Abstract Transition to interprofessional team-based care is a quickly progressing healthcare model and requires changes in medical training approaches. The Department of Veteran Affairs (VA) has taken a lead role in creating such training experiences, one of which is the establishment of multiple Centers of Excellence in Primary Care Education (CoEPCE). These sites are tasked with developing teaching innovations to better facilitate interprofessional team-based care. The patient-aligned care team interprofessional care update (PACT-ICU) is an interprofessional workplace learning activity with the goals of simultaneously addressing educational and patient care needs. Participants of the PACT-ICU included trainees and faculty of a variety of medical disciplines (e.g., internal medicine, psychology, and pharmacy) involved in a training primary care clinic. Two medically complex patients were presented at each PACT-ICU conference with the purpose of creating a plan of care that maintained an interprofessional team-based approach. Following implementation of the PACT-ICU conference intervention, two primary outcomes were assessed. First, self-assessment of PACT-ICU attendee learner outcomes was measured using a brief questionnaire surveying knowledge gain as it related to increase in knowledge of other professions’ capabilities, roles, and responsibilities. Secondly, trainee provider behavior change was evaluated by measuring number of “within PACT” consults before and after participating in PACT-ICU. There was a significant positive change in self-assessed knowledge along with an indication of trainee behavioral change, as measured by electronic medical record consult patterns. This study demonstrates that interprofessional case conferences involving trainees and staff from multiple professions can increase awareness of other professions roles in patient care as well as facilitate interprofessional collaboration. Implications Practice: Interprofessional case conferences can be used to increase knowledge and awareness of other healthcare professionals’ roles in patient care as well as facilitate improved interprofessional collaboration. Policy: Medical facilities invested in providing integrated care services should consider programs that allow for interprofessional development and learning. Research: Future research should also consider patient outcomes following interprofessional development interventions. INTRODUCTION There has been a national shift toward patient-centered medical homes (PCMH) that focus on providing team-based primary care . This shift has been felt within the Department of Veteran Affairs (VA) healthcare system as well and led to the adoption of the patient-aligned care teams (PACT) model . PACT is the VAs version of PCMH, developed in 2010, and intended to improve staffing ratios of nursing/clerical staff, as well as integrate behavioral health and pharmacy beyond simple co-location into truly collaborative care. Both models, PACT and PCMH, focus on team-based, patient-centered care models delivered by interprofessional providers. The transition toward team-based care begets the necessity to train providers in collaborative approaches that support coordinated interprofessional function. The need for synergistic training exists for both current healthcare professionals as well as trainees. Trainees that are provided foundational experiences in interprofessional team-based care will graduate uniquely situated to work in these environments and have skills that could increase their value for interprofessional collaboration . Interprofessional education and workplace learning activities have been shown to have a positive impact on the process/delivery of care and on disease markers such as blood pressure and HgA1c for diabetic patients . With awareness of the benefits and utility of such training, in 2011, the VA created five Centers of Excellence in Primary Care Education (CoEPCE). These sites are intended to develop teaching innovations to facilitate interprofessional team-based care for the next generation of healthcare providers and the patients that they serve [5, 6]. Our Veterans Affairs Medical Center (VAMC) was selected as one of the initial CoEPCE sites and has developed innovations to target improvement in patient care and interprofessional training. One of these innovations was the development of an interprofessional care conference for high-risk patients, locally referred to as patient-aligned care team interprofessional care update (PACT-ICU). This conference provides a workplace learning opportunity for an interprofessional team of trainees and staff to discuss the care needs of high-risk patients using a biopsychosocial perspective  and create an interprofessional action plan to target the patient’s needs, while also learning about the different roles and responsibilities of their fellow healthcare professionals. Patient characteristics and curriculum overview with PACT-ICU have been discussed in previous works such as Weppner et al. [8, 9]. As interprofessional education continues to grow, it is important that programs provide information on the impact of these innovative endeavors . One model that has been suggested as a conceptual framework for interprofessional education outcomes is the expanded Kirkpatrick model [11, 12]. This model highlights multiple levels and aspects of outcome evaluations, including reaction, learning, behavior change, and results. To create a robust assessment of the interprofessional educational outcomes of PACT-ICU, multiple levels of evaluation are needed that address the entire continuum of learning. The current study focuses on learner outcomes that include trainees’ reaction, perception, self-reported change in knowledge, and preliminary outcomes regarding collaborative behavior and behavior change. This study explored two hypotheses related to learner outcomes. Our first hypothesis predicted that the PACT-ICU attendees would report an increase in knowledge related to other professions’ capabilities, roles, and responsibilities. The second hypothesis predicted that, because of the knowledge gained from PACT-ICU, more consults would remain with training team members rather than with professionals outside the team. That is, an increase in within-primary care team consults (e.g., consults placed by trainee PCPs to PACT pharmacy, psychology, and social work) may represent enhanced interprofessional awareness and real-time collocated team collaboration. METHODS This study was reviewed and approved by the Institutional Review Board of VA Puget Sound Health Care System. Participants Participants of the PACT-ICU conference included trainees, staff, and faculty involved in the training primary care clinic. Trainees included internal medicine residents who were in the second or third year, nurse practitioner (NP) students and residents, nursing students, clinical psychology interns and postdoctoral fellows, and ambulatory pharmacy residents. Additional attendees included supervisors of the aforementioned professions, as well as staff members who provide care in the training clinic. These staff members included nurse care managers (RNs), chaplaincy, and social workers. Intervention PACT-ICU is an interprofessional case conference that has both educational and patient care goals. Interprofessional student and postgraduate trainees meet for 1 hr to discuss high-risk patients presented by two primary care provider (PCP) trainees. Two PCP trainees (NP or internal medicine residents) select a patient from their primary care panel utilizing VA-based Care Assessment Needs (CAN) registry, which predicts 90-day risk of death or hospitalization . The selected patients’ identifiers are sent in an encrypted email to the interprofessional team so that each profession can conduct a chart review prior to the conference and offer consultation during the conference. Following the discussion, the team creates a care plan that details the profession-specific action items, which is documented in the patient’s chart. For more details regarding the structure of PACT-ICU, please see Weppner et al. . Evaluation Knowledge gain was assessed by a self-report survey. All PACT-ICU participants (i.e., staff, faculty, and trainees) were asked to complete a questionnaire following their first PACT-ICU experience. Survey data were collected between January 2013 and January 2016. The questionnaire asked participants to rate their perceived knowledge about interprofessional care, with a five-point Likert scale (1 = minimal knowledge, 5 = excellent knowledge), using a retro-pre/post approach . Participants were also asked to rate, using a five-point Likert scale, their level of understanding of the biopsychosocial elements considered in patient care (1 = few of the elements, 5 = most of the elements), as well as the value of other professions’ support in the management of complex patients before and after attending PACT-ICU (1 = not helpful in support, 5 = very helpful in support). To assess behavioral change and potential diffusion as a result of participation in PACT-ICU, a random sample of five patients from each PCP trainee’s entire panel (excluding patients who were discussed in PACT-ICU) were selected. The researchers reviewed the consult data, including ‘within’ and ‘outside of’ the primary care team consults. Consults directed to core members of the primary care team (i.e., pharmacy, psychology, and social work) were considered a within-primary team consult. Other consults were outside of the primary care team (e.g., endocrine, cardiology, and outpatient mental health). Data were collected during the 2012–2013 academic year (the first year of PACT-ICU implementation) over two distinct 2-month time intervals: 6 months before PACT-ICU and immediately after PACT-ICU. Data analysis To assess perception of knowledge gain, paired t-tests were performed to evaluate significance of reported change on the PACT-ICU attendees’ responses to survey questions. To assess behavior change in the trainee clinic, a paired t-tests was conducted to evaluate whether there was an increase in the number of within-primary care team consults following implementation of PACT-ICU. Descriptive statistics were conducted at each 2-month time interval to inspect overall number of consults placed during each period, average number of consults placed per patient, and profession to which the consult was directed. RESULTS A total of 48 trainees and 10 staff/faculty members, from pharmacy, internal medicine, nurse practioners, nursing, and psychology units, completed the retro-pre/post survey following their first experience with PACT-ICU. Consult data were collected from 85 trainee patients (5 each for 17 trainees) not presented to PACT-ICU. Table 1 summarizes the descriptive statistics collected across each 2-month interval for the trainee clinic. Table 1 Self-reported Change in Knowledge Trainees N Pre-mean Post-mean Mean difference (95% CI) My understanding of all of the elements (biological, psychological, social) that must be considered in this patient’s care 47 2.8 4.4 1.6* (1.4–1.9) My understanding of the roles that each of the team can play in hard to manage patients like the one presented 48 3.1 4.4 1.3* (1.1–1.5) Staff and faculty My understanding of all of the elements (biological, psychological, social) that must be considered in this patient’s care 10 3 4.4 1.4* (0.7–2.1) My understanding of the roles that each of the team can play in hard to manage patients like the one presented 9 3.2 4.3 1.1* (0.3–1.9) Trainees N Pre-mean Post-mean Mean difference (95% CI) My understanding of all of the elements (biological, psychological, social) that must be considered in this patient’s care 47 2.8 4.4 1.6* (1.4–1.9) My understanding of the roles that each of the team can play in hard to manage patients like the one presented 48 3.1 4.4 1.3* (1.1–1.5) Staff and faculty My understanding of all of the elements (biological, psychological, social) that must be considered in this patient’s care 10 3 4.4 1.4* (0.7–2.1) My understanding of the roles that each of the team can play in hard to manage patients like the one presented 9 3.2 4.3 1.1* (0.3–1.9) *p < .01. View Large Table 1 Self-reported Change in Knowledge Trainees N Pre-mean Post-mean Mean difference (95% CI) My understanding of all of the elements (biological, psychological, social) that must be considered in this patient’s care 47 2.8 4.4 1.6* (1.4–1.9) My understanding of the roles that each of the team can play in hard to manage patients like the one presented 48 3.1 4.4 1.3* (1.1–1.5) Staff and faculty My understanding of all of the elements (biological, psychological, social) that must be considered in this patient’s care 10 3 4.4 1.4* (0.7–2.1) My understanding of the roles that each of the team can play in hard to manage patients like the one presented 9 3.2 4.3 1.1* (0.3–1.9) Trainees N Pre-mean Post-mean Mean difference (95% CI) My understanding of all of the elements (biological, psychological, social) that must be considered in this patient’s care 47 2.8 4.4 1.6* (1.4–1.9) My understanding of the roles that each of the team can play in hard to manage patients like the one presented 48 3.1 4.4 1.3* (1.1–1.5) Staff and faculty My understanding of all of the elements (biological, psychological, social) that must be considered in this patient’s care 10 3 4.4 1.4* (0.7–2.1) My understanding of the roles that each of the team can play in hard to manage patients like the one presented 9 3.2 4.3 1.1* (0.3–1.9) *p < .01. View Large PACT-ICU conference attendees endorsed a significant self-reported increase in knowledge following the conference (prior to conference M = 2.8, post conference M = 4.4) (Table 2). Table 2 P CP Trainee Consults Number of patients Mean patient age Total consults per patient mean (SD) Within-primary care teama consults per patient mean (SD) 6 months prior PACT-ICU 85 65 2.8 (2.3) 1.0 (1.4) Following PACT-ICU 85 62 4.8 (3.9) 3.2 (2.3) Number of patients Mean patient age Total consults per patient mean (SD) Within-primary care teama consults per patient mean (SD) 6 months prior PACT-ICU 85 65 2.8 (2.3) 1.0 (1.4) Following PACT-ICU 85 62 4.8 (3.9) 3.2 (2.3) PACT-ICU patient-aligned care team interprofessional care update. aWithin-primary care team refers to psychologists, pharmacists, and social workers embedded in primary care. View Large Table 2 P CP Trainee Consults Number of patients Mean patient age Total consults per patient mean (SD) Within-primary care teama consults per patient mean (SD) 6 months prior PACT-ICU 85 65 2.8 (2.3) 1.0 (1.4) Following PACT-ICU 85 62 4.8 (3.9) 3.2 (2.3) Number of patients Mean patient age Total consults per patient mean (SD) Within-primary care teama consults per patient mean (SD) 6 months prior PACT-ICU 85 65 2.8 (2.3) 1.0 (1.4) Following PACT-ICU 85 62 4.8 (3.9) 3.2 (2.3) PACT-ICU patient-aligned care team interprofessional care update. aWithin-primary care team refers to psychologists, pharmacists, and social workers embedded in primary care. View Large Analyzing change in within-primary care team consults placed by PCP trainees prior to PACT-ICU (M = 1.0, SD = 1.4) and following PACT-ICU (M = 3.2, SD = 2.3), utilizing a paired t-test, demonstrated a significant growth in within-primary care team consults (p < .01) placed. Further exploratory analysis was conducted by examining which professions were consulted within the primary care team (Fig. 1). There was a nonsignificant trend toward increased utilization of individual professions within the primary care team. Fig 1 View largeDownload slide Profession breakdown of within-primary care team consults. Fig 1 View largeDownload slide Profession breakdown of within-primary care team consults. DISCUSSION The Institute of Medicine put forth a report in 2015 outlining the current state of measuring the impact of interprofessional education, as well as providing recommendations for future studies . Some of the noted areas of needed improvement included addressing gaps in the research such as employing mixed methodological designs (e.g., validated measures of change, behavioral/clinical outcomes), as well as utilizing realist approaches (i.e., mixed randomized control studies may not generalize across individuals/clinics). The current study was developed with this proposal in mind and attempted to assess the utility of an interprofessional case conference by measuring change in both participant knowledge and behavior. To improve both quality of care as well as interprofessional education, our VAMC CoEPCE developed an interprofessional case conference, PACT-ICU. High-risk patients were presented to a team of interprofessional trainees who learned about the unique roles of their colleagues through discussion and development of care plans for these patients. By creating a case conference that included multiple professions, our facility was able to capitalize on meeting multiple educational needs at once. Medical facilities that house multiple professional training programs are uniquely situated to provide learning opportunities for multiple trainees to develop interprofessional skills. These skills and early experiences can impact later interprofessional work and attitudes . As training programs implement interprofessional educational endeavors, it is important that programs provide information on the impact of their innovations . The expanded Kirkpatrick model [11, 12] highlights multiple levels and aspects of outcome evaluations, including learner, patient health, and system outcomes. To create a robust assessment of the interprofessional educational outcomes of PACT-ICU, an adapted Kirkpatrick model  was employed. This model divides the process of learning into four main outcome areas: reaction, attitude/perception, knowledge, and behavior/performance change. The first outcome level, reaction, was discussed in a paper by Weppner et al. . A Likert scale self- assessment following participation in PACT-ICU was very positive as measured by trainee satisfaction, with almost all trainees describing the conference as “very helpful” or “helpful” . The second outcome level addresses learning specific skills and changes in learner’s perception. We evaluated perception of knowledge gain by self-report survey. Survey results indicate that both trainees and staff reported a significant increase in their understanding of the biopsychosocial aspects of patient care, as well as how different professionals contribute to patient care. Changes in perception and knowledge are particularly important as many primary care providers are unprepared to manage high-risk patients in primary care  and underlying psychosocial issues are often not addressed in primary care appointments . With improved knowledge of capability, roles, and responsibilities, trainees and the entire primary care team can work together to better address the complex needs of their patients. However, as has been previously noted, evaluations of interprofessional education need to target changes in trainee collaborative behavior . Behavior change is the third level of learning outcomes in the adapted Kirkpatrick model. To capture information on behavioral change, the consult patterns of PCP trainees were collected. Our second hypothesis was that the experience of attending PACT-ICU would facilitate learning that would carry over into the trainees’ general primary care practice and create an increase in within-primary care team consults indicating increased utilization of primary care team members to address patient care needs. To evaluate this hypothesis, PCP trainee consult patterns were evaluated prior to implementation of the conference. Consults were divided into two groups: within the primary care team (e.g., psychology, pharmacy, social work) and outside of the primary care team. There was a significant increase in collaborative patient care as well as a diffusion of knowledge from having participated in the PACT-ICU conference. Additionally, while group sizes were too small to detect statistically significant change, an interesting trend toward equal distribution of within-primary care consults following PACT-ICU participation was observed (Fig. 1); that is, trainee PCPs appeared to utilize more of their PACT team indicative of improved collaborative care. There were several limitations to the study. First, PACT-ICU was implemented within the context of broad, facility-wide cultural change. During the same timeframe as the PACT-ICU intervention, the entire medical center’s primary care model was restructured to a PACT, the VA’s version of a patient-centered medical home. A component of this organizational change to PACT involved trainings that had a specific focus on the use of interprofessional team members. As a result, it is unclear if the changes documented are related to facility-wide cultural change. Similarly, interprofessional training provided to trainees took place within the context of many educational opportunities, of which PACT-ICU was only one component, thus making it difficult to make causative inferences about exposure to PACT-ICU and change in behaviors such as consult patterns. As a result, there is the possibility that a co-intervention may account for the changes that were seen . To focus the evaluation on the specific content, we employed a retro-pre/post survey on the impact of the conference, minimizing the impact of co-intervention on learning and perception of knowledge gain . Second, we were unable to comment on any patterns seen in our data that may correlate with individual professions or training level. While it could have been interesting to determine the potential impact of the case conference separated by profession, we decided to remove this potentially identifying information to protect the confidentiality of our trainees. Third, we tracked consults placed in an electronic health record (EHR) as a strategy to assess referrals. However, by using only consults placed in the EHR, we may have underrepresented the amount of primary care team engagement with the patient. For example, “warm handoffs” and same-day consults may not have resulted in an EHR consult and would not have been captured in our evaluation. Fourth, further investigation into trainee perception of change following participation in PACT-ICU may have helped to elucidate whether trainees felt that other team members better understood their professional role. Overall this study demonstrates that interprofessional case conferences involving trainees and staff from multiple professions can help healthcare trainees understand the roles of other team members and increase the collaboration of the entire primary care team to ensure that primary care patients receive quality team-based care. Next steps in the evaluation process of PACT-ICU should address patient outcomes. This could include evaluation of the patient’s experience and disease-specific outcomes targeted by the interprofessional care plan. Another aspect of the evaluation process could include utilization patterns such as changes in ED and episodic care, with the assumption that engagement in team-based care would lower the need for urgent care access. Acknowledgments The authors would like to acknowledge the feedback from the Coordinating Center of the VA Centers of Excellence in Primary Care Education. This research was not grant funded. Support is provided by VA Centers of Excellence in Primary Care Education and Office of Academic Affairs. The authors alone are responsible for the data, content, and writing of the article. Data reported in this article may be reviewed upon request. The data have not been previously published elsewhere nor submitted simultaneously to another source. Previous presentations: Findings from the Patient-Aligned Care Team Interprofessional Care Update (PACT-ICU) have been presented at the Northwest Regional and National Society of General Internal Medicine meetings in 2014. Compliance with Ethical Standards Conflict of Interest: The authors report no conflicts of interest. Ethical Approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors. Informed Consent: In accordance with the intuition review board’s review of the study, informed consent was not required for individual participants included in the study. References 1. Grundy P , Hagan KR , Hansen JC , Grumbach K . The multi-stakeholder movement for primary care renewal and reform . 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Google Scholar Crossref Search ADS Published by Oxford University Press on behalf of the Society of Behavioral Medicine 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US.
Translational Behavioral Medicine – Oxford University Press
Published: Nov 21, 2018
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