http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, 2014; 28(5): 473–474 ! 2014 Informa UK Ltd. DOI: 10.3109/13561820.2014.891575
SHORT REPORT
Moving from silos to teamwork: integration of interprofessional trainees into a medical home model Theodore Long1, Sarah Dann2, Marissa Lynn Wolff2 and Rebecca S. Brienza2,3 1
Robert Wood Johnson Clinical Scholars Program, Yale School of Medicine, New Haven, CT, USA, 2VA Connecticut Healthcare System, West Haven, CT, USA, and 3Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
Abstract
Keywords
As the United States faces an impending shortage in the primary care workforce, interprofessional teamwork training to improve clinic efficiency and health outcomes is becoming increasingly important. Currently there is limited integration of interprofessional training in educational models for health professionals. The implementation of Patient Aligned Care Teams at the Department of Veterans Affairs (VA) has provided an opportunity for interprofessional collaboration among trainee and faculty providers within the VA system. However, integration of interprofessional education is also necessary to train future providers in order to provide effective team-based care. We describe a transportable educational model for health professional collaboration from our experience as a VA Center of Excellence in Primary Care Education, including a complementary novel one-year post-Master’s adult nurse practitioner interprofessional clinical fellowship. With growing recognition that interprofessional care can improve efficiency and outcomes, there is an increasing need for programs that train future providers in collaboration and team-based care.
Evaluation research, interprofessional collaboration, interprofessional education, teamwork
Introduction By the year 2025, the United States (US) may face a shortage of up to 44 000 primary care providers (Colwill, Cultice, & Kruse, 2008). Developing strategies for effective interprofessional teamwork and collaboration are a crucial component of the solution to the primary care workforce shortage and transformative educational models for primary care training must also evolve to meet these demands. Effective teamwork in healthcare has been shown to significantly improve patient safety and clinic efficiency (Salas et al., 2008). It has also been demonstrated that interprofessional team-building training substantially reduced annual mortality rates in surgical centers (Neily et al., 2010). However, team training has yet to be widely adopted in health professional education. To meet the challenge of our impending primary care workforce shortage, we must have a frame-shift change from training health professionals in ‘‘silo’’ models to implementing team-based interprofessional education and practice. Patient-centered medical homes (PCMH) have come forward as an effective model for providing such team-based care. The Department of Veterans Affairs (VA) has been at the forefront of recognizing the importance of the PCMH model with the creation of Patient Aligned Care Teams (PACT), which were implemented with the goal of improving patient-centered and interprofessional team-based care. Many health professional training programs are now challenged to integrate trainees into PCMH models given rotation and scheduling constraints. The Josiah Macy Jr. Correspondence: Theodore Long, MD, Robert Wood Johnson Clinical Scholars Program, 333 Cedar Street, SHM IE-61, PO Box 208088, New Haven, CT 06520, USA. Tel: 203.785.4148. Fax: 203.785.3461. E-mail: [email protected]
History Received 11 July 2013 Revised 16 December 2013 Accepted 3 February 2014 Published online 4 March 2014
Foundation recently addressed the importance of including interprofessional training into clinical practices through a series of recommendations linking improvements in health-care delivery to interprofessional educational reform (Josiah Macy Jr. Foundation, 2013).
An interprofessional training model The VA Connecticut Healthcare System Center of Excellence in Primary Care Education (CoEPCE) is one of five program sites funded through the VA’s Office of Academic Affiliations. The mission of the CoEPCEs is to develop exportable models that will foster transition from profession-specific ‘‘silos’’ to interprofessional, team-based education and patient care models. In alignment with the goals of patient-centered care, the core curricular domains for all sites include: shared decision-making, sustained relationships, interprofessional collaboration, and performance improvement. The trainees at our program site include medicine resident (MD), nurse practitioner (NP), pharmacy, and health psychology trainees, who spend approximately fifty percent of their time in interactive educational sessions focusing on the core domains and the remaining time providing care to assigned panels of patients, reinforcing newly acquired skills in the clinic setting. The core faculties include MD, NP, health psychology, and pharmacy providers that provide supervision, mentorship, and collaborative shared care with trainees on interprofessional teams. Based on our experience to date, we believe that this model provides a potentially successful example of interprofessional training and practice. At our site, the skills-based curriculum includes integration of the four core curricular domains into interactive seminars focusing on clinical topics. For example, we developed and implemented an educational module on colon
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cancer screening and shared decision-making. In this session, trainees participated in role plays of patients, providers and family members. In addition, we have developed modules focusing on necessary core knowledge and skills for all health professionals to work in today’s complicated health-care environment incorporating facilitation and conflict management skill training to improve communication between patients and providers, as well as modules in health policy and advocacy. In addition, and unique to our site, we developed a one-year post-Master’s adult NP interprofessional clinical fellowship. We created this additional training year for NPs at our site to further develop independent clinical proficiency and train collaboratively with interprofessional teams. In our overall training program, all trainees were assigned to paired MD/NP faculty provider teams for supervision and mentorship throughout the duration of their training. As part of our interprofessional education curriculum, we have developed weekly sessions that focus on understanding each team member’s role, collaborative teamwork skills, and the application of this knowledge and skill set into managing patients on shared practice panels. Interprofessional team development training includes reviewing the stages of team development, understanding team function and incorporating SWOT (Strengths, Weaknesses, Opportunities, Threats) analyses into real patient scenarios.
Evaluation Preliminary evaluation of routinely collected productivity and performance data after the first year of implementation has indicated that productivity, or total amount of clinical work (patient care), of faculty providers has more than doubled in addition to a marked increase in same-day clinic access for patients that are seen by members of the interprofessional team of NP and MD trainees and faculty. These results of improved efficiency are consistent with former meta-analysis conclusions of interprofessional team training improving teamwork processes and performance outcomes (Salas et al., 2008).
Discussion Based on this preliminary data as well as our experience with trainee recruitment and satisfaction, we believe that our model, including the creation of an adult interprofessional NP fellowship, comprises a cohesive strategy for interprofessional teamwork training that could be transported to other sites seeking to implement post-graduate interprofessional training. Furthermore, this model of interprofessional training has inspired trainee development of several clinical innovations with the goal of improving care for patients. For example, the need for an end of the year transitions clinic sign out, or communication about patients on a panel from a trainee leaving the rotation to a
J Interprof Care, 2014; 28(5): 473–474
trainee coming on the rotation, has been recognized at other institutions (Garment, Lee, Harris, & Phillips-Caesar, 2013). At our site, interprofessional trainee teams developed a tool to ensure safe transitions of care and communication about high-risk patients between rotations of practice partners within teams. The tool serves the purpose of assigning tasks to a specific trainee for follow up, and can be updated electronically in compliance with VA’s privacy and information security requirements. Our exposure to the team-based interprofessional model of education and care has demonstrated that its successful application requires leadership and organizational buy-in and support. There must be an organizational culture that values and supports this approach to education and patient care. The importance of transforming the institutional culture has been studied at some of the most high-performing hospitals, where organizational value of communication was found to be tied to improved quality of care (Curry et al., 2011). The core principles of teamwork and appreciation for the contribution of all health professionals must be effectively taught, sufficiently valued, and continuously practiced to have a lasting effect among trainees into practice. Our experience with this model has enabled us to move past individual silo-based models of training and care to effective, collaborative learning and patient care teams.
Declaration of interest The authors declare no conflicts of interest. The authors are responsible for the writing and content of this paper.
References Colwill, J.M., Cultice, J.M., & Kruse, R.L. (2008). Will generalist physician supply meet demands of an increasing and aging population? Health Affairs (Millwood), 27, w232–241. Curry, L.A., Spatz, E., Cherlin, E., Thompson, J.W., Berg, D., Ting, H.H., Carole Decker, R.N., et al. (2011). What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? A qualitative study. Annals of Internal Medicine, 154, 384–390. Garment, A.R., Lee, W.W., Harris, C., & Phillips-Caesar, E. (2013). Development of a structured year-end sign-out program in an outpatient continuity practice. Journal of General Internal Medicine, 28, 114–120. Josiah Macy Jr. Foundation. (2013). Transforming patient care: Aligning interprofessional education with clinical practice redesign. Retrieved from http://macyfoundation.org/docs/macy_pubs/TransformingPatient Care_ConferenceRec.pdf. Neily, J., Mills, P.D., Young-Xu, Y., Carney, B.T., West, P., Berger, D.H., & Bagian, J.P. (2010). Association between implementation of a medical team training program and surgical mortality. Journal of the American Medical Association, 304, 1693–1700. Salas, E., Diaz Granados, D., Klein, C., Burke, C.S., Stagl, K.C., Goodwin, G.F., & Halpin, S.M. (2008). Does team training improve team performance? A meta-analysis. Human Factors, 50, 903–933.
Copyright of Journal of Interprofessional Care is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
SHORT REPORT
Moving from silos to teamwork: integration of interprofessional trainees into a medical home model Theodore Long1, Sarah Dann2, Marissa Lynn Wolff2 and Rebecca S. Brienza2,3 1
Robert Wood Johnson Clinical Scholars Program, Yale School of Medicine, New Haven, CT, USA, 2VA Connecticut Healthcare System, West Haven, CT, USA, and 3Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
Abstract
Keywords
As the United States faces an impending shortage in the primary care workforce, interprofessional teamwork training to improve clinic efficiency and health outcomes is becoming increasingly important. Currently there is limited integration of interprofessional training in educational models for health professionals. The implementation of Patient Aligned Care Teams at the Department of Veterans Affairs (VA) has provided an opportunity for interprofessional collaboration among trainee and faculty providers within the VA system. However, integration of interprofessional education is also necessary to train future providers in order to provide effective team-based care. We describe a transportable educational model for health professional collaboration from our experience as a VA Center of Excellence in Primary Care Education, including a complementary novel one-year post-Master’s adult nurse practitioner interprofessional clinical fellowship. With growing recognition that interprofessional care can improve efficiency and outcomes, there is an increasing need for programs that train future providers in collaboration and team-based care.
Evaluation research, interprofessional collaboration, interprofessional education, teamwork
Introduction By the year 2025, the United States (US) may face a shortage of up to 44 000 primary care providers (Colwill, Cultice, & Kruse, 2008). Developing strategies for effective interprofessional teamwork and collaboration are a crucial component of the solution to the primary care workforce shortage and transformative educational models for primary care training must also evolve to meet these demands. Effective teamwork in healthcare has been shown to significantly improve patient safety and clinic efficiency (Salas et al., 2008). It has also been demonstrated that interprofessional team-building training substantially reduced annual mortality rates in surgical centers (Neily et al., 2010). However, team training has yet to be widely adopted in health professional education. To meet the challenge of our impending primary care workforce shortage, we must have a frame-shift change from training health professionals in ‘‘silo’’ models to implementing team-based interprofessional education and practice. Patient-centered medical homes (PCMH) have come forward as an effective model for providing such team-based care. The Department of Veterans Affairs (VA) has been at the forefront of recognizing the importance of the PCMH model with the creation of Patient Aligned Care Teams (PACT), which were implemented with the goal of improving patient-centered and interprofessional team-based care. Many health professional training programs are now challenged to integrate trainees into PCMH models given rotation and scheduling constraints. The Josiah Macy Jr. Correspondence: Theodore Long, MD, Robert Wood Johnson Clinical Scholars Program, 333 Cedar Street, SHM IE-61, PO Box 208088, New Haven, CT 06520, USA. Tel: 203.785.4148. Fax: 203.785.3461. E-mail: [email protected]
History Received 11 July 2013 Revised 16 December 2013 Accepted 3 February 2014 Published online 4 March 2014
Foundation recently addressed the importance of including interprofessional training into clinical practices through a series of recommendations linking improvements in health-care delivery to interprofessional educational reform (Josiah Macy Jr. Foundation, 2013).
An interprofessional training model The VA Connecticut Healthcare System Center of Excellence in Primary Care Education (CoEPCE) is one of five program sites funded through the VA’s Office of Academic Affiliations. The mission of the CoEPCEs is to develop exportable models that will foster transition from profession-specific ‘‘silos’’ to interprofessional, team-based education and patient care models. In alignment with the goals of patient-centered care, the core curricular domains for all sites include: shared decision-making, sustained relationships, interprofessional collaboration, and performance improvement. The trainees at our program site include medicine resident (MD), nurse practitioner (NP), pharmacy, and health psychology trainees, who spend approximately fifty percent of their time in interactive educational sessions focusing on the core domains and the remaining time providing care to assigned panels of patients, reinforcing newly acquired skills in the clinic setting. The core faculties include MD, NP, health psychology, and pharmacy providers that provide supervision, mentorship, and collaborative shared care with trainees on interprofessional teams. Based on our experience to date, we believe that this model provides a potentially successful example of interprofessional training and practice. At our site, the skills-based curriculum includes integration of the four core curricular domains into interactive seminars focusing on clinical topics. For example, we developed and implemented an educational module on colon
474
T. Long et al.
cancer screening and shared decision-making. In this session, trainees participated in role plays of patients, providers and family members. In addition, we have developed modules focusing on necessary core knowledge and skills for all health professionals to work in today’s complicated health-care environment incorporating facilitation and conflict management skill training to improve communication between patients and providers, as well as modules in health policy and advocacy. In addition, and unique to our site, we developed a one-year post-Master’s adult NP interprofessional clinical fellowship. We created this additional training year for NPs at our site to further develop independent clinical proficiency and train collaboratively with interprofessional teams. In our overall training program, all trainees were assigned to paired MD/NP faculty provider teams for supervision and mentorship throughout the duration of their training. As part of our interprofessional education curriculum, we have developed weekly sessions that focus on understanding each team member’s role, collaborative teamwork skills, and the application of this knowledge and skill set into managing patients on shared practice panels. Interprofessional team development training includes reviewing the stages of team development, understanding team function and incorporating SWOT (Strengths, Weaknesses, Opportunities, Threats) analyses into real patient scenarios.
Evaluation Preliminary evaluation of routinely collected productivity and performance data after the first year of implementation has indicated that productivity, or total amount of clinical work (patient care), of faculty providers has more than doubled in addition to a marked increase in same-day clinic access for patients that are seen by members of the interprofessional team of NP and MD trainees and faculty. These results of improved efficiency are consistent with former meta-analysis conclusions of interprofessional team training improving teamwork processes and performance outcomes (Salas et al., 2008).
Discussion Based on this preliminary data as well as our experience with trainee recruitment and satisfaction, we believe that our model, including the creation of an adult interprofessional NP fellowship, comprises a cohesive strategy for interprofessional teamwork training that could be transported to other sites seeking to implement post-graduate interprofessional training. Furthermore, this model of interprofessional training has inspired trainee development of several clinical innovations with the goal of improving care for patients. For example, the need for an end of the year transitions clinic sign out, or communication about patients on a panel from a trainee leaving the rotation to a
J Interprof Care, 2014; 28(5): 473–474
trainee coming on the rotation, has been recognized at other institutions (Garment, Lee, Harris, & Phillips-Caesar, 2013). At our site, interprofessional trainee teams developed a tool to ensure safe transitions of care and communication about high-risk patients between rotations of practice partners within teams. The tool serves the purpose of assigning tasks to a specific trainee for follow up, and can be updated electronically in compliance with VA’s privacy and information security requirements. Our exposure to the team-based interprofessional model of education and care has demonstrated that its successful application requires leadership and organizational buy-in and support. There must be an organizational culture that values and supports this approach to education and patient care. The importance of transforming the institutional culture has been studied at some of the most high-performing hospitals, where organizational value of communication was found to be tied to improved quality of care (Curry et al., 2011). The core principles of teamwork and appreciation for the contribution of all health professionals must be effectively taught, sufficiently valued, and continuously practiced to have a lasting effect among trainees into practice. Our experience with this model has enabled us to move past individual silo-based models of training and care to effective, collaborative learning and patient care teams.
Declaration of interest The authors declare no conflicts of interest. The authors are responsible for the writing and content of this paper.
References Colwill, J.M., Cultice, J.M., & Kruse, R.L. (2008). Will generalist physician supply meet demands of an increasing and aging population? Health Affairs (Millwood), 27, w232–241. Curry, L.A., Spatz, E., Cherlin, E., Thompson, J.W., Berg, D., Ting, H.H., Carole Decker, R.N., et al. (2011). What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? A qualitative study. Annals of Internal Medicine, 154, 384–390. Garment, A.R., Lee, W.W., Harris, C., & Phillips-Caesar, E. (2013). Development of a structured year-end sign-out program in an outpatient continuity practice. Journal of General Internal Medicine, 28, 114–120. Josiah Macy Jr. Foundation. (2013). Transforming patient care: Aligning interprofessional education with clinical practice redesign. Retrieved from http://macyfoundation.org/docs/macy_pubs/TransformingPatient Care_ConferenceRec.pdf. Neily, J., Mills, P.D., Young-Xu, Y., Carney, B.T., West, P., Berger, D.H., & Bagian, J.P. (2010). Association between implementation of a medical team training program and surgical mortality. Journal of the American Medical Association, 304, 1693–1700. Salas, E., Diaz Granados, D., Klein, C., Burke, C.S., Stagl, K.C., Goodwin, G.F., & Halpin, S.M. (2008). Does team training improve team performance? A meta-analysis. Human Factors, 50, 903–933.
Copyright of Journal of Interprofessional Care is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
