting (classroom or practice based), clinical conditions (specific illnesses or primary care), duration (1-to 2-hour sessions, 1 month, to a full academic year), and scope (specific interprofessional relationships or entire models of care) (Meyer, Potter, and Gary 1997;Reeves et al. 2012;Gilman et al. 2014;Rugen et al. 2014). ...
... By 2013, 142 VA medical centers had active affiliation agreements with 152 of the nation's 170 medical schools (including 29 osteopathic) and over 1,800 other education programs involving annually 40,420 physician residents, 21,541 medical students, and 56,585 nursing, dental, and associated health trainees. The setting is appropriate since VA emphasizes a patient-centered medical home, known as the Patient Aligned Care Team (PACT) model of care (Rosland et al. 2013;Rugen et al. 2014). ...
Objective:
To assess how changes in curriculum, accreditation standards, and certification and licensure competencies impacted how medical students and physician residents value interprofessional team and patient-centered care.
Primary data source:
The Department of Veterans Affairs Learners' Perceptions Survey (2003-2013). The nationally administered survey asked a representative sample of 56,569 U.S. medical students and physician residents, with a comparison group of 78,038 nonphysician trainees, to rate satisfaction with 28 elements, in two overall domains, describing their clinical learning experiences at VA medical centers.
Study design:
Value preferences were scored as independent adjusted associations between an element (interprofessional team, patient-centered preceptor) and the respective overall domain (clinical learning environment, faculty, and preceptors) relative to a referent element (quality of clinical care, quality of preceptor).
Principal findings:
Physician trainees valued interprofessional (14 percent vs. 37 percent, p < .001) and patient-centered learning (21 percent vs. 36 percent, p < .001) less than their nonphysician counterparts. Physician preferences for interprofessional learning showed modest increases over time (2.5 percent/year, p < .001), driven mostly by internal medicine and surgery residents. Preferences did not increase with trainees' academic progress.
Conclusions:
Despite changes in medical education, physician trainees continue to lag behind their nonphysician counterparts in valuing experience with interprofessional team and patient-centered care.
... A variety of instructional approaches (didactics, workplace learning, and reflective practice) [9] were used to address the four core domains: interprofessional collaboration, sustained relationships, shared decision making, and performance improvement. These educational domains and the implementation of curricula have been described in several previously published studies [9,15]. In brief, interprofessional collaboration involved trustful, collaborative relationships among professions for delivering team-based, coordinated care; sustained relationships included fostering respectful and trusting relationships between patients, families, and other health professionals; shared decision making involved supporting patients to make healthcare decisions that embraced their values and preferences; and performance improvement trained HPTs to foster a culture of continuous improvement and assessment to optimize patient outcomes. ...
Few post-graduate training programs offer a comprehensive curriculum that includes structured clinical experiences to teach interprofessional care. To address this need, the United States Department of Veterans Affairs, Office of Academic Affiliations funded the Centers of Excellence in Primary Care Education (CoEPCE) from 2011–2019 to provide interprofessional curricula for health profession trainees (HPTs), including physician residents, nurse practitioner residents, pharmacy residents, and psychology residents. We examined changes over time in curricular domains, system impacts, and program practices based on HPT survey data and the qualitative evaluation of narrative feedback. An annual survey was administered to participants. Indirect standardized ratios were calculated for interprofessional professional education (IPE) program domains, system impacts, and program practices. Qualitative responses were coded based on curricular domains and key program components. The study cohort included 369 HPTs. Site and profession standardized indirect ratios across all professions indicated improvements in curricular domains, system impacts, and program practices, with significant differences observed for associated health HPTs as compared to other HPTs for performance improvement. Qualitative data indicated that profession was associated with differences in perceptions of the curriculum. Although improvements occurred over time, our findings support the need for the thoughtful consideration of profession-specific identity characteristics when designing interprofessional curricula.
... As is typical for primary care clinics within the VA, the largest group of trainees were internal medicine residents, both in terms of numbers of trainees and number of years of exposure to the training. New nurse practitioner residencies were created at each site and several established other post-graduate programs, including registered nurse or chiropractic residencies [9]. Trainees were included in evaluations if they provided clinical care in CoEPCE clinic according to their licensure (e.g. ...
Background
Team-based care is critical to achieving health care value while maximizing patient outcomes. Few descriptions exist of graduate-level team training interventions and practice models. Experience from the multisite, decade-long Veterans Affairs (VA) Centers of Excellence in Primary Care Education provides lessons for developing internal medicine training experiences in interprofessional clinical learning environments.
Methods
A review of multisite demonstration project transforming traditional silo-model training to interprofessional team-based primary care. Using iterative quality improvement approaches, sites evaluated curricula with learner, faculty and staff feedback. Learner- and patient-level outcomes and organizational culture change were examined using mixed methods, within and across sites. Participants included more than 1600 internal medicine, nurse practitioner, nursing, pharmacy, psychology, social work and physical therapy trainees. This took place in seven academic university-affiliated VA primary care clinics with patient centered medical home design
Results
Each site developed innovative design and curricula using common competencies of shared decision making, sustained relationships, performance improvement and interprofessional collaboration. Educational strategies included integrated didactics, workplace collaboration and reflection. Sites shared implementation best practices and outcomes. Cross-site evaluations of the impacts of these educational strategies indicated improvements in trainee clinical knowledge, team-based approaches to care and interest in primary care careers. Improved patient outcomes were seen in the quality of chronic disease management, reduction in polypharmacy, and reduced emergency department and hospitalizations. Evaluations of the culture of training environments demonstrated incorporation and persistence of interprofessional learning and collaboration.
Conclusions
Aligning education and practice goals with cross-site collaboration created a robust interprofessional learning environment. Improved trainee/staff satisfaction and better patient care metrics supports use of this model to transform ambulatory care training.
Trial registration
This evaluation was categorized as an operation improvement activity by the Office of Academic Affairs based on Veterans Health Administration Handbook 1058.05, in which information generated is used for business operations and quality improvement (Title 38 Code of Federal Regulations Part 16 (38 CFR 16.102(l)). The overall project was subject to administrative oversight rather Human Subjects Institutional Review Board, as such informed consent was waived as part of the project implementation and evaluation.
... It also stimulates residents and professionals to enter the area of research by linking their academic training with problems that require a solution. Nursing is the cornerstone in intensive care, palliative and mental health promotion in patients, companions, and family members; the linking of undergraduate and graduate students in nursing has given good results [34], as it stimulates their education skills in primary and secondary prevention of diseases, also stimulates the formation of specialists in areas of oncological care among others. Regarding the training for MSc and PhD, the alliance with universities can be critical in the initial stages. ...
Urological cancers are one of the leading causes of morbidity and mortality in the world, representing more than 10% of the total number of new cancer cases worldwide. Being a complex disease, several problems are currently related to its diagnosis, management, monitoring, and treatment. These problems require multidisciplinary solutions that encompass and manage patients as complex entities. In response to this, the so-called Cancer Centers of Excellence (CCEs) emerged, which are defined as multidisciplinary institutions specialized in the diagnosis, management, monitoring, and treatment of specific diseases, including cancer; different institutions such as the European Society of Urology (EUS) have proposed and encouraged its consolidation, especially for the management of prostate cancer. These institutions must be composed of three areas: healthcare, education, and research, which have complementary interactions and relationships, stimulating research and problemsolving from a multidisciplinary approach and also covering elements of basic sciences and mental health. Implementing these CCEs has brought excellent results; therefore, it is necessary to stimulate their implementation with a uro-oncological approach.
... Previous studies have cited the key characteristics of success of NP residency/fellowship programs, including communication with preceptors, mentoring consistency, building evaluation components to quantify program results, developing standard characteristics of successful NP residency and fellowship graduates, and developing evidence-based competency assessment tools (Brown et al., 2015;Goudreau et al., 2011;Kells et al., 2015;Rugen et al., 2014;Sciacca & Reville, 2016). Many of these results, however, are based on single case studies. ...
Nurse practitioner (NP) education has followed the pattern of other health professions in recent years to place an emphasis on competency-based education. In recent years, postgraduate NP residency/fellowship programs to achieve competence and successful transition to practice have emerged and flourished. Currently, there is no standard competency framework in use for NP residency/fellowship programs in the United States, despite numerous published frameworks available. This article aimed to provide a comprehensive analysis of competency frameworks for NP education and to summarize and compare the competency frameworks used in NP education and residency/fellowship programs. Recommendations were sought for standardization of these competencies to create consistent evaluation and outcome measurements. Seven competency frameworks used across NP education and residency/fellowship programs were reviewed and compared in table format. Commonalities, differences, and themes were extracted from this comparison. There were more similarities than differences between the competency frameworks; however, common themes emerged as the emphasis on patient-centered, evidence-based practice, systems-based and quality improvement, and interprofessional practice and teamwork. The American Association of Colleges of Nursing Common Advanced Practice Registered Nurse Doctoral-Level Competencies, published in 2017, provided the most current, inclusive, comprehensive, and complete set of competencies for NPs at the time of graduation; however, they have not defined a progression indicator for postgraduate NP competency evaluation. This review of the competencies emphasizes (a) the need for consistent and consensus-based standards and (b) areas that NP education and residency/fellowship programs can strengthen to assess their ability to describe observable, measurable competencies. Instruments to evaluate competencies are recommended.
... All core curricula are interprofessionally coauthored and cotaught. 1 ...
Physician, nurse practitioner trainees, medical center faculty, and clinic staff develop proactive, team-based, interprofessional care plans to address unmet chronic care needs for high-risk patients.
... The San Francisco VA Health Care System (SFVAHCS) Education in PACT (EdPACT) /CoEPCE developed and implemented a workplace learning model that embeds trainees into PACT teamlets and clinic workflow. 1 Trainees are organized in practice partner triads with 2 second-or third-year internal medicine residents (R2s and R3s) and 1 NP student or resident. Physician residents rotate every 2 months between inpatient and outpatient settings and NP trainees are present continuously for 12 months. ...
In short team huddles, trainees and PACT teamlets meet to coordinate care and identify ways to improve team processes under the guidance of faculty members who reinforce collaborative practice and continuous improvement.
... The Veterans Health Administration (VHA) educates and trains the largest number of health care professionals in the country, including over 65% of all US-trained physicians (VA COEPCE mission statement, 2017). Since 2010, seven VHA Centers of Excellence in Primary Care Education (CoEPCE) have been created with the mission to foster diverse learning environments that emphasize interprofessional collaboration regarding diagnoses, patient-centered care, evidence-based practice, and promoting continuity of care (Rugen et al., 2014). The West Haven, CT campus of the VHA encompasses three academic primary care training clinics. ...
Musculoskeletal pain is a prominent complaint in primary care resulting in increased referrals to physical therapy (PT); however, the referral system often results in delays and discontinuation of care. Several models have been developed to improve the referral process including integrating PT into primary care clinics. The Veterans Health Administration (VHA) Center of Excellence in Primary Care Education (CoEPCE), which educates postgraduate trainees in interprofessional teams, began (in 2015) embedding physical therapists into primary care clinics enabling patients to see a physical therapist during their primary care visit. To evaluate the efficacy of this model we tracked the numbers of PT referrals, the number of completed referrals, and the length of time between referral and completion. PT referral parameters from PT-integrated trainees in the CoEPCE were compared to two traditional primary care training clinics at the same VHA site (Firm A and Firm B). Results indicate that the CoEPCE placed and completed more PT referrals and did so with a shorter turnaround time than was seen in the other two clinics. Further analysis suggests that the decreased turnaround time can be attributed to the integration of PTs into the primary care clinic. The results support extending the use of interprofessional clinics that integrate PT into primary care settings. ARTICLE HISTORY
... Its mission is to advance quality health care by supporting postgraduate residency and fellowship programs for NPs (NNPRFTC, 2019). In addition, the Veterans Administration Centers of Excellence in Primary Care Education was established to test innovative longitudinal learning experiences for health professions, including advanced practice nurses working in primary care practices (Rugen et al., 2014). To date, the NNPRFTC, the Commission on Collegiate Nursing Education (CCNE), and the American Nurse Credentialing Center (ANCC) have emerged as accrediting bodies for postgraduate NP programs. ...
Background:
Nurse practitioner (NP) residency/fellowship programs are an emerging industry across the country.
Purpose:
This study aimed to conduct an in-depth exploration about postgraduate NP residency/fellowship programs in the United States and to gain an understanding of program characteristics, educational content, and implementation methods to assist NPs to transition to practice.
Methods:
This exploratory study used a quantitative design to conduct an online survey of program directors of NP residency/fellowship programs to collect data about program characteristics to assist graduates to transition to practice. Descriptive statistics were calculated for continuous variables, whereas frequency and percentage were calculated for categorical variables.
Results:
Nurse practitioner residency/fellowship programs lack consistency in standards for educational content and delivery methods. Only 26% of the programs were accredited, and the programs were not consistently based on nationally recognized competencies. Ninety percent of the programs relied on didactic and clinical supervision delivery methods. More than 90% of the residents/fellows cared for adults older than 65 years of age and managed chronic diseases. Family Nurse Practitioner was the most commonly cited population track offered (73%). Nurse practitioner residency/fellowship programs are sparsely offered in the most rural states with underserved populations.
Implications for practice:
This study provides data and insight into the emerging industry of postgraduate NP residency/training programs for educators and employers. In addition, it informs regulators and decision makers about the quality and consistency of programs and the impact of programs on the care delivered by new graduate NPs.
... hology interns, and psychology postdoctoral fellows participate in a comprehensive curriculum and practice together for one to three years. The goal is to produce providers who are able to lead and practice health care in patient-centered primary care and rural care environments. All core curricula are interprofessionally coauthored and co-taught. (Rugen, K.W., et. al, 2013). ...
A primer to curricular activities and strategies that can lead to the advancement of interprofessional Veteran and person centered care in clinical workplace education programs
... Early in Stage 1, NP residency programs in primary care were established at each Center as core CoEPCE training programs . NP residents were graduates of masters or doctor of nursing practice NP programs who participated in year-long specialized training in primary care delivery, leadership, and scholarly activities (Rugen, Gilman, & Traylor, 2015;Rugen et al., 2016Rugen et al., , 2014. ...
This paper describes the Centers of Excellence in Primary Care Education (CoEPCE), a seven-site collaborative project funded by the Office of Academic Affiliations (OAA) within the Veterans Health Administration of the United States Department of Veterans Affairs (VA). The CoEPCE was established to fulfill OAA’s vision of large-scale transformation of the clinical learning environment within VA primary care settings. This was accomplished by funding new Centers within VA facilities to develop models of interprofessional education (IPE) to teach health professions trainees to deliver high quality interprofessional team-based primary care to Veterans. Using reports and data collected and maintained by the National Coordinating Center over the first six years of the project, we describe program inputs, the multicomponent intervention, activities undertaken to develop the intervention, and short-term outcomes. The findings have implications for lessons learned that can be considered by others seeking large-scale transformation of education within the clinical workplace and the development of interprofessional clinical learning environments. Within the VA, the CoEPCE has laid the foundation for IPE and collaborative practice, but much work remains to disseminate this work throughout the national VA system.
... Previous studies have cited the importance of key characteristics toward the success of NP residency and fellowship programs, including communication with preceptors, mentoring consistency, building evaluation components to quantify program results, identifying key stakeholders and funding sources to support implementation and sustainability of the programs, developing standard characteristics of successful NP residency and fellowship graduates, and developing evidence-based competency assessment tools. 10,11,[18][19][20] Many of these insights are drawn from single case studies. More systematic and extensive identification and dissemination of these best practices would be an important contribution to promoting the success of these programs. ...
Little is known about the potential of nurse practitioner (NP) residency and fellowship programs in preparing NPs for the future of the health care system. We describe NP residency and fellowship programs in terms of their number and general characteristics. We found nearly 70 residency and fellowship programs across the country. The programs are geographically dispersed and diverse in terms of the specialty area, type of organization overseeing the program, and program length. Our study is the first to describe these programs, but a more in-depth investigation is necessary to understand the role that these programs can play in the future.
... Findings from the review reveal that some partnerships have limited awareness M A N U S C R I P T A C C E P T E D ACCEPTED MANUSCRIPT 10 among partners and this suffocates growth. If other healthcare professions are excluded from the partnership, they would likely provide poor support [22,32]. Formal information sharing sessions are critical to gain support of other healthcare professionals. ...
A competent nursing workforce is critical for an effective healthcare system. However, concerns of poor quality of nursing care and poor competences among nursing students, nurses and midwives are increasing in Malawi. Anecdotal notes from stakeholders show shortfalls in nursing education. There is a huge gap between theory and practice. This study described the role of academic clinical partnership in strengthening nursing education. A search of ScienceDirect, Pub Med, Medline and PsychINFO on EBCSOhost and Google scholar was conducted using the following key words; academic clinical collaboration, academic clinical partnership, academic practitioner gap, college hospital partnership or/and nursing. In addition peer reviewed reports on academic clinical partnership in nursing were included in the search. Thirty three records for the period 2002 to 2016 were reviewed. Six themes emerged from the review; mutual and shared goals, evidence based practice, resource sharing and collaboration, capacity building, partnership elements and challenges of academic clinical partnership. The review highlighted that academic practice partnerships promote shared goal development for the healthcare system. The gap between theory and practice is reduced because of sharing of expertise and increased evidence based practice. Academic clinical partnership improves competences among students, improves patients’ safety and health outcomes. The study concluded that nursing education that is implemented within an academic clinical partnership becomes relevant to the needs and demands of the health system.
... The formal educational curriculum included a full-day, team-building retreat for all staff and 2 hours per week of IP learning activities related to teambased care (e.g., communication skills and panel management) for trainees. 19 The university and safety net clinics developed team-based care models to improve patient care, continuity and trainee oversight. Both sites provided a brief orientation to the teambased care model for all staff, but did not have formal curricula or additional funding. ...
In order to teach residents how to work in interprofessional teams, educators in graduate medical education are implementing team-based care models in resident continuity clinics. However, little is known about the impact of interprofessional teams on residents' education in the ambulatory setting.
To identify factors affecting residents' experience of team-based care within continuity clinics and the impact of these teams on residents' education.
This was a qualitative study of focus groups with internal medicine residents.
Seventy-seven internal medicine residents at the University of California San Francisco at three continuity clinic sites participated in the study.
Qualitative interviews were audiotaped and transcribed. The authors used a general inductive approach with sensitizing concepts in four frames (structural, human resources, political and symbolic) to develop codes and identify themes.
Residents believed that team-based care improves continuity and quality of care. Factors in four frames affected their ability to achieve these goals. Structural factors included communication through the electronic medical record, consistent schedules and regular team meetings. Human resources factors included the presence of stable teams and clear roles. Political and symbolic factors negatively impacted team-based care, and included low staffing ratios and a culture of ultimate resident responsibility, respectively. Regardless of the presence of these factors or resident perceptions of their teams, residents did not see the practice of interprofessional team-based care as intrinsically educational.
Residents' experiences practicing team-based care are influenced by many principles described in the interprofessional teamwork literature, including understanding team members' roles, good communication and sufficient staffing. However, these attributes are not correlated with residents' perceptions of the educational value of team-based care. Including residents in interprofessional teams in their clinic may not be sufficient to teach residents how team-based care can enhance their overall learning and future practice.
... Increased interprofessional education could assist PCPs in appropriately delegating tasks between staff members with different levels of training. 26 For most tasks, clerical staff reported not being relied upon with the exception of receiving and responding to messages, following up on referrals, and responding to prescription refill requests. This suggests that MAs have well defined, but limited roles in primary care teams, and that there may be capacity to take on additional tasks. ...
Background:
Unclear roles in interdisciplinary primary care teams can impede optimal team-based care. We assessed perceived task allocation among primary care providers (PCPs) and staff during implementation of a new patient-centered care model in Veterans Affairs (VA) primary care practices.
Methods:
We performed a cross-sectional survey of PCPs and primary care staff (registered nurses (RNs), licensed practical/vocational nurses (LPNs), and medical assistants/clerks (MAs)) in 23 primary care practices within one VA region. We asked subjects whether PCPs performed each of 14 common primary care tasks alone, or relied upon staff for help. Tasks included gathering preventive service history, disease screening, evaluating patients and making treatment decisions, intervening on lifestyle factors, educating patients about self-care activities and medications, refilling prescriptions, receiving and resolving patient messages, completing forms, tracking diagnostic data, referral tracking, and arranging home health care. We then performed multivariable regression to determine predictors of perceived PCP reliance on staff for each task.
Results:
162 PCPs and 257 staff members responded, a 60% response rate. For 12/14 tasks, fewer than 50% of PCPs reported relying on staff for help. For all 14 tasks, over 85% of RNs reported they were relied upon. For 12/14 tasks, over 50% of LPNs reported they were relied on, while for 5/14 tasks a majority of MAs reported being relied upon. Nurse practitioners and physician assistants (NP/PAs) reported relying on staff less than physicians.
Conclusions:
Early in the implementation of a team-based primary care model, most PCPs perceived they were solely responsible for most clinical tasks. RNs, and LPNs felt they were relied upon for most of the same tasks, while medical assistants/clerks reported being relied on for fewer tasks. Better understanding of optimal inter-professional team task allocation in primary care is needed.
... Care Education (CoEPCEs), 3 we have developed, implemented, and updated these guidelines over the past three years using rapid change cycles. The foundation of our CoEPCE clinical model is interprofessional trainee, faculty, and staff core teams that provide shared longitudinal care for patient panels. ...
... Case conferences generated from clinical practice experiences facilitate interprofessional learning from reflection. 16,17 In early 2011, an interprofessional panel of VA health educators and leaders competitively selected five demonstration centers involving VA medical centers and their academic affiliates in Boise, Idaho; Cleveland, Ohio; San Francisco, California; Seattle, Washington; and West Haven, Connecticut. Educational program accreditations were the res ponsibility of the academic affiliates, with the VA serving as a participating institution. ...
Health systems around the United States are embracing new models of primary care using interprofessional team-based approaches in pursuit of better patient outcomes, higher levels of satisfaction among patients and providers, and improved overall value. Less often discussed are the implications of new models of care for health professions education, including education for physicians, nurse practitioners, physician assistants, and other professions engaged in primary care. Described here is the interaction between care transformation and redesign of health professions education at the largest integrated delivery system in the United States: the Veterans Health Administration (VA). Challenges and lessons learned are discussed in the context of a demonstration initiative, the VA Centers of Excellence in Primary Care Education. Five sites, involving VA medical centers and their academic affiliates in Boise, Cleveland, San Francisco, Seattle, and West Haven, introduced interprofessional primary care curricula for resident physicians and nurse practitioner students beginning in 2011. Implementation struggles largely revolved around the operational logistics and cultural disruption of integrating educational redesign for medicine and nursing and facilitating the interface between educational and clinical activities. To realize new models for interprofessional teaching, faculty, staff, and trainees must understand the histories, traditions, and program requirements across professions and experiment with new approaches to achieving a common goal. Key recommendations for redesign of health professions education revolve around strengthening the union between interprofessional learning, team-based practice, and high-value care.
Objective:
Globally, interest in excellence has grown exponentially, with public and private institutions shifting their attention from meeting targets to achieving excellence. Centres of Excellence (CoEs) are standing at the forefront of healthcare, research and innovations responding to the world's most complex problems. However, their potential is hindered by conceptual ambiguity. We conducted a global synthesis of the evidence to conceptualise CoEs.
Design:
Scoping review, following Arksey and O'Malley's framework and methodological enhancement by Levac et al and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.
Data sources:
PubMed, Scopus, CINAHL, Google Scholar and the Google engine until 1 January 2021.
Eligibility:
Articles that describe CoE as the main theme.
Results:
The search resulted in 52 161 potential publications, with 78 articles met the eligibility criteria. The 78 articles were from 33 countries, of which 35 were from the USA, 3 each from Nigeria, South Africa, Spain and India, and 2 each from Ethiopia, Canada, Russia, Colombia, Sweden, Greece and Peru. The rest 17 were from various countries. The articles involved six thematic areas-healthcare, education, research, industry, information technology and general concepts on CoE. The analysis documented success stories of using the brand 'CoE'-an influential brand to stimulate best practices. We identified 12 essential foundations of CoE-specialised expertise; infrastructure; innovation; high-impact research; quality service; accreditation or standards; leadership; organisational structure; strategy; collaboration and partnership; sustainable funding or financial mechanisms; and entrepreneurship.
Conclusions:
CoEs have significant scientific, political, economic and social impacts. However, there are inconsistent use and self-designation of the brand without approval by an independent, external process of evaluation and with high ambiguity between 'CoEs' and the ordinary 'institutions' or 'centres'. A comprehensive framework is needed to guide and inspire an institution as a CoE and to help government and funding institutions shape and oversee CoEs.
Leadership to improve quality and safety is a core component of care delivery. The article presents a crosswalk of the core competencies of the VA Centers of Excellence in Primary Care Education nurse practitioner residency programs with the Quality and Safety Education for Nurses competencies for graduate education to identify areas to enhance leadership in quality and safety in the curriculum.
Nurse practitioner residency programs assist new graduates to transition to practice. This article describes the development of a primary care nurse practitioner residency program at a large academic medical center in the mid-Atlantic region. Organizational factors related to program development and support as well as fiscal and human resource considerations are presented. Curricular considerations inclusive of both clinical and didactic content are presented in conjunction with a curricular outline. Finally, recommendations for nurse practitioner residency program development and expansion within academic and nonacademic medical centers are provided.
The aims of this study were to implement and evaluate an innovative collaborative event with hospitalized patients to help develop dental hygiene and nursing students' interprofessional competence. The Interprofessional Collaborative Competency Attainment Survey (ICCAS) was used to assess the students' perceptions of interprofessional skill acquisition. Participants were 24 dental hygiene and 25 nursing students at the University of Southern Indiana in spring 2016. The results showed that all students had statistically significant improvement on the ICCAS items from pretest to posttest. There were no significant differences in improvement between the two groups on any single posttest item as the impact of the responses was similar. These results suggest that incorporating collaborative experiences in hospital settings can be an effective means to develop students' skills in interprofessional competence.
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.
Background and purpose:
Improving healthcare delivery for U.S. veterans is a national priority. The Veterans Health Administration (VHA) employs a variety of team-based, population health strategies to address critical issues in veterans' health including the effective management of chronic disease. Nurse practitioners (NPs) are integral members of the VHA patient care team with a substantial role to play in the organization and delivery of healthcare services for veterans. This report explores the contributions of NPs in team-based, population health strategies within the VHA.
Methods:
This review of the literature examines peer-reviewed articles published between 2006 and 2017 to explore the contributions of NPs in team-based, population health strategies within the VHA. Search words include veterans, VHA, NPs, population health, panel management, and chronic disease.
Conclusions:
NPs are vital members of the VHA primary care team; however, there is a dearth of available evidence reflecting the unique contribution of NPs within VHA team-based, population health management strategies.
Implications for practice:
The VHA adoption of full practice authority for NP practice provides NPs with an expanded capacity to lead improvements in veterans' health. Future research is needed to fully understand the unique role of the NP in the delivery of population health management strategies for veterans.
This article describes the systematic efforts undertaken by a school of nursing in the Northeastern United States to foster innovation in health professions education. We present an application of modified team coaching and plan-do-study-act improvement methods in an educational context to rapidly integrate a quality and safety curriculum across programs. We discuss applications in generalist, advanced practice, doctoral, residency, and advanced fellowship programs and provide examples of each.
Background:
The Institute of Medicine has recommended the establishment of residency programs for advanced practice nursing graduates. Currently, the evidence about program effectiveness is limited.
Purpose:
To describe the nurse practitioner (NP) resident outcomes on seven competency domains established by the VA Centers of Excellence in Primary Care Education (VA CoEPCE).
Methods:
We evaluated mean NP resident competency self-ratings and mean mentor ratings over the 12-month program across NP residency programs at five sites. Highest and lowest rated items and differences between NP resident self-ratings and mentor ratings were analyzed.
Results:
Mean NP resident self-ratings and mean mentor ratings demonstrated statistically significant improvement in all domains (p < .0001). At 12 months, NP residents were rated by their mentors as able to practice without supervision in all competency domains. At 1 and 12 months, clinical, leadership and quality improvement/population management competencies were the lowest scored domains while patient-centered care, interprofessional team collaboration, shared decision-making and sustained relationships competencies were highest.
Conclusions:
These results provide initial evidence for the effectiveness of VA CoEPCE NP residency programs and also highlight areas of needed improvement.
Background/Objective: The number of veterans and their families seeking healthcare and support within civilian communities is increasing worldwide. There is a need for healthcare providers to provide sensitive, comprehensive care for veterans with both physical and behavioral health conditions. Many civilian providers are unfamiliar with veterans’ issues and need training on military culture and combat experiences in order to provide compassionate, high quality care. An interprofessional (IPE) course to increase health professional students’ understanding of military culture and the associated health problems of veterans was implemented and evaluated. Methods: An 8-week IPE immersion course was offered for students with clinical experience at a Veterans’ Health primary care clinic and a didactic component. The class content included military culture, behavioral and physical health disorders common among veterans, and the related behavioral and pharmacological treatments. Faculty-led discussions with students in IPE teams used veteran-focused case studies and standardized patients to prepare students to work in IPE teams in the clinical care of veterans. Results: This educational project was evaluated using quantitative surveys and qualitative reflection questions and focus groups. Students scored high for readiness for interprofessional learning pre-course. Post-course students reported valuing the team approach to veterans care and students engaged in high levels of communication and collaboration within the team. Students’ knowledge scores increased related to understanding of military culture and their patient advocate role. Conclusions: Students learned about military culture and the provision of humanistic, high quality care for military veterans in this clinical and didactic immersion IPE course.
The Institute of Medicine recommended the implementation of nurse practitioner transition-to-practice programs, either called residency or fellowship, for new graduates. These programs are rapidly expanding on the national level in a variety of practice areas. However, there is a lack of literature on the effectiveness of these programs. The Veterans Affairs Centers of Excellence in Primary Care Education developed a competency-based assessment tool to measure program effectiveness, document the achievement of competency, and promote standardization. This article describes the development of the tool along with curricular examples to promote nurse practitioner transition to practice.
Programs to facilitate nurse practitioner (NP) transition-to-practice have been developed at public and private institutions across the United States, yet there is no published evidence of their influence on NP job satisfaction. The Misener Nurse Practitioner Job Satisfaction Scale was administered to a convenience sample of two groups of NPs: one group with a formal postgraduate education and another group without formal postgraduate education. Postgraduate education has a statistically significant positive impact on NP job satisfaction. Knowledge of factors that influence job satisfaction is advantageous to employers, policymakers, and NPs considering postgraduate education opportunities.
The purpose of this study was to identify and prioritize critical aspects needed in the design and execution of new nurse practitioner (NP) residency programs. Subjects answered a series of questions on formulating residency programs and on key outcomes and cost measures related to their sustainability. These results serve as potential guideposts for future work in NP residency standardization and sustainability development.
Background:
Despite rapid advances in the clinical and psycho-educational management of diabetes, the quality of care received by the average patient with diabetes remains lackluster. The "collaborative" approach--the Breakthrough Series (BTS; Institute for Healthcare Improvement [IHI]; Boston)--coupled with a Chronic Care Model was used in an effort to improve clinical care of diabetes in 26 health care organizations.
Methods:
Descriptive and pre-post data are presented from 23 health care organizations participating in the 13-month (August 1998-September 1999) BTS to improve diabetes care. The BTS combined the system changes suggested by the chronic care model, rapid cycle improvement, and evidence-based clinical content to assist teams with change efforts. The characteristics of organizations participating in the diabetes BTS, the collaborative process and content, and results of system-level changes are described.
Results:
Twenty-three of 26 teams completed participation. Both chart review and self-report data on care processes and clinical outcomes suggested improvement based on changes teams made in the collaborative. Many of the organizations evidencing the largest improvements were community health centers, which had the fewest resources and the most challenged populations.
Discussion:
The initial Chronic Illness BTS was sufficiently encouraging that replication and evaluation of the BTS collaborative model is being conducted in more than 50 health care systems for diabetes, congestive heart failure, depression, and asthma. This model represents a feasible method of improving the quality of care across different health care organizations and across multiple chronic illnesses.
It was postulated that home hospitalisation (HH) of selected chronic obstructive pulmonary disease (COPD) exacerbations admitted at the emergency room (ER) could facilitate a better outcome than conventional hospitalisation.
To this end, 222 COPD patients (3.2% female; 71±10 yrs (mean±sd)) were randomly assigned to HH (n=121) or conventional care (n=101). During HH, integrated care was delivered by a specialised nurse with the patient's free-phone access to the nurse ensured for an 8‐week follow-up period.
Mortality (HH: 4.1%; controls: 6.9%) and hospital readmissions (HH: 0.24±0.57; controls: 0.38±0.70) were similar in both groups. However, at the end of the follow-up period, HH patients showed: 1) a lower rate of ER visits (0.13±0.43 versus 0.31±0.62); and 2) a noticeable improvement of quality of life (Δ St George's Respiratory Questionnaire (SGRQ), −6.9 versus −2.4). Furthermore, a higher percentage of patients had a better knowledge of the disease (58% versus 27%), a better self-management of their condition (81% versus 48%), and the patient's satisfaction was greater. The average overall direct cost per HH patient was 62% of the costs of conventional care, essentially due to fewer days of inpatient hospitalisation (1.7±2.3 versus 4.2±4.1 days).
A comprehensive home care intervention in selected chronic obstructive pulmonary disease exacerbations appears as cost effective. The home hospitalisation intervention generates better outcomes at lower costs than conventional care.
To determine whether using the chronic care model (CCM) in an underserved community leads to improved clinical and behavioral outcomes for people with diabetes.
This multilevel, cluster-design, randomized controlled trial examined the effectiveness of a CCM-based intervention in an underserved urban community. Eleven primary care practices, along with their patients, were randomized to three groups: CCM intervention (n = 30 patients), provider education only (PROV group) (n = 38), and usual care (UC group) (n = 51).
A marked decline in HbA(1c) was observed in the CCM group (-0.6%, P = 0.008) but not in the other groups. The magnitude of the association remained strong after adjustment for clustering (P = 0.01). The same pattern was observed for a decline in non-HDL cholesterol and for the proportion of participants who self-monitor blood glucose in the CCM group (non-HDL cholesterol: -10.4 mg/dl, P = 0.24; self-monitor blood glucose: +22.2%, P < 0.0001), with statistically significant between-group differences in improvement (non-HDL cholesterol: P = 0.05; self-monitor blood glucose: P = 0.03) after adjustment. The CCM group also showed improvement in HDL cholesterol (+5.5 mg/dl, P = 0.0004), diabetes knowledge test scores (+6.7%, P = 0.07), and empowerment scores (+2, P = 0.02).
These results suggest that implementing the CCM in the community is effective in improving clinical and behavioral outcomes in patients with diabetes.
The study addressed whether a collaborative model for chronic care, described in part I (this issue), improves outcome for bipolar disorder.
The intervention was designed to improve outcome by enhancing patient self-management skills with group psychoeducation; providing clinician decision support with simplified practice guidelines; and improving access to care, continuity of care, and information flow via nurse care coordinators. In an effectiveness design veterans with bipolar disorder at 11 Veterans Affairs hospitals were randomly assigned to three years of care in the intervention or continued usual care. Blinded clinical and functional measures were obtained every eight weeks. Intention-to-treat analysis (N=306) with mixed-effects models addressed the hypothesis that improvements would accrue over three years, consistent with social learning theory.
The intervention significantly reduced weeks in affective episode, primarily mania. Broad-based improvements were demonstrated in social role function, mental quality of life, and treatment satisfaction. Reductions in mean manic and depressive symptoms were not significant. The intervention was cost-neutral while achieving a net reduction of 6.2 weeks in affective episode.
Collaborative chronic care models can improve some long-term clinical outcomes for bipolar disorder. Functional and quality-of-life benefits also were demonstrated, with most benefits accruing in years 2 and 3.
Although we are rapidly improving our understanding of how to manage patients with chronic illness in Australian general practice, many patients are still receiving suboptimal care. General practices have limited organisational capacity to provide the structured care that is required for managing chronic conditions: regular monitoring, decision support, patient recall, supporting patient self management, team work, and information management. This requires a shift away from episodic, acute models. Overseas research has shown that areas such as team work, clinical information systems, decision support, linkages and leadership are also important in managing chronic illness, but we do not know which of these are most important in Australia.
Leading health care experts in the United States have stated that the greatest primary care challenge today is meeting the complex needs of patients with chronic illness/long-term conditions or impairment.To address this challenge, there is a need for health care system redesign that requires a multidisciplinary team approach, including active participation from professional nurses. In particular, it is essential for advanced practice nurses to provide leadership in health systems design for which they are specifically trained and experienced. In this article, the primary care challenge related to chronic illness care management is addressed. Future implications for community-based, chronic illness care delivery and the education of future health care providers with a focus on advanced practice nurses will also be discussed.
Despite rapid advances in the clinical and psycho-educational management of diabetes, the quality of care received by the average patient with diabetes remains lackluster.
While key components of the Patient-Centered Medical Home (PCMH) have been described, improved patient outcomes and efficiencies have yet to be conclusively demonstrated. We describe the rationale, conceptual framework, and progress to date as part of the VA Ann Arbor Patient-Aligned Care Team (PACT) Demonstration Laboratory, a clinical care-research partnership designed to implement and evaluate PCMH programs. Evidence and experience underlying this initiative is presented. Key components of this innovation are: (a) a population-based registry; (b) a navigator system that matches veterans to programs; and (c) a menu of self-management support programs designed to improve between-visit support and leverage the assistance of patient-peers and informal caregivers. This approach integrates PCMH principles with novel implementation tools allowing patients, caregivers, and clinicians to improve disease management and self-care. Making changes within a complex organization and integrating programmatic and research goals represent unique opportunities and challenges for evidence-based healthcare improvements in the VA.
Background:
The Veterans Health Administration (VHA) is the largest integrated US health system to implement the patient-centered medical home. The Patient Aligned Care Team (PACT) initiative (implemented 2010-2014) aims to achieve team based care, improved access, and care management for more than 5 million primary care patients nationwide.
Objectives:
To describe PACT and evaluate interim changes in PACT-related care processes.
Study design:
Data from the VHA Corporate Data Warehouse were obtained from April 2009 (pre- PACT) to September 2012. All patients assigned to a primary care provider (PCP) at all VHA facilities were included.
Methods:
Nonparametric tests of trend across time points.
Results:
VHA increased primary care staff levels from April 2010 to December 2011 (2.3 to 3.0 staff per PCP full-time equivalent). In-person PCP visit rates slightly decreased from April 2009 to April 2012 (53 to 43 per 100 patients per calendar quarter; P < .01), while in-person nurse encounter rates remained steady. Large increases were seen in phone encounters (2.7 to 28.8 per 100 patients per quarter; P < .01), enhanced personal health record use (3% to 13% of patients enrolled), and electronic messaging to providers (0.01% to 2.3% of patients per quarter). Post hospitalization follow-up improved (6.6% to 61% of VA hospital discharges), but home telemonitoring (0.8% to 1.4% of patients) and group visits (0.2 to 0.65 per 100 patients per quarter; P < .01) grew slowly.
Conclusions:
Thirty months into PACT, primary care staff levels and phone and electronic encounters have greatly increased; other changes have been positive but slower.
Twenty ethnically and geographically diverse health care organizations, including 15 Bureau of Primary Health Care centers, participated in an Institute for Healthcare Improvement (IHI) collaborative Breakthrough Series (BTS) project on depression. Teams attended three learning sessions that emphasized the chronic illness care model, key depression change concepts, and how to initiate plan-do-study-act cycles.
Seventeen of the 20 organizations completing the BTS achieved a faculty assessment of at least a 4 (5 indicates significant improvement). More than 2000 patients initiated depression treatment and were registered in the plan's depression registries. Patients in the centers who used the recommended measures had the following outcomes: 56% had significant change in their depressive symptoms at 12 weeks, 87% completed follow-up assessments, 54% continued antidepressant medication for at least 10 weeks, and 90% completed a structured diagnostic assessment before treatment.
On the basis of the feedback from ten successful teams, the essential change concepts for depression were establishing and maintaining a patient registry, care coordination, diagnostic assessment, and proactive follow-up. Many of the BTS centers have continued to expand their depression treatment programs. The IHI BTS appears to be a viable method of disseminating evidence-based depression care.
The Health Disparities Collaboratives of the Health Resources and Services Administration (HRSA) were designed to improve care in community health centers, where many patients from ethnic and racial minority groups and uninsured patients receive treatment.
We performed a controlled preintervention and postintervention study of community health centers participating in quality-improvement collaboratives (the Health Disparities Collaboratives sponsored by the HRSA) for the care of patients with diabetes, asthma, or hypertension. We enrolled 9658 patients at 44 intervention centers that had participated in the collaboratives and 20 centers that had not participated (external control centers). Each intervention center also served as an internal control for another condition. Quality measures were abstracted from medical records at each health center. We created overall quality scores by standardizing and averaging the scores from all of the applicable measures. Changes in quality were evaluated with the use of hierarchical regression models that controlled for patient characteristics.
Overall, the intervention centers had considerably greater improvement than the external and internal control centers in the composite measures of quality for the care of patients with asthma and diabetes, but not for those with hypertension. As compared with the external control centers, the intervention centers had significant improvements in the measures of prevention and screening, including a 21% increase in foot examinations for patients with diabetes, and in disease treatment and monitoring, including a 14% increase in the use of antiinflammatory medication for asthma and a 16% increase in the assessment of glycated hemoglobin. There was no improvement, however, in any of the intermediate outcomes assessed (urgent care or hospitalization for asthma, control of glycated hemoglobin levels for diabetes, and control of blood pressure for hypertension).
The Health Disparities Collaboratives significantly improved the processes of care for two of the three conditions studied. There was no improvement in the clinical outcomes studied.
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