Integrating Resident Education into 

PACT: Experience of the Portland VA 

Medical Center

Presenters:

Anaïs Tuepker, PhD, MPH

Investigator, VISN 20 PACT Demo Lab

Elizabeth Allen, MD

Section Chief, General Medicine, Portland VA Medical Center
Overview of this seminar

• Key differences between a teaching clinic and a non- teaching clinic

• Unique implications for implementing PACT model in 

teaching clinic

• Insights and innovations developed in PVAMC Teaching 

clinic

• Process used to advocate for change

• Staffing model

• Team structure & function

• Teaching learners about PACT

• Meaningful integration of residents in PACT teams 
Poll Question #1

Please tell us which of the following statements 

best describes resident education practices in your 

VA facility:

• 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/CBOC.

• Residents are on PACT teams at more than one 

clinic/CBOC.
What’s different in a teaching clinic?

• Dual mission: resident education AND patient care

• Provider profiles are different

– Staff Providers are engaged in teaching and research

• Only in clinic part time; multiple competing responsibilities

– Resident Providers 

• Only available episodically; multiple competing clinical responsibilities

• Variable interest in primary care

• Frequent turn over

• Clinic staff have to function as educators, evaluators

• Willing (excited?) to “start over” with each new cohort

• Willing (excited?) to teach

• Willing to correct the same mistakes over and over...

• High functioning clinic translates to improved ability to recruit 

future PCPs
PACT in a Teaching Clinic: 

Unique Implications 

“Natural” disadvantages

• Multiple PCPs (faculty and residents) per PACT team leads to:

– More challenges for coordination, scheduling logistics, communication 

– PACT team members have to adapt to multiple provider styles

– Multiple providers from same team may practice simultaneously 

• Part-time providers create challenges in preserving continuity & access

• Part-time providers are less available to assist in day to day patient care triage 

translating to a greater burden placed on nursing staff

• Regular resident turnover disrupts team continuity

“Natural” advantages

• Residents expect to be learning, enabling a true team approach

• Providers often have research and best practice expertise that facilitates PACT 

activities like population management

• Diversity of roles can contribute to higher staff satisfaction, as supported by Demo 

Lab employee survey results 2010-2011 

• Greater autonomy and potential for leadership for nursing staff
Insights and innovations developed in 

the Portland VAMC resident clinic 

This presentation draws on the work of many clinic staff:

RNs:

Andrew Marges 

Denona Lee (Operations Manager)

Jenny Richardson

LPNs/MAs: 

Maria Anderson

Kristine Hendrickson

Mystery Wells

Providers: 

Elizabeth Allen

Linda Lucas

Carol Sprague

Lisa Winterbottom

Pharmacy: 

Eric Huynh

Social Work: 

Yvette Arey
Clinic snapshot

• All Residents conduct Primary Care 

Clinic at same site. 

• Resident Primary Care Practice is 

completely comprised of part- time 

providers: 

 12 staff providers 

 43 resident providers

 4587 patients (as of 1/12). 

• Majority of staff providers conduct 1-

2 half days of clinic and 1-2 half days 

of precepting per week.

• Since 2011, residents on “3 +1” 

schedule 

• Panel sizes for residents start at 35 

patients in Y1, grow to 75 by Y3

• Staff provider panels are 130 

patients per half day of clinic. 

• 5 PACT teams as of June 2013; 2-4 

staff providers plus 8-9 residents 

per team

• 1-4 providers from the same team 

may conduct clinic at the same 

time. 
How we advocated for change – 

and got it

• Our group developed a detailed proposal for what WE needed

– Identified what was different about the resident clinic

– Highlighted mismatches with current PACT model

• We took a multidisciplinary approach, involving invested 

people from all roles in clinic

– Team members collected data on time use

• Our Primary Care leadership was open and supportive, asked 

clinic team to present the plan to executive leadership
Advocating for Change

Team Member Staffing Level in 2011 Proposal/Rationale

RN – team 

anchor

-3 RN’s for 4600 patients

-Panel size 1500 – 1600 pts/RN

5 RN’s for 5 teams

-Maximum panel size 800-900 pts/RN

-70% time direct care, 30% other PACT 

roles

LPN/MA -1 LPN per team

-Total of 3 LPN’s

1.5 LPN’s/team (7 LPN’s total)

-This number would allow 1 team LPN to 

always work with team providers

Admin 1 facilitator

2 LPN’s cross-covering this role 

1 admin 

4 Administrative Staff: 

-2 full time facilitators 

-1 front desk administrative assistant

-1 dedicated administrative CSS staff

SW 1 SW for 5800 patients -1.5 SW for Area 4 (1 SW/3100pts)

-Separate SW for Women’s Health

Pharmacy 1 Pharmacist for 5800 pts plus 

additional work for pharmacy

1 Pharmacist for Area 4 (4600 pts)

-remove Women’s Health, remove extra 

Pharmacy work
Staffing model as of 6/2013: 

NCMs as team anchor

900 

patients

NCM-A

NCM-C

F 1

P 1

P 2

A1

L1

L2

L3

L3

NCM-B

NCM-D NCM-E 

P3

P4

P5

P6

P7

P8

P11

P12

P9

P10

900 

patients

900 

patients

900 

patients

900 

patients

A2

A3

A4

A5

A6 A7

F2

NCM-A Nurse care manager team A

L1 LPN/MA team A

L2 LPN/MA team B

L3 LPN/MA team A & B

P1 Staff Provider team A

A1 Associate provider team A

F1 Facilitator team A and B

F2 Facilitator teams C, D & E

F3 Front desk

F4 CSS

F3

F4

Covers Front Desk

Covers Phone 

Calls (CSS)

L4

L5 L6

L7

L7
Team roles: some observations

• Since the NCM is the core of the team, s/he must function 

more autonomously and have a higher skill set than has been 

the case in the past

• LPN role also requires more diverse skills than in other clinic 

settings

• To help achieve these performance standards:

– We’ve attempted to recruit more experienced RNs;

– All team members are involved in interviewing candidates;

– We’ve made aggressive use of feedback from providers to 

help develop performance plans, and followed up on 

them. 
Teaching residents about PACT

Poll Question #2

Which best describes your facility? 

We have developed new resident orientation 

practices to teach specifically about PACT...

1) A lot

2) A little bit

3) Not at all

4) Not sure
Teaching residents about PACT

• Resident orientation now includes expanded time devoted to:

– Processes for communication, in team and with patients

– Team function in managing chronic illnesses

– All team members participate in orientation

• Ambulatory Curriculum overhaul led to development of 

practice management sessions for each +1 week

– Team members participate in these sessions
Living the team approach

• During their first week in clinic, residents shadow the RNs and 

facilitators, to understand what they do

- Shadowing repeated later in intern year, when residents are more experienced

• Evaluation of residents is done by all team members

– More diverse feedback contributes to improvement

– Very effective with some residents

• Time spent with residents on process issues like recall 

management and opioid management

• Orientation constantly reinforced in practice, in management 

and weekly large team debriefs
Challenges

• No huddles – full team is never all there

• Response: Friday “debrief” with all clinic staff

• Access for routine chronic care management is excellent, BUT 

it’s rarely possible to achieve same day access with own 

provider

• Access for acute care is in reality excellent – patients can get same- day/next day access with a member of team - but that does not count 

toward performance metric

• Continuity scores likewise suffer

– Possible response: develop new performance metrics to capture this 

dynamic?

– The question remains: is this as good as being seen by your 

provider? This is not yet known.

• Poorly designed space and lack of sufficient space to achieve 

PACT goals and educational mission simultaneously
Concluding points 

• Teams work better when residents have dedicated outpatient 

time with no other competing clinical duties

– “3 +1” works in our setting; more than 3 weeks out of 

clinic would probably not work

– Residents learn a lot more about full process of teambased 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 

residents

• Nurses and administrative staff have to embrace the 

educational mission
Thank you

Interested in seeing our PACT training materials

for residents?

Contacts:

Elizabeth Allen, MD elizabeth.allen@va.gov

Linda Lucas, MD linda.lucas@va.gov

Carol Sprague, MD carol.sprague@va.gov
Educating Primary Care Residents 

about Primary Care Mental Health 

Integration within PACT

Megan Dwight Johnson, MD MPH

Pamela Diefenbach, MD 

Neil Paige, MD

Greg Orshansky, MD

Lauren Simmons, PhD

Kristin Kopelson, MS, RN, NP, FNP-BC, ACNP

Susan Vivell, PhD

VISN 22 VAIL PACT Team
Objectives 

• Why is it important for primary care residents 

to learn about Primary Care Mental Health 

Integration (PCMHI)?

• How have we changed our approach to 

teaching residents about PCMHI within PACT?

• Preliminary results of evaluation

• Challenges and opportunities
Resident Physicians in VA 

• 65% of US physicians in training are 

educated within VA.

• They are an important part of the VA 

workforce.

• They carry what they learn in VA into their 

future careers within VA and beyond.
Behavioral Health in VA Primary Care

• Most mental disorders are treated in primary care.

• Mental disorders and health behaviors (including 

self-care) impact outcomes of medical illness. 

• Patient Aligned Care Teams (PACT) and Primary 

Care Mental Health Integration (PCMHI) provide 

opportunities to improve the quality of behavioral 

health within primary care.

• Primary care residents can benefit from training to 

effectively collaborate with PCMHI to improve the 

behavioral health of their patients. 
Previous approaches

Didactic Methods:

• One month psychiatry rotation for family medicine residents 

(Christiansen 2003, Tinsley 2000) 

• Didactics (lectures, case conferences, games, skills training and 

practice, simulated patients) (Huzij 2005, Hottema 2012, Stein 2011) 

• Psychiatry residents provide consultation & didactics in PC clinics 

(Servis 2000) 

Content areas:

• General behavioral health

• Substance abuse (Alford 2009; Nigwekar 2006) 

• Homelessness (Buchanan 2004, 2007)

• Brief interventions:

– Screening, Brief Intervention, and Referral to Treatment (SBIRT) 

(Hettema 2012) 

– Problem Solving Treatment (PST) for depression (Hegel 2004)

– Motivational Interviewing (Triana 2012) 

– Enhancing patient self-efficacy (Jerant 2009) 
Key principals for teaching adult learners

• Subject must be relevant to the learner’s 

experience

• Active learning (“Learning by doing”)

• Learning within the context in which the 

knowledge will be applied 

• Specific competencies as learning objectives

(Knowles 1990, Savory & Duffy 1995)
Our previous strategy for teaching PC 

residents about mental health

• One afternoon a week for 4 weeks

• Residents completed 2-3 psychiatry consults per week

• Limited opportunity for follow-up visits

• Resident evaluations: 

– High satisfaction

– Residents liked practicing in-depth assessments and spending 

more time with patients

• However, later informal feedback from PC residents suggested 

that they did not often apply new skills and knowledge in their 

own PC practices. 
New Model

• During PC continuity clinics medical residents come to a central 

conference room for supervision from medical attendings. 

• Psychiatry attendings are now present during that time to provide:

– Information about behavioral health resources

– Supervision of residents’ management of behavioral issues 

(e.g., uncomplicated depression, anxiety, substance misuse, 

health behaviors) 

– Same-day consultation for complicated or urgent mental health 

concerns
Overall Goals 

• Improve resident skills, knowledge, and 

confidence related to behavioral health in 

primary care

• Improve access to and quality of mental 

health care in primary care
Measures 

• Resident/Attending satisfaction

• Resident Pre-Post Knowledge Assessment 

(pilot)

• CPRS data

– Number of consults generated 

– Number of completed consults
PDSA cycle 1

• Implement model

• Obtain formative feedback from attending 

physicians

– Mostly positive

– Wanted medical attending involved in the 

discussion of behavioral management of the patient

– Suggested use of educational materials and 

possibly didactics
PDSA cycle 2

• Implement modifications

• Develop educational materials 

– Depression

– Anxiety

– Substance abuse 

– Motivational interviewing

• Develop CPRS outcome measures

• Pilot test knowledge survey
Outcomes: Resident Satisfaction 

• Resident satisfaction

– How helpful with care of patients (3.3/5)

– How much did you learn (3.2/5)

– How much did you enjoy learning (3.2/5)

– Suggestions for improvement:

• “Doing a great job. Keep it up!”

• “Enjoyed the experience; very convenient to have 

mental health in our office during PACC”

• “More support. We don’t really have too much 

interaction with MH providers.”
Outcomes: Resident Knowledge and 

Attitudes Assessment (pilot test)

June 2012 

N=22

June 2013

N=13

% (N)

Definitely or probably need to improve how you 

manage depression

67% (14) 54% (7)

Very or somewhat skilled in using antidepressants 33% (7) 62% (8)

Behavioral problems adversely affect medical 

outcomes in my patients (moderately or a lot)

80% (16) 62% (8) 

Major Depression vignette

 Assess but not treat 41% (9) 38% (5)

 Personally prescribe medication 55% (12) 62% (8)

 Personally counsel 59% (13) 62% (8)

 Refer to MH specialty 60% (14) 85% (11)
Pilot Resident Survey (continued) 

7/16/2013 VAIL-PACT VISN22 15

June 2012 

N=22

June 2013

N=13

% (N)

Moderately or frequently do the following when 

talking to patients about depression

 Encourage positive thinking 36% (8) 54% (7)

 Increase pleasurable activities 41% (9) 70% (9)

 Reframe or clarify problems 50% (11) 70% (9) 

 Discuss how depression affects medical illness 41% (9) 62% (8)

Correctly identify medications that interact with 

antidepressants 

38% (8) 54% (7)
Process of Care Outcomes 

Consults from WLA PACC to WLA 

Mental Health Integrated Care Team

8/ 1 /11 – 5/31 /12 8/1 /12 – 5/31 /13 Change from

8'11-5'12 to 

8'12-5'13

NUMBER PERCENT NUMBER PERCENT

MHIC Consults from WLA PACC Clinics: TOTAL 559 505 -10%

Consult Requestors

Attendings 362 64.8% 258 51.9% -29%

IM Housestaff 90 16.1% 120 23.4% 33%

NPs & PAs 107 19.1% 127 24.8% 19%

Consult Status

Completed 385 68.9% 412 81.7% 9%

Cancelled or Discontinued 174 31.1% 73 14.2% -63%
Process of Care Outcomes (con’t) 

WLA PACC Consult Requestors

8/1 /11 – 5/ 31 /12 8/1 /12 – 5/31 /13 Change from 

8'11-5'12 to 

8'12-5'13

NUMBER PERCENT NUMBER PERCENT

MHIC Consults from WLA PACC Medicine Attendings: 

TOTAL 362 258 -29%

Completed 259 71.5% 213 82.7% -18%

Cancelled or Discontinued 103 28.5% 34 13.2% -67%

Scheduled 0 11 4.1% 

Consults from WLA PACC IM Housestaff: TOTAL 90 120 33%

Completed 57 63.3% 97 80.8% 70%

Cancelled or Discontinued 33 36.7% 22 18.3% -42%

Scheduled 0 1 0.1%

Consults from WLA PACC NPs & PAs: TOTAL 107 127 19%

Completed 69 64.5% 102 80.3% 48%

Cancelled or Discontinued 38 35.5% 16 12.6% -60%

Scheduled 0 9 7.1%
Challenges 

• Buy-in for addressing behavioral health issues when 

clinic is busy

• Finding opportunities for formal teaching

• Temptation of PCMHI providers to take over care 

themselves rather than supervising residents in 

providing the treatment

• Tracking PCMHI provider workload

• Changes in PCMHI and PACT implementation and 

staffing in the clinic overall
Preliminary Lessons Learned

• New model appears to have increased:

• Number of patients referred by residents to mental health

• Proportion of those patients completing a MH assessment

• Self-reported likelihood to treat depression (including use 

of antidepressant medication and personal counseling)

• However: 

– Lower resident satisfaction than with previous model
Next Steps

• Psychiatry lectures to be added to PC resident didactics

• Improve orientation for PC attendings and residents

• Increasing PC resident and attending involvement in program 

design

• Improve uptake of knowledge & attitude survey

• Producing tool-kit:

– Educational materials

– CPRS templates for notes, consults

– Resident knowledge survey

– Satisfaction assessments

– Outcome measures

• Dissemination to other sites
• Megan Dwight Johnson, MD MPH

Megan.Johnson4@va.gov

Questions? 

7/16/2013 VAIL-PACT VISN22 21