**Transcript of Cyberseminar**

**Patient Aligned Care Teams (PACT) Demonstration Labs**

**Integrating Resident Education into PACT**

**Presenters: Anaïs Tuepker, PhD, MPH; Elizabeth Allen, MD**

**July 17, 2013**

**Integrating Resident Education into PACT**

**July 17, 2013**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact:**Megan.Johnson4@va.gov*

Moderator:We are at the top of the hour so at this point in time I want to introduce our presenters. Speaking first we have Dr. Anais Tuepker, she is a Core Investigator for Health Services Research at the Portland VA Medical Center. She is also a research assistant professor in the Division of Internal Medicine and Geriatrics at the School of Medicine in Oregon Health and Science University.  Joining her is Dr. Megan Johnson a primary care psychiatrist for the Primary and Ambulatory Care Center in West Los Angeles VA Medical Center also Associate Professor and Resident in the Department of Psychiatry and Behavioral Sciences at the US UCLA David Gaston School of Medicine. Finally also joining us is Dr. Elizabeth Allen, she is the Section Chief of General Internal Medicine at the Portland VA Medical Center and also an Associate Professor in the Division of General and Internal Medicine also at Oregon Health and Science University.

At this time, I would like to turn it over to Dr. Tuepker. Are you ready to share your screen?

Dr. Anais Tuepker:Good morning.  Is my screen up now Molly? 

Moderator:Go ahead and click the button that says ‘Show My Screen’. 

Dr. Anais Tuepker:Show my screen. Okay.

Moderator:There you go; now just go open slide show mode and we are all set. 

Dr. Anais Tuepker:Okay there we go, thank you so much everyone for joining us this morning.  I am going to actually be doing a small piece of this presentation and then Dr. Allen is going to be talking mostly about the experience that our resident clinic here in Portland has had. If I can just advance my slides. 

Let me give a quick overview. What we are going to talk about this morning is first start with some of the differences we have observed between a teaching clinic and a non-teaching clinic in terms of what the challenges are and what the experiences in implementing the patient care team model. I am going to talk a little bit there about what we have learned from our work as a demo lab interviewing the staff that works in the resident clinic here. Then some of the unique implications that this leads to for how you implement the PACT model in a teaching clinic. Then as I said most of what we are going to do today is Dr. Allen is going to talk about some of the insights and innovations that have developed within our teaching clinic here. They have made some significant changes and we are going to talk about the process of how they advocated for that change; changes they have made to their staffing model slightly different from what standard PACT staffing model is; changes they have made to team structure and how team members function and what their roles are and then how you teach learners about PACT and how you really meaningfully integrate the residents into PACT teams. 

Molly we have a poll question. 

Moderator:Thank you very much. For our attendees as you can see there is a poll question on your screen, please click the circle that best represents your answer.

The question is:  Please tell us which of the following statements best describes resident education practices in your VA facility. The answer options:  We don’t do resident education at our facility. Residents are not assigned to PACT teams. We’re developing plans to assign residents to PACT teams. Residents are on PACT teams in one clinic or CBOC. Residents are on PACT teams at more than one clinic or CBOC. 

Please do not be shy it does help inform our presenters to find out what level of participation the audience members have. Looks like we have had about half our audience vote and they are still coming in so we will give people a few more seconds. I am going to go ahead and close the poll now and I will share the results. You should be able to see those on your screen now if you want to talk through them real quick. 

Dr. Anais Tuepker:Okay, great, so the most common answer, forty-three percent of you have residents on PACT teams in one clinic or CBOC, that is forty-three percent. The other responses are all evenly split, they each got fourteen percent. Fourteen percent of you do not have resident education at your facility; fourteen percent of your residents are not assigned to PACT teams; fourteen percent of you are in the process of developing plans to assign residents to PACT teams and fourteen percent of you have residents on PACT teams at more than one clinic or CBOC. It sounds like most of the audience is following a very similar model at least right now, to what we are doing because here in Portland we also have residents within what we call the resident clinic. Everyone is within one clinic. But what we learned from the demo lab is there are actually many different models throughout the VA.

Moderator:I apologize for interrupting. Can you press ‘show my screen’ again? 

Dr. Anais Tuepker:Oh, I am sorry. 

Moderator:No problem. There we go.

Dr. Anais Tuepker:My screen looks a little strange right now to me; does it look okay to you?

Moderator:It is just a delay in the streaming over the internet. 

Dr. Anais Tuepker:I see, okay.

Moderator:Now we are back.

Dr. Anais Tuepker:Okay. What I wanted to say was we found in the demo lab there are a lot of different models but it sounds like a lot of you are pursuing a similar model to what we have done here in Portland. Hopefully there will be some good questions and maybe also some feedback from your experience. 

What is different in a teaching clinic? I think the first thing that is thoroughly obvious to anyone who is doing this work is that you have a dual mission in a teaching clinic. Your resident education, the training of the residents is a key piece of what you are doing alongside the patient care that is the VA’s core mission. Both of those things are equally important and that does complicate the job of people working in such a clinic. 

Another thing that is a bit different is the provider profiles are different. The Staff Providers, the PCPs are certainly engaged in teaching, they are often engaged in research. What this means is they are only in clinic part time, they have multiple competing responsibilities. In turn, the Resident Providers are also different, they are only available episodically. They too have competing clinical responsibilities. They have variable interest in primary care, not all of them are planning to go into that field so you have a range of their level of commitment to that area of care. And intrinsically you have frequent turnover. You are always getting a new class. 

The clinic staff, this is everyone in the clinic not just the providers, everyone has to function as educators and evaluators. They have to be willing and with luck, they are excited to start over every year with a new cohort. They have to be willing and hopefully excited to teach, and they definitely have to be willing to correct the same mistakes, to teach the same lessons, to show the same procedures, over and over without losing their own enthusiasm or attention to doing it right. 

The final point is that in high functioning clinic is going to have a long-term effect, not just for the performance of the clinic itself, but because you are training residents. It actually translates into an improved ability to recruit future PCPs and to strengthen the field of primary care overall.  So that is kind of the big picture thinking about why it matters what you do in a teaching clinic when you are integrating PACT.

So as I said, what we did in our demo labs we conducted focus groups and interviews with the staff in the resident clinic here. and much of what we found was actually very much the themes were very much in line with what we saw for PACT implementation overall in terms of the opportunities and challenges but there were some unique aspects and I will just highlight a few. 

There were some what we term “natural” disadvantages meaning they are almost intrinsic to the situation. Because you have multiple PCPs on each PACT team this leads to a lot more challenges for coordination. Just the scheduling logistics, how you get people to communicate, there is another level of complexity because you have multiple providers. All of the team members have to work with multiple providers. I think we already learned in general that team dynamics are an important and are not always easy piece of shifting to the PACT model. And when you have more people on the team, that is just naturally more difficult. There is also the fact that multiple providers from the same team may be in the clinic at the same time. So how can the other team members really do everything that they are supposed to do when they are having to coordinate with more than one provider at the same time? As mentioned, many providers have other responsibilities so there are a lot more part time providers at least in our facility that is definitely the case and this creates challenges for continuity and access. They are less able as part time providers to assist in day-to-day patient care. And this creates more of a burden for nursing staff, they have to be able to handle that. Again, the resident turnover just regularly is going to destruct team continuity in a way that you will not see in another clinic. 

There are also some of what we thought of as “natural” advantages that we should not lose sight of in focusing on the challenges. Residents are there to learn and what we found from talking to the staff is that many of them felt that this helps with the implementation of a true team approach. The residents want to learn from everyone on the team and they listen to the nurse care manager and the other team members in a way that sometimes is a challenge in other settings. The providers often have research and best practice expertise. They are often very interested in evidence-based medicine all of which facilitates many PACT activities. 

The diversity of roles that the providers and staff have in this clinic sometimes contributes to higher staff satisfaction. That has certainly been the case in our clinic where this clinic scored highly on a number of the staff satisfaction items in our employee survey results. 

Finally, there is greater autonomy and potential for leadership from the nursing staff. That is one of the really interesting things in the model that has been developing here. With that, I am going to turn it over to Dr. Allen who has been leading and working with her team on actually doing what I am talking about so without further ado here is Dr. Elizabeth Allen. 

Dr. Elizabeth Allen:Hello all, thanks for joining us. I am going to be talking about some insights we gleaned and innovations we developed in our Portland VA Resident Clinic. The presentation that I am going to give draws on the work of all members of the PACT team, several of our RNs, LPNs, providers, our pharmacists and our social worker and I will put their names because they want them all to get credit for their participation and helping to implement this model. 

I want to give you a clinic snapshot so you can figure out whether this content is relevant to your site. As Anais already mentioned, all of our residents at the Portland VA conduct primary care clinic at the same site. We have six CBOCs in our region, the resident clinic is located adjacent to the main medical center. We chose that so it would provide ease of access for our health staff and allow them to go to other conferences even while they are on their clinical rotations. Our resident primary care practice is comprised completely of part time providers. We have twelve staff providers, forty-three resident providers at present and moving up to fifty-one over the next several years. Currently we are caring for around forty-six hundred patients. That varies between forty-five  hundred and five thousand. The majority of staff providers conduct one to two half days of clinic per week and an additional one to two half days of precepting in the resident clinic per week. 

Since 2011, our residents have been on a three plus one schedule and that is a tiny little bullet point but it is a huge part of what has enabled us to successfully implement the PACT model and integrate residents into that model. I know some of you have similar curricular structures, in your programs, but just in case let me explain what we mean by three plus one. Our residents are divided into four groups, at any one time, one of those groups is on a clinic week where they do nothing but outpatient activities. Then that group of residents moves on to three weeks of an inpatient or consult rotation. Essentially every fourth week they are in clinic with us. We decided to go to that model in 2011 partially because we wanted to improve the quality of our ambulatory experience and partially because we needed to radically change the way, we were doing things to match duty hour restrictions that were going into place that year. 

We drew on the experience of others before us who had gone to the four plus one models and five plus one models. We pushed hard to make it a three plus one and that we did not want our residents out of clinic for more than three weeks in a row as we thought it would be too disruptive to patient care continuity.

The panel sizes for residents start at thirty-five patients in the first year, then grow to seventy-five actually by the end of the second year, and stay there for the third year as well. Our staff provider panels are a hundred and thirty patients per half day of clinic. As of last month, we are now up to a five PACT teams in our clinic, we have two to four staff providers on each PACT team and eight to nine residents per team. Each of those residents is linked to a staff provider. At any given time, one to four providers on the same team may be conducting clinic.  

Moving on. Actually, I cannot get this slide to advance. 

Moderator:If you click anywhere on the slide it should advance for you. There we go.

Dr. Elizabeth Allen:Thank you.  A little bit on how we advocated for change. In 2011, our group got together and developed a detailed proposal for what we thought we needed in our academic PACT clinic that was unique to an academic PACT and different from what was experienced in other CBOCs. We identified what was different about our resident clinic and we highlighted the mismatches with the current PACT model. We took a multidisciplinary approach involving invested individuals, RNs, LPNs, admin assistants, social worker. Each of the team members collected data on their time use and how they were or were not able to accomplish the tasks required of them in the PACT model. This information came out over a series of about seven meetings, first we collected our data and then came up with a model of what we thought we needed to accomplish to our roles appropriately. We were fortunate that our primary care leadership was open and supportive to this effort and actually commissioned us to do it. They were so sick of hearing me and my fellow clinic directors complain about how this was not working at our site that they asked us to develop a proposal for what we thought we needed, listened to that and had us present it to the executive leadership who then approved our plan for what we needed from the staffing perspective. 

On this slide, you will see what we came up with in our advocating for change process. The first step in column one, I will go by team member, focusing on the nurse care manager RN role first. We decided that we need an RN as our team anchor. Our providers so part time in nature, we needed a person within the clinic who is the core around which based the PACT team, an RN centric team. In 2011 when we started, we had three RN nurse care managers for our panel of forty-six hundred patients so each one had around sixteen hundred patients they were responsible for. With this number of patients, they were only able to accomplish acute care needs and not able to get to many of the chronic care management tasks that are desirable in a PACT model. We proposed that we needed five RNs for five teams and that the maximum panel size for RNs should be about nine hundred patients. At the LPN level, we had one LPN for team, total of three. What that meant as I mentioned before we had one to four providers from the same team practicing at a time. We were never able to work with our own LPN, it was interchangeable so we were never able to develop a real relationship with one LPN, kind of going against the PACT ideals. We advocated for one and a half LPNs per team such that there would be always between two different LPNs, we would always be working with one or the other so at least we would be able to develop a relationship with two LPNs and become accustomed to working with them time and time again. I will not read through what we came up with for the administrative staff because we actually did not want to change our model there, sticking with four across five teams. Our social worker at the time was responsible for the care of fifty-eight hundred patients, which we thought, was excessive and we advocated for additional social work support. We did not think one social worker should be responsible for more than about three thousand to thirty-five hundred patients. Additionally our pharmacist was overextended.

The next slide depicts the model for what we thought we needed in our clinic to best function and I will walk you through it. at the center of each team is a nurse care manager so five teams, nurse care manager A, B, C, D and E. each nurse care manager is responsible for the care of nine hundred patients and these patients come from the panels of three staff providers – P1, P2 and P3. Each of those staff providers is affiliated with a number of linked residents, that is the A1, A2, A3 pieces on that slide that you see are so between the staff providers and the resident providers we bring in nine hundred patients for which the nurse care manager was responsible. We had one LPN one, that is L1 who was purely affiliated with Team A and then the second LPN who spent half of his or her time with Team A and half their time with Team B depending on what the mix of providers in clinic was that day. 

Some observations about team roles – since the nurse care manager is the core of the team, she or he must be able to function autonomously and have a higher skillset that has traditionally been the case. It has always been a tenant at PACT we need individual team members to be functioning at the top of their license. It was particularly key in the nurse care manager role because we needed this individual to be able to accomplish core triage tasks. That meant hiring at a different level and having an entry period before we would officially say this nurse care manager could actually function in our clinic. The LPN role also required a more diverse skillset then in other clinic settings. To help achieve these performance standards we attempted to recruit more experienced RNs. This has been a challenge, that is why it took us two years to get up to our five RNs. All team members are involved in interviewing candidates and we made aggressive use of feedback from providers to help develop performance improvement plans for our PACT team members and we followed through on these, which has made a huge difference in our ability to achieve the goals of PACT. 

This brings me to poll question number two. I am going to turn it over to you Molly.

Moderator:Thank you very much. Once again, for our attendees, you do see the poll question on your screen. Please click the circle next to your answer and then press submit. The question is - Which best describes your facility?**We have developed new resident orientation practices to teach specifically about PACT. The level is - A lot; A little bit; Not at all; or Not sure. It looks like we had about half of our audience vote but answers are still streaming in so we will give people just a little bit more time. We appreciate our audience answering these questions as it helps better inform our presenters going forward and also provides the PACT team’s in general valuable information. Okay it looks like we maxed out at about sixty percent. I am going to go ahead and close the poll and share the results and you should be able to see those now.  Do you want to talk through those real quick?

Dr. Elizabeth Allen:Yes, there is something blocking my screen now. Alright thanks all for responding. We have the majority of the audience; thirty-eight percent indicated that they are not sure if they revised orientation practices to teach residents specifically about the PACT model, that is thirty-eight percent. Twenty-four percent felt that they had done a lot to revise orientation procedures. Twenty-four percent felt they did that a little bit and fourteen percent of you have done nothing at all so far to adapt orientation procedures to educate about PACT. 

Alright, moving on to talk a little bit about teaching residents about PACT and what we are doing in Portland and see how it compares to what you are doing at your own sites for those of you who have made changes. We vastly changed our resident orientation and now includes expanded time devoted to processes for communication in the team and with patients.  We spend a significant amount of time teaching about team function in managing chronic illnesses. We do this in orientation and then we reinforce it and we block. For instance if our block two is diabetes block, that month in every plus one week, we have practice management sessions in which residents are provided with data on their diabetes performance A1Cs etcetera. During those sessions the pharmacist, the nurse care manager, the LPNs are all present to assist residents in addressing their fallouts in performance and develop plans to correct these issues. All team members participate in a resident orientation. Second key feature of what we changed was that we did a major ambulatory correctional overhaul. We had to do this anyway to adapt to the three plus one model. And in this ambulatory curriculum, we now included these practice management sessions that I just described in every plus one week so we have a fourth of the residents there in any given plus one week. And we spend approximately two hours of time doing practice management and two whole half days teaching about different ambulatory topics and team members participate in many of these sessions. 

I am going to talk a little bit about how we try and live the team approach and get residents to really live the team approach during their first week and clinic residents shadow RNs and facilitators to understand exactly what they do. Then later in the year we have them shadow again. The residents are a little more experienced and have a better ability to appreciate what their team members are doing. By this way we hope that they understand how best to direct their requests to the appropriate level within the team, evaluation of residents is done by all team members. We found that this more diverse feedback contributes to improvement in resident performance. It has been a very unique avenue to receive feedback and it has been very effective for some of our residents who struggled with communication issues and we kind of knew about it, but never knew exactly from the nursing or administrative support perspective what it was exactly they were doing that was not working. Now we are getting that communication directly. We spend time with residents on process issues like recall management and opioid management in every one of our practice management sessions. The orientation is constantly being reinforced in practice management sessions and weekly enlarged team degree. Had a very tough time figuring out how to huddle so we compromised by saying once a week on Friday afternoons we will have a big team debrief where all the residents that are there in any given particular week, many of the staff and all of the PACT team staff, nurses, pharmacists that get together to discuss how the week went and what we might want to change for the future. 

We have some continued challenges. We do not have ideal huddles as prescribed by the traditional PACT model. Our full team is never all there and our response was to develop these Friday debrief sessions with all clinic staff instead. Our access for routine chronic care management is excellent; the residents are there a whole week, once every fourth week. We never run out of appointments for them, but it is rarely possible for us to achieve same day access with a patient’s own provider. Our access for acute care is fabulous. Our patients can get same-day/next day access with a member of team. We run an urgent day clinic every day of the week and the resident clinic, but that does not count toward the VA performance metric, which dictates that access has to be with one’s own provider for it to count. Likewise, our continuity scores suffer because if a patient is seen by another team provider that is not captured as patient care continuity, which is a little bit of a conundrum for us, and I believe others around the country. The question remains, is it as good to be seen for an acute problem by a team member as opposed to your own provider. We do not really know that. Our final challenge is that we have a poorly designed clinic space and lack of sufficient space to achieve PACT goals and educational mission simultaneously. We have already put in a proposal for space ratings that we designed but I believe we all know how difficult it can be achieve funds for this sort of activity so we are waiting to hear back on that. 

Concluding Points - Teams work better when residents have dedicated outpatient time with no other competing clinical responsibility. The three plus one has worked in our setting; more than 3 weeks out of clinic we thought would probably not work thought others have found that it does. It will be up to your site. Residents learn a lot more about full process of team-based care, using this approach. An RN centric PACT model works better in our clinic staffed by multiple part time providers. Creative structure to huddle sessions allows us to involve more residents. The people you hire to work in your clinic, the nurses and administrative staff have to embrace the educational mission for this really to work. 

I thank you all for your attention and if any of you are interested in seeing our PACT training material or orientation materials or ambulatory curriculum materials we are happy to share that. I have listed three contacts on this slide; send an email to all three of us, myself, Linda Lucas and Carol Sprague and we will be happy to get you the materials. 

Moderator:Thank you very much to both of you and at this time I would like to turn it over to Dr. Johnson. Are you ready to share your screen? You may still be on mute if you are trying to speak.

Dr. Megan Johnson:Yes, I am ready.

Moderator:Great, can you pick up the handset the audio is quite low.

Dr. Megan Johnson:Yes.

Moderator:Excellent, thank you. 

Dr. Megan Johnson:Thank you. Welcome everyone and thank you for attending, virtually attending our cyber seminar. I am going to continue with the theme of resident education but with a slight twist in that we were interested in how to educate primary care residents about learning about primary care mental health integration within the PACT model. I am presenting but I am representing a large team that included Dr. Pamela Diefenbach and Dr. Warren Simmons who are the other primary care mental health providers on our team. Then Dr. Neil Paige, Dr. Greg Orshansky and Kristen Kopelson who are the primary care leads within our clinic. Then Susan Vivell from the VISN 22 VAIL PACT team who helped us with our data analysis. Then or course this whole project could not have happened without the great support that we got from the VISN 22 VAIL PACT team. 

During this presentation, I am going to go over why it would be important for primary care residents to learn about Primary Care Mental Health Integration. How have we changed our approach for teaching our primary care residents about primary care mental health integration? Then some preliminary results of the evaluation we did of this 2I project. Then some of the challenges and opportunities that we had in making this transformation. 

Part of the context of why we felt like this was important is that as the former presenters talked about resident education is a huge mission within the VA. Actually, the VA plays a huge part in resident education throughout the country. So sixty-five percent of US physicians in training are educated at least in part of their residency within the VA. Number one they are an important part of the VA workforce. In most clinics, residents provide a portion of the care. Then conversely what we teach them in the VA, they are going to carry what they do their future practices both within the VA and outside the VA.

Then a little bit of context about behavioral health within VA primary care. It has been well documented that most mental disorders actually get treated in primary care rather than specialty care. Especially in regards to depression and anxiety of those people in the US who get care, they are more likely to get care with a primary care than in specialty mental health. So it is very important that primary care Dr.s and other providers know how to screen, triage, treat and/or refer those patients. Certainly, we know mental disorders especially depression and anxiety can affect the outcomes of medical illness. And as well, there are issues that are not mental health disorders, but are health behaviors such as ability to care for yourself; ability to adhere to recommendations for diet and exercise. So there are behavioral issues that also impact the outcomes of medical illness. The combined approaches of the Patient Aligned Care Teams (PACT) as well as Primary Care Mental Health Integration are both opportunities that the VA presents to really improve the quality of behavioral health within primary care both to address mental disorders as well as address behavioral issues that affect the care of chronic illness. So we really felt that primary care residents could benefit from some training about how to really effectively collaborate with the integrated primary care mental health providers who were in the primary care clinic to optimize the care of their patients. 

How did we use to this because we actually have been, we have collocated mental health team that is within primary care and some members of our team have been here as long as nineteen years. We have had a mental health presence in the clinic for a long time and the primary care residents had an educational experience with mental health for many years. The way that it used to be set up is that for one month per year, the residents would spend one afternoon a week with the mental health team. They were treated like psychiatry residents so they were given two to three psychiatry consults from the primary care clinic to complete in the afternoon and were supervised on how to do those consults. They completed a full psychiatric evaluation in about an hour and then came up with an initial plan of treatment. Although because they were only there for a month there was really very limited opportunity for them to be able to see any of the patients come back. The residents really like this rotation they said they enjoyed having a chance to do more in-depth assessments and spend more time with patients. They rated the experience very highly, however, when we would run into the residents in the clinic while they were conducting their primary care clinic, and talked to them we would find out that they really did not feel like they could take what they learned in that rotation and apply it within their own primary care practices. It just was not the knowledge did not transfer into practice. So we felt that we needed to make some changes in that. 

With the help of the VISN 22 VAIL team, we did a literature search to try to look at what are some of the other approaches that various folks in the past have used. Other folks have published about the idea of doing a one-month psychiatry rotation. There are people who have published about various didactic approaches separate from a clinical experience. Then some have even tried combining psychiatry residents with family practice residents in order to provide onsite consultation. The general areas that people have focused on in that past have been; general behavioral health issues; screening for depression, anxiety; substance abuse; homelessness. Then some have even focused on teaching residents a very specific brief intervention such as SBIRT which is screening for brief intervention and referral to treatment, which is a substance abuse intervention or problem solving therapy. 

We also when we were planning this approach we also tried to look at what is known about adult learning and how could we shape this to best impact the learning of our adult learners. Some of the principles that were relevant to us was that the subjects that you are teaching have to be really relevant to the learner’s experience. Then also, adults learn better through active learning so learning by doing and that learning within the context in which the knowledge will be applied is also very important. Again, sort of getting back to that they really enjoyed coming and doing the psychiatry rotation separately but then it did not really transfer to the context in which they really needed the knowledge. Then the fourth thing that seemed relevant was really trying to focus on very specific skills or competencies as learning objectives. 

Our newly redesigned model was to try to integrate the psychiatry attendings into the resident’s continuity clinics. The way that we did that was that the way that the continuity clinics are fun at this facility or the primary care residents that they are there for an afternoon and there is a central conference room where all of the medical attending’s sit and after the residents have seen patients they come and present the cases and then the medical attending supervises them. So what we have done is we have added a psychiatry attending to that conference room. Now, when primary care residents come and present cases to their medical attending’s, if there is a behavioral issue that is going on with that patient then the psychiatry attending can be drawn into the supervision. We do a variety of things. Sometimes it is just a matter of giving information to the primary care residents that they can pass on. For example how to help patients who are having trouble with adherence to a diabetes regiment or information about referrals in the community or at the VA. If the resident has identified say an uncomplicated depression or anxiety, then the psychiatry attending is there to supervise them in the treatment of that uncomplicated disorder. So we may go in with the resident to help them complete the brief evaluation and come up with a treatment plan. Then if there is sort of a more complicated or urgent concern that comes up, say someone with a serious mental illness or someone who is suicidal or homicidal then at that point the psychiatry attending can do a same day consultation and help manage that issue. 

Our goals with this change was that we really hoped that we were going to improve resident skills, knowledge and confidence related to the behavioral health in primary care and that we were hoping that by doing this, not only would we help the residents, but we would help improve the quality of care for the patients in the primary care clinic. [Sorry I went too fast, Molly how do I get back?]

Moderator:If you hover over the left hand corner of your slide, the bottom left hand corner, there will be a blue area. 

Dr. Megan Johnson:Okay there we go. Thank you. We decided with the help of the VAIL team we wanted to have this be as much as we could a data driven QI project. We developed some different measures of whether or not we were being successful one of which was looking at resident and attending satisfaction with the change. The other was to develop a pre/post knowledge assessment that we piloted with some of the residents. Then we also used CPRS data to look at how we were impacting quality of care. 

Within our first PDSA cycle, we implemented this new model of supervision and then early on we obtained some formative feedback from the attending physician most of whom felt positive about the change. They were very happy to have us there.one of their feedbacks was that I guess in some instances what would happen is that the resident would do a sidebar with the psychiatry attending. And the medical attendings really felt that it was important that the whole team of the residents, medical attending and the psychiatry attending be part of the discussion of the behavioral management so we made that change. Then they also suggested that they wanted some more formal education materials and possibly figure out a way to develop some didactics. 

So when our second PDSA cycle we implemented those modifications and as mentioned part of that was developing some handouts or educational materials for residents. So far we have developed some handouts on management of depression and anxiety; management of substance abuse at our facility what resources are available and then a handout on simple motivational interviewing techniques that primary care providers can use if they are trying to help patients make behavioral changes. Of course we also worked with the VISN 22 VAIL team to develop our CPRS outcome measures and then we pilot tested our knowledge surveying. 

Our first outcome was looking at resident satisfaction. And although we used the different forms to evaluate resident satisfaction for the new intervention then we used when they were doing their one-month psychiatry rotation, there is not sort of exact comparison, but we can say that the resident satisfaction with the new model is sort of in the middle. The scale was from zero being no satisfaction and five being high satisfaction and they are running sort of in the middle, slightly above the middle in terms of how much they have been satisfied with the new model. In terms of their qualitative comments, some of them are very enthusiastic and supportive and other people have felt that they have not had enough interaction with the mental providers. When I presented this to some of the primary care attending’s one of the feedbacks that I have gotten is that we are really asking a lot more of the residents in terms of managing behavioral health within their busy primary care clinics rather than when we had them doing this rotation that was separate in which they only had to focus on one thing. 

We also wanted to look at resident knowledge and we had small group, a convenience sample of residents who filled out an attitude assessment and we did see some interesting changes. We administered the survey the first time at in June 2012 and then administered it again in June 2013. Over the course of the year, the percentage of residents who felt they needed to improve how they managed depression went down and the number who felt that they were very or somewhat skilled in using antidepressants went up and the number who felt that behavioral problems were adversely affecting the medical outcomes in their patients went down slightly. We also presented them with a vignette of a patient with major depression and asked them what they would do to manage that patient and they could say yes to all of those below. Although there were not really significant changes in the number or the percentage of residents who said they would assess or prescribe or personally counsel there was a big increase in the percentage who said that they would refer to specialty mental healthcare. 

Then we also asked them whether in their own practices, whether they do any of the following and these were the percentages of residents who said that they do these things moderately or frequently. You can see that in each category there has been a fairly sizable increase in the percentage of residents who are saying they are encouraging positive thinking, that they are encouraging their patients to increase pleasurable activities or reframe or clarify problems or discussing how depression affects their medical illness. It appears as though there is some change in how they are talking to patients about behavioral health. 

We also put in a few fact based, knowledge questions to get a sense of their actual knowledge about medications. One of the questions as an example was asking them to identify which medications could potentially interact with antidepressants. The percentage who could correctly identify the medications that interacted the proportion increased over the course of the year. 

I apologize for the small type on the slide, but this is looking at our CPRS data and looking at what actually happened with consults over the course of the year. So we compared the year prior to us implementing this intervention so august to May of 2011/2012 to the year that we implemented this change. Overall there has been a small decrement in the total number of consults submitted to mental health, but if you look down into the middle of the slide, while there has been a decrement in the number of consults that are being submitted by attending physicians within the clinic, the number of consults that are coming from house staff has gone up by a third. The other thing that is interesting is that overall, the number of completed consults has gone up by nine percent. I am going to tell you a little bit more and the number that we have had to cancel or discontinue because the patient never came or we were unable to contact the patient has gone down by sixty-three percent. So pretty dramatic change there. This just gives you a little bit more detail and the big picture for this slide is that if you look at the middle section where it looks at the consults from internal medicine house staff you can see that the number of consults that have been submitted and completed has gone up by seventy percent. That means that the number of patients for whom the resident submits a consult and the patient actually shows up for the consult or we are able to complete the same day while they are in clinic has gone up by seventy percent. The number of consults that had either to be cancelled or discontinued has gone down by forty-two percent. 

We feel like the preliminary lessons that we have learned through this first year implementing this new model is that we have significantly increased the number of patients referred by residents to mental health as well as a proportion of those patients who are actually completing the mental health assessment. We are hoping that is related to the fact that the resident is more knowledgeable about the disorders and enable to engage the patient and help motivate the patient to complete the assessment. In addition, we saw some changes in their self-reported likelihood to treat depression as well as some of the measures of knowledge. However, the cautionary point is that the residents are expressing less satisfaction then they had with the previous model. 

We feel like some of the challenges that we have had to deal with is that – one, sometimes challenging to get buy-in for addressing behavioral issues when clinic is very busy, there are a lot of competing other medical disorders that the residents are needing to treat so it sometimes can be difficult for them to be interested in adding another attending into the mix and then another disorder to treat. Given the way that our clinics are structured it has been a little bit challenging up until now to come up with a way to do any kind of formal didactics which we think would actually help them get increased knowledge as well as investment in the behavioral health topics. 

We also realized that from our own part as primary care mental health providers when we saw that the clinics were so busy and the providers were feeling overwhelmed sometimes there was a real temptation to just take over the care ourselves rather than taking the time to spread the residents in providing the treatments. The other challenge we have had is that when primary care mental health providers are surprising residents as well as the resident is being supervised by a medical attending, we have had some challenges in terms of trying to track workload and who gets credit for these various pieces of supervision. Then of course, this whole QI project took place in the context of a lot of other changes within primary care mental health integration and PACT implementation within the clinic. Those have certainly impacted this QI project. 

In terms of next steps, we have now actually at the behest of the general internal medicine residency we have been invited to develop a series of lectures for the formal resident didactics. We are thinking that is going to really help and we will try to work to link those didactic lectures to their clinic experience. We are also going to work on trying to put PCMHI into the resident orientation in a more significant way so that they are more aware of the learning opportunity within clinic. We are hoping also to increase the primary care resident and attending involvement in the program design as we go forward. We are opening that in the following year we will be able to engage a lot more of the residents in the knowledge and attitude survey. Then we are working on putting together a toolkit with our various QI tools with the hope that then we could help disseminate the model to other sites if they are interested. 

Certainly if you have questions, I would be happy to answer any questions or share our materials and our experience with you. Thank you.

Moderator:Thank you very much Dr. Johnson. I know a lot of people joined us after the top of the hour so I just want to let you know how to submit a question or comment. There is a Go to Webinar control panel on the right hand side of your screen. Dr. Johnson can you leave that up in full screen mode just so we have something to stare at. Thank you. For those attendees that joined us after the top of the hour please use the question section ion that Go to Webinar dashboard on the right hand side of your screen to submit a question or comment for the presenters. 

We do have a few pending here. The first one came in I believe when Dr. Allen was speaking. How did you get the nursing staffing up to get an RN to have a panel of five hundred patients or points, pts? 

Dr. Elizabeth Allen:So if I am hearing this correctly, how did we get approval to hire more nurses so that we could restrict their panel at nine hundred patients?

Moderator:I believe so, they said five hundred, but the number could have been wrong. 

Dr. Elizabeth Allen:We did not get it for five hundred, we got it for nine hundred. I believe we made a very compelling argumenta bout what as so uniquely different about our clinic and how the RN role was so much, it is always critical, but it was really critical in our setting in that they were the foundation for the team. They needed high level triage abilities and we were able to prove where they were sending their, for the sixteen hundred patients, they were following at the time, where they were spending their time and how it was virtually impossible for them to complete all their view alerts and post discharge phone calls. There were not enough hours in a day to accomplish those tasks then do the additional work they are supposed to do as part of the PACT team. We presented our time use data, the mismatch between what was expected and what was possible with the number of patients and modeled what we thought would work. Fortunately, we had a supportive executive leadership who then approved the reduction in the number of patients that RNs would have to follow. Where we shorted was we said we could get by with less administrative staff that we would trade off some of them, one specifically for an extra nurse. 

Moderator:Thank you. There is a follow up portion from the same question submitter. Will you share your data in order for others to request the RN staffing increase?

Dr. Elizabeth Allen:Most definitely, you email me at the address on our last slide I would be happy to send you the report we presented, the slide show we presented to executive leadership and specifically the data our RN collected to demonstrate how they simply could not accomplish what was expected of them. 

Moderator:Thank you for that response. The next question – the RN team anchor plays a critical role in the functioning of the PACT. What kind of back up is there when an RN goes on leave or is pulled to cover another clinic?

Dr. Megan Johnson:Yes, that is a problem. We have our RN set surrogates in CPRS when they are going to be on leave and basically, we have four other RNs so basically one of them covers. We do not have an additional resource to draw on during times of leave, but our nurses are required to set surrogates when they are on leave. I hope that answers you question. 

Moderator:Thank you for that reply. Our attendees can always submit further clarification if necessary. This one is a multi-part question so we will take it one bit at a time. Please say more about advancing inter-professional education. Have staff rom nursing, pharmacies, psychology, social work become more formally involved in either didactic or workplace learning. 

Dr. Elizabeth Allen:This is Elizabeth I believe that question is for me. This is a bit of a work in progress. I can tell you that within our clinic, much of the education is done with the clinic staff present. If we are talking about advance directives, end of life management, our social worker is present in all the sessions and participates in teaching them. I can think of less circumstances where our RNs or LPNs are involved in teaching clinical topics say like a module on depression or the like. But when we do the practice management sessions they are there educating our residents about their role in managing diabetes, how they can be of assistance. Certainly some of our educational sessions, they are present at but not all. This is a big initiative at our academic affiliates at Oregon Health and Science University advancing inter-professional education on a wider scale, more to come in about a year. 

Moderator:Thank you I will read the two follow up questions and you may have touched on some of this. Are there trainees from other professions engaged in these academic PACT settings? If so, has there been any integration of didactic instruction and workplace learning between the trainees of the different professions. 

Dr. Elizabeth Allen:Partially. We have trainees from other medical subspecialties; I was interested in hearing Megan’s talk. We have psychiatry residents practicing embedded within our clinic and we have psychiatrists staffing along with our medical attendings. I believe your question might be focusing on do we have nursing students or pharmacy students who are working in the clinic and moving with us. At present, we have pharmacy students who participate in our clinic and receive education there. We frequently have LPN students there, so far that is about it. 

Moderator:Thank you. We do have our last question. Did you have to negotiate with the medical school to meet their requirements to change to the three plus one schedule?

Dr. Elizabeth Allen:Most definitely. Fortunately, the faculty who are involved in running our VA resident clinic are also highly involved in running the residency program so there is a lot of overlap there. As we were struggling in 2011 to figure out what to do to better meet duty hour regulations and to do a better job educating in the ambulatory session, I was at the table, some of my colleagues were at the table trying to sort out what model would work best for us. We attached to this idea of plus one model and then debated in length should it be four plus one or five plus one. We were all worried about the implications of a five plus one having residents out of clinic for five weeks in a row that might not render them available sufficiently to be able to accomplish their chronic care management. We pushed hard for three plus one thinking that was a happy medium, they would only be out of clinic for three weeks. So yes, we negotiated and were at the table in all the decision in what to do for the residents because we are very tightly linked so it was quite easy actually. I am sure that is not the case at all VAs and their academic affiliates, it helps to be involved in running the program. 

Moderator:Thank you for that reply. As we are at the top of the hour, I want to give each of you a chance to make any concluding comments and we will go ahead and start with Dr. Tuepker. 

Dr. Anais Tuepker:I do not have any concluding comments except thank you so much for listening and we hope there was something in the presentation you can take to your own clinics and find useful. 

Moderator:Thank you, Dr. Elizabeth Allen.

Dr. Elizabeth Allen:This is Elizabeth Allen, I cannot think of anything additional to say, other than that if there are those in the audience members who have successfully sorted out how this maintaining continuity scores and access scores, I would love to hear from you. We are struggling with that and trying to present our case to our executive leadership. I cannot say enough about how much going to a plus one schedule really helped us integrate residents into the PACT model. 

Moderator:Thank you and Dr. Johnson.

Dr. Megan Johnson:Just thank you for attending and please contact if you have any questions. Also, I would be interested if there are other attendees who have experience with teaching mental health to primary care residents. We would love to learn from your experience as well. 

Moderator:Great, I would also like to echo the thanks to our audience for joining us today and also to our three presenters for their very informative talk. As you can see on the screen, when you exit today’s session a survey will populate on your screen, please take just a moment to fill out those few questions as it is your opinions and advice that help guide where this program goes and what we present on. So thanks to everyone again for joining us and this does conclude today’s HSR&D cyber seminar. Please join us on August twenty-first for our next PACT session which will also be at noon eastern. Thanks again to everyone and have a great day. 

Page 1 of 15

Page 16 of 16