Center of Excellence in Primary Care Education - Education in Patient Aligned Care Teams

The mission of the San Francisco VA Center of Excellence in Primary Care Education (COEPCE) - Education in Patient Aligned Care Teams (EdPACT) program is to develop and implement an inspirational model of patient-centered interprofessional education.  The goal is for teams of health care providers, staff and trainees to consistently participate in all aspects of a patient-centered care approach.  The program is set in the primary care clinic at the main hospital and two community-based outpatient clinics.

One of five centers across the United States, the San Francisco VA Medical Center (SFVAMC) COEPCE was selected and funded by the Veterans Affairs (VA) Office of Academic Affiliations to participate in this effort for an initial five year period.  The SFVAMC and the University of California, San Francisco (UCSF) are also each providing institutional support and donated efforts for this initiative. This partnership requires collaboration and teamwork amongst physician and nursing faculty, associated health care providers, internal medicine residents, adult nurse practitioner students and fellows, as well as associated health trainees.

Primary goals of the program are to teach and implement the following:  teambuilding and interprofessional collaboration, patient-centered communication and shared decision making, sustained relationships across all aspects of health care delivery, and performance improvement.

Core learners of this COEPCE are trainee triads comprised of two second year residents in internal medicine and a second year nurse practitioner student. Post-graduate year two residents (PGY2s) rotate between two months of outpatient training and two months of inpatient training. Instead of going to the clinic during their inpatient months, residents attend their primary care clinic three half-days per week. The nurse practitioner student sees patients three half-days per week every week for one year.

Organizing Framework for the Center of Excellence:  Five fundamental design principles were used to guide the development of EdPACT. 

1. Culture: Establish a culture committed to the values of the VA patient aligned care team (PACT) initiative by providing ongoing teamwork and communication training to all members of the PACT.
2.  Relationships: Promote a relationship-centered approach to communication by teaching skills and reinforcing them in practice through modeling and feedback.
3.  Activation: Encourage self-awareness, self-regulation, and proactive behavior through regular opportunities for reflection, professional development, and discussion of action steps.
4. Clinically-Oriented: Use trainees’ own experiences of working in clinical microsystems and caring for patients as material for learning activities; provide reinforcement in practice.
5. Accountability: Create accountability for performance and continuously strive for improvement on an individual, team, and clinic levels.

Key innovation in shared decision-making: The program has implemented an interprofessional curriculum emphasizing core skills in patient-centered communication, shared decision-making and motivational interviewing. Trainee patient encounters are videotaped and then reviewed, discussed, and feedback is provided in an interprofessional group setting.

Key innovation in sustained relationships: Trainee triads form EdPACT teams with individual and shared patient panels. Nurse practitioner and MD faculty mentors precept assigned EdPACT teams allowing team members and assigned faculty to have continuity in supervision and patient care. The program evaluates patient-provider and patient-team continuity as well as patient and team perceptions of and satisfaction with continuity and coordination of care.

Key innovation in interprofessional collaboration: Each EdPACT team participates in a half-day team building retreat.  Training is reinforced through learning sessions throughout the year and during bi-weekly huddles between trainee triads and the registered nurse, licensed vocational nurse and clerical associate on the team.  Huddles are facilitated by interprofessional faculty who provide ongoing feedback using a huddle checklist. In addition, the larger PACT team, including interprofessional trainees in psychiatry, psychology, podiatry, pharmacy, social work, and dietetics, participate in collaborative case conferences and a diabetes board where patients with complex medical issues are presented and discussed by interprofessional trainees and their faculty mentors. Team members complete the "Team Development Measure" twice a year to evaluate team cohesiveness, communication, role clarity, goals, and means clarity.  The program’s psychology faculty and primary care psychology fellows debrief results of the team development measure with trainee and staff team members, emphasizing team process and opportunities for improving team performance.

Key Innovation in performance improvement: Prior to EdPACT, interprofessional trainees learned and implemented performance improvement projects in discipline-based silos. Now, trainees engage in team-based interdisciplinary performance improvement training and projects. Designing, implementing, and evaluating these projects are key elements of the training. Evaluation includes the quality improvement knowledge assessment tool (QIKAT) and demonstration of performance improvement in the domain targeted by the project.

Faculty development plan: A patient-centered collaborative culture has been established by engaging Center of Excellence faculty and staff in teamwork and patient communication workshops (along with trainees) such as TeamSTEPPS training as well as additional teambuilding training led by the American Academy on Communication in Healthcare. This collaborative culture is reinforced through monthly faculty development meetings and faculty are encouraged to participate in UCSF Office of Medical Education faculty development courses; funds are made available to support faculty in pursuing additional training.