Reflections on Interprofessional Education, Practice and Academic Pathways at the SFVA

March 2017
San Francisco VA Medical Center

Guest authors this month are JoAnne Saxe, Anna Strewler and Krista Gager.

Around the country, team-based, interprofessional care is recognized as the ideal approach to many aspects of care delivery. But training a generation of clinicians who are truly prepared to deliver such care continues to present numerous challenges – to say nothing of implementing such care in real-world practice settings.

With this in mind, since 2011, UC San Francisco School of Nursing faculty members have contributed to the development and leadership of the San Francisco Veterans Affairs Center of Excellence in Primary Care Education (CoEPCE), an innovative program that has successfully forged and documented successful new approaches to interprofessional education and training. The program aims to advance the delivery of primary care that is patient-centered and team-based at the VA and beyond. Perhaps equally important, by assisting with the development, implementation and evaluation of this program, the involved faculty themselves have undergone a remarkable professional journey.

How It Works

Led by physician Rebecca Shunk and adult-gerontology primary care nurse practitioner (AGPCNP) Anna Strewler, the San Francisco VA Health Care System CoEPCE is one of seven such centers in the country. Most of the faculty members are affiliated with UCSF; working together, they have essentially flipped the traditional primary care education model on its head.

In traditional primary care education, faculty members educate trainees in their own professional silos through coursework and clinical experiences. In contrast, the CoEPCE brings together trainees from across professions – including second-year AGPCNP students, postgraduate UCSF NP residents and second- and third-year UCSF internal medicine residents, as well as psychology, pharmacy, social work and dietetics trainees. The model provides these trainees with precepted, team-based primary care experiences that allow them to refine how they work together, while building their individual professional competencies. Specifically:

  • The CoEPCE preceptors receive formal mentoring in effective clinician education in an interprofessional setting.
  • The NP students and NP residents are paired with internal medicine residents for a one- to two-year rotation, in which they care for a shared panel of patients along with their other interprofessional trainee colleagues and clinic staff members. Each trainee provider has an individual panel of patients, which combine to form a shared team panel.
  • NP trainees see their own patients and also serve as backup providers for their practice partners while they cycle through inpatient rotations.
  • Case-based clinical learning, patient-centered communication, quality improvement (QI) and panel management training, and team huddles and retreats all help guide the workplace learning experience.

Documenting Results

We consistently document the importance and success of this approach. Among the outcomes:

  • Quarterly surveys have revealed that trainees from all involved health care professions have found supportive and satisfying clinical experiences.
  • Patient surveys show high levels of satisfaction with CoEPCE trainee providers.
  • Involved NP faculty from the School and the CoEPCE use their experiences to drive ongoing improvements in the CoEPCE and the School’s AGPCNP curricula.
    • JoAnne Saxe and Caitlin Garvey have used the CoEPCE core curriculum to redesign a patient-centered medical home course for AGPCNP students.
    • Krista Gager and Saxe co-facilitate a primary care clinical seminar for the CoEPCE AGPCNP students.
    • Gager and Saxe co-lead the CoEPCE performance improvement and patient safety learning experiences with physician Maya Dulay.
    • Anna Strewler and Saxe have enhanced geriatric learning experiences for CoEPCE trainees and all AGPCNP students via case-based discussions and/or standardized patient experiences.
    • Strewler, Gager, Dulay and physician Abbi Eastburn developed and implemented a new curriculum for panel management CoEPCE trainees.
  • Drawing on what they learn about performance/QI, trainees are helping to drive important system changes at the SFVA. To date, there have been 33 completed QI projects, with approximately 50 percent of these leading to sustained improvements in care delivery, including increasing the rate of annual urine drug screens among patients receiving chronic opioids and reducing the inappropriate use of proton pump inhibitors.
  • CoEPCE faculty have published six articles, two books and a white paper about the related curriculum and lessons learned. Additionally, faculty and/or trainees have presented findings about various aspects of the program at several conferences across the United States. (For additional details, go to http://www.va.gov/oaa/apact/docs/CoEPCE_Bibliography_and_Scholarly_Works.pdf.)

Bolstering the VA Workforce

The program has also helped build a new type of workforce for the SFVA, which is deeply committed to sustaining an academically affiliated, interprofessional, practice-based model where patients receive high-quality care – and to hiring UCSF graduates dedicated to supporting this model. Since the program’s inception, 34 NP students have completed the program; 13 have completed the NP residency. Seven of these NP residents now practice at the SFVA, with six working in primary care and directly involved with the CoEPCE as clinician educators. Two of the practicing NPs are precepting NP students outside of the CoEPCE. As for the physician residents, 94 have completed the program, with several taking on faculty positions or fellowships at the UCSF School of Medicine and/or clinical positions at the SFVA where clinical education is a standard component of their role. One of the pharmacy residents, Andrew Lau, is now pharmacy co-director of the program, and several psychology fellows and social work interns have been retained at the VA in primary care.

Influencing Career Development and Day-to-Day Practice

We have all found that participation in this program has been a career builder, with both Anna and Krista using it as a platform to move into leadership positions at the SFVA and faculty positions at the School.

Yet perhaps most interesting is the impact on how we practice each and every day. In brief, by gaining an in-depth understanding of how our fellow professionals deliver care – their priorities, mindset, type of expertise and communication strategies – and by working through the many large and subtle challenges involved in transforming a culture of practice, we find that our work is both more effective and more rewarding. As experience allows this understanding to deepen – as we become better at understanding how, when and where to deploy a particular type of expertise and as we learn from each other – we believe that the impact on patient outcomes will continue to be significant.

We expect to focus in more detail on this idea in future posts, but already we believe the CoEPCE here in San Francisco and at VAs around the country will ultimately transform primary care education and practice, while creating further opportunities for academic pursuits.

JoAnne Saxe is a founding faculty member in the CoEPCE, director emerita of the Adult-Gerontology Primary Care Nurse Practitioner program at UCSF School of Nursing and a health sciences clinical professor at the School. Anna Strewler and Krista Gager are 2014 graduates of the AGPCNP program and the CoEPCE. Both are now volunteer clinical faculty at the School; Strewler currently co-directs the CoEPCE, and Gager is one of the associate directors for this program.

Each year, UC San Francisco School of Nursing is ranked among the top graduate schools in the nation. Please visit the Adult-Gerontology Primary Care Nurse Practitioner section of our website to learn more about our work in this area.

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