U.S. Department of Veterans Affairs

Veterans Health Administration

Office of Academic Affiliations

Centers of Excellence in Primary Care Education

Compendium of Five Case Studies: Lessons for

Interprofessional Teamwork in Education and  

Workplace Learning Environments 2011‐2016

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

September 2017

BOISE: Interprofessional Case Conferences

for High Risk/High Need Patients‐The “PACT

ICU” Model

CLEVELAND: The Dyad Model

SAN FRANCSICO: Huddling for High

Performing Teams

SEATTLE: The Panel Management Model

WEST HAVEN: Initiative to Minimize

Pharmaceutical Risk in Older Veterans

(IMPROVE) Polypharmacy Clinic
 

 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 

Centers of Excellence in Primary Care Education (CoEPCE) 

VA Leadership in interprofessional Academic Patient Aligned Care Teams (iAPACT) 

Compendium of Five Case Studies: Lessons for Interprofessional Teamwork 

in Education and Workplace Learning Environments 2011-2016 

VA’s Office of Academic Affiliations
 

Developing the next generation of health professions’ leadership
 

For additional information contact:
 

Office of Academic Affiliations
 

Center of Excellence in Primary Care Education Coordinating Center
 

Long Beach, California Field Office
 

VA OAA CoEPCE Website and VA OAA Academic PACT Website
 

562.826.5974
 

© 2017 US Department of Veterans Affairs, Veterans Health Administration, Office of Academic Affiliations

ISBN: 978-0-16-094202-0 

Centers of Excellence in Primary Care Education. Compendium of Five Case Studies: Lessons for Interprofessional Teamwork in 

Education and Workplace Learning Environments 2011-2016 

Licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. 

Permissions beyond the scope of this license may be available at www.va.gov/oaa/coepce 

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ABOUT THE ENTERPRISE 

VA launched the Office of Academic Affiliations Centers of Excellence in Primary Care Education in 

2010 to accomplish several goals. 

1.	 Establish clinical and educational infrastructure for optimal teaching, working, learning and

leading in interprofessional care teams.

2.	 Attract, prepare and retain diverse health professionals prepared as leaders in collaborative

interprofessional team-based practice.

3.	 Improve upon team-based teaching, learning, working and leading in support of Veteran and

patient-centered care.

4.	 Work closely with Veterans, their families and caregivers to support necessary changes in policy

and practice that improve Veterans safety, experience and well-being.

"Remember that health professions education... all professions and especially in the last stages of 

preparation, is an apprenticeship model. The trainees are learners in our clinical environments... and 

are ‘doing’ while learning under supervision. That necessarily requires that clinical environment, the 

patients, the clinical staff, the institutions and systems in which we all work, to be (working) together." 

Stuart Gilman, MD, MPH 

“This program serves as an excellent example of how VA can lead the way in developing new and 

innovative training models that will help address the health care needs of our nation’s Veterans and 

influence inter-professional training for years to come." 

Malcolm Cox, MD 

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CASE STUDY FEEDBACK AND SURVEY 

VA CoEPCE Case Studies Quality Improvement Questionnaire 

The Centers of Excellence in Primary Care Education partner with Academic Institutions and public and 

other professional organizations to improve interprofessional education and collaborative practice. 

We hope to better understand the usefulness of the case studies in this compendium in three areas: 

1.	 Dissemination – Are efforts successful towards reaching a broad audience? 

2.	 Effectiveness (Does the end-user perceive that this package will be/is/was useful and in what 

ways. 

3.	 Adoption/Implementation – Does the end-user adopt or reproduce strategies within the 

document and were efforts to adopt or reproduce these strategies successful. 

Please note: Information gathered in this assessment will be anonymous and information collected 

is intended for operational program improvement. 

Questionnaire Link: https://www.research.net/r/VA-CoEPCE-CASESTUDIES 

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AUTHORS AND EDITORS 

Annette Gardner, PhD, MPH
 

Assistant Professor, Department of Social and Behavioral Sciences
 

Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
 

Boise Case Study #1 

Interprofessional Case Conferences for High Risk/High Need Patients-The “PACT ICU” Model 

William G. Weppner, MD, MPH; Janet Willis, BSN, RN; Jared Bernotski, BA 

Cleveland Case Study #2 

The Dyad Model 

Laura Clementz, MA, MS; Renée H. Lawrence, PhD; Mary A. Dolansky, PhD, RN; Alli M. Heilman, NP;
 

Anne R. Rusterholtz, MSN, NP; Simran Singh, MD; Matthew Sparks, MSN, NP; and Mamta K. Singh, MD, MS
 

San Francisco Case Study #3 

Huddling for High Performing Teams 

Rebecca Shunk, MD; Maya Dulay, MD; Anna Strewler, MS, AGNP-BC and Bridget O’Brien PhD 

Seattle Case Study #4 

The Seattle Panel Management Model 

Catherine P. Kaminetzky, MD, MPH; Anne P. Poppe, PhD, RN; and Joyce E. Wipf, MD 

West Haven Case Study #5 

Initiative to Minimize Pharmaceutical Risk in Older Veterans (IMPROVE) Polypharmacy Clinic 

John M. Thomas, MD; Marcia C. Mecca, MD; Anne Hyson, MD, MSc; Kristina M. Niehoff, PharmD, 

BCPS; Sean Jeffery, PharmD, GCP, FASCP, FNAP; John Sellinger, PhD; Rebecca Brienza, MD, MPH 

Editors 

VA Office of Academic Affiliations Coordinating Center
 

Centers of Excellence in Primary Care Education
 

Stuart Gilman, MD, MPH
 

Laural Traylor, MSW
 

Editorial Assistance: Jason Lee, BS 

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Centers of Excellence in Primary Care Education 

FIVE CASE STUDIES:
 

Lessons for Interprofessional Teamwork in Education
 

and Workplace Learning Environments 2011-2016
 

Support for this compendium is through
 

Department of Veterans Affairs, Office of Academic Affiliations.
 

Robert Jesse, MD, VA Chief Academic Affiliations Officer 

2015 CoEPCE Annual Meeting, Dallas, TX 

"The goal of the Centers of Excellence in Primary Care Education is to 

transform the primary care workforce where healthcare begins...
 

in the systems of teaching and training."
 

Robert Jesse, MD
 

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The Centers of Excellence in Primary Care Education 

The Cleveland COEPCE Dyad Model 

The san Francis<o COEPCE Hudcle 

The West Haven COEPCE Potyphannacy Model 

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CONTENTS 

About the Enterprise .................................................................................................................................................................. iii
 

Case Study Feedback and Survey................................................................................................................................................ iv
 

Authors and Editors ..................................................................................................................................................................... v
 

Foreword .................................................................................................................................................................................... xi
 

Foreword References................................................................................................................................................................ xiv
 

Note from the Editors............................................................................................................................................................... xvi
 

Program Educational Domains .................................................................................................................................................. xii
 

Acknowledgements .................................................................................................................................................................. xiii
 

CASE STUDY #1: PACT ICU MODEL-INTERPROFESSIONAL CASE CONFERENCES FOR HIGH RISK/HIGH NEED PATIENTS.............1
 

Contact Information .............................................................................................................................................................. 15
 

Resources .............................................................................................................................................................................. 15
 

Works Cited ........................................................................................................................................................................... 15
 

CASE STUDY #2: THE DYAD MODEL ..........................................................................................................................................17
 

Contact Information .............................................................................................................................................................. 30
 

Resources .............................................................................................................................................................................. 30
 

Works Cited ........................................................................................................................................................................... 30
 

CASE STUDY #3: HUDDLING FOR HIGH PERFORMING TEAMS...................................................................................................32
 

Contact Information .............................................................................................................................................................. 44
 

Resources .............................................................................................................................................................................. 44
 

Works Cited ........................................................................................................................................................................... 44
 

CASE STUDY #4: PANEL MANAGEMENT MODEL ....................................................................................................................... 46
 

Contact Information .............................................................................................................................................................. 57
 

Resources .............................................................................................................................................................................. 58
 

Works Cited ........................................................................................................................................................................... 58
 

................................................................................................................................................................................................... 59
 

CASE STUDY #5: INITIATIVE TO MINIMIZE PHARMACEUTICAL RISK IN OLDER VETERANS (IMPROVE) POLYPHARMACY CLINIC
 

Contact Information .............................................................................................................................................................. 72
 

Resources .............................................................................................................................................................................. 72
 

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Works Cited ........................................................................................................................................................................... 72
 

Appendix A: CoEPCE Project Resources and Publications .........................................................................................................74
 

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FOREWORD 

Foreword by Barbara Brandt, EdM, PhD
 

for
 

Department of Veterans Affairs Office of Academic Affiliations
 

Centers of Excellence in Primary Care Education
 

Ever since the 1972 Institute of Medicine publication of Educating the Health Team, the field 

of interprofessional education (IPE) and collaborative practice (IPCP) has experienced the 

“long and winding road” of implementation (Hall & Weaver, 2001). Until the early 2000s, the 

progress in the field was “stuttering”. Early on, important environmental factors such as feefor service reimbursement that favors physicians over other professions and teams, little interest in 

processes of health care, and the lack of evidence of team effectiveness produced barriers, hindering 

the full-scale adoption and mainstreaming of IPCP in United States (U.S.) healthcare (Brandt, 2015; 

Schmitt, Baldwin, & Reeves, 2011). In many ways, the hurdles in IPE such as scheduling times and 

classrooms for students to meet, siloed and rigid curricula in individual health professions schools, 

tensions between professions and specialties, and the lack of perceived value haunt the field to this 

day (Curran, Sharpe, & Forristall, 2007). 

Bright spots in health teams have existed in such areas as rehabilitation, hospice, geriatrics, renal, 

intensive care and transplantation teams since the 1970s. Starting in geriatric care, the Veterans 

Health Administration healthcare system has been an important exception in their early, sustained and 

expansive commitment to team-based care and IPCP. Since 2000, after the publication of the Institute 

of Medicine To Err is Human and Crossing the Quality Chasm, interest in and momentum for IPCP has 

been exponentially growing in the United States. Many turn to the Veterans Health Administration for 

not only historic lessons learned about teams but more importantly the contemporary, bold initiative 

of deploying thousands of Patient-Aligned Care Teams (PACT) in new models of care throughout the 

U.S. (Rosland et al., 2013). Since 2010, building upon the well-known concept of patient-centered 

medical homes, staffed by high-functioning teams, PACT’s aim has been to redesign care that is 

patient-driven, proactive, personalized, team-based care focused on wellness and disease prevention 

resulting in improvements in Veteran satisfaction, improved healthcare outcomes, and costs (US 

Department of Veterans Affairs, 2016). 

By 2010, the transforming U.S. healthcare system has renewed focus on IPE for IPCP, and the breadth 

of external drivers stimulating interest in IPE is impressive. Unfortunately, because the implementation 

of IPE has primarily been in the classroom and not practice, it has experienced ebbs and flows of 

interest over the past fifty years. The evidence of the effectiveness of IPE to patient and health 

outcomes is slim (IOM, 2015). Therefore, we are looking for models and solutions – and again turn to 

the VA for answers. With the deployment of the PACTs, the VA Office of Academic Affiliations had the 

foresight to understand that without investment in workforce development across pre-licensure, 

residency and current clinicians, they would fall short of their bold goals. To respond, in 2012 the VA 

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invested in five Centers of Excellence of Primary Care Education to serve as important incubators for 

not only implementing new models of care but also new models of learning in practice (Gilman, 

Chokshi, Bowen, Rugen, & Cox, 2014). The Compendium of Five Case Studies: Lessons for 

Interprofessional Teamwork in Education and Workplace Learning Environments 2011-2016 is an 

important resource written from the voice of those implementing innovative IPE approaches in 

practice over the first five years. 

The VA Office of Academic Affiliations and the staff of the Coordinating Center and sites of the VA 

Centers of Excellence for Primary Care Education are committed to and have been publishing their 

results in reputable peer reviewed journals. This Compendium, however, is different and the National 

Center for Interprofessional Practice and Education team is honored to have managed the peer review 

and serve as partners in dissemination. With this report, the CoEPCE team wanted to tell a different 

story – one rarely published in traditional academic venues. When I first read the five cases, what 

impressed me was the reflection, the deeper story behind the story. We have the opportunity to 

learn about context and developmental issues from a national large-scale complex adaptive systems 

perspective. This report provides important lessons of workplace learning while implementing IPE 

(Nisbet, Lincoln, & Dunn, 2013). 

Since the publication of the IOM Measuring the Impact of IPE on Collaborative Practice and Patient 

Outcomes in 2015, we now place greater emphasis on continuing professional development and 

learning in practice than what happens in the classroom with pre-licensure students. We are learning 

that it is imperative to introduce entry-level students to IPCP. But we can only take students so far to 

prepare for the future if they enter traditional, hierarchical practices, or the “hidden curriculum on 

steroids”, during experiential rotations. Students and residents, rightly so, question whether 

classroom-only team problem-based learning, simulations, or activities represent authentic care 

experienced every day by health professionals and their patients. The CoEPCE programs hit these 

complex issues head on by focusing on improving patient care through improvement in 

interprofessional collaboration and teamwork (“Best Evidence Medical Education (BEME): report of 

meeting: 3-5 December 1999, London UK,” 2000; Hammick, Freeth, Koppel, Reeves, & Barr, 2007; 

Reeves et al., 2016) 

The comparative analysis sheds light on the facilitating factors for advancing sustainable 

interprofessional collaboration models in diverse settings. What is particularly exciting is that the 

CoEPCE lessons learned in the first five years triangulate with emerging findings from the National 

Center scholarship as well as important work by Scott Reeves and his colleagues (F. Cerra, Pacala, 

Brandt, & Lutfiyya, 2015; Collaborative, 2014; Reeves et al., 2016). With findings and lessons learned 

from multiple projects, we can take what we know from different venues to educate senior leaders 

about what we are learning about models that work and the investments that are needed to support 

those on the ground in clinical settings, working to implement IPE in practice every day. 

Two factors for success cut across all COEPCE cases: 1) center expertise—faculty and leadership and 2) 

logistics management – and the interaction between the two. It takes extraordinary facility leadership 

xii 
 

commitment and support to address the chronic, daunting barriers that most do not have the appetite 

to address. For example, scheduling is key to executing the five initiatives. All sites have to work with 

diverse trainee schedules and integrate them with the clinic and curriculum schedules, while being 

careful not to affect direct patient care activities. In the National Center, we call this “the Nexus” – 

aligning interprofessional education with clinical practice redesign (Earnest & Brandt, 2014; Josiah 

Macy Jr. Foundation, 2013). 

Second, sites described three CoEPCE program outcomes common to all the cases. Because these 

aligned tightly with other work in the IPE field, these findings are especially important: 

The trainees from various health professions intentionally learn “with, from, and about” each other’s 

skillsets, roles, and responsibilities in practice, mirroring one of the four Interprofessional Education 

Collaborative (IPEC) four domains (Interprofessional Education Collaborative, 2017; Interprofessional 

Education Collaborative Expert Panel, 2011). Through experiencing the interfaces and tensions every 

day, all learned their own strengths and limitations and how to seek their input and new perspectives 

to benefit first and foremost, their patients. 

All five sites reported increased integration of trainees into the PACT Team, creating a positive team 

dynamic. This finding is consistent with what National Center learned with the Patient-Centered 

Primary Care Collaborative interviews. We found that exemplary teaching sites that focus first on 

patients develop shared team understanding over time and rapid innovations introduced by any 

member of the team led to culture change (C. Cerra & Brandt, 2014). 

Consistent with the IPEC competency domain and research in teamwork, trainees demonstrated 

increased communications, such as sharing of pertinent information or seeking a consult. 

Finally, we commend the VA Office of Academic Affiliations and Veterans Health Administration senior 

leaders for their vision and investment in implementing national innovations sites through the U.S. 

Visible senior leadership engagement in IPE implementation and appropriate investment in resources 

are strong critical success factors (F. Cerra et al., 2015; Reeves et al., 2016). Without this strong and 

visible advocacy, IPE will fail –again, taking us down the long and winding road. 

Barbara F. Brandt, PhD, Director 

National Center for Interprofessional Practice and Education 

University of Minnesota 

June 2017 

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FOREWORD REFERENCES 

Best Evidence Medical Education (BEME): report of meeting: 3-5 December 1999, London UK. (2000). 

Medical Teacher, 22(3), 242–245. Weblink 

Brandt, B. (2015). Interprofessional Education and Collaborative Practice: Welcome to the "New" 

Forty-Year Old Field. The Advisor, March, 9–17. Weblink 

Cerra, C., & Brandt, B. F. (2014). Appendix: Interprofessional Education: “Thinking and Acting 

Differently:” PCMH Workforce Development Models. Weblink 

Cerra, F., Pacala, J., Brandt, B. F., & Lutfiyya, M. N. (2015). The Application of Informatics in Delineating 

the Proof of Concept for Creating Knowledge of the Value Added by Interprofessional Practice and 

Education. Healthcare, 3, 1158–1173. Weblink 

Collaborative, P.C.P.C.C. (2014). Progress and Promise: Profiles in Interprofessional Health Training to 

Deliver Patient-Centered Primary Care. Weblink 

Curran, V. R., Sharpe, D., & Forristall, J. (2007). Attitudes of health sciences faculty members towards 

interprofessional teamwork and education. Medical Education, 41, 892–896. 

https://doi.org/doi:10.1111/j.1365-2923.2007.02823.x Weblink 

Earnest, M., & Brandt, B. (2014). Aligning practice redesign and interprofessional education to advance 

triple aim outcomes. Journal of Interprofessional Care, 28(6), 497–500. 

https://doi.org/10.3109/13561820.2014.933650 Weblink 

Gilman, S., Chokshi, D., Bowen, J., Rugen, K., & Cox, M. (2014). Connecting the Dots: Interprofessional 

Health Education and Delivery System Redesign at the Veterans Health Administration. Academic 

Medicine, 89(8), 1113–1116. https://doi.org/doi:10.1097/ACM.0000000000000312 Weblink 

Hall, P., & Weaver, L. (2001). Interdisciplinary education and teamwork: A long and winding road. 

Medical Education, 35(9), 867–875. https://doi.org/10.1046/j.1365-2923.2001.00919.x Weblink 

Hammick, M., Freeth, D., Koppel, I., Reeves, S., & Barr, H. (2007). A best evidence systemic review of 

interprofessional education: BEME Guide no. 9. Medical Teacher, 29(8), 735–51. 

https://doi.org/10.1080/01421590701682576 Weblink 

Interprofessional Education Collaborative. (2017). About IPEC. Retrieved May 9, 2017, from 

https://www.ipecollaborative.org/about-ipec.html Weblink 

Interprofessional Education Collaborative Expert Panel. (2011). Core Competencies for Interprofessional 

Collaborative Practice: Report of an Expert Panel. Washington, DC. Retrieved from 

http://www.aacn.nche.edu/education-resources/ipecreport.pdf Weblink 2011; Weblink 2016 

Update 

Josiah Macy Jr. Foundation. (2013). Transforming Patient Care: Aligning Interprofessional Education 

with Clinical Practice Redesign. In M. Cox & M. Naylor (Eds.), Transforming Patient Care: Aligning 

Interprofessional Education with Clinical Practice Redesign. Atlanta. Weblink 

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Nisbet, G., Lincoln, M., & Dunn, S. (2013). Informal interprofessional learning: an untapped opportunity 

for learning and change within the workplace. Journal of Interprofessional Care, 27(6), 469–475. 

https://doi.org/10.3109/13561820.2013.805735 Weblink 

Reeves, S., Fletcher, S., Barr, H., Birch, I., Boet, S., Davies, N., ... Kitto, S. (2016). A BEME systematic 

review of the effects of interprofessional education: BEME Guide No. 39. Medical Teacher, 38, 

656–668. https://doi.org/10.3109/0142159X.2016.1173663 Weblink 

Rosland, A., Nelson, K., Sun, H., Dolan, E., Maynard, C., Bryson, C.,Stark, R.; Shear, J.; Kerr, E.; Fihn, S.; 

Schectman, G. (2013). The patient-centered medical home in the Veterans Health Administration. 

The American Journal of Managed Care, 19(7), e263-272. Weblink 

Schmitt, M., Baldwin, D. C., & Reeves, S. (2011). Continuing interprofessional education: collaborative 

learning for collaborative practice. In D. Wentz (Ed.), Continuing Medical Education: Looking Back, 

Planning Ahead (pp. 300–316). Lebanon, NH: University Press of New England. Weblink 

US Department of Veterans Affairs. (2016). Patient Aligned Care Team (PACT). Retrieved from 

https://www.patientcare.va.gov/primarycare/PACT.asp. Weblink 

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NOTE FROM THE EDITORS 

In today’s complex system of primary care, it is increasingly important that the expertise and 

professional perspectives of all team members, along with the values and needs of Veterans, families, 

and caregivers are intentionally integrated to promote optimal outcomes for Veterans. Developing 

systems in which multiple professions learn, practice and communicate together is not a simple 

undertaking. In a nutshell, team members must continually improve their own practice, understand 

and be willing to seek out the contributions of other professionals and communicate and implement a 

plan that leads to safe and effective care for their patients. The VA Centers of Excellence in Primary 

Care Education1 began educational activities in Academic Year 2011-2012 to improve primary care 

education, particularly to harmonize the education of clinician trainees with the emerging and future 

practice of primary care exemplified by patient centered care such as VA’s Patient Aligned Care Team 

model for primary care delivery. This volume shares examples of educational strategies that have 

emerged from the first four academic years of the project, with each chapter being a case study from a 

participating site. Each case study reports on the implementation of a curricular element within their 

unique Center of Excellence. These case studies are intended to be of use to those interested in 

introducing curricular activities in accredited programs for health profession trainees that will lead to 

the advancement of interprofessional, Veteran/patient-centered primary care. These case studies also 

represent one component of the project’s evaluation plan, designed by Annette Gardner, Ph.D. We 

have attempted to inform readers about the context of the institutions and readiness for change, the 

steps each program completed to design and develop strategies, gain leadership commitments, 

implement, and evaluate these interventions in the spirit of continuous improvement. Additional 

reports about the project have been published2, are in press, or are in the pipeline. Further, many of 

the references in this document have full-text available online. We have provided live links for ease of 

access to these additional resources. 

In 2010, Veterans Health Administration (VA) began implementation of a version of the ‘Patient 

Centered Medical Home’ at all of the approximately 1000 points of care to serve over 5 unique million 

Veterans annually. VA called this new system of care Patient Aligned Care Teams (PACT)3. This 

transformation of VA’s clinical system of care did not initially take into account VA’s primary care 

settings in which health professions trainee education occurred. However, VA Office of Academic 

1 VA Centers of Excellence in Primary Care Education, U.S. Department of Veterans Affairs, Office of Academic Affiliations 2 Centers of Excellence in Primary Care Education/Interprofessional Academic PACT Publications and other scholarly work. 3 Patient Aligned Care Team (PACT) Home Page. U.S. Department of Veterans Affairs. 

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Affiliations (OAA)4 recognized the need to concurrently transform VA’s primary care teaching and 

learning environment to prepare future health professionals and leaders in VA and the community. It 

was important to address these educational needs for two reasons. First, the engagement of current 

trainees had to be taken into account as the clinics underwent PACT transformation. More strategically, 

the task was to optimize these transformed primary care clinics by developing practitioners across all 

relevant professions capable of entering the workforce ready to practice in these systems. This wasn’t a 

simple issue: primary care education activities occurring in these transforming clinical systems had their 

own fragmentation challenges. First, there were challenges within professions as the 

inpatient/outpatient structure of health professions education often frustrated efforts to advance 

continuity of care between trainees and Veterans. Second, the primary care clinical educational 

experiences were too often failing to expose trainees to a positive primary care experience. In addition, 

there was seldom integration between the educational programs across professions in primary care, 

such as physicians, nurse practitioners, physician assistants, psychologists, pharmacists, social workers, 

and others. The result was that VA believed that the existing model of primary care education was 

failing to adequately prepare emerging health professionals for their practice in contemporary primary 

care settings, failing to adequately expose learners to the professional satisfaction possible in properly 

functioning primary care systems, and failing to adequately prepare them to participate in, lead, and 

improve the interprofessional teams which are a hallmark of effective modern primary care. 

To address these challenges, VA funded the Centers of Excellence in Primary Care Education as a fivesite demonstration project with a national coordinating center. The project required sites to develop 

curricula that would address the domains of shared decision-making, sustained relationships, 

interprofessional collaboration, and performance improvement (Table 1: Note from Editors). In 

addition, sites were expected to use instructional strategies that emphasized workplace learning 

techniques rather than classroom-based strategies. VA required selected sites to engage physician 

residents and nurse practitioner students for at least 30% of their total training time. Additionally, VA 

required co-leadership by physician and nurse-practitioner faculty co-directors. Other academic levels 

for these professions, and other professions were encouraged to be included. 

Over 30 VA Medical Centers and their academic affiliates applied to participate. Ultimately, 5 sites were 

selected in Boise, Cleveland, San Francisco, Seattle, and West Haven. Over the first five academic years 

of the project nearly 1000 trainees of the above professions have participated in the program across 

these sites. 

4 Office of Academic Affiliations Home Page. U.S. Department of Veterans Affairs. 

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Though most of these initiatives took six months or less to design and implement initial versions, sites 

put a great deal of effort into development and improvement of complex curricula over time that 

integrate formal instruction, workplace learning and reflection. These emerging curricula are also 

intricate because some elements are intended to address the learning needs specific to a participating 

profession while other curricular elements are intended to facilitate interprofessional learning and 

practice. These case studies provide examples of a specific educational intervention that was part of 

the overall curriculum and either was itself successful or was felt to best illustrate the development 

process for interprofessional primary care instruction. The five sites participating in the Centers of 

Excellence in Primary Care project are modeling what VA has come to call interprofessional Academic 

PACT (iAPACT), based on principles described in a VA position paper 5 developed to guide system-wide 

transformation in primary care education. Interprofessional Academic PACTs (iAPACTs) are Patient 

Aligned Care Teams that have two or more health professions trainees collaboratively engaged in 

learning, working and teaching. This is and are the preferred model for VA Academic Primary Care 

PACTs. In 2016, two additional sites were competitively selected to join the project as the effort 

advances to the next stage. 

We have chosen the case study approach to describe these activities in order to provide the reader 

with the broadest possible base of information about these interventions. The usual format of research 

manuscripts can minimize full descriptions of unique local opportunities and barriers as these are not 

generalizable factors- indeed such factors may be specified as ‘limitations’ to the report. From an 

implementation perspective, we believe it is vital to describe local factors where the innovation was 

adopted, as those who wish to reproduce these activities will likely want to compare their own current 

state with the starting state of the site during the intervention design. 

The educational interventions selected for descriptions in this volume demonstrate their genesis in the 

curricular domains of the project. Readers will note that each example emphasizes workplace-learning 

6 strategies to achieve at least one of the four curricular domains of shared decision-making, sustained 

relationships, performance improvement, and interprofessional practice. We recommend that readers 

5 VA Whitepaper: “Academic PACT: A blueprint for primary care redesign in academic practice settings” (October 2013) 

6 Workplace learning in VA is contains an element of reflective practice and is learning "...that takes place as part of 

everyday thinking and acting in authentic clinical care delivery settings." “Academic PACTs will improve quality of Veterans 

care experience by enhancing workplace learning for all team members, patients, clinician, staff and students alike.” (VA 

Whitepaper, 2013) 

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pay close attention to the development process for the interventions, noting the interprofessional 

faculty engagement in activity development, delivery, and evaluation. We would also suggest that 

readers note that these case studies are principally demonstrating innovations in educational processes 

and strategies on topics, and not a syllabus for instruction on points of clinical knowledge or skill. For 

example, San Francisco’s example of the improved interprofessional academic PACT huddle describes 

how to use regular team meetings to support education and patient care, while Seattle’s example 

engages an interprofessional teaching team to strengthen trainee knowledge and improve the skillset 

of clinical faculty using proactive population health strategies. Cleveland’s descriptions of trainee dyads 

illustrate how synergies can be created in interprofessional learning and practice. Boise’s and West 

Haven’s cases provide examples of intricate blending of formal instruction with supervised clinical 

practice to accomplish the dual goals of learning, and improving patient care. 

The Editors 

Stuart Gilman, MD, MPH, National Director 

and 

Laural Traylor, MSW, National Program Manager 

VA Office of Academic Affiliations,
 

Coordinating Center,
 

Centers of Excellence in Primary Care Education
 

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PROGRAM EDUCATIONAL DOMAINS 

The Centers of Excellence in Primary Care Education enterprise efforts employ four basic concepts 

within teaching and learning in primary care clinical environments 

in the Department of Veterans Affairs. 

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ACKNOWLEDGEMENTS 

Annette Gardner, PhD, MPH 

The editors gratefully recognize the many contributions of Dr. Annette Gardner in leading the vision 

and development of these case studies. 

Special thanks to Barbara Brandt, EdM, PhD 

Director of the National Center for Interprofessional Practice and Education (NEXUS)
 

We salute Dr. Brandt for steadfast support, inspiration and encouragement of interprofessional
 

practice and education, and through the elevation of this compendium by way of 

NEXUS coordinated peer review and community dissemination. 

Peer Review: The NEXUS developed the peer review strategy for this anthology to assist VA in creating
 

a practical tool for both VA and the community. Individuals selected for this review have diverse
 

perspectives and expertise in interprofessional education and primary care and reviewed this
 

compendium in draft form. Review comments and the draft manuscript remain confidential to protect 

the integrity of the process. Although the reviewers listed below provided constructive comments and 

suggestions, they did not see the final draft of the Case Studies before its release. 

We wish to thank the following peer reviewers for their support and contribution:
 

Constance F. Swenty, DNP, RN 

Director of Nursing
 

University of Southern Indiana
 

Madeline Schmitt, PhD, RN, FAAN, FNAP 

Professor Emerita and Registered Nurse
 

University of Rochester School of Nursing
 

Craig Roth, MD 

Co-Chief, Section of General Medicine, Minneapolis VA Healthcare System
 

Professor of Medicine, Director of Interprofessional Education,
 

University of Minnesota Medical School
 

Elyse Perweiler, MA MPP, RN 

Co-Director, New Jersey Institute for Successful Aging
 

Rowan University School of Osteopathic Medicine
 

Associate Professor, Department of Geriatrics & Gerontology
 

Lauren Collins, MD 

Co-Director, Jefferson Center for InterProfessional Education (JCIPE)
 

Josiah Macy Jr. Foundation Faculty Scholar
 

Associate Professor, Division of Geriatric Medicine
 

Department of Family and Community Medicine
 

Sidney Kimmel Medical College at Thomas Jefferson University
 

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ACKNOWLEDGEMENT CONTINUED 

VA Academic Affiliates 

Boise State University School of Nursing
 

Breen School of Nursing at Ursuline College
 

California State University East Bay School of Social Work
 

California State University Long Beach School of Social Work
 

Case Western Reserve University School of Medicine
 

Case Western Reserve University, Frances Payne Bolton School of Nursing
 

Case Western University, School of Applied Social Sciences Social Work Program
 

Cleveland Clinic Foundation
 

Golden Gate Dietetic Internship
 

Idaho State University College of Pharmacy
 

Fairfield University School of Nursing
 

Gonzaga University School of Nursing & Human Physiology
 

Northwest Nazarene University
 

Quinnipiac University School of Nursing
 

San Francisco State University Consumer & Family Studies-Dietetics
 

San Francisco State University School of Social Work
 

San Jose State University School of Social Work
 

San Jose State University Nutritional Science Program-Dietetics
 

Smith College School for Social Work
 

Southern Connecticut State University, School of Social Work
 

University of California at Berkeley, Social Welfare
 

University of California at San Francisco School of Medicine
 

University of California at San Francisco School of Nursing
 

University of Connecticut School of Medicine
 

University of Connecticut School of Nursing
 

University of Hartford School of Physical Therapy
 

University of Washington School of Medicine
 

University of Washington School of Nursing
 

University of Washington School of Pharmacy
 

University of Washington School of Psychology
 

University of Washington School of Public Health Social Work Program
 

Yale University School of Medicine, Department of Internal Medicine and Psychiatry
 

Yale University School of Nursing
 

VA Sponsored Programs 

VA Office of Academic Affiliations supports post-doctoral clinical residencies for pharmacists, 

psychologists and other professions. These programs are coordinated at local medical centers with the 

program education director or designee in collaboration with VA’s profession specific national offices. 

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ACKNOWLEDGEMENTS CONTINUED 

Office of Academic Affiliations 

Malcolm Cox, MD Former Chief Academic Affiliations Officer (Retired)
 

Robert Jesse, MD, PhD Chief Academic Affiliations Officer 

Karen Sanders, MD, Deputy Chief Academic Affiliations Officer
 

Kathleen Klink, MD, FAAFP, Chief Health Professions Education
 

William Marks, MD, Chief Health Professions Education (Previous Role)
 

Office of Academic Affiliations CoEPCE Coordinating Center 

Jayson Adler, Management Analyst
 

Stuart C. Gilman, MD, MPH; Director
 

Nancy Harada, PhD, MPA, PT; Evaluation Manager
 

Deborah Ludke, MHA, Administrative Officer
 

Laural Traylor, MSW; Program Manager
 

Kimberly Uhl, MBA, Management Analyst
 

Office of Academic Affiliations CoEPCE Consultants 

Judith Bowen, MD; Physician Consultant/Curriculum Consultant
 

Bradford Felker, MD; Primary Care Mental Health Consultant
 

Annette Gardner, PhD, MPH; Evaluation Consultant
 

Joshua Ruberg, PhD; Psychology Consultant
 

Kathryn Rugen, PhD, FNP-BC, FAANP; Nurse Practitioner Consultant
 

C. Scott Smith, MD; Physician Consultant 

Ivy Tonnu-Mihara, PharmD, MS; Pharmacist Consultant 

VA’s 1st Stage Academic PACT Workgroups 

Members and Contributors to the Academic PACT Whitepaper 

Office of Primary Care Members: 

Gordon Schectman (Co-Chair, VA Office of Primary Care)
 

Christian Donohue
 

Michael A. Doukas
 

Joseph Leung
 

David S. MacPherson
 

Storm L. Morgan
 

Rina N. Shah
 

Richard Stark
 

Office of Academic Affiliations Members: 

Judith L. Bowen (Co-Chair, Office of Academic Affiliations)
 

Judy L. Brannen
 

Kathryn W. Rugen
 

Rebecca L. Shunk
 

Robert A. Zeiss
 

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ACKNOWLEGEMENTS CONTINUED
 

Second Stage Interprofessional Academic PACT (iAPACT) Workgroup 

Rina Shah, MD and Catherine Kaminetzky, MD, MPH, Co-Chairs
 

Maher Roman, MD, MBA, FACP Needs Assessment Subgroup Chair
 

Laural Traylor, MSW Program Manager
 

Jayson Adler, Management Analyst
 

National VISN representatives
 

Special thanks
 

to all the many hundreds of faculty and staff of the 

Centers of Excellence in Primary Care Education
 

for tireless contributions to this critical work.
 

2013 Leaders from Boise, Cleveland, San Francisco, Seattle, West Haven 

and Long Beach at the Long Beach, California Program Planning Meeting 

Left Side: Terry Keene; Kathryn Rugen; Deborah Ludke (back); Rebecca Shunk Front; Mary Dolanski,
 

Rebecca Brienza; Sue Zapatka
 

Middle: Malcolm Cox and Stuart Gilman
 

Right Side: Front Mamta (Mimi) Singh; Annette Gardner; Laural Traylor
 

Right Side Back L-R: Scott Smith; Melanie Nash; Kameka Brown; Kim Uhl; Joyce Wipf; Judy Bowen
 

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CASE STUDY #1: PACT ICU MODEL-INTERPROFESSIONAL 

CASE CONFERENCES FOR HIGH RISK/HIGH NEED PATIENTS 

Boise VA Center of Excellence in Primary Care Education (CoEPCE) 

Interprofessional Academic Patient Aligned Care Team (iAPACT) 

Prepared by: Annette L. Gardner, PhD, MPH, with Boise VA CoEPCE: William G. Weppner, MD, MPH; 

Janet Willis, BSN, RN; Jared Bernotski, BA. 

Academic Partners: Boise State University School of Nursing; Gonzaga University School of Nursing; 

University of Washington School of Medicine; and Idaho State University School of Pharmacy 

SURVEY LINK 

Key Theme of the Innovation: Practice-based trainee/faculty/staff didactics and workplace 

collaborative care opportunity. Curriculum includes pro-active identification of high risk, high need 

Veteran/patients on trainee panels as the foundation for bi-weekly case conferences and 

interprofessional team-based care planning activity. 

Goals: 

- Improve quality and health of complex/high-risk 

Veterans 

- Advance trainee interprofessional and 

clinical/patient centered care competency 

- Enhance staff roles and team coordination and 

function 

- Optimize system resources 

Trainees: Nurse practitioner students and residents, 

internal medicine physician residents and students, 

pharmacy residents and students, psychology interns 

and postdoctoral fellows, nursing students. 

Faculty and/or Staff: Internal medicine physicians, 

nurse practitioners, nurse care managers, pharmacists, 

psychologists, social workers, chaplaincy and ethics 

service. Boise CoEPCE PACT ICU Session 

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SUMMARY 

This case study describes Boise Center of Excellence in Primary Care Education (CoEPCE, CoE or Center) 

Patient Aligned Care Team Interprofessional Care Update (PACT ICU), a bi-weekly, interprofessional 

patient case conference for intensive management of high-risk, high-needs patients. The PACT ICU is 

an interprofessional Academic PACT (iAPACT). VA defines an iAPACT as PACTs (or Patient Aligned Care 

Teams) that have at least two or more fields of health professions trainees engaged in learning, 

working and teaching. This is the preferred model for VA Academic Primary Care PACTs. 

On a bi-weekly basis, physician and nurse practitioner trainees, Center faculty, and clinic staff develop 

a proactive, team-based, interprofessional care plan to address high-risk patients’ unmet chronic care 

needs. In addition to training learners, established providers and staff across professions to work 

together to provide patient-centered care, this innovative, interprofessional education activity 

strengthens clinic communications and supports sustained relationships with providers and patients. 

INTRODUCTION 

In 2011, VA’s Office of Academic Affiliations (OAA) selected five VA Medical Centers to establish 

Centers of Excellence in Primary Care Education (CoEPCE). VA's New Models of Care initiative, through 

five Centers of Excellence (CoE’s) (Boise, Cleveland, San Francisco, Seattle and West Haven) are 

developing, implementing, and evaluating curricula and best practices to prepare physician residents 

and students, advanced practice nurse and undergraduate nursing students, and other professions of 

health trainees (such as pharmacy, social work, psychology, physician assistants, etc.) for effective 

primary care practice in the 21st Century. 

For example, the Boise CoE developed and implemented a practice-based learning model. Nurse 

practitioner students and residents, physician residents, pharmacy residents, psychology 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). 

METHODS 

In 2015, evaluators from VA’s Office of Academic Affiliations reviewed background documents and 

conducted open-ended interviews with 10 CoE staff, participating trainees, VA faculty, VA facility 

leadership, and affiliate faculty. In response to questions focused on their experiences, informants 

described lessons learned, challenges encountered, and benefits for participants, Veterans, and the VA. 

Using a qualitative and quantitative approach, this case study draws on those interviews, surveys of 

PACT ICU participants, and analysis of presented patients to examine PACT ICU outcomes. 

2
 

 

THE ISSUE: LACK OF CLINICAL APPROACHES TO INTERPROFESSIONAL EDUCATION AND CARE 

A key CoEPCE program aim is to create more clinical opportunities for CoE trainees from a variety of 

professions to work together as a team in ways that anticipate and address the care needs of Veterans. 

This emphasis on workplace learning is needed since most current healthcare professional education 

programs lack settings where trainees from different professions can learn and work together with 

their clinic partners to provide care for patients. With the emphasis on patient-centered medical 

homes (PCMH) and team-based care in the Affordable Care Act, there is an imperative to develop new 

training models that address this gap in the preparation of future health professionals. Along with this 

imperative, clinicians are increasingly required to optimize the health of complex patients, who 

consequently require a multi-disciplinary approach to care, particularly high-risk, high-needs patients 

inappropriately using services such as frequent ER use. 

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A Typical PACT ICU Case Conference is a bi-weekly, one hour case conference that focuses on highrisk patients, that is attended by CoE trainees from multiple professions (RN, NP, MD, PsyD, PhD, 

PharmD), CoE faculty, and Silver Team clinic staff (RN Care Manager, LPN, Social Work). One Center 

faculty member facilitates the case conference and is responsible for applying the EFECT model and 

facilitating an interprofessional discussion, including the development of an interprofessional care 

plan. Two trainees—a physician and/or nurse practitioner—present a high risk patient from his or 

her panel selected from the top five highest- risk patients as determined by the Care Assessment 

Needs (CAN) registry. The trainees prepare prior to the presentation and complete a chart review 

and may consult CoE faculty. They provide a summary of the patient and his or her health issues. The 

other trainees from various professions provide input from their perspective, such as the dynamic 

between the provider and the patient and other VA resources, but do not present. Patient data from 

the electronic medical record is displayed on a large screen. The group performs an evidence-based 

gap analysis of the patient’s care needs, how they can be addressed, and how to align patient values 

with obtaining care. All participants are encouraged to use a standardized worksheet to identify 

strengths, needs, and gaps in care. Each profession contributes recommendations to work towards 

improvement as an interprofessional team. At the end of the case conference, the presenting trainee 

summarizes the shared care plan, identifying specific action items for each member of the team, 

such as follow-up tasks for the RN Care Manager. In addition to physician or nurse practitioner 

interventions, action items commonly address a full range of biopsychosocial needs that often 

include pharmacy, social work and behavioral health referrals, coordinated future visits with warm 

hand-offs, nurse care management coordination, and non-traditional forms of care provision (e.g. 

telephone visits, home telemonitoring, and secure messaging). CoE trainees are mentored before 

they see a patient so they can tap in to the expertise and experience of their PACT team, which is 

particularly helpful for difficult patients. PACT ICU normalizes this support and provides psychological 

support and options in considering a treatment plan for what may be perceived as a dense problem. 

Ultimately, PACT ICU is designed to improve proactive and coordinated care, with the goal of 

minimizing emergency room and urgent care visits and maximizing continuity with the team as part 

of PACT-based care. 

EFECT Model = Elicit the narrative of illness, Facilitate a group meeting, Evidence-based gap 

analysis, Care plan and Track Changes. 

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PROMISING SOLUTION: PACT ICU—A TEAM APPROACH TO ADDRESSING THE COMPLEX NEEDS OF 

VETERANS 

In 2010, the Boise VA worked towards developing such shared understanding by phasing in PatientAligned Care Teams (PACTs), the VA-mandated version of the Patient Centered Medical Home, which 

consists of a Primary Care Provider (physician or nurse practitioner), an RN Care Manager, a LVN 

(licensed vocational nurse), and an MSA (medical support assistant). Research shows that when 

trainees develop a shared understanding of each other’s skillsets, care procedures, and values, patient 

care is improved (Billett 2013). To facilitate a move towards a care model featuring this shared 

understanding, the Boise CoE developed an interprofessional, bi-weekly case conference for the 

highest risk patients (who are also high utilizers) in the trainee panels. Patient Aligned Care Team 

Interprofessional Care Update (PACT ICU) focuses appropriate resources on patients with the highest 

need in clinic (e.g., high clinic/ER utilization, chronic pain, multiple co-morbidities or psychosocial 

impediments to care). PACT ICU also serves as a venue in which trainees and supervisors from different 

professions (internal medicine physicians, nurse practitioners, nurse care manager, pharmacists, 

psychologists, social workers, chaplaincy and ethics service) use a patient-centered framework to 

collaborate on these specific patient cases. Pact ICU is easily applied to a range of health conditions, 

such as diabetes, mental and behavioral health, lack of social support, and delivery system issues, such 

as emergency room (ER) utilization. The goals of PACT ICU are to: 

•	 Improve the quality and satisfaction of patient care for high-risk patients; 

•	 Encourage appropriate utilization of health care resources by prioritizing continuity with the 

PACT team; and 

•	 Enhance interprofessional PACT team function, decreasing provider and staff stress in primary 

care. 

PLANNING AND IMPLEMENTATION 

“I think it represents a very high level of learning. I’m not just giving you the facts of what happens on 

the team and asking you to memorize them and get them back to me. And I’m also not asking you to 

apply them in the hypothetical situation so much. I’m asking you to live them out in the PACT ICU. I’m 

asking you to take that information, synthesize it and then make it live—I’m giving you a great needto-know moment when you’re on the PACT ICU. And I think that it’s an incredible level of learning. It’s 

so much more like practice than it is like for instance, reading it in a book.” 

Affiliate Representative 

In January 2013, Boise VA and the Caldwell community outpatient clinic (CBOC) implemented PACT 

ICU. Other non-teaching clinics followed later in the year. Planning and executing PACT ICU took 

approximately 10 hours of CoE staff time and required no change in Boise VA policy. Program 

leadership approval was necessary for participation of CoE residents and postdocs. Service-line 

leadership support was required to protect clinic staff time (nurse care manager, social workers, 

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chaplaincy, and ethics service). At the Caldwell CBOC, the Section Chief granted approval for the 

program, and it took about one month to initiate a similar version of PACT ICU. 

Table 1: CoEPCE Core Domains 

Shared Decision-Making (SDM): Care is aligned with the values, preferences and cultural perspectives 

of the patient. Curricula focus is on communication skills necessary to promote patient’s self-efficacy. 

Sustained Relationships (SR): Care is designated to promote continuity of care; curricula focus on 

longitudinal learning relationships. 

Interprofessional Collaboration (IPC): Care is team based, efficient and coordinated, curricula focus is 

on developing trustful, collaborative relationships. 

Performance Improvement (PI): Care is designed to optimize the health of populations; curricula 

focus on using the methodology of continuous improvement in redesigning care to achieve quality 

outcomes. 

Curriculum 

PACT ICU is a workplace clinical activity with roots in the case conference model, specifically the 

EFECT7 model (Bitton, et al., 2016). PACT ICU emphasizes a patient-centered approach to developing 

care plans. Staff review the five highest risk patients, who are identified by the VA Care Assessment 

Need (CAN)8 registry. Physician and nurse practitioner residents select one of the five patients to 

discuss in PACT ICU, while the remaining four serve as case-control comparisons to examine long-term 

patient outcomes. All trainees, faculty, and staff are provided patient data that can be discussed on a 

VA-approved secure website. 

PACT ICU combines didactic teaching with workplace learning. For example, the patient’s medical 

issues may lead to a formal presentation about a topic such as secondary stroke medication 

prophylaxis. The workplace learning occurs as the trainees observe and participate in the decision 

making towards a treatment plan. Interprofessional interactions are role-modeled by clinical faculty 

and staff during these discussions, and the result impact the patients care. PACT ICU embodies the four 

core domains (Table 1) that shape the CoEPCE curriculum: Interprofessional Collaboration (IPC), 

Performance Improvement (PI), Sustained Relationships (SR), and Shared Decision Making (SDM). First, 

trainees learn IPC concepts, such as role clarification and how to work with an interprofessional team. 

7 EFECT Model: Elicit the narrative of illness, Facilitate a group meeting, Evidence-based gap analysis, Care plan, and Track
 

changes)
 8 VA CAN: Analytic tool available throughout VA, which estimates patients’ risk of mortality or hospitalization in the next 90
 

days.
 

6
 
 

 

 

 

 

 

 


 

Second, CoE trainees work with data from the CAN registry to develop a care plan that includes a PI 

objective. Third, the huddle creates SR among team members while improving the quality of the clinic 

experience, as well as SR with patients though increased continuity of care. Last, PACT ICU strengthens 

communications, understanding of team roles, and system resources to support SDM. 

There have been some changes to the PACT ICU model over time. Initially, conferences took place on a 

weekly basis, to build momentum among the team and to normalize processes. After approximately 

two years, this decreased to every other week, in order to reduce time burden. Additionally, the CoE 

has strengthened the “tracking changes” component of the EFECT model - trainees now present a fiveminute update on the last patient they presented at the prior PACT ICU case conference. Most 

recently, psychology post-doctoral candidates have instituted a pre-conference call with the patients to 

further improve the teams understanding of the patients’ perspective and narrative. 

Faculty Roles and Development 

“I think the hidden curriculum in PACT ICU is kind of learning how to speak to a team that is coming 

from many perspectives, and I think that translates into the clinic.” 

CoE Faculty 

CoE faculty who facilitate the PACT ICU participate in faculty development concerning facilitation of 

interprofessional meetings. All faculty are expected to role model collaborative behavior and mentor 

trainees on the cases they present. 

Resources 

Space is an important resource in an interprofessional academic PACT. PACT ICU requires a room large 

enough to accommodate at least 12 people. One staff member is required to review patient cases prior 

to the case conferences (usually about one hour of preparation per case conference), while another 

staff person creates and shares an Excel spreadsheet stored with VA-approved information security 

with data fields to include the site, PACT ICU date, patient identifier, the CAN score and a checkbox for 

whether the patient was selected or part of a control group). Logistical support is required for 

reserving the room and sending information to presenters. A clinic-based registered nurse (RN) with 

training in interprofessional care case management uses a web-based schedule to facilitate selection 

and review of patients. RN care managers can use a secure management tool to track patient care and 

outreach. An example of the format of this locally developed website and tools can be seen at Boise VA 

CoEPCE Courses (Contact staff for access). 

The nurse care manager also needs to be available to attend the PACT ICU case conferences. The CoE 

has built a website to share and standardize resources, such as an up-to-date presenter schedule, PACT 

ICU worksheet and provider questionnaire http://boisevacoe.org/courses/course/view.php?id=29). 

(Contact staff for access.) For the initial evaluation of impact, PACT ICU utilized staff data support in the 

form of a data manager and biostatistician to identify, collect, and analyze data. While optional, this 

was helpful in refining the approach and demonstrating the impact of the project. Other resourcerelated requirements for exporting PACT ICU include: 

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• Staff members, usually RN care managers, who coordinate meetings with participants and 

identify appropriate patients using a registry such as CAN 

•	 Meeting facilitators who enforce use of the EFECT model and interprofessional participation to 

ensure that the interprofessional care plan is carried out by the presenting provider; and 

•	 Interprofessional trainees and faculty, who participate in PACT ICU and complete surveys after 

the first conference. 

Monitoring and Assessment 

CoE staff are triangulating the evaluation of PACT ICU with participant self-evaluation, consultation 

referral patterns, and utilization statistics (composite ER, episodic care, hospitalization). The CoE is 

continuing to analyze utilization data. Pharmacy faculty are exploring the use polypharmacy registries 

and psychology will use registries of poor psychosocial function. 

Partnerships 

Beyond support and engagement from VA CoEPCE and affiliate faculty, PACT ICU has greatly benefited 

from partnerships with VA facility department and CBOC leadership. The CoEPCE co-director and 

faculty are in facility committees, such as the PACT Strategic Planning Committee. 

The academic affiliates are integral partners who assist with nurse practitioner student and resident 

recruitment as well as participate in the planning and refinement of CoEPCE components. PACT ICU 

supports their mandate to encourage interprofessional teamwork. Faculty members from Gonzaga 

University (nurse practitioner affiliate) were involved in the initial discussion on PACT ICU and consider 

it a “learning laboratory where the professions work together with knotty problems, with challenging 

problems.” (Gonzaga Affiliate Representative). Gonzaga CoEPCE nurse practitioner trainees are asked 

to talk about their PACT ICU experience—its strengths, weaknesses and challenges—to other Gonzaga 

students who don’t have exposure to the team experience. 

CHALLENGES AND SOLUTIONS 

The demand for direct patient care puts pressure on indirect patient care approaches like PACT ICU, 

which is a time intensive process with high impact on only a small number of patients. The argument 

for deploying strategies such as PACT ICU is that managing chronic conditions and encouraging 

appropriate use of services will improve outcomes for the highest risk patients and save important 

system resources 

in the long-run, but in the short-term, a strong case must be made for the diversion of resources from 

usual clinic flow, particularly securing recurring blocks of provider time and clinic staff members. In 

addition, issues around team communication and understanding of appropriate team-based care can 

overflow to complex patients not presented in the PACT ICU conference. Providing a facilitated 

interprofessional venue to discuss how to appropriately coordinate care improves the participation 

and perceived value of different team members. This has led to improved engagement of the team for 

patients discussed in the PACT ICU, as well as in general care within the participating clinic. In the 

current iteration, the VA does not see a workload benefit, and participants do not get encounter credit. 

8
 
 

 

 

 


 

Other challenges include logistical challenges of finding appropriate patients and distributing sensitive 

patient information among the team. Additionally, PACT ICU has to wrestle with staffing shortages and 

episodic participation by some professions which are chronically understaffed. We have addressed 

many of these problems with the following solutions. First, achieving buy-in from leadership, who 

allow time for participation in clinic staffs’ schedules, has been crucial. Second, gaining buy-in from 

participants, who have committed to participation in PACT ICU, has been vital. For example, we require 

each participant to recruit a substitute in case of a conflict. 

“It provides a space, you know, outside of clinic where everyone can sit down and really hear what 

the other professions have to say and offer, and I think there is a level of respect and appreciation 

that comes out of PACT ICU for all the professions because it’s where the trainees realize a lot that 

you don’t have to handle this really complex patient alone, and really you shouldn’t be, and that the 

team can help.” 

CoE Faculty 

FACTORS FOR SUCCESS 

A realization of the value of coordinating care for high risk/high need patients is important for the 

success of a program. The commitment from the Boise VA facility, primary care clinic leadership and 

affiliated training programs to support staff and trainee participation has also been critical. 

Additionally, VA facility leadership commitment to ongoing improvements to PACT implementation 

was a key facilitating factor. Co-localization of trainees and clinic staff on the academic PACT Silver 

Team facilitates communications in between PACT ICU case conferences, while also supporting team 

dynamics and sustained relationships with patients presented in PACT ICU. Also, since many of these 

patients can and will typically seek care as part of this shared clinic, many of the staff and trainees 

already have “skin in the game” to motivate coordinated participation in a proactive manner. Last, this 

model has been successfully replicated and sustained at four of the five CoEPCE sites. As another 

example, the Caldwell clinic PACT ICU has been up and running for two years, and two other nonacademic clinics have piloted PACT ICU managed care conferences. 

ACCOMPLISHMENTS AND BENEFITS 

There is evidence that PACT ICU is achieving the desirable goals of both improving trainee learning and 

patient outcomes. Trainees are using team skills to provide patient-centered care; trainees are 

strengthening their overall clinical skills by learning how to improve their responses to high-risk 

patients. There is also evidence of an increase in interprofessional warm hand-offs within the clinic. 

Interprofessional Educational Capacity 

Unlike a traditional didactic with classroom case conferences on interprofessional collaboration, PACT 

ICU is an opportunity for health care professionals to work together to provide care in clinic. Moreover, 

co-location of diverse trainee and faculty professions during the case conferences better prepares 

trainees to work with other professions and supports all participants to work and communicate as a 

team. 

9
 
 

 


 

“One of the biggest advantages to doing this is that the trainees from the different disciplines are 

getting to know each other, getting comfortable talking with each other and the also knowing— 

getting a much better perspective of what each other’s roles are.” 

CoE Staff 

Participant Knowledge, Attitudes, Skills, and Competencies 

CoE staff have assessed PACT ICU educational outcomes before and after attendance in PACT ICU. On 

average, trainees (n=30) said they found the PACT ICU case conferences to be “very helpful” (at the top 

of the Likert scale) in developing treatment plans. Second, trainees reported increased understanding 

of the elements that should be considered in developing a care plan and the variety of roles played by 

team members in providing care to difficult or complex patients (Table 2). 

Table 2. PACT ICU Evaluation Summary (Weppner, et al.) 

Trainee survey question pre and post-involvement in a PACT ICU 

session (n=30) 

Pre Post P-value 

“My understanding of all the elements (biological, social, 

psychological) that must be considered in the patient’s care” (1-5) 

2.9 4.5 p<0.01 

“My understanding of the roles that each of the team can play in 

hard to manage patients like this one.” (1-5) 

3.0 4.4 p<0.01 

Participants’ Interprofessional Collaboration (IPC) 

“I guess I didn’t really know all the resources I had available until I went to PACT ICU, and I’ve never 

really worked on a collaborative approach like that with so many different disciplines even the 

physicians and nurse practitioners and nurses in the room had different levels of experience.” 

CoE Nurse Practitioner Resident Trainee 

Teambuilding and co-locating trainees, faculty and clinic staff from different professions is a primary 

focus of PACT ICU. PACT ICU case conferences are intentionally designed to break down silos and foster 

a team approach to care. 

Trainees learn how the team works and the ways other professionals can help them take care of the 

patient. For example, trainees learn early about the contributions and expertise that the pharmacist 

and psychologist offer in terms of their scope of practice and referral opportunities. Additionally, the 

RN nurse care manager increases the integration with the PACT clinical team by sharing pertinent 

information on individual patients. Based on recent trainee survey findings, the CoE has observed a 

positive change in the team dynamic and trainee ability to interface between professions. PACT ICU 

participants were more likely to make referrals to other members within the PACT team, such as a 

warm hand-off during a clinic appointment, while they were less likely to seek a consult outside the 

team (Weppner, W.G., et. al, 2016) 

10
 
articipants’ Clinical Performance

 

 

 

 

 

 

 


 

“...the provider will come back with another patient shortly after and ask me to do a medication 

reconciliation, even if it’s a separate patient the PACT ICU still has reminded them of what pharmacy 

can do, which for me is a huge accomplishment of what PACT ICU achieves.” 

P 

CoE Pharmacy Trainee 

PACT ICU is an opportunity for a trainee to increase clinical expertise. It provides exposure to a variety 

of patients and their care needs and serves as an opportunity to present a high-risk, challenging patient 

to colleagues of various professions. As of January 2016, 48 physician resident and nurse practitioner 

residents have presented complex patient cases. 

In addition, a structured forum for discussing patients and their care options strengthens team clinical 

performance, which supports people to work to the full scope of their practice. Trainees learn and 

apply team skills, such as communication and the warm handoff9, which can be used in other clinical 

settings. An interprofessional care plan that is delineated during the meeting supports the trainee and 

is carried out with help from consultants as needed. These consultants often facilitate plans for a covisit or warm handoff at the next clinic visit, a call from the RN care manager, a virtual clinic 

appointment, or other non-traditional visits. The clinic staff can get information from providers about 

patient’s plan of care, and providers get a more complete picture of a patient’s situation (e.g. history, 

communications, and life-style factors). In addition, surveys of PACT ICU participants suggest the 

curriculum’s effectiveness at encouraging use of PACT principles within the clinic team and improving 

appropriate referrals to other members of the PACT team, such as pharmacy and behavioral health. 

9 A warm handoff is often described as an intervention in which: “a clinician directly introduces a patient to 

another clinician at the time of the patient’s visit, and often a brief encounter between the patient and the health 

care professional occurs” (Cohen, et al., 2015). 

11
 
 

 

 

 

 

 


 

Participants’ Satisfaction with Interventions 

“They walk away with a clear ‘Here’s what I’m going to do for this patient.” 

CBOC Representative 

Patients presented at PACT ICU can be particularly challenging, so there may be a psychological benefit 

to working with a team to develop a new care plan. Providers who feel they are overwhelmed and 

have exhausted every option step back, get input and look at the patient in a new light. 

“But definitely in health care, we can’t be solo in our delivery model anymore. Patients expect more. 

Staff can’t do it alone. And so, I think from the collaborative approach in knowing there are resources 

and if I just have to do this part and there’s other people to do other parts of the health care delivery, 

then I think that lightens the load of the specific individual provider, as well as team members.” 

Caldwell CBOC Representative 

CoEPCE Function 

PACT ICU is flexible and has been adapted to different ambulatory care settings within the Boise VA. 

Currently, PACT ICU case conferences take place at the VA facility and two VA community-based 

outpatient clinics (CBOC) in Caldwell, Idaho and more recently at a smaller CBOC in Burns, Oregon. The 

PACT ICU structure is slightly different in the two clinic settings since the VA primary care clinic has 

different resources to draw upon, such as hospital and specialty services. The Caldwell CBOC was 

unable to protect time for providers, so it holds a monthly PACT ICU case conference. 

PACT ICU is continuing under Stage 2 of the CoEPCE program, which is described in the Future section. 

In addition to continuing expansion in other non-academic PACT clinics and collaboration with other 

CoEPCE sites, work is underway to disseminate generalizable principles for interprofessional education, 

as well as exporting the model for implementation in non-VA settings. 

Primary Care Delivery System 

PACT ICU is part of a system wide transformation to provide team-based, patient-centered care to 

Veterans. The staffs’ efforts to provide a team-based, real patient learning experience have the 

potential to hasten this transformation while improving relationships and quality of care. 

Primary Care Services 

PACT ICU has the potential to create efficiencies in busy clinic settings. It strengthens communication 

between providers and is an opportunity to touch base on the patient, delegate care, and keep track of 

high-risk patients who might otherwise receive attention only when having an acute problem. Nurses 

gain a deeper understanding of the patients presented at PACT ICU. 

“...we’re all coming together for this one patient, that at the end of the day it’s this one patient who’s 

the center of our mind, we’re all just there to help, which is awesome for me.” 

CoE Pharmacy Trainee 

12
 
 

 

 

 

 


 

PACT ICU’s benefits to primary care are that it leverages and builds on existing PACT resources in an 

achievable and sustainable manner. CoE trainees, who are part of the Silver Team, tap into the 

information that Team nurses gain from checking in with these high-risk patients biweekly. Moreover, 

the integration with the Silver Team improves continuity, which helps enhance a patient’s level of 

trust. The relationship strengthened between primary care and behavioral health at the Caldwell 

CBOC, providing improved patient access and increased professional sharing. 

Patient Outcomes 

”You know, the nurse practitioner may say, well, ‘this is a whole patient, this isn’t a patient that just 

has hypertension. They do fit into the age group of hypertension, this into the population, it is the 

most likely diagnosis, but have you thought about the patient being homeless...?’” 

Affiliate Representative 

PACT ICU provides a forum to invite perspectives beyond the primary care provider’s. This feature 

results in a more robust treatment plan than might be developed by individual providers, who might 

not have time to consider options that are outside their scope of practice. Formulating an enriched 

care plan, informed by multiple professions has the potential to improve utilization and provide better 

care. 

PACT ICU has presented 117 patients as of May 2015. While clinical outcomes data are difficult to 

collect, the CoE has data on utilization differences on all patients presented at the PACT ICU case 

conferences. This includes 4 control patients from the same provider, with similarly high risk based on 

CAN scores at the time of selection. A single control patient is selected based on gender, closest age 

and CAN score; this serves as a comparator for subsequent utilization. 

“What makes it really stick is when it’s a real patient and you’re actually truly applying the 

information and what you’re saying could have a true impact.” 

CoE Pharmacy Resident 

Data from the first two years of this study demonstrate that although PACT ICU did not show an 

increased number of visits with the PCP compared to a high-risk control group. However, there was an 

increase in contacts with PACT team members including behavioral health, clinical pharmacists, and 

nurse care management, persisting up to 6 months following the PACT ICU presentation. This was 

associated with an improvement in chronic disease quality metrics related to diabetes and 

hypertension, as well statistically significantly decreased hospitalizations and a trend towards 

decreased ER visits. These findings persisted when compared to controls in the PCP’s panel with similar 

CAN scores, making “regression to the mean” often seen in these studies much less likely. 

Analysis of early patients in the project suggests the possibility of improved glycemic control in diabetic 

patients and improved blood pressure control in hypertensive patients presented at the PACT ICU, 

compared to non-PACT ICU patients. Buu, J., Fisher, A., Weppner, W., Mason, B. (2016). 

13
 
 

 

 

 


 

“I think that the big thing is everyone is kind of more aware of the patient. And I think we work 

together as a team to help that patient. That’s what I’ve enjoyed of it, getting to know the different, 

you know, like what psychology can do for them, what pharmacy can do for them, and just getting 

different perspectives to help the patient meet their goals. So it definitely spills into the team.” 

RN Care Manager 

Another potential benefit includes better team-based coordination. Because the patient now has a 

team focusing on care, this new dynamic results in improving outreach, identifying patients who could 

receive care by a telephone and better preparing team members to establish rapport when the patient 

calls or comes in for a visit. Although the numbers are too small for statistical inference, there is a 

perception at the Caldwell CBOC that there has been a reduction in patients’ low-acuity use of ER visits. 

THE FUTURE 

Under Stage 2 of the CoEPCE program, a multi-site trial of PACT ICU is underway to better understand 

which elements are critical to success, with the goal of facilitating broader exportability. The multi-site 

PACT ICU trial will focus on three intertwined elements: structure, delivery, and evaluation. Using local 

implementation and the multi-site trial, the most effective practices will be documented as part of an 

implementation kit. The goal of the implementation kit is to facilitate step-by-step implementation of 

PACT ICU to other settings beyond the multi-site study. Since PACT ICU’s open-ended structure enables 

accommodating different professions and/or specialties beyond the Boise model’s participants, it could 

be easily adapted to potentially support a variety of implementations elsewhere. 

Another opportunity for expansion is increased patient involvement. Currently, PACT ICU patients have 

the opportunity to review and ask questions about their multidisciplinary care plans before starting. 

Patients know they have a team working on their behalf but there are opportunities for more followup, including presenting patients who are seen by other providers outside the CoE, such as the 

attending physician who may also have challenging patients. 

14
 
 

 

 

 


 


 


 


 

CONTACT INFORMATION
 

Boise VA Medical Center 

For more information: 

William G. Weppner, MD MPH FACP 

Co-Director, Center of Excellence in Primary Care Education 

Assistant Professor, University of Washington Department of Medicine 

Primary Care Provider, Boise VA Medical Center 

Email: william.weppner@va.gov 

RESOURCES
 

National VA CoEPCE Websites: http://www.va.gov/oaa/coepce/ 

National VA APACT Website, Publications, Executive Briefing Videos: Academic PACT Videos 

Boise CoEPCE web and video: http://www.va.gov/oaa/coepce/boise.asp 

PACT ICU Course materials: http://boisevacoe.org/courses/course/view.php?id=29 

(Guest password required – contact staff for access) or http://boisevacoe.org/products/pact-icu/ 

WORKS CITED
 

Buu J., Fisher A., Weppner W., Mason B. (2016). Impact of Patient Aligned Care 

Team Interprofessional Care Updates (ICU) on metabolic parameters. Federal 

Practitioner; February; 33(2):44-48. Retrieved from Federal Practitioner Article 

Billett, S. (2013). Learning through practice: Beyond informal and towards a framework for 

learning through practice. In UNEVOC (Ed.), Revisiting global trends in TVET: 

Reflections on theory and practice (pp. 123-163). Retrieved from www.unevoc.unesco.org 

Bitton A., Pereira, A.G., Smith C.S., Babbott S.F., Bowen J.L. (2013). The EFECT framework for 

interprofessional education in the patient centered medical home. Healthcare. Dec; 1(3-4):63-68. 

Weblink 

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Rugen, K.W., Watts, S., Janson, S., Angelo, L.A., Nash, M., Zapatka, S.A., Brienza, R., Gilman, S.C., 

Bowen, J.L., Saxe, J.M. (2013). Veteran Affairs Centers of Excellence in Primary Care Education: 

Transforming nurse practitioner education. Nursing Outlook. 62 (2):78-88. Weblink 

Weppner, W.G., Davis, K., Sordahl, J., Willis, J. , Fisher, A., Brotman, A. Tivis, R. Gordon, T., Smith, C.S. 

(2016). PACT-ICU Interprofessional care conferences for high risk primary care patients. Academic 

Medicine. Jun; 91(6):798-802. doi: 10.1097/ACM.0000000000001151. Weblink 

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CASE STUDY #2: THE DYAD MODEL 

Louis Stokes Cleveland VA Medical Center: Center of Excellence in Primary 

Care Education (CoEPCE) Interprofessional Academic Patient Aligned Care 

Team (iAPACT) 

Prepared by: Annette L. Gardner, PhD, MPH with the Cleveland VA Medical Center CoEPCE: Laura 

Clementz, MA, MS; Renée H. Lawrence, PhD; Mary A. Dolansky, PhD, RN; Alli M. Heilman, NP; Anne R. 

Rusterholtz, MSN, NP; Simran Singh, MD; Matthew Sparks, MSN, NP; and Mamta K. Singh, MD, MS 

Academic Partners: Case Western Reserve School of Medicine, Francis Payne Bolton School of Nursing 

at Case Western Reserve University, Cleveland Clinic Foundation, The Breen School of Nursing at 

Ursuline College 

Key Theme of the Innovation: This workplace learning strategy employs practice partnerships between 

students and residents. Nurse practitioner students and advanced physician residents are highlighted 

in this model. 

Goals: 

- Activate a dyad model/interprofessional 

clinical practice pair
 

- Provide collaborative patient care
 

- Enhance interprofessional teamwork and
 

collaboration
 

- Focus on trainee developmental needs and 

levels of experience
 

- Improve resident teaching skills and clinical 

practice
 

Trainees: Students and residents 

Faculty and/or Staff: Clinic preceptors 

17
 

Cleveland TOPC/CoEPCE Dyad Microteaching Session 
 

 

 


 

SUMMARY 

This case study describes the Cleveland Center of Excellence in Primary Care Education dyad model, 

which combines interprofessional education, clinical or workplace learning, and resident as teacher in 

the ambulatory setting. For one-half day a week, a nurse practitioner student and physician resident 

work collaboratively in a primary care setting to provide care to Veterans at the Louis Stokes Cleveland 

Department of Veterans Affairs. In addition to enhancing teamwork skills, this novel interprofessional 

education activity has helped increase nurse practitioner students’ clinical competence, strengthened 

physician resident teaching skills and efficacy, and enhanced delivery of team-based patient-centered 

care. 

INTRODUCTION 

In 2011, five VA Medical Centers were selected by VA’s Office of Academic Affiliations (OAA) to 

establish Centers of Excellence in Primary Care Education (CoEPCE or CoE). As part of VA's New Models 

of Care initiative, the five CoE’s (Boise, Cleveland, San Francisco, Seattle and West Haven) are using VA 

primary care settings to develop and test innovative approaches to prepare physician residents and 

students, advanced practice nurses, undergraduate nursing students, and other health professions 

trainees (such as pharmacy, social work, psychology, physician assistants, etc.) for primary care 

practice in the 21st Century. The CoEPCE’s are developing, implementing, and evaluating curricula to 

prepare learners from relevant professions to practice in patient-centered, interprofessional teambased primary care settings. The CoE’s are known as Interprofessional Academic PACTs (iAPACTs) and 

Patient Aligned Care Teams that have at least two or more health professions trainees engaged in 

learning, working and teaching. This is the preferred model for VA Academic Primary Care PACTs. 

The Cleveland Transforming Outpatient Care (TOPC) CoEPCE was designed for collaborative learning 

among nurse practitioner students and physician residents. Its curriculum consists of a dedicated halfday of didactics for all learners, interprofessional quality improvement projects, panel management 

sessions, and primary care clinical sessions for nursing and physician learners. 

METHODS 

In 2015, the lead evaluator from VA’s Office of Academic Affiliations observed the TOPC/COEPCE Dyad 

Model process, reviewed background documents, and conducted ten open-ended interviews with 

TOPC/COEPCE staff, participating trainees, faculty, and affiliate leadership. Informants described their 

involvement, challenges encountered, and benefits of the TOPC/COEPCE Dyad Model to participants, 

Veterans, the VA, and affiliates. 

THE ISSUE: LACK OF INTERPROFESSIONAL LEARNING OPPORTUNITIES IN PRIMARY CARE 

Current healthcare professional education models typically do not have many workplace learning 

settings where physician and nursing trainees learn together and provide patient-centered care. While 

often in a shared clinical environment, trainees may engage in “parallel play”, which can result in 

physician trainees and nurse practitioner students learning independently, and being ill-prepared to 

18
 
 

 

 


 


 


 

practice effectively together. Moreover, each type of trainee has different learning needs. For 

example, less experienced nurse practitioner students require greater time, supervision, and 

evaluation of their patient care skills. On the other hand, senior physician residents, who require less 

clinical instruction, need to be engaged in ways that provide opportunities to enhance their 

ambulatory teaching skills. Although enhancement of resident teaching skills occurs in the inpatient 

hospital setting, there have been limited teaching experiences for residents in a primary care setting 

where the instruction is traditionally faculty-based. The TOPC/COEPCE Dyad Model offers an 

opportunity to simultaneously provide trainees with a true interprofessional experience through 

advancement of skills in primary care, teamwork, and teaching, while addressing the health care needs 

of Veterans. 

“This is not about learning to work together; it is about working to learn together.”
 

Howkins, Centre for the Advancement of Interprofessional Education, 2012
 

PROMISING SOLUTION: THE DYAD MODEL 

In 2011, the VA Office of Academic Affiliations, Coordinating Center for the CoEPCE directed sites to 

expand their workplace learning instruction strategies and create more opportunities for physician and 

nurse practitioner trainees to work as a team to provide Veteran’s care. There is evidence 

demonstrating that when students develop a shared understanding of each other’s skill set, care 

procedures, and values, patient care is improved (Billett, 2014). Further, training in pairs can be an 

effective strategy in education of pre-clerkship medical students (Tolsgaard, Bjorck, Rasmussen, 

Gustafsson, & Ringsted, 2013). In April 2013, TOPC/CoEPCE staff asked representatives from the 

Student-Run Free Clinic at Case Western University to present their approach to pairing nursing and 

medical students in clinic under supervision by volunteer faculty. However, formal structure and 

curricular objectives were lacking. To address diverse TOPC/CoEPCE trainee needs and create a team 

approach to patient care, TOPC/CoEPCE staff formalized and developed a workplace curriculum, called 

the TOPC/CoEPCE Dyad Model. Specifically, the model pairs one nurse practitioner student with a 

senior (PGY2 or PGY3) physician resident to care for ambulatory patients as a dyad teaching/learning 

team. The TOPC/CoEPCE Dyad Model has three goals of improving clinical performance, learning team 

dynamics, and, for the physician resident, improving their teaching abilities in an ambulatory setting. 

PLANNING AND IMPLEMENTATION 

“The dyad could be anything. It could be a psychology resident with a physician resident. It’s very 

generic but you need to be familiar with the trajectory of both learners, where they’ve come from and 

where they’re going because the reality is you can’t teach somebody if you are only talking to one 

group. Then you’re leaving the other group out.” TOPC CoE Co-Director 

Planning the TOPC/CoEPCE Dyad Model took four months, and the program officially started in July 

2013. Initial conceptualization of the Model was discussed at TOPCE/CoEPCE infrastructure meetings. A 

workgroup with representatives from medicine, nursing, evaluation and medical center administration 

19
 
 

 

 


 

were formed to finalize the Model. They worked together to develop protocols for scheduling, ongoing 

monitoring and assessment, microteaching session curriculum development, and logistics. During the 

planning and initial implementation, the workgroups met weekly or biweekly as needed. They also 

piloted the program for a month with two dyads to monitor learner progress and improve 

components, such as adjusting the patient exam start times and curriculum. In maintaining the 

program, the workgroups continue to meet monthly to check for areas for further improvement and 

maintain dissemination activities. 

Curriculum 

Table 1. Core of ORIME Model Relevant to TOPC CoE Dyad Model (Tham, 2013) 

The TOPC/CoEPCE Dyad Model is a novel opportunity to have trainees from different professions not 

only collaborate in the care of the same patient at the same time, but also negotiate their respective 

responsibilities pre- and post-visit. The experience focuses on interprofessional relationships and open 

communication. TOPC/CoEPCE used a modified version of the RIME (Reporter-Interpreter-ManagerEducator) Model (Pangaro, 1999) called the O-RIME Model (Table 1), which includes an Observer (O) 

phase as the first component for clarification about a beginners’ role (Tham, 2013). Trainees undergo a 

short orientation for the dyad that provides the foundation for the overall structure and purpose and a 

formalized microteaching session curriculum, which is completed each week with the dyad team after 

the morning huddle. The sessions consist of three components: curriculum content, reflection on 

application of previous content, and a check-in on teamwork skills. The curriculum content is based in 

adult learning theory and focuses on the team approach to care, case presentation for precepting, and 

clinical skills. After the microteaching session, dyad teams engage in collaborative care of patients 

using structured method (Table 2). 

“We are trying to teach teams to listen to each other and when someone has a concern, to think 

about how you might change your behavior or how it’s affecting that person and how you can 

change your behavior to function better as a team. We’re trying to get them to talk and have crucial 

conversations and give each other feedback and learn from the feedback and be open to change your 

mind.” 

TOPC CoE Co-Deputy Director 

20
 
The dyad pairs each then go to their exam rooms and conduct a quick discussion on their four 

patients for that morning clinic. Visits are scheduled for Sam, 9am, 10am, and 10:3oam and there 

are different ways of splitting responsibility for patient care. The dyad pair sees patients from the 

r~id"'nt'~ oanel. 

At the mid-point of each visit, the pair reconvenes in the precepting room to debrief on the 

relevant aspects of the case among themselves and then present to the preceptor. The Dyad team 

discusses their strategy for precepting beforehand, including who will present. 

The dyad completes the clinic visit and returns to the precepting room to debrief each of the clinic 

sessions with a preceptor. 

Table 2. Typical Dyad Session 

21 
 

 

 

 

 

 


 

Four dyads provide collaborative clinical care for Veterans during one half-day session per week. The 

dyad conducts four one-hour patient visits per session. To be a dyad participant, the physician 

residents must be at least a PGY2 and their schedule must align with the nurse practitioner student 

clinic schedule. Participation is mandatory for both nurse practitioner students and physician residents. 

TOPC/CoEPCE staff assemble the pairs. 

The TOPC/CoEPCE Dyad Model requires knowledge of the clinical and curricular interface and when to 

block the dyad team members’ schedules for four patients instead of six. Physician residents are in the 

TOPC/CoEPCE for 12 weeks and then off for 12 weeks. Depending on the nursing school affiliate, nurse 

practitioner student trainees are scheduled for either a 6 or 12-month TOPC/CoEPCE experience. For 

the 12-month nurse practitioner students, they are paired with up to four internal medicine residents 

over the course of their TOPC/ CoEPCE experience so they can experience the different teaching styles 

of each resident while developing more varied interprofessional communication skills. 

Faculty Roles and Development 

The Dyad Model also seeks to address the paucity of deliberate interprofessional precepting in 

academic primary care settings. TOPC/CoEPCE staff decided to use the existing primary care clinic 

faculty development series at the Cleveland VAMC, which is one hour long and occurs twice a month. 

TOPC/CoEPCE Dyad Model team members presented sessions covering foundational material in 

interprofessional teaching and precepting skills, which prepare faculty to precept for different 

professions and the dyad teams. It is important for preceptors to develop awareness of learners from 

different professions and the corresponding educational trajectories, so they can communicate with 

paired trainees of differing professions and academic levels who may require different levels of 

discussion. 

Resources 

By utilizing advanced residents as teachers, TOPC/CoEPCE staff were able to increase the number of 

learners in the clinic without increasing the number of staff to teach and precept them. For example, 

precepting a student typically requires more preceptor time, especially when we consider that the 

preceptor must also see the patient. 

TOPC/CoEPCE staff includes TOPC/CoEPCE faculty who run the microteaching sessions and a TOPC/ 

CoEPCE evaluator who monitors and evaluates the program. The microteaching sessions were derived 

from several teaching resources. 

Monitoring and Assessment 

The Cleveland TOPC/CoEPCE administered two different surveys (Dolansky et al., (under review) 

developed by the TOPC/CoEPCE Dyad Model Infrastructure and Evaluation workgroup. A seven-item 

survey assesses dyad team communication and interprofessional team functioning, and an eight-item 

survey assesses the teaching/mentoring of the resident as teacher. Both were collected from all 

participants to evaluate the resident’s and student’s point of view. Surveys are collected in the first and 

last weeks of the dyad experience. 

22
 
 

 

 

 


 

Feedback from participants is used to make improvements to the program, such as monitor how the 

dyad teams are functioning, and coach individual learners. 

PARTNERSHIPS 

In addition to TOPC/CoEPCE staff and faculty support and engagement, the initiative has benefited 

from partnerships with VA clinic staff and with the associated academic affiliates. In particular, the VA 

General Medicine Division Director helped to institute changes to the clinic structure. Additionally, 

buy-in from the clinic nurse manager was needed to make adjustments with staff schedules and clinic 

resources. To implement the TOPC/CoEPCE Dyad Model, the facility director had to approve reductions 

in the residents’ clinic loads for the mornings when they participated. 

The nurse practitioner affiliates’ faculty at the schools of nursing are integral partners who assist with 

nurse practitioner student recruitment and participate in the planning and refinement of TOPC/CoEPCE 

components. The Frances Payne Bolton School of Nursing and the Breen School of Nursing of Ursuline 

College were involved in the planning stages of the TOPC/CoEPCE Dyad Model and continue to receive 

monthly updates from TOPC/CoEPCE. Similarly, the Case Western Reserve School of Medicine and 

Cleveland Clinic Foundation affiliates contribute on an on-going basis to the improvement and 

implementation process. 

CHALLENGES and SOLUTIONS 

One challenge has been advancing aspects of a non-hierarchical team approach while it is a teacherstudent relationship. The TOPC/ CoEPCE Dyad Model is viewed as an opportunity to recognize nonhierarchical structures and teach negotiation and communication skills. The TOPC/CoEPCE Dyad Model 

is an opportunity to increase interprofessional understanding of each other’s education, expertise, and 

scope of practice. 

Another challenge is accommodating the diversity in nurse practitioner training and clinical expertise. 

The nurse practitioner students can be in either the first or second of their two semesters. This is a 

challenge since both physician residents and physician faculty preceptors need to assess the nurse 

practitioner students’ skills before providing opportunities to build on the nurse practitioner student’s 

skill level. TOPC/CoEPCE staff members have learned the value of checking in weekly on this issue. For 

example, one of the dyad teams had a physician resident who had poor time management skills and 

the nurse practitioner student working with the physician resident was in the last semester of the 

program. TOPC/CoEPCE faculty coached the dyad team to appreciate the expertise of each member 

and the nurse practitioner student facilitated the physician resident to manage time better. 

“...two people working together there’s obviously going to be different values and different things 

that each brings to the table, so it’s about negotiating, it’s about acknowledging what the other 

person values and devising a plan, you know, collaborating.” 

TOPC CoE NP Student 

23
 
 

 

 

 

 

 

 

 

 


 


 

FACTORS FOR SUCCESS
 

“Our students love it. They think this whole learning environment is excellent. If we could send all of 

our students there, we would, primarily because they learn from each other and they also appreciate 

each other’s’ skills and then begin to understand their role.” 

TOPC CoE Affiliate Representative 

VA facility support and TOPC/CoEPCE Co-director leadership in the primary care clinic and the 

operations/academic partnership remains critical to integrating and sustaining the model into the 

Cleveland primary care clinic. The expertise of TOPC/CoEPCE Dyad Model faculty who serve as 

facilitators has been crucial, as they oversee team development concepts such as developing problem 

solving and negotiation skills. The workgroups ensured that faculty were skilled in understanding the 

different types of learners and provided guidance to dyad teams. Another success factor was the 

continual monitoring of the process and real-time evaluation of the program to adapt the model as 

needed. 

ACCOMPLISMENTS AND BENEFITS 

There is evidence that the TOPC/CoEPCE Dyad Model is achieving its goals: trainees are using team 

skills during and outside the Dyad Model; nurse practitioner students report improvements in skill 

levels and comfort; and physician residents feel the teaching role in the dyad pair is an opportunity for 

them to improve their practice. 

Interprofessional Educational Capacity 

The TOPC/CoEPCE Dyad Model complements TOPC/CoEPCE curriculum components and advances 

trainee understanding of all four core domains: IPC, SDM, SR, and PI (Table 3). For example, as a venue 

for SDM, the model affords trainees an opportunity to learn from each other, problem solve, and 

manage patients together. Nurse practitioner students contribute their knowledge on the psychosocial 

aspects of patient diagnosis and treatment while strengthening their clinical skills. Physician residents 

learn how to teach, delegate responsibility, and collaborate with nurse practitioner students to provide 

team-based care. The TOPC/CoEPCE Dyad Model supports the other TOPC/CoEPCE interprofessional 

education activities and is reinforced by these activities. The model is a learning laboratory for studying 

team dynamics, and developing a curriculum that strengthens a team approach to patient-centered 

care. 

“Because she [nurse practitioner student] brings out aspects that I don’t usually think about...so I 

think clearly there are different minds, different ideas and having that perspective is very important 

because some of them are very important to patient care in the end.” 

TOPC CoE Physician Resident 

24
 
 

 

 

 

 


 

Table 3. CoEPCE Core Domains 

Shared Decision-Making (SDM): Care is aligned with the values, preferences and cultural perspectives 

of the patient. Curricula focus is on communication skills necessary to promote patient’s self-efficacy. 

Sustained Relationships (SR): Care is designated to promote continuity of care; curricula focus on 

longitudinal learning relationships. 

Interprofessional Collaboration (IPC): Care is team based, efficient and coordinated, curricula focus is 

on developing trustful, collaborative relationships. 

Performance Improvement (PI): Care is designed to optimize the health of populations; curricula 

focus on using the methodology of continuous improvement in redesigning care to achieve quality 

outcomes. 

Participants’ Knowledge, Attitudes, Skills, and Competencies 

“I’ve had instances where the medical resident learned from the nurse practitioner student a really 

good example of motivational interviewing and the use of open-ended questions, and the use of 

reflection...I think that was a way to have the resident appreciate the differences in training and 

embrace that.” 

TOPC CoE Faculty 

As of May 2015, 35 trainees (21 internal medicine physician residents and 14 nurse practitioner 

students) have participated in the TOPC/CoEPCE Dyad Model. Because physician residents participate 

over two years, and may partner with different nurse practitioner students from one year to another, 

this has resulted in 27 dyad pairs engaging in the Dyad Model in this timeframe. Findings from TOPC/ 

CoEPCE Dyad workgroups analysis of evaluations suggest that the dyad pair trainees learn from one 

another and the model provides a safe space where trainees can practice and increase their 

confidence (Billett, 2014; Clementz, et al., 2015; Singh, et al., 2015). The nurse practitioner students 

appear to increase clinical skills quickly—expanding physical exam skills, building a differential 

diagnosis, and formulating therapeutic plans—and progressing to the Interpreter and Manager levels in 

the O-RIME model. The physician resident achieves the Educator level. 

As of September, 2015 the results from the pairs who completed beginning and end evaluations show 

that the physician residents increased the amount of feedback they provided about performance to 

the student and likewise the student nurse practitioners also felt they received an increased amount of 

feedback about performance from the physician resident. In addition, physician residents reported 

improving the most in the following areas: allowing the student to make commitments in diagnoses 

and treatment plans and asking the student to provide supporting evidence for their commitment to 

the diagnoses. Nurse practitioner students reported the largest increases in receiving weekly feedback 

about their performance from the physician and their own ability to listen to the patient (Billett, 2014; 

Clementz, et al., 2015; Singh et al., 2015). 

25
 
 

 

 

 

 


 

“What it (the dyad) has provided and what we have evidence for are relationships. They are the glue 

between all the work. We see it in the huddle when they are communicating with each other. We see 

it when they are debriefing before or after a visit. We see it during precepting, that they have this 

evidence of relational coordination, the team aspect.” 

TOPC CoE Co-Director 

Participants’ Interprofessional Collaboration (IPC) 

TOPC/CoEPCE staff observed strengthened dyad pair relationships and mutual respect between the 

dyad partners. Trainees communicate with each other and work together to provide care of the 

patient. Second, dyad pair partners are learning about the other profession—their trajectory, their 

education model, and their differences. The physician resident develops an awareness of the partner 

nurse practitioner student’s knowledge and expertise, such as their experience of social and 

psychological factors to become a more effective teacher, contributing to patient-centered care. The 

evaluation results illustrate increased ability of trainees to give and receive feedback, and the change in 

roles for providing diagnosis and providing supporting evidence within the TOPC /CoEPCE dyad team 

(Clementz, et al., 2015; Lawrence, et al,. 2014; Singh, et al., 2015). 

“It’s been excellent to see my nurse practitioner students grow within the dyads. They really learn a 

lot from working with their physician counterparts. Particularly because students working with 

residents pick up an incredible amount of clinical knowledge and have the opportunity to get that 

direct observation and feedback. In many ways those medicine residents know how the nurse 

practitioner students are performing better than I do because they’re with them.” 

TOPC CoE Faculty 

Participants’ Satisfaction with Interventions 

As evidenced by the representative quotes included both internal medicine residents and nurse 

practitioner students found the experience to be of added value and satisfying. 

CoEPCE Function 

Facility level effort (e.g. allowance for truncated schedule when in dyads) placed in sustaining the 

improvement is one indicator of added value. TOPC/ CoEPCE’s Dyad Model is slated to continue and 

expand under Stage 2 of the CoEPCE program. 

Primary Care Delivery System 

The model has broad applicability for interprofessional education in the VA, since it enhances skills that 

providers need to work in a PACT/PCMH model. Additionally, the TOPC/CoEPCE Dyad Model has proven 

to be an effective interprofessional training experience for the TOPC/CoEPCE affiliates and may have 

applicability in other VA/affiliate training programs. 

26
 
 

 

 

 

 

 

 

 

 

 

 


 


 

“One of the outcomes is that we’ve been able to increase the number of learners in our clinic without 

having to increase the number of staff to train them. What’s unique about the Dyad is that you can 

get two people in a clinical situation where there’s academic benefit for them but you don’t have to 

increase the amount of staff in order to do that; that is great with limited resources.” 

TOPC CoE Faculty 

“I love the aspect of teaching and I think this has only strengthened it. I think the Dyad Model 

strengthens your bond. It helps you understand where each person stands and how they think and 

what their schooling and background is....it’s fun to work with a colleague.” 

TOPC CoE Physician Resident 

Primary Care Services 

The TOPC/CoEPCE Dyad Model is an opportunity to add to the growing body of evidence that a team 

approach is well suited for complex, ambulatory visits. The dyad serves as a setting to develop a more 

robust picture of the patient informed by different perspectives, such as integrating the medical model 

with the psychosocial aspects that are strengths of nurse practitioner training. 

The model creates opportunities for increased continuity of care and the nurse practitioner student 

can see the resident’s patient and follow-up when the resident isn’t there. 

“I’ve gained the basics of chronic disease management. I feel more comfortable discussing with 

patients, gathering a review of systems, conducting the HPI (History of Present Illness), assessing 

their adherence with medications, so I feel comfortable with making clinical decisions. So right now 

the point I’m at is I usually conduct the patient encounter and then when the resident and I step 

outside the room he asks me what your plan is now moving forward.” 

TOPC CoE Nurse Practitioner Student 

THE FUTURE
 

“This has given me an interprofessional approach to caring for patients with chronic diseases. Just 

from the basics of chronic disease management to the continuity of care of patients in a primary care 

setting. So that’s been fantastic.” 

TOPC CoE Nurse Practitioner Student 

TOPC/CoEPCE Dyad Model can be adapted to different trainee types in the ambulatory care setting. 

TOPC/CoEPCE is piloting a version of the TOPC/CoEPCE Dyad Model with nurse practitioner residents 

(post-graduate) and first year medical students. Additionally, the TOPC/CoEPCE is paving the way for 

integrating improvement of physician resident teaching skills into the primary care setting and 

27
 

 

facilitating bi-directional teaching among different professions. TOPC/CoEPCE intends to develop 

additional resources to facilitate use of the model application in other settings such as the dyad 

implementation template (Figure 1). 

28
 

 


 

1

29
 
 

 

 

 

 

 

 

 

 


 


 


 


 


 


 

CONTACT INFORMATION
 

Louis Stokes Cleveland VA Medical Center 

For more information: 

Mamta Singh, MD, MS 

Director, Cleveland VA Center of Excellence in Primary Care Education 

Associate Professor of Medicine and 

Assistant Dean of Health Systems Science Education, 

Case Western Reserve University School of Medicine 

Email: mamta.singh@va.gov 

(216) 791-2300 Ext. 2326 

RESOURCES
 

National VA CoEPCE Websites: http://www.va.gov/oaa/coepce/ 

National VA APACT Website, Publications, Executive Briefing Videos: VA's OAA CoEPCE Academic PACT 

Website 

Cleveland CoEPCE Website and Video: http://www.va.gov/oaa/coepce/Cleveland.asp 

WORKS CITED
 

Billett, S.R. (2014). Securing intersubjectivity through interprofessional workplace learning experiences. 

Journal of Interprofessional Care, 28(3), 206-211. Weblink 

Clementz, L., Dolansky, M.A., Lawrence, R.H., Rusterholtz, A., Singh S., Heilman, A., Singh, M. (2015, 

April). Dyad teams: Interprofessional Collaboration and Learning in Ambulatory Setting. Poster 

session presented at the 38th Annual Meeting of the Society of General Internal Medicine, Toronto, 

Canada. Weblink 

Lawrence, R.H., Dolansky, M. A., Clementz, L., Rusterholtz, A., Singh, S., Heilman, A., Singh, M. K. 

(2014). Dyad teams: Collaboration and learning in the ambulatory care setting. Poster session 

presented at the AAMC meeting, Innovations in Academic Medicine, Chicago, IL, November, 7-11. 

Pangaro, L. (1999). A new vocabulary and other innovations for improving descriptive in-training 

evaluations. Academic Medicine, 74(11), 1203-1207. Weblink 

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Singh, M., Clementz, L., Dolansky, M. A., Lawrence, R.H., Rusterholtz, A., Sparks, M., Singh S. (2015, 

August 27). MD-NP Learning Dyad Model: An Innovative Approach to Interprofessional Teaching and 

Learning. Workshop presented at the Annual Meeting of the Midwest Society of General Internal 

Medicine, Cleveland, Ohio. 

Tham, K.Y. (2013). Observer-Reporter-Interpreter-Manager-Educator (O-RIME) Framework to Guide 

Formative Assessment of Medical Students. Annals Academy of Medicine Singapore, 42(11), 603­

607. Weblink 

Tolsgaard, M.G., Bjorck, S., Rasmussen, M.B., Gustafsson, A., Ringsted, C. (2013). Improving efficiency 

of clinical skills training: A randomized trial. Journal of General Internal Medicine, 28(8), 1072-1077. 

Weblink 

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CASE STUDY #3: HUDDLING FOR HIGH PERFORMING TEAMS 

San Francisco VA Health Care System: Center of Excellence in Primary 

Care Education (CoEPCE) Interprofessional Academic Patient Aligned Care 

Team (iAPACT) 

Prepared by: Annette L. Gardner, PhD, MPH with San Francisco CoEPCE: Rebecca Shunk, MD; Maya 

Dulay, MD; Anna Strewler, MS, AGNP-BC; and Bridget O’Brien, PhD; 

Academic Partner: University of California at San Francisco Schools of Medicine and Nursing 

Key Theme of the Innovation: Improving education and patient care through refining team 

communication and strategies related to team role and function. 

Goals: 

- Daily interprofessional communication team “huddle” supporting relationship building, 

coordination needs, scheduling, case management and chronic disease management 

- Practice partnerships, coordinated care and 

sustained relationships in shared patient 

panels 

- Weekly didactics and faculty development 

Trainees: Physician residents, nurse practitioner 

students and/or nurse practitioner residents, 

psychology fellow, pharmacy resident, and/or a 

social work intern 

Faculty and/or Staff: Physician and/or Nurse 

Practitioner, Licensed Vocational Nurse, Medical San Francisco EdPACT/CoEPCE Huddle 

Support Assistant and Registered Nurse Care 

Manager 

32
 
 

 

 

 


 

SUMMARY 

This case study describes team huddles in the San Francisco Veterans Affairs Medical Center (SFVA) 

Education for Patient Aligned Care Teams (EdPACT) Center of Excellence in Primary Care Education 

(CoEPCE or CoE), which combines interprofessional education and team-based primary care in VA 

clinics. In these 15 minute huddles, trainees and PACT teamlets 10meet to: discuss the day’s patients, 

coordinate care for a shared panel of patients, and identify ways to improve team processes. Faculty 

members attend the huddles as coaches to guide and reinforce collaborative practice and continuous 

improvement. In addition to training learners from different professions to collaboratively provide 

team-based, patient-centered care, team huddles strengthen communication in the clinic and support 

sustained relationships among providers and patients. 

INTRODUCTION 

In 2011, five VA Medical Centers were selected by VA’s Office of Academic Affiliations (OAA) to 

establish Centers of Excellence in Primary Care Education (CoEPCE). Part of the VA's New Models of 

Care initiative, the five CoEPCE’s (Boise, Cleveland, San Francisco, Seattle and West Haven) are utilizing 

VA primary care settings to develop and test innovative approaches to prepare physician residents, 

nurse practitioner students and residents (post-graduate) and other health professions trainees (such 

as pharmacy, social work, psychology, physician assistants, dieticians, etc) for primary care practice and 

leadership in the 21st Century. The CoEPCE’s are interprofessional Academic PACTs (iAPACTs) defined 

by VA as a PACT that has at least two or more professions of trainees engaged in learning on the PACT 

team. This model is VA’s preferred method for teaching and learning in Primary Care. 

The CoEPCE’s are developing, implementing and evaluating curricula within 4 core domains (Table 1) 

designed to prepare learners to practice in primary care settings that are patient-centered, 

interprofessional, and team-based. 

The SFVA EdPACT/CoEPCE developed and implemented a workplace learning model, which embeds 

trainees into PACT teamlets and clinic workflow. Trainees are organized in practice partner triads with 

two second or third year internal medicine residents (R2s and R3s) and one nurse practitioner student 

or resident. Physician residents rotate every two months between inpatient and outpatient settings 

and nurse practitioner trainees are present continuously for 12 months. In this model, each trainee in 

the triad has his/her own patient panel and also serves as a partner who delivers care to his/her 

partners’ patients when they are unavailable. Didactic sessions on clinical content and on topics 

10 A teamlet is the subset of staff to which one entire panel of patients is assigned. VA 2014 Patient Aligned Care Team 

(PACT) Handbook. 

33
 
 

 

 

 

 

 


 

related to the core domains occur three times a week during pre- and post-clinic conferences (Rugen 

et al., 2014). 

Table 1: CoEPCE Core Domains 

Shared Decision-Making (SDM): Care is aligned with the values, preferences and cultural 

perspectives of the patient. Curricula focus is on communication skills necessary to promote 

patient’s self-efficacy. 

Sustained Relationships (SR): Care is designated to promote continuity of care; curricula focus on 

longitudinal learning relationships. 

Interprofessional Collaboration (IPC): Care is team based, efficient and coordinated, curricula focus 

is on developing trustful, collaborative relationships. 

Performance Improvement (PI): Care is designed to optimize the health of populations; curricula 

focus on using the methodology of continuous improvement in redesigning care to achieve quality 

outcomes. 

METHODS 

In 2015, evaluators from VA’s Office of Academic Affiliations reviewed background documents and 

conducted open-ended interviews with nine CoE staff, participating trainees, VA faculty, VA facility 

leadership, and affiliate faculty. Informants described their involvement, challenges encountered, and 

benefits of the huddle to participants, Veterans, and the VA. 

THE ISSUE: PROVIDING CLINICALLY-BASED APPROACHES TO INTERPROFESSIONAL EDUCATION 

With the emphasis on patient-centered medical homes (PCMH) and team-based care in the Affordable 

Care Act, there is an urgent need to develop new training models that provide future health 

professionals with skills that support interprofessional communication and collaborative practice 

(Chang et al., 2013; Zabar 2016). 

PROMISING SOLUTION: THE HUDDLE 

A key aim of the CoEPCE is to expand workplace learning strategies and clinical opportunities for 

interprofessional trainees to work together as a team to anticipate and address the health care needs 

of Veterans. Research suggests that patient care improves when team members develop a shared 

understanding of each other’s skill sets, care procedures, and values (IOM 2015). In 2010, the SFVA 

began phasing in VA-mandated Patient-Aligned Care Teams (PACTs). Each PACT teamlet serves 

approximately 1,200 patients and is comprised of Primary Care Provider(s) (physician or nurse 

practitioner) and a registered nurse (RN) care manager, a licensed vocational nurse (LVN), and a 

medical support assistant (MSA). Approximately every three teamlets also works with a ‘profession 

specific team member’ from Social Work and Pharmacy. The implementation of PACT created an 

opportunity for the CoEPCE to add trainees of various professions to 13 preexisting PACTs in three 

SFVA primary care clinics. This arrangement benefits both trainees and teamlets: trainees learn how to 

34
 
 

 

 

 

 


 

collaborate with clinic staff while the clinic PACT teamlets benefit from coaching by faculty skilled in 

team-based care. 

A Typical Center Team Huddle: The team members gather for 15 minutes at the beginning of the 

clinic day to huddle. Huddle team members include a faculty huddle coach, a trainee dyad (one of 

two internal medicine resident practice partners and one nurse practitioner student or resident), a 

psychology fellow, a pharmacy resident, and/or a social work intern, an LVN who communicates with 

patients in advance of their visit (such as if they need to go to the lab) an MSA who schedules or 

reschedules appointments and provides administrative support, and an RN Care Manager who 

provides case management and chronic disease management for the patients in the panel. The team 

typically meets in the nurse practitioner trainee’s exam room, with the nurse practitioner trainee 

seated at his/her computer. The patient charts have been reviewed beforehand and trainees are 

usually familiar with the patient and come ready to discuss specific items. The team checks in 

personally with each other about issues for the day and upcoming absences. Next the LVN will 

present the cases for the day including reports from pre-visit calls to patients and the group will 

discuss any concerns about specific patients or care coordination issues. The trainees and/or RN Care 

Manager discuss patients who are scheduled in upcoming weeks and patients who need care outside 

a scheduled visit. Alternative care options may be discussed, such as shifting patients to a telephone 

clinic or connecting the patient to resources such as housing. Hospitalized patients or recently 

discharged patients are discussed with the RN Care Manager, who has been following them closely. 

Administrative issues, such as appointments and scheduling may be discussed, as well as clinic-wide 

changes. Participants are encouraged to give feedback to team members and comment on the 

huddle (citing examples such as uneven team member participation). 

As part of routine clinical activities, huddles provide opportunities for workplace learning related to 

coordination of care, building relationships, and developing a sense of camaraderie that is essential for 

team-based, patient-centered care. In their ideal state, huddles are “...the hub of interprofessional, 

team-based care”; they provide a venue where trainees can learn communication skills, team member 

roles, systems issues and resources, and clinical knowledge expected of full-time providers and staff 

(Shunk et al., 2014). Embedding faculty in huddles as huddle coaches helps ensure trainees are learning 

and applying these skills. 

PLANNING AND IMPLEMENTATION 

After OAA funded the CoEPCE in 2011, faculty had six months to develop the EdPACT curriculum, which 

included a team building retreat, interactive didactic sessions, and workplace learning activities (i.e. 

huddles). 

In July 2011, ten trainee triads (each consisting of two physician residents, and either a nurse 

practitioner student or nurse practitioner resident) were added to preexisting PACTs at the San 

Francisco VA Medical Center primary care clinic and two community-based outpatient clinics. These 

35
 
 

 

 

	 


 

trainee triads partnered with their PACT teamlets and huddled for 15-minutes at the beginning of each 

clinic day to plan for the day’s patients and future scheduled patients and to coordinate care needs for 

their panel of patients. CoEPCE staff built on this basic huddle model and made the following lasting 

modifications: 

•	 Developed and implemented a huddle coach model and a huddle checklist to provide structure 

and feedback to the huddle 

(http://www.va.gov/oaa/CoePCE/docs/Huddle_Checklist_for_EdPACT_Trainees.pdf ) 

• Scheduled huddles in nurse practitioner student/resident’s exam room to reduce the hierarchy 

in the trainee triad. 

• Incorporated trainees from other professions and levels into the huddle (psychology fellows, 

pharmacy residents, social work) 

• Linked the PACT teamlet (staff) to quality improvement projects that are discussed periodically 

in huddles and didactics 

“It is through these relationships, the ability to give each other feedback directly, to debrief 

situations that have happened, and to learn to trust and know how to best communicate with each 

other, that leads to higher quality work throughout the rest of the week...it can bring more 

meaning to the work of the whole clinic and all the staff in our clinic” 

CoE Faculty 

Curriculum 

The huddle allows for practical application of the four core domains: Interprofessional Collaboration 

(IPC), Performance Improvement (PI) Sustained Relationships (SR), and Shared Decision Making (SDM) 

that shape the CoE curriculum. Interprofessional collaboration (IPC) is the primary domain reinforced 

in the huddle. Trainees learn key content in half-day team retreats held at the beginning of the 

academic year and in interactive didactic sessions. These sessions, which draw on concepts from 

TeamSTEPPS®, an evidence-based teamwork training program for health care workers, teach skills like 

closed-loop communication, check-backs, negotiation and conflict resolution. CoE trainee triads also 

lead quality improvement (QI) projects and the huddle is a venue for getting input, which reinforces 

the CoE’s performance improvement (PI) curriculum. For example, PACT teamlet staff members 

provide trainees with feedback on proposed QI interventions, such as increasing the use of telephone 

visits. The huddle supports sustained relationships (SR) among team members that enhance patient 

care while improving the quality of the clinic experience for team members. Strengthened 

communications and increased understanding of team member roles and system resources supports a 

patient-centered approach to care and lays the foundation for shared decision making (SDM) between 

patients and team members. 

36
 
 

 

 

 

 

 


 

“...kind of stepping back, it’s not only about prescribing the treatment, it’s also about the quality of 

life at work and making sure we’re all supporting each other and making the day less stressful so we 

can be better people for our patients...” 

RN Care Manager 

Faculty Roles and Development 

“They (nurse practitioner students) feel supported. They get to know the roles and responsibilities of 

other people on the team. They have a better appreciation of who to go to with certain types of 

questions so that they can quickly triage problems, issues and concerns based on knowing the 

different players’ key roles and responsibilities. They come to appreciate, over time, how the huddle 

does level the power of hierarchy instead of it being a pyramid: that at least slowly, over time, it 

starts to feel more of a horizontal type of structure.” 

CoEPCE Affiliate Representative 

CoEPCE physician and nurse practitioner faculty members who precept and function as huddle coaches 

participate in monthly two-hour faculty development sessions to address topics related to IPE. At least 

one session each year covers review of the items on the huddle checklist, tips on how to coach a 

huddle, discussions of the role of huddle coaches, and feedback and mentoring skills. Many huddle 

coach activities are inherent to clinical precepting, such as identifying appropriate clinical resources, 

answering clinical questions, etc., but the core function of the huddle coach is to facilitate effective 

communication among team members. 

Initially, a coach may guide the huddle by rounding up team members or directing the agenda of the 

huddle (i.e. prompting the LVN to present the day’s patients and suggesting the group identify and 

discuss high-risk patients). As the year progresses, coaches often take a back seat and the huddle may 

be facilitated by the trainees, the RN, LVN, or a combination of all members. During the huddle, 

coaches may also reinforce specific communication skills such as a ‘check back’ or ISBAR (Identify who 

you are, describe the Situation, provide Background information, offer an Assessment of the 

situation/needs, make a Recommendation or Request)—skills that are taught during CoE didactic 

sessions. The coach may call attention to particular feedback points, such as clarification of the order 

as an excellent example of a check-back. Each preceptor coaches one huddle per precepting session. 

After the teams huddle, preceptors do a smaller, shorter huddle in the precepting room to share 

successes, such as interprofessional trainees demonstrating backup behavior (e.g., “in today's huddle, I 

saw a great example of back-up behavior when the medicine resident offered to show the NP student 

how to consent someone" and discuss challenges (e.g., getting all team members to the huddle). 

Resources 

CoE staff schedule at least 20 huddles per week and coordinate preceptor and room schedules. The 

other required resources are clinic staff (RNs, LVNs, and MSAs) and exam rooms large enough to 

accommodate eight or more people. Sufficient staffing coverage and staggered huddles are also 

37
 
 

 

 

 

 

 

 

 


 

important to allow cross-coverage for other clinical duties while team members and faculty are 

huddling. 

Monitoring and Assessment 

CoE staff administer the Team Development Measure (TDM) (Stock et al., 2013) two times per year 

and a modified version of the TEAM 360 feedback survey (ABIM; Chesluk et al., 2012) once per year. 

The TDM member gages perceptions of team functioning (cohesiveness, communication, role clarity, 

and clarity of goals and means). Teams meet with a facilitator to debrief their TDM results and discuss 

ways to improve their team processes. Three-quarters of the way through the academic year, team 

members also complete the modified TEAM 360 survey on trainees. Each trainee receives a report 

describing his/her self-ratings and aggregate team member ratings on leadership, communication, 

interpersonal skills, and feedback. 

PARTNERSHIPS 

In addition to CoEPCE staff and faculty support and engagement, huddles at SFVA have benefited from 

partnerships with VA primary care leadership and with academic affiliates. In particular, support from 

the VA clinic directors and nurse managers was key to instituting changes to the clinics’ structure to 

include interprofessional trainees in huddles. 

The affiliates—the University of California, San Francisco (UCSF) School of Medicine and School of 

Nursing—are integral partners and assist with nurse practitioner student and medicine resident 

recruitment. These affiliates also participate in planning and refinement of CoEPCE curricular activities. 

The UCSF School of Nursing, School of Medicine, and Center for Faculty Educators were involved in the 

planning stages of the huddle model. 

CHALLENGES AND SOLUTIONS 

Having a staffing ratio that supports trainee participation in and learning through huddles is critical. 

Preceptor coverage must be in sufficient numbers to allow preceptors to coach the huddles and clinical 

staff must be adequate to create cohesive and consistent teams for trainee providers. Clinic staff 

turnover and changes in teamlet staff can be very disruptive. Over time, teamlet staff often know key 

details and helpful contextual information about particular patients and clinic processes. This 

knowledge may be lost with turnover among teamlet staff. If team members miss huddles due to 

staffing shortages and clinical duties, there may be delays and errors in patient care. An example is if 

information discussed in the huddle is not relayed back to the absent team member in a timely or 

accurate manner, care is impacted. However, potential disruptions can be mitigated by a high 

functioning team with strong communication skills and situational awareness who readily assist and 

distribute the workload. Consistent huddling, huddle coaches and checklists all help stabilize the group. 

Integration of trainees in the PACT team initially requires extra work because trainees are part-time 

and have panels significantly smaller than 1200 (which means the teamlet staff are assigned to 

multiple trainee and provider huddles). However, teamlet staff find working with trainee teams 

personally rewarding and developing highly functioning teams helps prevent burnout. Integration of 

38
 
 

 

 

 

 

 


 

trainees from pharmacy, psychology, and social work takes time and thoughtful planning of activities 

and contributions that enhance team functioning while not overburdening trainees with additional 

responsibilities. If these other professions of health trainees are joining several teams’ huddles, their 

role may be to weigh in as needed versus preparing for and reviewing several PCPs’ schedules and 

patients in advance. 

FACTORS FOR SUCCESS 

“I firmly believe that these (huddles) are the best way to do IP education and training because they’re 

realistic, authentic activities that hopefully add value to patient care and to clinic experiences for 

trainees.” 

CoEPCE Faculty 

VA facility and primary care clinic leadership’s commitment to supporting staff participation in huddles 

was critical for integrating trainees into PACTs. Additionally, VA facility commitment to implementation 

of PACT was a key facilitating factor. Implementation of PACT, including huddles, has not been 

consistent at all VA facilities (Rodriguez et al., 2015). The CoE’s approach to integrating trainees into 

the huddle was an opportunity to strengthen the huddle and to teach new staff members how to 

participate with team members in huddles. CoEPCE leadership, which has embraced change, meets 

regularly with facility leadership as well as an advisory board of UCSF leaders to update them on CoE 

activities. A critical factor for success was the CoE’s expertise in interprofessional education and its 

ability to integrate concepts from the four core domains into an effective workplace learning 

experience, including attention to the physical space, scheduling, and the development and 

implementation of the huddle coach role and checklist. 

ACCOMPLISMENTS AND BENEFITS 

There is evidence that team huddles at SFVA are achieving their goals and CoE trainees are being 

trained to provide team-based, patient-centered care to Veterans. Key outcomes of the CoE’s 

approach to huddles include components in the next sections. 

Interprofessional Educational Capacity 

“So I think the benefits for the trainees are what kind of feedback you have for them. And I guess 

whatever issues that you can bring to them about clarifying what they want, like what they’re 

instructing you to do, and I think definitely they know my roles a little bit more.” 

Clinic MSA 

CoEPCE faculty and staff consider the huddle to be one of the best ways to teach interprofessional 

communication and collaboration, team functioning and clinical performance. Unlike a traditional 

didactic, classroom-based session on interprofessional collaboration, the huddle is an opportunity for 

health care professionals to work together to provide care in a clinic setting. It is also an activity in 

which the Coe has continued innovative activities such as adding a preceptor huddle, incorporating 

39
 
 

 

 

 

 

 

 

 


 

additional professions, and encouraging panel management activities during huddles. The CoE has 

received significant interest and visibility and has been invited to share the model in numerous 

presentations. 

Participants’ Knowledge, Attitudes, Skills, and Competencies 

One aim of the CoE’s approach to huddles was to provide trainees with general skills in the core domain 

interprofessional collaboration, including teamwork and communication that transfer to other settings 

such as inpatient teams and specialty clinics. Learning about other professions and their scopes of 

practice and areas of expertise can be helpful beyond huddles and primary care. (See below) Trainees 

also learn concepts and practices from the other three core domains: 

• Performance Improvement: The huddle is a venue for utilizing clinic metrics as well as focusing 

on quality improvement projects that benefit from a team approach to solving problems; 

• Sustained Relationships: The huddles support and teach the importance of relationships among 

the team. Trainees learn about the roles of clinic staff members and clinic staff have more 

opportunities to interact with trainees and become comfortable with them, supporting 

coordinated care; and 

• Shared Decision Making: The huddle is a venue for discussing options for providing patient 

decision-making support, such as discussing the pros and cons of colon cancer screening with a 

patient, improving patient-centered care. 

”So now in San Bruno I’m still a provider on that panel and so just as we were modeling out there, a lot 

of checking in on patients for today, looking forward to next week, as well as talking about high risk 

patients. I’m also the huddle coach for that huddle so some of it is doing naming when a good teachback 

happens, the more process goals of the huddle. And then in my medical practice huddles I’m the 

provider and there actually is no huddle coach and we get done what we need to get done. We do a lot 

of panel management though, like looking at clinic metrics. And then in the intern huddle, I act a little 

bit like a huddle coach because they’re so new to the clinic and the huddle.” 

Nurse practitioner resident 

Additionally, huddles can address differences in trainee clinical expertise. For example, new physician 

interns with less experience in the clinic receive more coaching on system resources and patient 

histories than they might otherwise. Nurse practitioner residents often participate in more than one 

huddle team and transition to a coaching role. 

Sustained Relationships, Role Clarity and Collaboration 

The huddles are structured to facilitate sustained relationships among trainees from different 

professions and among the PACT teamlet in detail as a team. 

The huddle increases team efficiency by educating trainees and staff about team member roles. For 

example, trainees learn how the LVNs and MSAs prepare for patient visits. Moreover, an opportunity 

40
 
 

 

 

 


 

exists to learn how provider and clinic staff expertise may overlap. RN Care Managers, who have their 

own hypertension clinics, can help manage a patient’s medication titration. Similarly, pharmacy 

trainees can suggest a referral for a complicated diabetic to pharmacy clinic, where clinical pharmacists 

can adjust medications and provide patient education for hypertension, hyperlipidemia and 

hyperglycemia. In this way, role clarity is improved and trainees learn how team members work within 

their scope of practice and are better able to ‘share the care.’ 

There is evidence that huddles have resulted in expanded participant interprofessional collaboration. 

The CoE administers the Team Development Measure, a 31-item survey developed by Peace Health 

(Stock et al., 2016), twice a year and the huddle teams rate themselves on several dimensions— 

cohesiveness, communications, role clarity, and goals. The 2011/12 findings showed that nearly all 

teams showed improvement, with the mean scores for all teams combined increasing from 59.4 in the 

fall to 64.6 in the spring (max score is 100). (Shunk et al., 2014) These scores increased again from 62.2 

to 70.3 in 2012/13; from 66.6 to 70.2 in 2013/14, and from 64.6 to 69.9 in 2014/15. 

Expanding Clinical Knowledge 

“I think being a health care provider we learn a lot about how to take care of patients. But especially 

in medical school, you’re training in school, we’re not trained how to be administrators as much or 

leaders or how to run an organization or how to run a team. So I think the training and learning how 

to manage a staff, and then really managing up to the attending is a very important skill that I 

certainly didn’t come in to the residency with, but I think I’m going to leave with. And I think these 

skills are highly transferable for people who aren’t going in to primary care, especially physicians. 

Because even if you don’t stay in primary care, most health care and subspecialties is still delivered in 

an ambulatory setting.” Internal Medicine Resident, R2 

At the individual level, the huddle is an opportunity for a trainees to expand their clinical expertise in 

real-time. The huddle provides exposure to a variety of patients and corresponding patient care needs. 

Trainees are encouraged to complete patient pre-rounds before the huddle in order to focus the huddle 

discussion on patients with chronic conditions, complex needs, recent hospitalizations, and upcoming 

appointments. CoEPCE trainees tap into the expertise and experience of their team members and 

coach. The clinic staff can get information from trainees about their plan of care while trainees get a 

41
 
 

 

 

 

 

 

 

 


 

more complete picture of a patient’s situation—for example, medical or social history or 

communication preferences. Additionally, trainees learn team skills such as communication techniques 

and warm handoffs11, which can be used in other clinical settings outside primary care and beyond the 

VA. As trainees advance, the huddle helps them learn to delegate appropriately, practice conflict 

negotiation and develop leadership skills. 

Participants’ Satisfaction with Interventions 

There is qualitative evidence that clinic RNs and LVNs like huddles and appreciate having the 

opportunity to communicate in-person with providers as well as to teach trainees how to work 

interprofessionally. Faculty members who are huddle coaches report that they develop a richer 

understanding of the skillset of trainees, information that can inform CoE curriculum design. Trainees 

appreciate the opportunity to develop relationships with team members. In end of year interviews, 

they describe their teams as their families, making them feel more connected to the clinic. They also 

enjoyed starting their day with familiar faces. 

Primary Care Delivery System 

The huddle is an important component of a system-wide transformation to provide team-based, 

patient-centered care to Veterans. The CoE’s efforts to strengthen and standardize the huddle have the 

potential to hasten this transformation while improving relationships and quality of care. Additionally, 

the CoE’s approach to integrating trainees into huddles has broader applicability and is being 

considered for adoption by other VA Centers of Excellence in Primary Care Education. 

Primary Care Services 

The huddle may contribute to efficiencies in a busy clinic setting. For example, the RN Care Manager 

can have upwards of 1,200 patients on his/her panel and, between staff and trainees, as many as 12 

providers with whom to communicate. The huddle strengthens the communications with providers 

and is an opportunity to touch base on the patients, coordinate care, and keep track of high-risk 

patients who might fall off the radar otherwise. The huddle is flexible and can occur with various clinic 

staff and providers. A two-person huddle can occur between an RN and the primary provider. QI 

11 A warm handoff is often described as an intervention in which: “a clinician directly introduces a patient to another 

clinician at the time of the patient’s visit, and often a brief encounter between the patient and the health care professional 

occurs. (Cohen et al., 2015). At SFVA, warm handoffs often begin in huddles with a medicine resident or NP student 

discussing a patient with a psychology fellow and arranging a time for the psychology fellow to join the patient's visit. 

42
 
 

 

 

	 

	 

	 

	 


 

projects that have been developed as a result of a huddle have improved clinic primary care services, 

such as completing opiate consents and urine toxicology or improving continuity through increased 

telephone clinic usage. 

“I definitely think there is a lot of communication that’s done and definitely a lot of patient care 

that’s a bit more improved because you get to review the patients like if they need to come in or if 

they don’t need to come in. You know, just resolve some problems that you may have questions 

about. And then you resolve it during the huddles so you can talk to them in person about it.” 

Clinic Staff Member 

Patient Outcomes 

The huddle results in a more robust plan of care than might be developed by an individual provider 

who might not have time to consider options outside the individual’s scope of practice or expertise. 

While there are few clinical outcomes that are directly influenced by huddles alone, huddles may help 

indirectly improve patient outcomes on many fronts, including: 

•	 Increased continuity of care because the patient now has a team focusing on care. At times 

throughout the day when team members cannot talk face to face with one another or with the 

patient, they know about the patient’s situation and are better able to establish a rapport when 

the patient calls or comes in for the visit. Trainees also become familiar with their practice 

partners’ patients, which allows them to ensure continuity when the patient’s primary trainee 

provider is out of clinic; 

•	 Panel management and identifying and tracking sicker patients; 

•	 Increased access, such as identifying patients who could receive care by a telephone visit, 

decreasing the number of no shows by making extra efforts to remind patients about 

appointments and improving follow up; and 

•	 Improved population health outcomes from process improvements, such as the development 

of a process for having opioid patients sign new contracts or identifying diabetics who might 

benefit from a group approach to care. 

THE FUTURE 

The huddle coach concept and checklist have been shared broadly and have applicability in other 

teaching settings where providers and clinic staff are learning how to implement huddles. A video and 

resources on “How to Huddle” are available at http://suzannecgordon.com/how-to-huddle/. 

Under Stage 2 of the CoEPCE program, the CoE will develop a Huddle Coaching Program 

Implementation Kit comprised of a Huddle ‘”How-To” Guide and a Coach training manual. The CoE 

team huddle is one of many VA huddles and an example of how the huddle continues to evolve. It is a 

versatile tool that can be used to focus on different topics and include different professions. Currently, 

it is being adapted to specialty care where there is large patient volume, such as cardiology and 

orthopedics. 

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____________________________________________________________________________________ 

 

 

 

 

 

 


 


 


 

CONTACT INFORMATION 

San Francisco VA Health Care System 

For more information: 

Rebecca Shunk, MD 

Co-Director, San Francisco VA Center of Excellence in Primary Care Education 

Associate Chief of Staff for Education, San Francisco VA Health Care System 

Associate Professor, Department of Medicine, University of California, 

San Francisco 

Email: Rebecca.Shunk@va.gov 

Bridget O’Brien, PhD 

Director of Evaluation and Scholarship, San Francisco VA Center of Excellence in Primary Care 

Education 

Associate Professor, Department of Medicine, University of California, San Francisco 

Email: bridget.obrien@ucsf.edu 

RESOURCES
 

National VA CoEPCE Websites: http://www.va.gov/oaa/coepce/ 

National VA APACT Website, Publications, Executive Briefing Videos: VA OAA Academic PACT website 

San Francisco CoEPCE web and video: http://www.va.gov/oaa/coepce/sanfrancisco.asp 

Huddle Checklist: http://www.va.gov/oaa/CoePCE/docs/Huddle_Checklist_for_EdPACT_Trainees.pdf 

WORKS CITED
 

Agency for Healthcare Research and Quality (2016). Teamstepps. Strategies and tools to enhance 

performance and patient safety. Retrieved February 19, 2015 from https://teamstepps.ahrq.gov . 

American Board of Internal Medicine (ABIM). (n.d.) Teamwork Effectiveness Assessment Module. 

Retrieved August 31, 2016 https://team.abim.org/ . 

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Chang A., Bowen J.L., Buranosky, R.A., Frankel, R.M., Ghosh, N., Rosenblum, M.J., Thompson, S., Reen, 

M.L. (2013). Transforming primary care training--patient-centered medical home entrustable 

professional activities for internal medicine residents. Journal General Internal Medicine. 

28(6):801-9. Weblink 

Chesluk B.J., Bernabeo, E., Hess, B., Lynn, L.A., Reddy, S., Holmboe, E.S. (2012). A new tool to give 

hospitalists feedback to improve interprofessional teamwork and advance patient care. Health 

Affairs. 31(11): 2485-2492. Weblink 

Institute of Medicine at the National Academies (2015). Measuring The Impact Of Interprofessional 

Education (IPE) On Collaborative Practice And Patient Outcomes. Washington, D.C.: The National 

Academies Press. Retrieved 2015 from http://iom.nationalacademies.org/Reports/2015/Impactof-IPE.aspx . 

Rodriguez H., Meredith L., Hamilton A., Yano E., Rubenstein L. (2015) Huddle up!: The adoption and use 

of structured team communication for VA medical home implementation. Health Care 

Management Review. 40(4):286-299. Weblink 

Rugen K., Watts, S., Janson, S, Angelo, L., Nash, M., Zapatka, S., Brienza, R., Gilman, S.C., Bowen, J.L., 

Saxe, J. (2014). Veteran Affairs Centers of Excellence in Primary Care Education: Transforming 

nurse practitioner education. Nursing Outlook. 62(2):78-88. Weblink 

Stock R., Mahoney E., Carney P. (2013). Measuring Team Development in Clinical Care Settings. Family 

Medicine. 45(10):691-700. Weblink 

Shunk R., Dulay M., Chou C., Janson S., O’Brien, B. (2014). Huddle-Coaching: A dynamic intervention 

for trainees and staff to support team-based care. Academic Medicine. 89(2):244-250. Weblink 

Zabar, S., Adams J., Kurland S., Shaker-Brown A., Porter B., Horlick M., Hanley, K., Altshuler, 

L. , Halet A., Gillespie C. (2016). Charting a key competency domain: understanding resident 

physician interprofessional collaboration skills. Journal General Internal Medicine. 31(8): 846-53. 

Weblink 

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CASE STUDY #4: PANEL MANAGEMENT MODEL 

VA Puget Sound Health Care System – Seattle Campus: Center of 

Excellence in Primary Care Education (CoEPCE) Interprofessional Academic 

Patient Aligned Care Team (iAPACT) 

Prepared by: Annette L. Gardner, PhD, MPH, with VA Puget Sound Health Care System at Seattle 

CoEPCE: Catherine P. Kaminetzky, MD, MPH, Anne P. Poppe, PhD, RN and Joyce E. Wipf, MD. 

Academic Partners: University of Washington Schools of Medicine and Nursing 

Key Theme of the Innovation: Use of panel management to address high-risk Veterans with chronic 

care needs and the assessment and management of these patients using population based data 

Goals: 

- Performance improvement 

- Interprofessional Collaboration 

- Chronic disease management 

Trainees: Doctor of nursing practice (DNP) 

students, nurse practitioner residents; internal 

medicine physician residents; postgraduate 

pharmacy residents and other health professions 

trainees 

Faculty and/or Staff: Chief Resident in medicine, 

clinical pharmacy specialists, an RN-Care Manager, 

social workers, nurse practitioners, internal 

medicine physicians residents and clinical 

psychologists 

Seattle CoEPCE Panel Management Session 

SUMMARY 

This case study describes the Seattle Center of Excellence in Primary Care Education Panel 

Management (PM) model, which combines interprofessional education, clinical or workplace learning 

and review of patient data to increase quality of care for Veterans. Center of Excellence in Primary Care 

Education trainees, faculty and clinic staff work collaboratively in a primary care setting to proactively 

provide team-based care to high-risk patients with unmet chronic care needs. The CoE’s PM model 

46
 
 

 

 

 

 

 


 

increases trainee knowledge, skills and performance in the care and management of populations by 

using data to identify appropriate care for individual patients within the trainee’s panel of patients. 

INTRODUCTION 

Table 1: CoEPCE Core Domains 

Shared Decision-Making (SDM): Care is aligned with the values, preferences and cultural 

perspectives of the patient. Curricula focus is on communication skills necessary to promote 

patient’s self-efficacy. 

Sustained Relationships (SR): Care is designated to promote continuity of care; curricula focus on 

longitudinal learning relationships. 

Interprofessional Collaboration (IPC): Care is team based, efficient and coordinated, curricula focus 

is on developing trustful, collaborative relationships. 

Performance Improvement (PI): Care is designed to optimize the health of populations; curricula 

focus on using the methodology of continuous improvement in redesigning care to achieve quality 

outcomes. 

In 2011, five Veterans Affairs (VA) Medical Centers were selected by VA’s Office of Academic 

Affiliations (OAA) to establish Centers of Excellence in Primary Care Education (CoEPCE or CoE’s). Part 

of VA's New Models of Care initiative, the five CoE’s (Boise, Cleveland, San Francisco, Seattle and West 

Haven) utilize VA primary care settings to develop and test innovative approaches to prepare physician 

residents, medical students, advanced practice nurses and undergraduate nursing students, and other 

health profession’s trainees, such as social workers, pharmacists, psychologists, physician assistants for 

primary care practice in the 21st Century. The CoEPCE’s are interprofessional Academic PACTs 

(iAPACTs) defined by VA as a PACT that has at least two or more professions of trainees engaged in 

learning on the PACT team. This model is VA’s preferred method for teaching and learning in Primary 

Care. The five CoE’s are developing, implementing, and evaluating curricula designed to prepare 

learners from relevant professions to practice in patient-centered, interprofessional team-based 

primary care settings. 

The VA Puget Sound Seattle CoEPCE curriculum is embedded in a well-established academic VA 

primary care training site. Trainees include doctor of nursing practice (DNP) students in adult, family 

and psychiatric mental health nurse practitioner programs; nurse practitioner residents; internal 

medicine physician residents; postgraduate pharmacy residents and other health professions trainees. 

A priority of the Seattle CoEPCE is to provide DNP students, DNP residents and physician residents with 

a longitudinal experience in team-based care as well as interprofessional education and collaborative 

practice (IPECP). Learners spend the majority of CoEPCE time in supervised, direct patient care, 

including primary care, women’s health, deployment health, homeless care, and home care. Formal 

IPECP activities comprise approximately 20% of time, supported by three educational strategies: 1) 

Panel management/quality improvement; 2) Team building/communications; and 3) Clinical content 

47
 
 

 


 

seminars to expand trainee clinical knowledge and skills and curriculum developed with the CoEPCE 

enterprise core domains in mind (Table 1). 

METHODS 

In 2015, evaluators from VA’s Office of Academic Affiliations CoEPCE Coordinating Center reviewed 

background documents describing Seattle’s panel management initiative and conducted ten openended interviews with CoEPCE staff, participating trainees, faculty, and affiliate leadership. Informants 

described their involvement, challenges encountered, and benefits of PM to participants, Veterans, the 

VA, and affiliates. 

THE ISSUE: ADDRESSING THE UNMET CARE NEEDS OF PATIENTS, IMPROVING POPULATION HEALTH 

Clinicians are increasingly being required to proactively optimize the health of an assigned population 

of patients, in addition to assessing and managing the health of individual patients presenting for care. 

This is an emerging competency that makes use of population data, team based care, evidence-based 

chronic care based on clinical data in electronic health records, and PI tools to effect improvements in 

care metrics. To address the twin objectives of increased accountability for population health 

outcomes and improved face-to-face care, the Seattle CoEPCE developed curriculum for trainees to 

learn panel management (PM), a set of tools and processes that can be applied in the primary care 

setting. 

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A Sample Panel Management Session: Reducing Low Acuity Visits to the Emergency Department 

Panel Management sessions are conducted 4 – 6 times a year and last two to three hours. They are held 

in a computer lab with 10 computer terminals and a large screen and projector and can readily 

accommodate 20 people. Usually participants include: 6-10 CoEPCE trainees and two to five clinical 

faculty, including clinical pharmacist, nurse practitioner, and/or physician, and occasionally RN care 

manager and other health professionals. The chronic care data for individual trainee patients is either 

pulled ahead of time by the CoEPCE data manager or is readily available through the VA Primary Care 

Almanac and is provided to trainees for the session. The CoEPCE faculty moderator starts the session 

with a review of PM and the goal of reviewing patient data as a team with the intent of improving 

patient care. There is a brief lecture on the session topic with an interactive session supported by 

CoEPCE faculty from diverse professions. Next, the participants discuss the causes of ED utilization, 

prioritize the causes for a chart analysis, then create a “Chart Biopsy Tool”. Trainees then, either alone 

or in pairs, review their panel data on two to five patients. CoEPCE faculty members float and assist on 

an as-needed basis. The group reconvenes and trainees present individual patients to the group, which 

explores management strategies and untapped resources to improve individual patients’ care. The 

CoEPCE clinical pharmacy faculty projects the electronic health record of each case on the screen, 

navigating chart information as the group discusses potential interventions. Trainees are encouraged to 

develop a treatment plan, write orders and notify team members of needed tasks. Additionally, a 

CoEPCE faculty member may track factors identified in discussion and plot results in a frequency graph. 

The group may also discuss themes of system processes and potential quality improvement. At the end, 

there is a session wrap up and trainees complete a session evaluation. 

PROMISING SOLUTION: PANEL MANAGEMENT 

In panel management clinical providers utilize data to proactively provide care to their patients 

between traditional clinic visits. PM clinical providers utilize data to proactively provide care to their 

patients between traditional clinic visits. The process is proactive in that gaps are identified regardless 

of whether an in-person visit occurs, and involves an outreach mechanism to increase continuity of 

care, such as follow-up communications with the patients (Neuwirth, Schmittdiel, Tallman, and Bellows 

2007). PM has also been associated with improvements in chronic disease care. (Loo, et al., 2011; 

Kanter, Martinez, Lindsay, Andrews, Denver, (2014); Kravetz, and Walsh (2016). 

The Seattle CoEPCE developed an interprofessional team approach to PM that teaches trainees about 

the tools and resources that can be used to close the gaps in care, including the use of clinical team 

members as healthcare systems subject matter experts. CoEPCE trainees are taught to analyze the care 

they provide to their panel of Veterans (e.g. identifying patients who have not refilled chronic 

medications or those who utilize the emergency room (ER) for non-acute conditions) and take action to 

improve care. PM yields rich discussions on systems resources and processes and is easily applied to a 

range of health conditions (e.g. diabetes, mental and behavioral health, and dermatology) as well as 

49
 
 

 

 


 

delivery system issues (e.g. ER utilization). PM gives learners the tools they can use to close these gaps, 

such as the expertise of their peers, clinical team and specialists. 

PLANNING AND IMPLEMENTATION 

In addition to completing a literature review to determine the state of PM practice and models, 

CoEPCE faculty polled recent graduates inquiring about strategies they did not learn prior to 

graduation. Based on their responses, CoEPCE faculty identified two skill deficits: management of 

chronic diseases and proficiency with data and statistics about performance improvement in panel 

patient care over time. Addressing these unmet needs became the impetus for developing curriculum 

for conducting panel management. Planning and launching the CoE’s approach to PM took 

approximately 3 months and involved CoE faculty, a data manager, and administrative support. The 

learning objectives of Seattle’s PM initiative are: 

- Promote preventive health and chronic disease care by utilizing performance data; 

- Develop individual- and population-focused action plans; 

- Work collaboratively, strategically and effectively with interprofessional care team; and 

- Learn how to effectively utilize system resources. 

Curriculum 

“It’s trying to marry the power of data and the power of relationships.” 

CoE Faculty Member 

The PM curriculum is a longitudinal, experiential approach to learning how to manage chronic diseases 

between visits by using data on patient measures. It is designed for trainees in a continuity clinic to 

review the care of their own patients on a regular basis. Seattle CoEPCE medicine residents are 

assigned patient panels, which increase from 70 patients in Year 1 to approximately 140 patients by 

the end of Year 3. Doctor of Nursing Practice (DNP) postgraduate trainees are assigned an initial panel 

of 50 patients that increases incrementally over the one year of residency. 

CoEPCE faculty determined the focus of PM sessions to be diabetes, hypertension, obesity, chronic 

opioid therapy, and low acuity ER utilization. Because PM sessions are designed to allow participants to 

identify systems issues that may affect multiple patients, some of these topics have expanded into 

quality improvement (QI) projects. 

Scheduling 

PM sessions run two to three hours per session, and are held four to six times a year. Each session is 

repeated twice to accommodate diverse trainee schedules. PM participants must have their patient 

visit time blocked for each session. 

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Faculty Roles and Development 

PM faculty involved in any individual session may include a combination of one of two CoEPCE clinical 

pharmacy specialists, an RN Care Manager, a social worker, a nurse practitioner, a physician, a clinical 

psychologist, and a medicine outpatient chief resident (PGY4, termed clinician-teacher fellow at Seattle 

VA). The chief resident is a medicine residency graduate, and takes on teaching responsibilities 

depending on the topic of the session. The CoEPCE clinical pharmacist role varies depending on the 

session topic: they may facilitate the session or provide recommendations for medication management 

for individual cases. Ideally, the RN Care manager would participate at every session since s/he often 

knows the patients and brings a unique perspective that complements that of the primary care 

providers. Because the patients of multiple RN Care Managers were presented at each session, it was 

not feasible to include all RN Care Managers in every session. However, immediately after case 

discussion, trainees often communicated with their RN Care Managers about the case, using instant 

messaging. In addition, CoEPCE provides other avenues for patient care discussion through huddles 

involving the provider, RN Care Manager, clinical pharmacist, and other clinical professions. 

Resources 

The primary resource required to support PM is an information technology (IT) system that provides 

relevant health outcome and health care utilization data on patients assigned to trainees. PM initially 

relied on data manager support to pull panel data for a given clinical measure for the session. With the 

increasing availability of chronic disease registry data in VA, this procedure has transitioned to 

developing toolkits to learn about resources for panel data. To promote this transition, PM sessions 

include teaching trainees how to access their own data. Since discussion about the care of panel 

patients during the learning sessions often results in real-time adjustments in the care plan, modest 

administrative support required post-PM sessions such as clerical scheduling of the requested clinic or 

telephone follow-up with the provider, nurse, or pharmacist 

Monitoring and Assessment 

PM participants’ panel performance are evaluated at each educational session. To assess the CoEPCE 

PM curriculum, participants provide feedback in eight questions over three domains: trainee 

perception of curriculum content, confidence in performing PM involving completion of a PM 

workshop, and likelihood of using PM techniques in the future. CoEPCE faculty use the feedback to 

improve their instruction of panel management skill and develop new sessions that target additional 

population groups. Evaluation of the curriculum also includes monitoring of panel patients’ chronic 

disease measures. 

PARTNERSHIPS 

Several partnerships have contributed to the success and integrations of PM into facility activities. 

First, having the Primary Care Clinic Director as a member of the CoEPCE faculty has encouraged the VA 

facility and CoEPCE clinic faculty and staff to operationalize and implement PM broadly, such as 

distributing data on a monthly basis to all clinic staff. Second, high facility staff interest outside the 

51
 
 

 

 

 

 


 

CoEPCE and primary care clinic has facilitated establishing communications outside the CoEPCE 

regarding clinic data. 

The Seattle CoE has further partnered with the other four CoEPCE’s on a multi-site Emergency 

Department (ED) utilization project that culminated in storyboard presentations by each site at the 

Institute of Healthcare Improvement National Conference in December 2014. Seattle’s initiative on 

panel management ED utilization curricula (low acuity high utilizers) revealed an unusual pattern or ED 

usage, which upon discussion with the other CoEPCE sites, was instrumental in the adoption of ED 

utilization as an all-site quality improvement project. 

CHALLENGES AND SOLUTIONS 

Addressing diverse trainee need 

Trainees at earlier academic levels often desire more instruction in clinical knowledge, such as 

treatment options for diabetes or goals of therapy in hypertension. In contrast, advanced trainees are 

able to review patient data, brainstorm and optimize solutions. Seattle CoEPCE balances these 

different learning needs via a flexible approach to the three-hour sessions. For example, advanced 

trainees progress from structured mini-lectures to informal sessions which train them to perform PM 

on their own. In addition, PM’s flexible design integrates trainees with diverse schedules, particularly 

among DNP students, DNP residents, pharmacy residents and physician residents. Some of this work 

falls on the RN care management team and administrative support staff. 

“The CoE constitutes a large majority of my clinician staff, as well as the trainees in our clinic, and so, 

the operations of that particular unit (CoE) are critical to, sort-of, how our nurses and larger PACT 

team function.” Clinic Director 

Competing priorities 

“...how helpful it was to hear from our pharmacist colleagues about what it was that they would 

recommend, and that was surprising to me. I think that in medical school, I hadn’t had that kind of 

cross-fertilization with colleagues, and so to have a little bit of what they had to offer so that I could 

be aware of that as a clinician and take advantage of that going forward. But I think that it changed 

the way that I’ve used the pharmacists on the hallways...” CoE Medicine Resident 

The demand for direct patient care points to the importance of indirect patient care activities like PM 

to demonstrate improved results. Managing chronic conditions and matching appropriate services and 

resources should improve clinical outcomes and efficiency long-term. In the interim, it is important to 

note that PM demonstrates the continuous aspect of clinical care, particularly for trainees who have 

strict guidelines defining “clinical care” for the experiences to count towards eligibility for licensure. 

Additionally, PM results in trainees who are making decisions with VA patients and are more efficiently 

providing and supporting patient care. Therefore, it is critical to secure important resources, such as 

provider time for conducting PM. 

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Health information technology (HIT) 

No single data system in VA covers the broad range of topics covered in the PM sessions, and not all 

trainees have their own assigned panels. For example, health professions students are not assigned a 

panel of patients. While they do not have access to panel data such as those generated by Primary 

Care Almanac in VSSC (a data source in VHA’s Support Service Center database), the Seattle CoEPCE 

data manager pulls a set of patient data from the students’ paired faculty preceptors’ panels for 

review. Thus they learn PM principles and strategies for improving patient care via PM as part of the 

unique VA longitudinal clinic experience and the opportunity to learn from a multi-disciplinary team 

that is not available at other clinical sites. Postgraduate nurse practitioner residents in VA CoEPCE 

training do have their own panels of patients and thus the ability to directly access their panel 

performance data. 

FACTORS FOR SUCCESS 

A key success factor includes CoEPCE facultys’ ability to develop and operationalize a panel 

management model that simultaneously aligns with the educational goals of an interprofessional 

education training program and supports VA adoption of the medical home or Patient-Aligned Care 

Teams (PACT). The CoEPCE contributes staff expertise in accessing and reporting patient data, 

accessing appropriate teaching space, managing panels of patients with chronic diseases and 

facilitating a team-based approach to care. Additionally, the CoEPCE brand is helpful for getting buy-in 

from the clinical and academic stakeholders necessary for moving PM forward. 

Co-locating CoEPCE trainees and faculty in the primary care clinic promote team identity around the 

RN Care Managers and facilitated communications with non-CoEPCE clinical teams that have trainees 

from other professions. RN Care Managers serve as the locus of high quality PM since they share 

patient panels with the trainees and already track admissions, ER visits, and numerous chronic health 

care metrics. RN Care Managers offer a level of insight into chronic disease that other providers may 

not possess, such as the specific details on medication adherence and side effects for that particular 

patient, as well as the medication side effects impacting that particular patient. RN Care Managers are 

able to teach about their team role and responsibilities, strengthening the model. 

“it’s just so nice to be able to hear how our colleagues use the resources here at the VA and to hear 

somebody who is a year ahead of me how he’s managed his patient—that I felt like I learned from that 

case. And we’re so busy as clinicians and we don’t get a lot of time to interact with each other and 

hear how each other is managing patients, especially the way our workroom is organized here.” 

CoE Medicine Resident 

ACCOMPLISHMENTS AND BENEFITS 

There is preliminary evidence that Seattle’s approach to PM is achieving its goals: trainees and faculty 

report that they are using team skills to provide patient-centered care and trainees are learning to 

work with data to strengthen their clinical skills in providing longitudinal care. Based on monthly clinic 

reports, more CoEPCE resident panels are meeting PACT chronic disease targets in blood pressure and 

53
 
 

 

 

 

 

 


 

diabetes than non-CoEPCE residents or overall Seattle primary care clinic performance. Results suggest 

that achievement of PM curriculum goals contributes to improvements in individual and populationwide patient care. 

PM curriculum contributes to trainee understanding of roles of PACT members to improve patient 

care. Preliminary clinic data on number of team member visits (e.g. nursing and pharmacy in addition 

to provider visits) are higher on CoEPCE teams than non-CoEPCE teams. 

Interprofessional Educational Capacity 

Panel management is an opportunity to expand CoEPCE interprofessional education capacity by: 

creating co-location of different trainee and faculty professions during the PM sessions; the sharing of 

data with trainees; sharing and reflecting on data strengthened communications between professions 

and within the PACT. The Seattle CoEPCE now has systems in place that allow the RN Care Manager to 

send notes to a physician and DNP resident and the resident is expected to respond. 

Participants’ Knowledge, Attitudes, Skills, and Competencies 

Seattle’s PM approach provides experience with analyzing panel data to improve care in an 

interprofessional team setting, which is an Accreditation Council for Graduate Medical Education 

(ACGME) requirement. 

CoEPCE staff have observed anecdotally that trainees who participate in the PM sessions become 

clinically proficient sooner than those who do not. It appears that PM participants develop earlier 

familiarity with finding information in VA’s Computerized Patient Record System (CPRS), writing orders, 

and linking patients to resources. For senior learners, PM is also an opportunity to strengthen their 

teaching skills. For example, as mentioned above, the chief residents play a pivotal role as co-teachers 

in the sessions. They also contribute to the design and implementation of new PM components, such 

as conducting a pilot of an abbreviated approach in session with non-CoEPCE internal medicine 

residents before teaching the method to other health profession learners in clinic. 

...CoE has helped accelerate this process of shifting providers from a reactive [who’s in clinic and what 

do I need to do for them based on what they’re telling me?] to a proactive approach where, [all right, 

when am I going to stop and think about all of the 15 patients I sent home in the last two weeks and 

how they are reacting to the changes we made or the treatment plans we talked about...] 

VA Facility Leader 

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Participants’ Interprofessional Collaboration (IPC) 

“I don’t know how you could ever function in primary care without approaching a patient with 

multiple resources; without a team based approach.” 

CoE DNP Student 

PM sessions are intentionally designed to improve communication among team members and foster a 

team approach to care. PM sessions provide an opportunity for trainees and clinician faculty to be 

together and learn about each profession’s perspectives. For example, medicine and DNP trainees learn 

early of the strong resource clinical pharmacist are to the team by prescribing and making medication 

adjustments within their scope of practice as well as make appropriate pharmacy referrals. 

Additionally, the registered nurse (RN) care manager and clinical pharmacy specialists who serve as 

faculty in the CoEPCE, provide pertinent information on individual patients, increasing integration with 

the PACT. Finally, there is anecdotal evidence that faculty are also learning more about 

interprofessional education and expanding their own skills. 

Participants’ Clinical Performance 

Participants—CoEPCE trainees, non-CoEPCE physician residents, and CoEPCE faculty—regularly receive 

patient data with which they can proactively develop or amend a treatment plan between visits. PM 

has resulted in improved data sharing with providers. Instead of once a year, providers and clinic staff 

now receive patient data monthly on chronic conditions, such as hypertension and diabetes, from the 

clinic director. In addition, advanced trainees and providers (medicine, nurse practitioner, and 

pharmacy) have taken the initiative to identify the problems and topics and pull their own data. 

Trainees on ambulatory rotations are expected to review their panel data at least one half-day per 

week. CoEPCE staff evaluate trainee likelihood to use PM and ability to identify patients who benefit 

from team-based care. The findings are promising, with trainees rating their likelihood and ability at 4.0 

or above on a 6-point interval rating scale. 

“PM or what I call accountable care is really more about stewardship, meaning this is a population for 

whom you are accountable to wellness and that means in many ways actually the person in front of 

you is less important because you have them and you can implement things. The real question is 

who’s not here and why and what’s happening to them because most of the things that impact their 

long-term outcomes are not things that happen in the hospital. It’s how they live their daily lives...” 

Clinic Director 

At the population-level of chronic disease management, preliminary evidence demonstrates that 

primary care clinic patient panels are increasingly within target for diabetes and blood pressure 

measures, as assessed by periodic clinical reports to providers. 

Participants’ Satisfaction with Interventions 

The CoEPCE collects data on trainee satisfaction with their PM experience after each teaching session 

and as trainees graduate from the program. Anecdotally, trainees report they would prefer earlier 

55
 
 

 

 

 

 

 


 

instruction on patient care data so that they could apply the techniques for management of their 

patient panels. Additionally, CoEPCE and non-CoEPCE trainees report satisfaction from being able to 

spend more time with a patient’s care beyond the clinic appointment, during PM sessions, and 

“actually taking care of their medical problems” (CoEPCE trainee) as part of the learning process. 

CoEPCE Functions 

The Seattle CoEPCE has demonstrated to facility leadership the value of teaching the utilization of data 

to improve team-based, patient and population care. PM is slated to continue under Stage 2 of the 

CoEPCE program. 

Primary Care Delivery System 

Some of the PM topics have resulted in systems-level improvements, such as reducing unnecessary use 

of the ER for non-acute conditions and better opioid prescription monitoring. Moreover, PM supports 

everyone working at the top of his/her professional capability. For example, the RN care manager has 

the impetus to do diabetes education with a particular patient. 

Primary Care Services 

Since CoEPCE began teaching PM, the Seattle primary care clinic has committed to the regular access 

and review of data, which encourages the alignment of standards of care for chronic disease 

management so that everyone is working toward the same benchmark goals. 

PM topics have spun off quality improvement (QI) projects resulting in new clinic processes and 

programs. Project examples include a process for managing wounds in primary care and a process to 

assure timely follow-up after an ED visit. Other areas for expansion include a follow-up QI project to 

reduce non-acute ER visits by patients on the homeless PACT panel and interventions for better 

management of care for women Veterans with mental health needs. PM has also “spilled over” to nonCoEPCE teams and to other clinic activities, such as strengthening huddles of team members 

specifically related to panel data and addressing selected patient cases between visits. Pharmacy 

residents and faculty are more involved in reviewing the panel before patients are seen, to review 

medication lists and identifying duplications. 

Patient Outcomes 

At the individual level, PM provide a mechanism to systemically review trainee panel patients with outof-target clinical measures, and develop new care approaches involving interprofessional strategies 

and problem-solving. PM also helps to identify patients who have missed follow-up, reducing the risk 

that patients with chronic care needs will be lost to clinical engagement if they are not reminded or do 

not pursue appointments. The PM trained PACT reaches out to patients with new care plans, who 

might not otherwise get care before the next clinic visit. Second, patients have the benefit of a team 

that manages their health needs. For example, including the clinical pharmacists in the PM sessions 

ensures timely identification of medication interactions and the potential side effects that a patient 

might experience. Additionally, PM contributes to the care coordination model by involving individuals 

on the primary care team who know the patient. These members review the patient’s data between 

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visits and initiate team-based changes to the care plan to improve care. More team members connect 

with a patient, resulting in more intense care and quicker follow-up to determine the effectiveness of a 

treatment plan. 

THE FUTURE 

Under Stage 2 of the CoEPCE program, the Seattle CoEPCE intends to lead in the creation of a panel 

management toolkit as well as a Data Access Guide that will allow VA facilities with limited data 

management expertise to access their chronic disease metrics. Second, the CoEPCE will continue its 

dissemination efforts locally to other residents in the internal medicine residency program in all of its 

continuity clinics. Additionally, there is high interest by DNP training programs to expand and export 

longitudinal training experience panel management curriculum to non-VA based students. 

CONTACT INFORMATION
 

VA Puget Sound Health Care System – Seattle Campus 

For more information contact: 

Catherine P. Kaminetzky, MD, MPH 

Acting Chief of Staff and Director, 

Center of Education and Development, 

VA Puget Sound Health Care System 

Assistant Professor of Medicine, University of Washington 

Email: Catherine.Kaminetzky@va.gov 

Anne P. Poppe, PhD, MN-APN, RN 

Associate Director for Assessment & Innovations, 

Seattle VA Center of Excellence in Primary Care Education and 

Consultant for Nursing Excellence, 

VA Puget Sound Health Care System 

Clinical Assistant Professor, School of Nursing, University of Washington 

Email: Anne.Poppe@va.gov 

Joyce E. Wipf, MD 

Director, Seattle VA Center of Excellence in Primary Care Education and Section Chief of General 

Internal Medicine, VA Puget Sound Health Care System 

Professor of Medicine, University of Washington 

Email: Joyce.Wipf@va.gov 

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RESOURCES
 

National VA CoEPCE Websites: http://www.va.gov/oaa/coepce/
 

National VA APACT Website, Publications, Executive Briefing Videos: VA OAA Academic PACT Website
 

Seattle CoEPCE Website: http://www.va.gov/oaa/coepce/seattle.asp
 

WORKS CITED
 

Kaminetzky C., Nelson, K., (2015). In the Office and In-Between: The Role of Panel Management in 

Primary Care. Journal of General Internal Medicine. 30(7):876-877. Weblink 

Loo, T.S., Davis, R.B., Lipsitz, L.A., Irish, J., Bates, C.K., Agarwal, K., Markson, L., Hamel, M.B. (2011). 

Electronic medical record reminders and panel management to improve primary care of elderly 

patients. Archives of internal medicine. 171(17):1552-1558. Weblink 

Kanter, M., Martinez, O., Lindsay, G., Andrews K., Denver, C. (2010).Proactive office encounter: a 

systematic approach to preventive and chronic care at every patient encounter. The Permanente 

Journal, 14(3):38. Weblink 

Kravetz, J.D., Walsh, R.F., (2016). Team-Based Hypertension Management to Improve Blood Pressure 

Control. J Prim Care Community Health 2016. Weblink 

Neuwirth, E., Schmittdiel, J., Tallman, K., Bellows, J. (2007). Understanding Panel Management (2007). 

A comparative study of an emerging approach to population care. The Permanente Journal. 11(3), 

12. Weblink 

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CASE STUDY #5: INITIATIVE TO MINIMIZE 

PHARMACEUTICAL RISK IN OLDER VETERANS (IMPROVE) 

POLYPHARMACY CLINIC 

West Haven VA Center of Excellence in Primary Care Education (CoEPCE) 

Interprofessional Academic Patient Aligned Care Team (iAPACT) 

Prepared by: Annette L. Gardner, PhD, MPH, with West Haven VA CoEPCE: John M. Thomas, MD; 

Marcia C. Mecca, MD; Anne Hyson, MD, MSc; Kristina M. Niehoff, PharmD, BCPS; Sean Jeffery, 

PharmD, GCP, FASCP, FNAP; John Sellinger, PhD; Rebecca Brienza, MD, MPH 

Academic Partners: Yale University Schools of Medicine and Nursing, Fairfield University School of 

Nursing, University of Connecticut School of Nursing and Medicine, Quinnipiac University School of 

Nursing 

SUMMARY 

Key Theme of the Innovation: Trainee-led performance improvement process that reduces 

polypharmacy in elderly Veterans and enhances trainee skills and knowledge related to safe 

prescribing. 

Goals: 

- Pre-Clinic Conferences 

- Trainee led/faculty supervised group and 

clinic visit 

- Comprehensive Medication Review 

- Shared decision making about medication 

tradeoffs in context of Veterans goals and 

preferences 

- Develop, execute and monitor 

prescribing and deprescribing plans 

Trainees: Medicine, Nursing, Pharmacy, 

Psychology and other trainees as available 

Faculty and/or Staff: Geriatric medicine 

faculty, pharmacy, primary care and psychology 

faculty 

West Haven CoEPCE IMPROVE Session 

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SUMMARY 

This case study describes the Initiative to Minimize Pharmaceutical Risk in Older Veterans (IMPROVE), 

an interprofessional polypharmacy clinic for intensive management of medication regimens of high-risk 

patients. This clinic is held monthly and involves internal medicine residents, nurse practitioner 

residents, pharmacy and health psychology trainees, and VA faculty working together to help older 

Veterans better manage their medications. Using a two-pronged approach—a 45-minute Group Visit 

and a 60-minute individual clinic visit—this trainee-led, faculty-supervised interprofessional education 

activity aims to increase trainee knowledge, skills, and performance in safe prescribing, strengthen 

interprofessional learning and team-based care, and reduce polypharmacy in elderly Veterans. 

INTRODUCTION 

In 2011, five VA Medical Centers were selected by the Office of Academic Affiliations (OAA) to establish 

Centers of Excellence in Primary Care Education (CoEPCE). Part of the VA's New Models of Care 

initiative, the five Centers of Excellence or CoE’s (Boise, Cleveland, San Francisco, Seattle and West 

Haven) are utilizing VA primary care settings to develop and test innovative approaches to prepare 

physician residents and students, advanced practice nurse residents and undergraduate nursing 

students, and other professions of health trainees (such as pharmacy, social work, psychology, 

physician assistants, etc.) for primary care practice in the 21st Century. The CoE’s are developing, 

implementing and evaluating curricula designed to prepare learners from relevant professions to 

practice in patient-centered, interprofessional team-based primary care settings. The curricula at all 

CoE’s must address four core domains (Table 1). 

Generally, healthcare professional education programs do not have many opportunities for workplace 

learning settings where trainees from different professions can learn and work together to provide 

care to patients in real time. With the emphasis on patient-centered medical homes (PCMH) (AHRQ, 

2016) and team-based care in the Affordable Care Act (HHS, 2016), there is an imperative to develop 

new training models that provide skills to future health professionals to address this gap. 

The VA Connecticut Healthcare System (VACHS) CoEPCE developed and implemented an education and 

practice-based “immersion” learning model with physician residents, nurse practitioner residents and 

pre-masters nurse practitioner students, pharmacy residents, post-doctorate psychology learners, and 

physician assistant learners. This interprofessional, collaborative team model breaks from the 

traditional independent model of siloed primary care providers caring for a panel of patients. 

METHODS 

In 2015, evaluators from the Office of Academic Affiliations reviewed background documents and 

conducted open-ended interviews with 12 West Haven CoEPCE staff, participating trainees, VA faculty, 

VA facility leadership, and affiliate faculty. Informants described their involvement, challenges 

encountered, and benefits of the IMPROVE program to trainees, Veterans, and VA. 

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THE ISSUE: LACK OF CLINICAL APPROACHES TO INTERPROFESSIONAL EDUCATION AND CARE 

Clinicians are increasingly required to optimize the health of elderly patients with polypharmacy 

reduction. Polypharmacy is a common problem among older adults with multiple chronic conditions, 

which places patients at higher risk of multiple negative health outcomes (Kantor et al., 2015; Fried et 

al., 2014). The typical primary care visit rarely allows for a thorough review of a patient’s medications, 

much less the identification of strategies to reduce polypharmacy and improve medication 

management. Rather, the complexity inherent to polypharmacy makes it an ideal challenge for a teambased approach. 

PROMISING SOLUTION: IMPROVE—A TEAM APPROACH TO ADDRESSING THE MEDICATION NEEDS 

OF OLDER VETERANS 

A key CoEPCE program aim is to expand work place learning instruction strategies, and to create more 

clinical opportunities for CoEPCE trainees to work together as a team to anticipate and address the 

health care needs of Veterans. To address this training need, the West Haven CoEPCE developed the 

Initiative to Minimize Pharmaceutical Risk in Older Veterans (IMPROVE). IMPROVE focuses on highneed patients and provides a venue in which trainees and supervisors from different professions can 

collaborate on a specific patient case, using a patient-centered framework. IMPROVE can be easily 

applied to a range of medication-related aims, such as reducing medications, managing medications 

and adherence, and addressing side effects. These goals are two-fold: 1) implement a trainee-led 

performance improvement project that reduces polypharmacy in elderly Veterans, and 2) develop a 

hands-on, experiential geriatrics training program that enhances trainee skills and knowledge related 

to safe prescribing. 

The first big step is just convincing people that this is important and could be a priority. And then the 

rest is logistical and might vary from site-to-site. The patient population at each clinic matters too. 

(CoE Chief Resident) 

PLANNING AND IMPLEMENTATION 

IMPROVE has its origins in a scholarly PI project developed by a physician resident trainee as part of his 

completion requirements. Planning for IMPROVE involved VA health psychology, geriatric medicine 

faculty, nurse practitioner faculty, and geriatric pharmacy residents and faculty. Planning started in 

September 2013 with a series of pilot clinics and became an official project of the West Haven CoE in 

September 2014. The intervention required no change in West Haven VAMC policy. However, the 

initiative required buy-in from West Haven CoE leadership and the Director of the VA primary care 

clinic. 

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Table 1: CoEPCE Core Domains 

Shared Decision-Making (SDM): Care is aligned with the values, preferences and cultural perspectives 

of the patient. Curricula focus is on communication skills necessary to promote patient’s self-efficacy. 

Sustained Relationships (SR): Care is designated to promote continuity of care; curricula focus on 

longitudinal learning relationships. 

Interprofessional Collaboration (IPC): Care is team based, efficient and coordinated, curricula focus is 

on developing trustful, collaborative relationships. 

Performance Improvement (PI): Care is designed to optimize the health of populations; curricula 

focus on using the methodology of continuous improvement in redesigning care to achieve quality 

outcomes. 

Curriculum 

IMPROVE is an educational, workplace-learning, clinical activity that combines a one-hour trainee 

teaching session, a 45-minute group visit, and a 60-minute individual clinic visit to address the complex 

problem of polypharmacy. It emphasizes the sharing of trainee and faculty backgrounds by serving as a 

venue for interprofessional trainees and providers to discuss pharmacologic and non-pharmacologic 

treatment in the elderly and brainstorm strategies to optimize treatment regimens, minimize risk, and 

execute medication plans with patients. 

All CoEPCE trainees in West Haven are required to participate in IMPROVE and on average, each 

trainee presents and conducts at least three visits per year. Up to five trainees participate in each 

IMPROVE session. Trainees are responsible for reviewing their own panels to identify patients who 

might benefit from participation, followed by inviting the patient to participate. Patients are instructed 

to bring their pill bottles to the visit. To prepare for the polypharmacy clinic, the trainees, the 

geriatrician, and the geriatric pharmacist perform an extensive medication chart review using the 

Medication Review Worksheet developed by West Haven VA facility providers (Mecca et al., 2015). 

They also work with a Protocol for Medication Discontinuation which was compiled by West Haven VA 

facility providers. The teams use a variety of tools that guide appropriate prescribing in older adult 

populations (American Geriatrics Society, 2015; O’Mahoney et al., 2014). During a pre-clinic 

conference, trainees present their patients to the interprofessional team for discussion, and also 

participate in a short topic discussion led by a pharmacist, geriatrician, or health psychologist on a topic 

related to prescribing safety in older adults or non-pharmacologic treatments. 

IMPROVE emphasizes a patient-centered approach to develop, execute and monitor medication plans. 

Patients and their family members are invited by their trainee provider to participate in a group visit. 

Typically, trainees invite patients age 65 or older who have ten or more medications and are 

considered appropriate for a group visit. Patients can decline to participate in the group visit and 

instead discuss their medications at his or her next regular visit. Participating Veterans receive a 

reminder call from the trainee one to two days before the visit. During the group visit, topics addressed 

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include medication management, medication adherence, medication side effects, and medication 

disposal. The recommended minimum number of patients for a group visit is three in order to generate 

discussion. The maximum is eight patients, to ensure everyone has adequate opportunity to 

participate. Five patients in a group visit are typical. 

The group visit process is based on health psychology strategies, which often incorporate group-based 

engagement with patients. The health psychologist can give advice to facilitate the visit and optimize 

participant involvement. There is a discussion facilitator guide that lists the education points to be 

covered by a designated trainee facilitator and sample questions to guide the discussion 

(http://improvepolypharmacy.yale.edu/ ). A health psychology resident and other rotating trainees cofacilitate the group visit with a goal to reach out to each group member, including family members, 

and have them discuss their perceptions and share their concerns and treatment goals. There is shared 

responsibility among the trainee participants to address the educational material, as well as involve 

their respective patients during the sessions. 

Immediately following the group visit, trainees conduct a one-hour clinic session that includes 

medication reconciliation, a review of the IMPROVE Questionnaire (Available at 

http://improvepolypharmacy.yale.edu/), and the St. Louis University Mental Status (SLUMS) (Tariq, 

Tumosa et al., 2006) exam to assess changes in cognition. Discussion involved the patient’s medication 

list as well as possible changes that could be made to the list. Using shared decision-making 

techniques, this conversation considers the patients’ treatment goals, their feelings about their 

medications, which they would like to stop, and the side effects they may be experiencing. After the 

individual visit is completed, the trainee participates in a 10-minute interprofessional precepting 

session, which may include a geriatrician, a pharmacist and a health psychologist, to discuss 

adjustments to medications and a safe follow-up plan, including appropriate referrals. Trainees discuss 

the plan with the patient and send a letter describing the plan shortly after the visit. 

IMPROVE combines didactic teaching with experiential education. It embodies the four core domains 

that shape the CoEPCE curriculum. First, trainees learn interprofessional collaboration concepts, 

including highlighting the roles of each profession and working with an interprofessional team to solve 

problems. Second, CoEPCE trainees learn performance improvement under the supervision of faculty. 

Third, IMPROVE allows trainees to develop sustained relationships with other team members while 

improving the quality of the clinic experience, as well as with patients through increased continuity of 

care. Trainees see patients on their panel and are responsible for outreach before and after the visit. 

Finally, with a focus on personalized patient goals, trainees have the opportunity to further develop 

skills in SDM. 

The IMPROVE model continues to evolve. The original curriculum involved an hour-long pre-clinic 

preparation session prior to the group visit in which trainees and faculty discussed the medication 

review for each patient scheduled for the day. This preparation session was later shortened to 40 

minutes, and a 20-minute didactic component was added to create the current pre-clinic session. The 

didactic component focuses on a specific topic in appropriate prescribing for older patients. For 

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example, one didactic lesson is on a particular class of medications, its common adverse effects, and 

practical prescribing and ‘deprescribing’ strategies for that class. Initially, the oldest patients or 

patients who could be grouped thematically, such as those taking both narcotics and benzodiazepines, 

were invited to participate, but that limited the number of appropriate patients within the CoEPCE. 

Currently, trainees identify a patient from their own panels who might benefit, based on age, number 

of medications, or potential medication-related concerns such as falls, cognitive impairment, or other 

concerns for adverse drug effects. These trainees have the unique opportunity to apply learned 

strategies to their own patients to continue to optimize the medication regimen even after the 

IMPROVE visit. Another significant change was the inclusion of Veterans who are co-managed with 

primary care providers outside the VA, because we found that diversity in providers and care put these 

patients at higher risk. 

Faculty role: 

CoE faculty and non-CoE VA faculty participate in supervisory, consulting, teaching and precepting 

roles. Some faculty members such as the health psychologists are already located in or near the VA 

primary care clinic, so they can assist in curriculum development and execution during their regular 

clinic duties. The geriatrician reviews the patient’s health records before the patients come into the 

clinic, participates in the group visit, and co-precepts during the 1:1 patient visits. Collaboration is 

inherent in IMPROVE. For example, the geriatrician works with the geriatric pharmacist to identify and 

teach the educational topic. IMPROVE is characterized by a strong faculty/trainee partnership, with 

trainees playing roles as both teacher and facilitator in addition to learning how to take a team 

approach to polypharmacy. 

Resources: 

IMPROVE requires administrative and academic support, especially faculty and trainee preparation of 

education sessions. The CoEPCE internal medicine resident and the internal medicine Chief Resident 

work with the health technicians for each PACT to enter the information into the VA medical 

scheduling system. Trainee clinic time is blocked for their group visits in advance. Patients are 

scheduled one to three weeks in advance. Trainees and faculty are expected to review the medication 

review worksheet and resources prior to the visit. One CoEPCE faculty member reviews patients prior 

to the pre-clinic session (about an hour of preparation per session). Sufficient space is also required: a 

room large enough to accommodate up to 10 people for both didactic lessons and pre-clinic sessions, a 

facility patient education conference room for the group visit, and up to five clinic exam rooms. 

CoEPCE staff developed a templated note in CPRS, the VA’s electronic medical record system to guide 

trainees step-by-step through the clinic visit and allow them to directly enter information into the 

system (http://improvepolypharmacy.yale.edu/ ). 

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Monitoring and Assessment: 

I think the most important part of the experience is that they’re learning while doing and they’re 

learning in a setting they’re always in...seeing their patients and looking at this particular problem and 

learning ways to fix it in their patients. (CoE Faculty) 

CoEPCE staff are evaluating IMPROVE by building a database for patient-level and trainee-level 

outcomes, including changes in trainee knowledge and attitudes over time. The CoEPCE also validated 

the polypharmacy knowledge assessment tool for medicine and nurse practitioner trainees (in review). 

PARTNERSHIPS 

IMPROVE has greatly benefited from partnerships with facility department leadership, particularly 

involvement of pharmacy staff. In addition, we have partnered with both the health psychology and 

pharmacy faculty and trainees to participate in the program. Geriatrics faculty and trainees have also 

contributed extensively to IMPROVE. Future goals include offering the program to non-COEPCE 

patients throughout primary care. 

The Yale Primary Care Internal Medicine Residency program and the Yale Categorical Internal Medicine 

Residency Program are integral partners to the CoEPCE. IMPROVE supports their mandate to 

encourage interprofessional teamwork in primary care, meet ACGME interprofessional milestones and 

promote individual trainee scholarship and performance improvement in areas of broad applicability. 

IMPROVE is also an opportunity to share ideas across institutions and stimulate new collaborations and 

dissemination of the model to other primary care settings outside the VA. 

CHALLENGES AND SOLUTIONS 

The demand for increased direct patient care pressures programs like IMPROVE, which is a time 

intensive process with high impact on a few patients. The assumption is that managing medications 

will save money in the long-run but in the short-term a strong case has to be made for securing 

resources, particularly blocking provider time and securing an Education Room for group visits and 

clinic exam rooms for individual visits. First, decision-makers need to be convinced that polypharmacy 

is important and should be a priority in health care professional’s training. The CoEPCE has tried 

different configurations to increase the number of patients being seen, such as having more than one 

IMPROVE session in an afternoon, but trainees found this to be labor intensive and stressful. 

Second, patients with medications prescribed by providers outside the VA require additional 

communication and coordination to reduce medications. The CoEPCE initially excluded these patients, 

but after realizing that these patients were some of those that needed the most help, it has developed 

a process for reaching out to outside providers and coordinating care. Additionally, there is significant 

diversity in patient polypharmacy needs, which can range from adherence problems to the challenge 

65
 
 

 

 

 

 


 

of complex psychosocial needs that are more easily (but less effectively) addressed with medications. 

The issue of polypharmacy is further complicated by evolving understandings of medications. IMPROVE 

is an effective vehicle for staying abreast of the current science in medications and their management, 

especially in complex older patients with multiple chronic conditions. 

Other challenges include developing a templated electronic note that interfaces with the VA IT system. 

The process of creating a template, obtaining approval from the forms committee, and working with IT 

personnel to implement the template was more time-intensive than anticipated and required multiple 

iterations of proofreading and editing. 

The resources are structured differently between the VA system and a non-VA system, so the type of 

personnel may vary a little bit, but the basic concept of having a specialty consultative opportunity for 

trainees in practice to refer their patients to and collaborate with in a professional way to manage 

medications, especially for people with chronic disease, is at the core of primary care training. 

(VA Academic Affiliate Representative) 

FACTORS FOR SUCCESS 

The implementation of IMPROVE was facilitated by West Haven CoEPCE faculty and leadership, VA 

facility and primary care clinic leadership in their commitment to support new models of trainee 

education. Additionally, there is strong CoEPCE leadership and collaboration at all levels—Co-Directors, 

faculty, and trainees—for the program. High interprofessional trainee interest, organizational insight, 

and an academic orientation were critical for developing and launching IMPROVE. 

...a great, unique learning experience to have a team based care approach with the patient. We 

generally always are precepting with either a physican or nurse practitioner but to really sit down 

and precept with a physician, a pharmacist, a geriatrician and a health psychologist that’s pretty 

great because they all have slightly different perspectives and may raise things that I didn’t pick up 

on. So in terms of the precepting experience, it’s definitely very robust. 

(CoE Trainee) 

Additionally, there is synergy with other team-based professions. Geriatrics has a tradition of working 

in multi-disciplinary teams as well as working with SDM concepts as part of care discussions. High 

interest and collaboration by a geriatrician and an experienced geriatric pharmacist has been key. The 

two specialties complement one another and address the complex health needs of participating 

Veterans. Health psychologists transition patients to non-pharmacologic treatments, such as sleep 

hygiene education and cognitive behavioral therapy, in addition to exploring barriers to behavior 

change. 

Another factor for success has been the CoEPCE framework and expertise in interprofessional 

education. While refining the model, program planners tapped into existing expertise in polypharmacy 

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within the VA—the Geriatrics, Pharmacy, and Clinical Health Psychology Departments. The success of 

the individual components—the preparation session, the group visit, and the 1:1 patient visit—is in 

large part the result of a collective effort by CoEPCE staff and the integration of CoEPCE staff through 

coordination, communications, logistics, quality improvement, and faculty involvement from multiple 

professions. 

The IMPROVE model is flexible and can accommodate diverse patient interests and issues. Model 

components are based on sound practices that have demonstrated success in other arenas, such as 

diabetes group visits. The model can also accommodate diverse trainee levels. Senior trainees can be 

more independent in developing their care plans, teaching the didactic topic, or precepting during the 

1:1 patient exam. 

ACCOMPLISHMENTS AND BENEFITS 

Trainees are using team skills to provide patient-centered care. They are strengthening their clinical 

skills through exposure to patients in a group visit and 1:1 clinic visit. There have been significant 

improvements in the trainees’ provision of individual patient care. Key IMPROVE outcomes include the 

following. 

Expanded CoEPCE interprofessional education capacity 

Unlike a traditional didactic, IMPROVE is an opportunity for health care professionals to work together 

to provide care in a clinic setting. It also expands CoEPCE interprofessional education capacity through: 

co-location of different trainee and faculty professions during the conference session. This 

combination trains participants to work as a team and reflect on patients together, which has 

strengthened communications among professions. The model provides sufficient time and expertise to 

discuss the medications in detail and as a team, something that would not normally happen during a 

regular primary care visit. 

Expanded participant knowledge, attitudes, skills, and competencies 

I think it’s been an eye-opening experience for a lot of trainees really understanding polypharmacy, and 

it’s been interesting because I see it in their notes when I get residents who refer patients for diabetes 

management to our continuity clinic. You see the polypharmacy because of this training. They take it to 

another level I’ve never seen with residents in the past. They really take it to heart and really try to look 

at patients’ medications and make sure there’s a need for what they are taking, and there’s an 

indication for the medicine they’re taking. (VA Facility Service Chief – Pharmacy) 

CoEPCE trainees learn about medication management, its importance in preventing complications and 

improving patient health outcomes. Trainees of all professions learn to translate the skills they learn in 

IMPROVE to other patients, such as how to perform a complete medication reconciliation or lead a 

discussion using SDM. IMPROVE also provides techniques useful in other contexts, such as group visits 

and consideration of different medication options for patients that have been cared for by other 

providers. 

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I don’t think I ever want to be in a clinic where I don’t have access to other disciplines. It’s been 

invaluable in taking care of my patients. I feel I do a better job when I have people around me who have 

a different perspective. (CoE Trainee) 

Increased participant interprofessional collaboration 

As a team, we’re there to provide education and perspective, but seeing the cross-sharing between 

patients, I definitely see the sense of ‘Wow – I’m not the only one who’s struggling with this.’ Many 

have developed their own strategies for managing it...’Well, I had that problem and this is what I did to 

help myself kind of keep track. (CoE Faculty) 

Understanding and leveraging the expertise of trainees and faculty from different professions is a 

primary goal of IMPROVE. IMPROVE education sessions, the group visit and precepting model are 

intentionally designed to break down silos and foster a team approach to care, which supports the 

PACT team model. Trainees and faculty all have their unique strengths and look at the issue from a 

different perspective, which increases the likelihood that the patient will hear a preferred solution or 

strategy, especially during the group visit. The end result is that trainees are more well-rounded and 

become better practitioners who seek advice from other professions and work well in teams. 

It builds teamwork even more than there already is teamwork...we’re in this big soup kitchen 

together, working for the betterment of the patient. Everyone has a level playing field...it makes the 

teamwork even better together. And the team listens to other people as far as the pharmacist, health 

psychologist...it takes it to another level. 

(VA Facility Service Chief – Pharmacy) 

Trainees are expected to learn about other professions and their skill sets. For example, trainees learn 

early on the roles and scopes of practice of Pharmacists and Health Psychologists for more effective 

referrals. Discussions during the session before the group visit may bring conditions like depression to 

the trainees’ attention. This is significant because issues like patient motivation may be better handled 

from a behavioral perspective. 

Expanded participant clinical performance 

IMPROVE is an opportunity for CoEPCE trainees to expand their clinical expertise. It provides exposure 

to a variety of patients and patient care needs, and is an opportunity to present a high-risk patient to 

colleagues of various professions. As of December 2015, approximately thirty internal medicine 

residents and 6 nurse practitioner residents have seen patients in the polypharmacy clinic. Each year, 

four nurse practitioner residents, two health psychology residents, four clinical pharmacy residents, 

and one geriatric pharmacy resident participate in the IMPROVE Clinic during their year-long training 

program. 17-19 Internal Medicine residents participate in IMPROVE during their three year training 

program. 

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A structured forum for discussing patients and their care options supports professionals’ utilization of 

their full scope of their practice. Trainees learn and apply team skills, such as communication and the 

warm handoff12, which can be used in other clinic settings. An interprofessional care plan supports 

trainee clinical performance, providing a more robust approach to patient care than individual 

providers might on their own. 

I am using the skills I learned [in IMPROVE] with other patients on my panel. 

(CoE medical resident) 

Improved patient outcomes 

IMPROVE is an enriched care plan informed by multiple professions with the potential to improve 

medication use and provide better care. Veterans are also receiving better medication education as 

well as access to a health psychologist who can help them with goal setting and effective behavioral 

interventions. On average, five patients participate each month. As of December 2015, 68 patients 

have participated in IMPROVE. 

The Group Visit and the 1:1 patient visits focus exclusively on medication issues and solutions, which 

would be less common in a typical primary care visit with a complex patient who brings a list of agenda 

items. In addition to taking a thorough look at their medications and related problems, it also educates 

patients on related issues such as sleep hygiene. Participating Veterans are also encouraged to share 

their concerns, experiences, and solutions with the group, which may increase the saliency of the 

message beyond what is offered in counseling from a provider. 

To date, preliminary data suggests that in some patients, cognition (as measured with SLUMS after six 

months) has modestly improved after decreasing their medications. Other outcomes being monitored 

in follow-up are utilization of care, reported history of falls, number of medications, and vital signs at 

initial and follow up visits. 

Patients experience increased continuity of care because the patient now has a team focusing on his or 

her care. Team members have a shared understanding of the patient’s situation and are better able to 

establish therapeutic rapport with patients during the group visit. Moreover, CoEPCE trainees and 

12 A warm handoff is often described as an intervention in which: “a clinician directly introduces a patient to 

another clinician at the time of the patient’s visit, and often a brief encounter between the patient and the health 

care professional occurs.” (Cohen, et al., 2015). 

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faculty try to ensure that everyone knows about and concurs with medication changes including 

outside providers and family members. 

Improved CoEPCE participant satisfaction 

Patients that are presented at IMPROVE can be particularly challenging and there may be a 

psychological benefit to working with a team to develop a new care plan. Providers are able to get 

input and look at the patient in a new light. 

But we’ve seen from patients we had so far that we are safely and consistently discontinuing on the 

order of two to three medications per patient on average. Patients appear to enjoy the visit and have 

a better understanding of what their medications are for. 

(CoE Faculty) 

Results of post-visit patient satisfaction questionnaires are encouraging, with a high level of patient 

satisfaction and perception of clinical benefit. Patients identify an improvement in the understanding 

of their medications, feel they are able to safely decrease their medications, and are interested in 

participating again. 

It’s pushing our trainees to pick up the phone and get in touch with the specialist and have that 

conversation and ultimately improves the care of the patient. (CoE Faculty) 

Improved CoEPCE primary care services 

I think it is doing exactly what I think the CoE is intended to do, which is have a medicine resident walk 

out of here after graduation with an understanding of what the role of the psychologist might be for 

something that they might not traditionally have thought about a psychologist as having a role in 

polypharmacy. Who would equate the two, right? The polypharmacy program is a nice microcosm of 

what the CoE is trying to do more broadly. 

(VA Facility Leadership – Clinical Health Psychology) 

IMPROVE expands the prevention and treatment options for populations at risk of hospitalization and 

adverse outcomes from medication complications, such as adverse effects and drug-drug or drugdisease interactions. Embedding the polypharmacy clinic within the primary care setting rather than in 

a separate specialty clinic results in an increased likelihood of implementation of pharmacist and 

geriatrician recommendations for polypharmacy and allows for direct interprofessional education and 

collaboration. 

Improved CoEPCE function 

IMPROVE combines key components of interprofessional education—an enriched clinical training 

model and knowledge of medications in an elderly population—into a training activity that 

complements other CoEPCE activities. The model has not only strengthened CoEPCE partnerships with 

other VA departments and specialties, but has also revealed opportunities for collaboration with 

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academic affiliates as a means to break down traditional silos among medicine, nursing, pharmacy, 

geriatrics, and psychology. 

Improved VA primary care delivery system 

IMPROVE combines key components of interprofessional education, including all four CoEPCE Core 

Domains, to provide hands on experience with knowledge learned in other aspects of the CoEPCE 

training program (e.g., Shared Decision Making strategies for eliciting patient goals, weighing risks and 

benefits in complex clinical situations, etc.). Physician and nurse practitioner trainees work together 

with trainees in pharmacy and health psychology in the complex approach to polypharmacy. The 

model has not only strengthened CoEPCE partnerships with other VA departments and specialties, but 

has also revealed opportunities for collaboration with academic affiliates as a means to break down 

traditional silos among medicine, nursing, pharmacy, geriatrics, and psychology. IMPROVE provides the 

framework for an interprofessional clinic that could be used in the treatment of other complex or high 

risk chronic conditions. 

It doesn’t necessarily have to be about polypharmacy. It could be any complex issue in primary care 

that requires an inter-professional approach. It could vary depending on the population involved. 

(CoE Chief Resident) 

THE FUTURE 

An opportunity for improvement and expansion includes increased patient involvement (as patients 

continue to learn that they have a team working on their behalf). Opportunities exist to connect with 

patients that have several clinicians prescribing medications outside of the CoEPCE to provide 

comprehensive care and decrease medication complexity. 

The CoEPCE has been proactive in increasing the visibility of IMPROVE through multiple presentations 

at local and national meetings, facilitating collaborations and greater adoption in primary care. 

Individual and collective IMPROVE components can be adapted to other contexts. For example, the 20­

minute geriatrics education session and the forms completed prior and during the patient visit can be 

readily applied to other complex patients that trainees meet in clinic. Under Stage 2 of the CoEPCE 

program, the CoEPCE is developing a kit that describes the training process, includes the medication 

worksheet and assessment tools, and directions for conducting the group visit. 

It is hoped that working collaboratively with the West Haven COEPCE polypharmacy faculty, a similar 

model of education and training will be implemented at the Yale University Primary Care training site 

in New Haven, CT in the future. 

Additionally, the West Haven CoEPCE is planning to partner with the other original CoEPCE program 

sites to implement similar interprofessional polypharmacy clinics. 

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CONTACT INFORMATION
 

VA Connecticut Healthcare System - West Haven Campus 

For more information: 

Rebecca Brienza, MD, MPH 

Physician Director, West Haven COEPCE 

Assistant Professor 

Yale University School of Medicine 

950 Campbell Avenue 

West Haven, CT 06516 

Email: rebecca.brienza@va.gov 

RESOURCES
 

National VA CoEPCE Websites: http://www.va.gov/oaa/coepce/
 

National VA APACT Website, Publications, Executive Briefing Videos: VA OAA Academic PACT Website
 

VAMC SLUMS Examination: http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf
 

IMPROVE Resources: http://improvepolypharmacy.yale.edu/
 

WORKS CITED
 

Health and Human Services (2016) AHRQ. Transforming the organization and delivery of primary care. 

Retrieved 11/18/16 from https://www.pcmh.ahrq.gov/ 

American Geriatrics Society (2015) Beers criteria update expert panel. American Geriatrics Society 

updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr 

Soc. 63(11):2227-46. Weblink 

Cohen, D.J.; Balasubramanian, B.A.; Davis, M.; Hall, J.; Gunn K.C., Stange K.C., Green L.A., Miller W.L., 

Crabtree B.F., England M.J., Clark K., Miller B.F. Understanding care integration from the 

ground up: Five organizing constructs that shape integrated practices. J Am Board Fam Med. 

2015; 28:S7-S20. Weblink 

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Fried, T.R., O’Leary, J.O., Towle, V., Goldstein, M.K., Trentalange, M., Martin DK. (2014). Health 

outcomes associated with polypharmacy in community-dwelling older adults: A systematic 

review. J Am Geriatr Soc. 62:2261-2272. Weblink 

Health and Human Services, (2016). The Affordable Care Act, section by section. Retrieved 11/18/16 

from https://www.hhs.gov/healthcare/about-the-law/read-the-law/. 

Kantor, E.D., Rehm, C.D., Haas, J.S., Chan, A.T., Giovannucci, E.L. (2015). Trends in prescription drug use 

among adults in the United States from 1999-2012. JAMA. 314(17):1818-1831. Weblink 

Mecca, M.C., Niehoff, K., Grammas, M. (2015). Medication review worksheet. POGOe - Portal of 

Geriatrics Online Education; Available from: http://pogoe.org/productid/21872. 

O’Mahoney, D., O’Sullivan, D., Byrne, S., O’Connor, N., Ryan, C., Gallagher, P. (2014). STOPP/START 

criteria for potentially inappropriate prescribing in older people: version 2. Age and Ageing. 

4;0;1-6. Weblink 

Tariq, S.H., Tumosa, N., Chibnall, J.T., Perry, M.H. 3rd, Morley, J.E. (2006). The Saint Louis University 

Mental Status (SLUMS) Examination for Detecting Mild Cognitive Impairment and Dementia is 

more sensitive than the Mini-Mental Status Examination (MMSE) – A pilot study. J Am Geriatr 

Psych; 14(11): 900-10. Weblink 

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APPENDIX A: COEPCE PROJECT RESOURCES AND PUBLICATIONS 

VA Office of Academic Affiliations: Centers of Excellence in Primary Care Education 

Websites: www.va.gov/oaa/coepce and www.va.gov/oaa/apact 

JOURNAL ARTICLES 

Bitton, A., Pereira, A. G., Smith, C. S., Babbott, S. F., & Bowen, J. L. (2013). The EFECT framework for 

interprofessional education in the patient centered medical home. Healthc (Amst), 1(3-4), 63­

68. Weblink 

Bowen, J. L., & Schectman, G. (2013). VA Academic PACT: A blueprint for primary care redesign in 

academic practice settings: Department of Veterans Affairs, Offices of Primary Care and 

Academic Affiliations. Weblink 

Brienza, R. S. (2016). At a Crossroads: The Future of Primary Care Education and Practice. Acad Med, 

91(5), 621-623. Weblink 

Brienza, R. S., Zapatka, S., & Meyer, E. M. (2014). The case for interprofessional learning and 

collaborative practice in graduate medical education. Academic Medicine, 89(11), 1438-1439. 

Weblink 

Brown, K., Poppe, A., Kaminetzky, C. P., Wipf, J. A., & Woods, N. F. (2015). Reflections of the Veterans 

Administration Puget Sound Health Care System Regional Nurse Practitioner Residency Forum. 

Nursing Forum, 51(1), 70-76. Weblink 

Brown, K., Poppe, A., Kaminetzky, C., Wipf, J., & Woods, N. F. (2015). Recommendations for nurse 

practitioner residency programs. Nurse Educator, 40(3), 148-151. Weblink 

Brown, K., Poppe, A., Kaminetzky, C., Wipf, J., & Woods, N. F. (2015). Advancing post-doctorate of 

nursing practice residency experience: First year reflections. Clinical Scholars Review, 8(1), 25­

28. Weblink 

Buu J., Fisher A., Weppner W., & Mason, B. (2016). Impact of patient aligned care team 

interprofessional care updates on metabolic parameters. Federal Practitioner, February 2016, 

44-48. Weblink 

Chaiyachati K. H., Gordon K., Long T., et al., (2014). Continuity in a VA patient-centered medical home 

reduces emergency department visits. PloS one,9(5), e96356. Weblink 

Chou, C. L., Ainsworth, A., & O'Brien, B. C. (2016). An assessment strategy for interprofessional 

interactions of primary care practitioner trainees. Journal of Interprofessional Education & 

Practice, 2, 1-3. Weblink 

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Clementz, L., McNamara, M., Burt, N.M., Sparks, M., Singh, M.K. Starting with Lucy: Focusing on Human 

Similarities Rather Than Differences to Address Health Care Disparities [published online ahead 

of print March 7, 2017]. Acad Med. Weblink 

Cox, M. (2013). Patient-centered model for continuous improvement in clinical education and practice. 

Institute of Medicine, Interprofessional Education for Collaboration: Learning How to Improve 

Health From Interprofessional Models Across the Continuum of Education to Practice: Workshop 

Summary. Global Forum on Innovation in Health Professional Education; Board on Global 

Health; Institute of Medicine. Weblink 

Cox, M., Cuff, P., Brandt, B. F., Reeves, S., & Zierler, B. (2015). Measuring the impact of 

interprofessional education on collaborative practice and patient outcomes. Washington, DC: 

Institute of Medicine. Weblink 

Davidson, M., Painter, E., Heilman, A., & Singh, M. (2015). Aligning care options: An interprofessional 

approach to engaging and managing complex patients. Journal of Interprofessional Education & 

Practice, 1(2), 55-56. Weblink 

Doolittle, B. R., Tobin, D., Genao, I., Ellman, M., Ruser, C., & Brienza, R. (2015). Implementing the 

patient-centered medical home in residency education. Educ Health (Abingdon), 28(1), 74-78. 

Weblink 

Geyer, J, Thomas, A, Mirza, S, Wipf J. (2016) Just Take Your Meds! A Seattle VA Medication Adherence 

Project. HOUSE. Journal of the UW Medicine GME Housestaff Quality and Safety Committee. 

Dec 2016:20-21. 

Gilman, S. C., Chokshi, D. A., Bowen, J. L., Rugen, K. W., & Cox, M. (2014). Connecting the dots: health 

professions education and delivery system redesign. Academic Medicine, 89(8), 1113-1118. 

Weblink 

Kaminetzky, C. P., & Nelson, K. M. (2015). In the office and in-between: The role of panel management 

in primary care. Journal of General Internal Medicine, 30(7), 876-877. Weblink 

Khan, A. M., Long, T., & Brienza, R. (2012). "Surely, we can do better": scaling innovation in medical 

education for social impact. Academic Medicine, 87(12), 1645-1646. Weblink 

King, I. C., Strewler, A., Wipf, J. E., Singh, M., Painter, E., Shunk, R., . . . Smith, C. S. (2017). Translating 

innovation: Exploring dissemination of a unique case conference. Journal of Interprofessional 

Education & Practice, 6, 55-60. Weblink 

Lawrence, D., Bryant, T., Nobel, T., Dolansky, M. A., & Singh, M. K. (2015). A comparative evaluation of 

patient satisfaction outcomes in an interprofessional student run free clinic. Journal of 

Interprofessional Care, 29(5), 445-450. Weblink 

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Levander, XA, Overland MK (2015). Care of Women Veterans. In Women’s Health issue (J Wipf Editor), 

Journal Medical Clinics of North America. May 2015;651-662. 

Long, T., Dann, S., Wolff, M. L., & Brienza, R. S. (2014). Moving from silos to teamwork: integration of 

interprofessional trainees into a medical home model. Journal of Interprofessional Care, 28(5), 

473-474. Weblink 

Long, T., Chaiyachati, K., Khan, A., Meyer, E., & Brienza, R. (2014). Expanding health policy education: 

Combining knowledge and skills curricula for the next generation of practitioners. Journal of 

Graduate Medical Education, 6(3), 547-550. Weblink 

Long, T., Uradu, A., Castillo, R., & Brienza, R. (2016). Addressing outpatient continuity for ambulatory 

training: A novel tool for longitudinal primary care sign out. Educ Health (Abingdon), 29(1), 51­

55. Weblink 

Meyer, E. M., Zapatka, S., & Brienza, R. S. (2015). The development of professional identity and the 

formation of teams in the Veterans Affairs Connecticut Healthcare System's Center of 

Excellence in Primary Care Education Program (CoEPCE). [Research Support, U.S. Gov't, NonP.H.S.]. Academic Medicine, 90(6), 802-809. Weblink 

Patel, S., Bachhuber, M., & O'Brien B. (2013). An interprofessional home visit curriculum for high risk 

patients. Medical Education, 47(11), 1138-39. Weblink 

Reisman, A., Harrington, F., & Brienza, R. (2016). Eight tips for presenting patients in an academic 

primary care clinic. SGIM Forum, 39(2), 1-2. Weblink 

Reynolds, P. , Klink, K., Gilman, S. C., Green, L. A., Phillips, R. S., Shipman, S., Keahey, D., Rugen, K., & 

Davis, M. (2015). The patient-centered medical home: Preparations of the workforce, more 

questions than answers. Journal of General Internal Medicine (available online February 23, 

2015). Weblink 

Rugen, K. W., Watts, S. A., Janson, S. L., Angelo, L. A., Nash, M., Zapatka, S. A., Brienza, R., Gilman, S. C., 

Bowen, J. L., & Saxe, J. M. (2014). Veteran Affairs Centers of Excellence in Primary Care 

Education: transforming nurse practitioner education. Nursing Outlook, 62(2), 78-88. Weblink 

Rugen, K. W., Speroff, E., Zapatka, S. A., & Brienza, R. S. (2016). Veterans Affairs interprofessional nurse 

practitioner residency in primary care: A competency-based program. The Journal for Nurse 

Practitioners, 12(6), e267-e273. Weblink 

Smith, C. S., Gerrish, W. G., Nash, M., Fisher, A., Brotman, A., Smith, D., & Dreffin, M. (2015). 

Professional equipoise: Getting beyond dominant discourses in an interprofessional team. 

Journal of Interprofessional Care, 29(6), 603-609. Weblink 

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Shunk, R., Dulay, M., Chou, C., Janson, S., & O'Brien B. (2014). Huddle-coaching: A dynamic intervention 

for trainees and staff to support team-based care. Academic Medicine, 89(2), 244-250. Weblink 

Silversteyn, L., Vonhaz, T., Christopher, B., Tuckerman, J., Spanos, P., Dolansky, M., & Heilman, A. 

(2015). Connecting the dots in interprofessional quality improvement education. Journal of 

Interprofessional Education & Practice, 1(2), 74-75. Weblink 

Singh, M. K., Ogrinc, G., Cox, K., Dolansky, M. A., Brandt, J., Morrison, L., Harwood, B., Petroski, G., 

West, A., & Headrick, L. (2014). The Quality Improvement Knowledge Application Tool Revised 

(QIKAT-R). Academic Medicine, 89(10), 1386-1391. Weblink 

Tobin, D. G., Doolittle, B.R., Ellman, M.S., Ruser, C.B., Brienza, R.S. Genao, I. (2017). Modifying the 

Primary Care Exception Rule to Require Competency-Based Assessment. Academic Medicine. 

Volume 92(3), March 2017, p 331–334 Weblink. 

Wakeman, A. (2015) A Triple Aim Approach: Pharmacy and Nurse Practitioner Resident 

Interprofessional Training. Nurse Practitioner Perspective Magazine. ADVANCE for NPs and PAs 

Published on line 12/23/15. Weblink 

Watts, B., Lawrence, R. H., Singh, S., Wagner, C., Augustine, S., & Singh, M. K. (2014). Implementation 

of quality improvement skills by primary care teams: Case study of a large academic practice. 

Journal of Primary Care & Community Health, 5(2), 101-106. Weblink 

Weppner, W. G., Davis, K., Sordahl, J., Willis, J., Fisher, A., Brotman, A., & Smith, C. S. (2016). 

Interprofessional care conferences for high-risk primary care patients. Academic Medicine, 1. 

Weblink 

Zapatka, S., Conelius, J., Edwards, J., Meyer, E., & Brienza, R. (2014). Pioneering a primary care adult 

nurse practitioner interprofessional fellowship. Journal for Nurse Practitioners, 10(6), 378-386. 

Weblink 

BOOKS 

Smith, C. S., Weppner, W., & Gerrish, G. W. (2015.) Interprofessional education in patient centered 

medical homes: Complex Adaptive Systems Theory and its implications. Switzerland: Springer. 

Weblink 

BOOK CHAPTERS 

Brown, K., & Wipf, J. (2015). VA Puget Sound Center of Excellence in Primary Care Education DNP 

residency evolution: Leveraging established best practices for transition to practice. 

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Keene, T., O’Brien, B., & Shunk, R. (2015). Academic PACT: The San Francisco VA experience. In C. Rick 

& P. Kritek (Eds.).Realizing the future of nursing: VA nurses tell their story. Washington, D.C.: 

Government Printing Office. Weblink 

Nash, M., & Fisher, A. (2015). Interprofessional education: Pressing for sustainable change and growth. 

In C. Rick & P Kritek (Eds.), Realizing the future of nursing: VA nurses tell their story. 

Washington, D.C.: Government Printing Office. Weblink 

Rugen, K. W., Gilman, S. C., & Traylor, L. (2015). Interprofessional education as the future of education. 

In C. Rick & P. Kritek (Eds.), Realizing the future of nursing: VA nurses tell their story. 

Washington, D.C.: Government Printing Office. Weblink 

Watts, S., Zimbardi, K., Dolansky, M. A., & Singh, M. (2015). Nurse practitioner residency development 

at the Louis Stokes Cleveland Department of Veterans Affairs Medical Center. In C. Rick & P. 

Kritek (Eds.), Realizing the future of nursing: VA nurses tell their story. Washington, D.C.: 

Government Printing Office. Weblink 

Zapatka, S., Brienza, R., & Edwards, J. (2015). Development and implementation of an adult 

interprofessional nurse practitioner fellowship: The West Haven VA Prototype. In C. Rick &P. 

Kritek (Eds.), Realizing the future of nursing: VA nurses tell their story. Washington, D.C.: 

Government Printing Office. Weblink 

VA WHITEPAPER 

Department of Veterans Affairs, Office of Academic Affiliations (2013) VA Academic PACT: A blueprint 

for primary care redesign in academic practice settings. Weblink 

CONFERENCE PROCEEDINGS 

Josiah Macy Foundation. Transforming Patient Care: Aligning Interprofessional Education with Clinical 

Practice Redesign Institute of Medicine Global Forum on Innovation in Health Professional Education. 

Weblink 

Institute of Medicine: Educating for Practice: Learning how to improve health from interprofessional 

models across the continuum of education to practice. Weblink 

Cox, M. Building Health Care Value Through System Redesign: Leverage at the Point of 

Interprofessional Care. Institute of Medicine: Best Practices Innovation Collaborative. Weblink 

BLOGS 

Early, J. From Interprofessionalism Lite to the Real Thing. AM Rounds- Beyond the Pages of Academic 

Medicine. January 15, 2015. Weblink 

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Norcott, A. Healthier and Happier. AM Rounds- Beyond the Pages of Academic Medicine. January 22, 

2015. Weblink 

Folki, A. Transforming Primary Care and Clinical Education in the VA: Education in the Patient Aligned 

Care Teams. Primary Care Progress. Sept 29, 2011. Weblink 

Shankar, M. (2017). Eggo Waffles, Empathy, and Caring for our Veterans Weblink 

WEB BASED EDUCATION 

Dolansky, M. A., Moore, S. M., Singh, M. K. (2014). Take the Lead on Quality Improvement. Massive 

Open Online Course. Weblink 

PODCASTS/WEBCASTS 

Shunk, R. (2015) Chapter 4, San Francisco VA Center of Excellence in Primary Care Education. Part of 

Progress and Promise: Profiles in Interprofessional Health Training to Deliver Patient-Centered 

Primary Care supported by the National Center for Interprofessional Practice and Education. 

Weblink 

Gilman, S. and Rugen, R. American Interprofessional Health Collaborative. Weblink. 

Gilman, S. (2014) National Center Journal Club with Dr. Stuart C. Gilman. Weblink 

Gordon, Suzanne. How to Huddle Video. San Francisco CoEPCE. Narrated by by Peter Coyote. Weblink 

Shunk, R. Was that Double Double Animal Style? Weblink 

EDUCATIONAL RESOURCES 

MedEdPortal 

Pearson, M., O’Brien B., & Shunk R. Development and Evaluation of an Interprofessional Collaborative 

Case Conference Series in Primary Care. MedEdPORTAL Publications; 2014. Weblink 

Coursera 

Wamsley M., Chen A., Rivera J., Hyde S., Shunk R., & UCSF IPE Development Team. Collaboration and 

Communication in Healthcare: Interprofessional Practice. Coursera Course. 2014. Particpated in 

development of Module 3: Understanding communication, accountability, and task distribution. 

Weblink 

PRESS 

Longman, P. First Teach No Harm. Washington Monthly. Jul/Aug. 2013. Weblink 

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Khanal Y. In the VA system, the future of primary health care. The Washington Post. November 30, 

2012. Weblink 

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