Interprofessional transformation of clinical education: The first six years of the Veterans Affairs Centers of Excellence in Primary Care Education

Figures & data

Figure 1. CoEPCE logic model.

Table 1. CoEPCE faculty academic appointments, 2016.

Faculty Profession	Number of Faculty	Has Academic Appointment n (%)
Nurse Practitioner	30	23	(77%)
Nursing^a	35	5	(14%)
Pharmacy	17	11	(65%)
Physician	82	69	(84%)
Psychology	14	7	(50%)
Social Work	5	0	(0%)
Other^b	29	10	(35%)
Total	212	125	(59%)

^aNursing includes licensed vocational nurses (LVN) and registered nurses (RN).

^bOther includes evaluators of different academic disciplines and program administrators.

Table 2. Examples of center reported teaching activities integrating instructional strategies and core domains.

	Instructional Strategy^a			PCMHI^b	Core Domain^c
Teaching Activity	Didactic	WPL	RP	PCMHI	IPC	SDM	SR	PI
Panel Management: Quarterly diabetic panel management sessions with NP, MD, Pharmacy, and Psychology trainees. Sessions are 3–4 hours and NP/MD co-facilitated. First hour is didactic on how to use the Diabetic Registry tool, followed by use of “toolbox” to plan interprofessional interventions for a population.	Yes	Yes	No	Yes	Yes	Yes	No	Yes
Ambulatory Noon Conference: Trainees of different professions co-present an ambulatory noon conference based on a topic list developed by the CoE. Faculty facilitate trainees working together to co-present. Faculty co-evaluate each trainee pair’s presentation using formal evaluation forms.	Yes	No	Yes	Yes	Yes	No	No	Yes
Integration of Workplace TeamStepps: Time is provided for reflection on experiences when TeamStepps tools are used and the effectiveness of the implementation.	No	Yes	Yes	No	Yes	No	No	No
Enhanced Mentoring: Sessions provide opportunities for trainees and faculty to identify common interests to match trainees with mentors. Trainees and mentors check in at least twice per year.	No	No	Yes	No	Yes	No	Yes	No
Mental Health Collaborative Care Conference: Monthly collaborative care conference to develop patient-centered integrated care plans in primary care. Participants include PACT team members (RN care manager, social work, pharmacy), primary care and mental health faculty, and trainees.	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Health Psychology (HP) Coaching: HP trainees provide coaching and observe primary care trainees and faculty coach patients to provide formative feedback in real time on issues such as efficiency, agenda setting, patient-centeredness, shared decision making, motivational interviewing, risk communication, and boundary setting.	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Super Huddle: Three PACT teams meet in a super primary care huddle for 10 minutes, followed by individual team meetings for any mental health, pharmacy, social work or primary care integration needs. Super Huddle Checklist used to identify if core goals of huddle are being met.	No	Yes	No	Yes	Yes	No	No	No
Polypharmacy Clinic: Trainee-led performance improvement process to reduce polypharmacy in older Veterans and enhances trainee skills and knowledge related to safe prescribing.	Yes	Yes	No	No	Yes	Yes	Yes	No

^aInstructional strategies include didactics, workplace learning (WPL), and reflective practice (RP)

^bPrimary care, mental health integration (PCMHI)

^cCoEPCE core domains include interprofessional collaboration (IPC), shared decision making (SDM), sustained relationships (SR), and performance improvement (PI)

Figure 2. Number of core trainee positions by profession academic years 2011–2012 to 2015–2016.

Table 3. Lessons learned for development of the interprofessional clinical learning environment within a national healthcare system.

Logic Model Component	Lessons Learned
Inputs
Funding and Resources	In VA, funding is necessary to ensure specific protected time of academic clinical staff to serve as faculty, and for development of Center infrastructure and leadership, interprofessional curriculum, interprofessional faculty, and evaluation activities. Funding was provided by OAA, a national VA program office, that embraced the vision of IPE in primary care settings to establish alignment with a new clinical care model known as PACT. Funding alone is not sufficient to achieve systems transformation because there was a myriad of challenges that required additional inputs, such as changing institutional and professional cultures and the complexity of aligning interests and logistics across all stakeholders.
National Coordinating Center (NCC)	The NCC was established within OAA to monitor compliance with VA regulations while also facilitating collaboration and fidelity to project goals. The two roles, assuring compliance and facilitating creative collaboration, could easily be in conflict requiring the NCC to develop deliberate strategies to distinguish between requirements and stretch goals. By monitoring fidelity to project goals, the NCC learned first-hand about system barriers and facilitators to IPE. The NCC addressed system barriers by seeking changes to existing local and national VA policies and procedures, developing new IPE national policies, advocating for ongoing resources through its communication with OAA, other VA leadership, and external agencies, and developing resources that could be disseminated throughout VA.
Academic Affiliate Partnerships	Because VA’s educational mission exists within the context of local community institutions and national professional standards, strong relationships are required between the VA and its academic affiliates. In this context, the academic affiliate is the sponsor of the training program and VA provides the clinical learning environment as a participating institution. Strong relationships are also required between academic affiliates to facilitate logistics and new processes required for IPE and faculty development.
Interventions
Program Structure and Leadership	Interprofessional leadership is essential to role model interprofessional behavior to staff, faculty and trainees, to work with local VA facility leadership, and to support the development of curricula involving all participating professions. Further work is required to understand the influence of factors such as individual personality, professional identity, and organizational structure on the effectiveness of interprofessional leadership. Leadership development of individuals to lead interprofessional teams should incorporate these influencing factors.
Space requirements	IPE education and collaboration between trainees, faculty, and patients require larger exam rooms and more space intentionally designed for the clinical education of groups rather than repurposed exam rooms.
Interprofessional Curriculum	Curriculum consists of learning objectives, instruction, and trainee assessment. Health professions’ trainees should experience both interprofessional and profession-specific curricula. The interprofessional curriculum should be interprofessionally co-developed. This is time-consuming but useful to understand each professions’ culture, capabilities, and roles. While it may be possible for profession-specific training programs to share learning objectives, didactic instruction, and trainee assessment strategies, workplace learning (clinical supervision) must be tailored to the local clinical environment. Advancing workplace learning requires making hidden curriculum explicit, as faculty and staff demonstrate the desired professional behaviors and attitudes that are presented to trainees in didactic instruction.
Interprofessional Faculty	Faculty development is necessary to teach skills across the four core domains and delivery of interprofessional team-based care. Faculty development should target clinical faculty and clinic staff such as RN care managers who interact with patients and trainees in the clinical setting. Formal clinical faculty academic appointments across all professions should be considered to ensure faculty development and the quality of education provided by VA clinical staff. The faculty appointment process varies by profession and therefore should be evaluated on a profession by profession basis.
Center Evaluation	Center evaluation should evaluate micro-level impacts on trainees, faculty, and patients; and meso level impacts such as institutional access and clinical metrics.
Outcomes
Short, Intermediate, and Long-Term Outcomes	Enterprise evaluation should include system outputs at the macro level to support policy and decision making, such as trainee learning, program satisfaction, patient-level clinical outcomes and costs of the program. Evaluation of interprofessional education requires interprofessional/interdisciplinary evaluation teams using mixed methods approaches. The enterprise evaluation program should be started early and include evaluators in discussions from project conceptualization.