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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
2
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
3
4
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
5
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
6
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
7
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
12
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: [email protected]
Judy L. Brannen, MD, MBA Clinical Director, Undergraduate & Graduate Medical Education Tel. (804) 675-5481 e-mail: [email protected] Web: http://www.va.gov/oaa
16
Questions?