John Sellinger, PhD

Chronic pain is common in veterans, and early engagement in pain treatment is recommended to forestall consequences of untreated pain, including depression, disability, and substance use disorders. The Veterans Health Administration (VHA) employs a stepped care model of pain treatment, with the majority of pain care based in primary care (step 1), and an array of specialty/multimodal treatment options made available at each step in the model for patients with more complex problems, or those who do not respond to more conservative interventions.¹

Recognizing the need for comprehensive pain care, the US Congress passed the Comprehensive Addiction and Recovery Act, 21 USC §1521 (2016), which included provisions for VHA facilities to offer multimodal pain treatment and to report the availability of pain care options at each step in the stepped care model.^2, With the passage of the Veterans Access, Choice, and Accountability Act of 2014, 38 USC §101 (2014) and now the MISSION Act of 2018, 38 USC §703 (2018) veterans whose VHA facilities are too distant, who require care unavailable at that facility, or who have to wait too long to receive care are eligible for treatment at either VHA or non-VHA facilities.³ These laws allocate the same pool of funds to both VHA and community care and thus create an incentive to engage veterans in care within the VHA network so the funds are not spent out of network.⁴

An opportunity to connect veterans with VHA care arises at specialized VHA Compensation and Pension (C&P) clinics during examinations that determine whether a veteran’s health conditions were caused or exacerbated by their military service. Veterans file claims with the US Department of Veterans Affairs (VA) Veterans Benefits Administration (VBA), which sends the patient to either a VHA facility or private practitioners for these examinations. Although the number of examinations conducted each year is not available, there were 274,528 veterans newly awarded compensation in fiscal year 2018, and a substantial number of the total of 4,743,108 veterans with C&P awards had reevaluation examinations for at least 1 of their conditions during that year.⁵ Based largely on the compensation examination results, military service records, and medical records, veterans are granted a service-connected rating for conditions deemed related to military service. A service-connection rating between 0% and 100% is assigned by the VBA, with higher ratings indicating more impairment and, consequently, more financial compensation. Service-connection ratings also are used to decide which veterans are in the highest priority groups for receipt of VHA health care services and are exempt from copayments.

Although traditionally thought of as a forensic evaluation with no clinical purpose, the C&P examination process affords many opportunities to explain VHA care to veterans in distress who file claims.⁶ A randomized clinical trials (RCT) involving veterans with mental health claims and a second RCT including veterans with musculoskeletal claims each found that veterans use more VHA services if offered outreach at the time of the C&P examination.^7,8 In addition to clinical benefits, outreach around the time of C&P examinations also might mitigate the well documented adversarial aspects of the service-connection claims process.^6,9,10 Currently, such outreach is not part of routine VHA procedures. Ironically, it is the VBA and not VHA that contacts veterans who are awarded service-connection with information about their eligibility for VHA care based on their award.

Connecting veterans to pain treatment can involve clarifying eligibility for VHA care for veterans in whom eligibility is unknown, involving primary care providers (PCPs) who are the fulcrum of VHA pain care referrals, and motivating veterans to seek specific pain treatment modalities. Connecting veterans to treatment at the time of their compensation examinations also likely involves bidirectional cooperation between the specialized C&P clinics where veterans are examined and the clinics that provide treatment.

Relational coordination is a theoretical framework that can describe the horizontal relationships between different teams within the same medical facility. Relational coordination theorizes that communication between workgroups is related synergistically to the quality of relationships between workgroups. Relational coordination is better between workgroups that share goals and often have high levels of relational coordination, which is thought to be especially important when activities are ambiguous, require cooperation, and are conducted under time pressure.¹¹ High relational coordination also has been associated with high staff job satisfaction, high satisfaction with delivered services, and adherence to treatment guidelines.^12-14 An observational cohort study suggested that relational coordination can be improved by targeted interventions that bring workgroups together and facilitate intercommunication.¹⁵

To better understand referral and engagement for pain treatment at compensation examinations, VA staff from primary care, mental health, pain management, and C&P teams at the 8 VHA medical centers in New England were invited to complete a validated relational coordination survey.^11,16 A subset of invited staff participated in a semistructured interview about pain treatment referral practices within their medical centers.

Methods

Assessments were conducted as part of a mixed methods formative evaluation involving quantitative and qualitative methods for a clinical trial at the 8 VHA medical centers in New England. The trial is testing an intervention in which veterans presenting for service-connection examinations for musculoskeletal conditions receive brief counseling to engage them in nonopioid pain treatments. The VHA Central Institutional Review Board approved this formative evaluation and the clinical trial has begun (ClinicalTrials.gov NCT04062214).

Potential interviewees were involved in referrals to and provision of nonpharmacologic pain treatment and were identified by site investigators in the randomized trial. Identified interviewees were clinical and administrative staff belonging to VHA Primary Care, Pain Management, and Compensation and Pension clinics. A total of 83 staff were identified.

Semistructured Interviews

A subset of the 83 staff were invited to participate in a semistructured interview because their position impacted coordination of pain care at their facilities or they worked in C&P. Staff at a site were interviewed until no new themes emerged from additional interviews, and each of the 8 sites was represented. Interviews were conducted between June and August 2018. Standardized scripts describing the study and inviting participation in a semistructured interview were e-mailed to VA staff. At the time of the interview the study purpose was restated and consent for audiotaping was obtained. The interviews followed a guide designed to assess a relational coordination framework among various workgroups. The data in this manuscript were elicited by specific prompts concerning: (1) How veterans learn about pain care when they come through C&P; and (2) How staff in C&P communicate with treatment providers about veterans who have chronic pain. Each interview lasted about 30 minutes.

Relational Coordination Survey

All identified staff were invited to participate in a relational coordination survey. The survey was administered through VA REDCap. Survey invitations were e-mailed from REDCap to VA staff and included a description of the study and assurances of the confidentiality of data collected. Surveys took < 10 minutes to complete. To begin, respondents identified their primary workgroup (C&P, primary care, pain management, or administrative leadership or staff), secondary workgroup (if they were in > 1), and site. Respondents provided no other identifying information and were assured their responses would be confidential.

The survey consisted of 7 questions regarding beliefs about the quality of communication and interactions among workgroup members in obtaining a shared goal.¹¹ The shared goal in the survey used in this study was providing pain care services for veterans with musculoskeletal conditions. Using a 5-point Likert scale, the 7 questions concerned frequency, timeliness, and accuracy of communication; response to problems providing pain services; sharing goals; and knowledge and respect for respondent’s job function. Higher scores indicated better relational coordination among members of a workgroup. Using the survey’s 7 items, composite mean relational coordination scores were calculated for each of the 4 primary workgroups. To account for the possibility that a member rated their own workgroups, 2 scores were created for each workgroup; one included members of the workgroup and another excluded them.

Data Analysis

The audio-recorded semistructured interviews were transcribed and entered into Atlas.ti qualitative data analysis software. To identify cross-cutting themes, a semistructured telephone interview guide was developed by the qualitative study team that emphasized interrelationships between different clinical teams. The transcripts were then analyzed using the grounded theory approach, a systematic methodology to reduce themes from collected qualitative data. Two research staff read each transcript twice; first to familiarize themselves with the text and then, using open coding, to identify important concepts that emerged from the language and assign codes to segments of text. To ensure accuracy, researchers included suitable contextual information in the coding. Using the constant comparative method, research staff then met to examine the themes that emerged in the interviews, discuss and coalesce coding discrepancies, and compare perspectives.¹⁷

The composite score (mean of the 7 items and 95% CI) of the survey responses was analyzed to identify significant differences in coordination across the 4 workgroups. Analysis of variance (ANOVA) was used to examine each relational coordination score by respondents’ workgroup. Post hoc analyses examined relational coordination survey differences among the 4 respondent groups.

Results

Thirty-nine survey respondents participated in the semistructured interviews. C&P examiners expressed varying degrees of comfort with their role in extending access to pain care for veterans. Some of the examiners strongly believed that their role was purely forensic, and going beyond this forensic role to refer or recommend treatment to veterans would be a violation of their role to conduct a forensic examination. “We don’t have an ongoing therapeutic relationship with any of the patients,” a C&P examiner explained: “We see them once; they’re out the door. It’s forensic. We’re investigating the person as a claimant, we’re investigating it and using our tools to go and review information from 30, 40 years ago.”

Other examiners had a less strict approach for working with veterans in C&P, even though examiners are asked not to provide advice or therapy. One C&P examiner noted that because he “can’t watch people in pain,” during the examination this doctor recommends that patients go to the office that determines whether they are eligible for benefits and choose a PCP. Another C&P examiner concurred with this approach. “I certainly spend a little time with the veteran talking to them about their personal life, who they are, what they do, what they’ve done, what they’re going to do to kind of break the ice between us,” the second examiner explained. “At the end, I will make some suggestions to them. I’m comfortable doing that. I don’t know that everybody is.”

Many of the VHA providers we interviewed had little knowledge of the C&P process or whether C&P examiners had any role or responsibilities in referring veterans for pain care. Most VHA providers could not name any C&P examiners at their facility and were generally unfamiliar with the content of C&P examinations. One provider bluntly said, “I’ve never communicated with anyone in comp and pen [C&P].”

Another PCP also expressed concerns with referrals, suggesting that C&P and primary care “are totally separate and should remain separate,” the PCP explained. “My concern with getting referral from comp and pen is that is it then they’re seeking all sorts of treatment that they wouldn’t necessarily need or ask for otherwise.”

Conversely a different PCP had a positive outlook on how C&P examiners might help ease the transition into the VHA for veterans with pain, especially for newly discharged veterans. “Having comp and pen address these issues is really going to be helpful. I think it could be significant that the topic is introduced early on.”

Relational Coordination Survey

Relational coordination surveys were sent to 83 participants of whom 66 responded. Respondents were from C&P (n = 7), primary care (n = 16), pain medicine (n = 32), and administration (n = 11). Of the 66 respondents, 18 indicated a secondary workgroup. Respondents on 2 teams (primary/secondary) were primary care/administrative (n = 4), pain management/primary care (n = 4), primary care/pain management (n = 3), administrative/primary care (n = 3), and C&P/administrative (n = 1).

The relational coordination composite scores were lowest for C&P. This finding remained whether C&P staff surveys were included or removed from the C&P responses. As demonstrated by the 95% CI, when team members’ surveys were included, C&P scores (95% CI, 2.01-2.42) were significantly lower than the primary care (95% CI, 3.34-3.64) and pain management (95% CI, 3.61-3.96) groups. All the relational coordination composite scores were slightly lower when staff who described their own workgroup were removed (ie, respondents rated their own workgroups as having higher relational coordination than others did). Using the composite scores excluding same workgroup members, the composite scores of the C&P remained significantly lower than all 3 other workgroups (Table). Means values for each individual item in the C&P group were significantly less than all other group means for each item except for the question on responses to problems providing pain services (data not shown). On this item only, the mean C&P rating was > 3 (3.19), but this was still lower than the means of the primary care and pain management workgroups.

Further analyses were undertaken to understand the importance of stakeholders’ ratings of their own workgroup compared with ratings by others of that workgroup. A 1-way ANOVA of workgroup was conducted and displayed significant workgroup differences between member and nonmember relational coordination ratings on 3 of the 4 workgroup’s scores C&P (F = 5.75, 3, 62 df; P < .01) primary care (F = 4.30, 3, 62 df; P < .008) and pain management (F = 8.22, 3, 62 df; P < .001). Post hoc contrasts between the different workgroups doing the rating revealed: (1) significant differences in the assessment of the C&P workgroup between the C&P workgroup and both the primary care (P < .01) and pain management groups (P < .001) with C&P rating their own workgroup significantly higher; (2) a significant difference in the scoring of the primary care workgroup with the primary care group rating themselves significantly higher than the C&P group; and (3) significant differences in the scoring of the pain management workgroup with both pain management and primary care groups rating the pain management group significantly higher than the C&P group. The results were not substantially changed by removing the 18 respondents who identified themselves as being part of > 1 workgroup .

Discussion

Mixed methods revealed disparate viewpoints about the role of C&P in referring veterans to pain care services. Overall, C&P teams coordinated less with other workgroups than the other groups coordinated with each other, and the C&P clinics took only limited steps to engage veterans in VHA treatment. The relational coordination results appeared to be valid. The mean scores were near the middle of the relational coordination rating scale, with standard deviations indicating a range of responses. The lower relational coordination scores of the C&P group remained after removing stakeholders who were rating their own workgroup. Further support for the validity of the relational coordination survey results is that they were consistent with the reports of C&P clinic isolation in the semistructured interviews.

The interview data suggest that one reason the C&P teams had low relational coordination scores is that VA staff interpret the emphasis on evaluative rather than therapeutic examinations to preclude other attempts to engage veterans into VHA treatment, even though such treatment engagement is permitted within existing guidelines. VBA referrals for examinations say nothing, either way, about engaging veterans in VHA care. The relational coordination results suggest that an intervention that might increase treatment referrals from the C&P clinics would be to explain the (existing) policy allowing for outreach around the time of compensation examinations to VHA staff so this goal is clearly agreed-upon. Another approach to facilitating treatment engagement at the C&P examination is to use other interventions that have been associated with better relational coordination such as intergroup meetings, horizontal integration more generally, and an atmosphere is which people from different backgrounds feel empowered to speak frankly to each other.^15,18,19 An important linkage to forge is between C&P teams and the administrative workgroups responsible for verifying a veteran’s eligibility for VHA care and enrolling eligible veterans in VHA treatment. Having C&P clinicians who are familiar with the eligibility and treatment engagement processes would facilitate providing that information to veterans, without compromising the evaluative format of the compensation examination.

An interesting ancillary finding is that relational coordination ratings by members of 3 of the 4 workgroups were higher than ratings by other staff of that workgroup. A possible explanation for this finding is that workgroup members are more aware of the relational coordination efforts made by their own workgroup than those by other workgroups, and therefore rate their own workgroup higher. This also might be part of a broader self-aggrandizement heuristic that has been described in multiple domains.²⁰ Staff may apply this heuristic in reporting that their staff engage in more relational coordination, reflecting the social desirability of being cooperative.

There are simple facility-level interventions that would facilitate veterans access to care such as conducting C&P examinations for potentially treatment-eligible veterans at VHA facilities (vs conducted outside VHA) and having access to materials that explain the treatment options to veterans when they check in for their compensation examinations. The approach to C&P-based treatment engagement that was successfully employed in 2 clinical trials involved having counselors not connected with the C&P clinic contact veterans around the time of their compensation examination to explain VA treatment options and motivate veterans to pursue treatment.^8,9 This independent counselor approach is being evaluated in a larger study.

Limitations

These data are from a small number of VA staff evaluating veterans in a single region of the US. They do not show causation, and it is possible that relational coordination is not necessary for referrals from C&P clinics. Relational coordination might not be necessary when referral processes can be simply routinized with little need for communication.¹¹ However, other analyses in these clinics have found that pain treatment referrals in fact are not routinized, with substantial variability within and across institutions. Another possibility is that features that have been associated with less relational coordination, such as male gender and medical specialist guild, were disproportionately present in C&P clinics compared to the other clinics.²¹Finally, veterans may be eligible for priority VA care for reasons that do not involve service-connection claims (38 CFR § 17.37).

Conclusions

There have been public calls to improve the evaluation of service-connection claims such that this process includes approaches to engage veterans in treatment.²² Referring veterans to treatment when they come for C&P examinations will likely involve improving relational coordination between the C&P service and other parts of VHA. Nationwide, sites that integrate C&P more fully may have valuable lessons to impart about the benefits of such integration. An important step towards better relational coordination will be clarifying that engaging veterans in VHA care around the time of their C&P examinations is a facility-wide goal.

Acknowledgments

The authors thank Brian Linde and Efia James for their perspectives on C&P procedures. This work was supported by the Veterans Integrated Service Network 1 Mental Illness Research Education and Clinical Center (MIRECC) and National Institute of Health, National Center for Complementary and Integrative Health Project # 5UG3AT009758-02. (MIR, SM mPIs).

Chronic pain is common in veterans, and early engagement in pain treatment is recommended to forestall consequences of untreated pain, including depression, disability, and substance use disorders. The Veterans Health Administration (VHA) employs a stepped care model of pain treatment, with the majority of pain care based in primary care (step 1), and an array of specialty/multimodal treatment options made available at each step in the model for patients with more complex problems, or those who do not respond to more conservative interventions.¹

Recognizing the need for comprehensive pain care, the US Congress passed the Comprehensive Addiction and Recovery Act, 21 USC §1521 (2016), which included provisions for VHA facilities to offer multimodal pain treatment and to report the availability of pain care options at each step in the stepped care model.^2, With the passage of the Veterans Access, Choice, and Accountability Act of 2014, 38 USC §101 (2014) and now the MISSION Act of 2018, 38 USC §703 (2018) veterans whose VHA facilities are too distant, who require care unavailable at that facility, or who have to wait too long to receive care are eligible for treatment at either VHA or non-VHA facilities.³ These laws allocate the same pool of funds to both VHA and community care and thus create an incentive to engage veterans in care within the VHA network so the funds are not spent out of network.⁴

An opportunity to connect veterans with VHA care arises at specialized VHA Compensation and Pension (C&P) clinics during examinations that determine whether a veteran’s health conditions were caused or exacerbated by their military service. Veterans file claims with the US Department of Veterans Affairs (VA) Veterans Benefits Administration (VBA), which sends the patient to either a VHA facility or private practitioners for these examinations. Although the number of examinations conducted each year is not available, there were 274,528 veterans newly awarded compensation in fiscal year 2018, and a substantial number of the total of 4,743,108 veterans with C&P awards had reevaluation examinations for at least 1 of their conditions during that year.⁵ Based largely on the compensation examination results, military service records, and medical records, veterans are granted a service-connected rating for conditions deemed related to military service. A service-connection rating between 0% and 100% is assigned by the VBA, with higher ratings indicating more impairment and, consequently, more financial compensation. Service-connection ratings also are used to decide which veterans are in the highest priority groups for receipt of VHA health care services and are exempt from copayments.

Although traditionally thought of as a forensic evaluation with no clinical purpose, the C&P examination process affords many opportunities to explain VHA care to veterans in distress who file claims.⁶ A randomized clinical trials (RCT) involving veterans with mental health claims and a second RCT including veterans with musculoskeletal claims each found that veterans use more VHA services if offered outreach at the time of the C&P examination.^7,8 In addition to clinical benefits, outreach around the time of C&P examinations also might mitigate the well documented adversarial aspects of the service-connection claims process.^6,9,10 Currently, such outreach is not part of routine VHA procedures. Ironically, it is the VBA and not VHA that contacts veterans who are awarded service-connection with information about their eligibility for VHA care based on their award.

Connecting veterans to pain treatment can involve clarifying eligibility for VHA care for veterans in whom eligibility is unknown, involving primary care providers (PCPs) who are the fulcrum of VHA pain care referrals, and motivating veterans to seek specific pain treatment modalities. Connecting veterans to treatment at the time of their compensation examinations also likely involves bidirectional cooperation between the specialized C&P clinics where veterans are examined and the clinics that provide treatment.

Relational coordination is a theoretical framework that can describe the horizontal relationships between different teams within the same medical facility. Relational coordination theorizes that communication between workgroups is related synergistically to the quality of relationships between workgroups. Relational coordination is better between workgroups that share goals and often have high levels of relational coordination, which is thought to be especially important when activities are ambiguous, require cooperation, and are conducted under time pressure.¹¹ High relational coordination also has been associated with high staff job satisfaction, high satisfaction with delivered services, and adherence to treatment guidelines.^12-14 An observational cohort study suggested that relational coordination can be improved by targeted interventions that bring workgroups together and facilitate intercommunication.¹⁵

To better understand referral and engagement for pain treatment at compensation examinations, VA staff from primary care, mental health, pain management, and C&P teams at the 8 VHA medical centers in New England were invited to complete a validated relational coordination survey.^11,16 A subset of invited staff participated in a semistructured interview about pain treatment referral practices within their medical centers.

Methods

Assessments were conducted as part of a mixed methods formative evaluation involving quantitative and qualitative methods for a clinical trial at the 8 VHA medical centers in New England. The trial is testing an intervention in which veterans presenting for service-connection examinations for musculoskeletal conditions receive brief counseling to engage them in nonopioid pain treatments. The VHA Central Institutional Review Board approved this formative evaluation and the clinical trial has begun (ClinicalTrials.gov NCT04062214).

Potential interviewees were involved in referrals to and provision of nonpharmacologic pain treatment and were identified by site investigators in the randomized trial. Identified interviewees were clinical and administrative staff belonging to VHA Primary Care, Pain Management, and Compensation and Pension clinics. A total of 83 staff were identified.

Semistructured Interviews

A subset of the 83 staff were invited to participate in a semistructured interview because their position impacted coordination of pain care at their facilities or they worked in C&P. Staff at a site were interviewed until no new themes emerged from additional interviews, and each of the 8 sites was represented. Interviews were conducted between June and August 2018. Standardized scripts describing the study and inviting participation in a semistructured interview were e-mailed to VA staff. At the time of the interview the study purpose was restated and consent for audiotaping was obtained. The interviews followed a guide designed to assess a relational coordination framework among various workgroups. The data in this manuscript were elicited by specific prompts concerning: (1) How veterans learn about pain care when they come through C&P; and (2) How staff in C&P communicate with treatment providers about veterans who have chronic pain. Each interview lasted about 30 minutes.

Relational Coordination Survey

All identified staff were invited to participate in a relational coordination survey. The survey was administered through VA REDCap. Survey invitations were e-mailed from REDCap to VA staff and included a description of the study and assurances of the confidentiality of data collected. Surveys took < 10 minutes to complete. To begin, respondents identified their primary workgroup (C&P, primary care, pain management, or administrative leadership or staff), secondary workgroup (if they were in > 1), and site. Respondents provided no other identifying information and were assured their responses would be confidential.

The survey consisted of 7 questions regarding beliefs about the quality of communication and interactions among workgroup members in obtaining a shared goal.¹¹ The shared goal in the survey used in this study was providing pain care services for veterans with musculoskeletal conditions. Using a 5-point Likert scale, the 7 questions concerned frequency, timeliness, and accuracy of communication; response to problems providing pain services; sharing goals; and knowledge and respect for respondent’s job function. Higher scores indicated better relational coordination among members of a workgroup. Using the survey’s 7 items, composite mean relational coordination scores were calculated for each of the 4 primary workgroups. To account for the possibility that a member rated their own workgroups, 2 scores were created for each workgroup; one included members of the workgroup and another excluded them.

Data Analysis

The audio-recorded semistructured interviews were transcribed and entered into Atlas.ti qualitative data analysis software. To identify cross-cutting themes, a semistructured telephone interview guide was developed by the qualitative study team that emphasized interrelationships between different clinical teams. The transcripts were then analyzed using the grounded theory approach, a systematic methodology to reduce themes from collected qualitative data. Two research staff read each transcript twice; first to familiarize themselves with the text and then, using open coding, to identify important concepts that emerged from the language and assign codes to segments of text. To ensure accuracy, researchers included suitable contextual information in the coding. Using the constant comparative method, research staff then met to examine the themes that emerged in the interviews, discuss and coalesce coding discrepancies, and compare perspectives.¹⁷

The composite score (mean of the 7 items and 95% CI) of the survey responses was analyzed to identify significant differences in coordination across the 4 workgroups. Analysis of variance (ANOVA) was used to examine each relational coordination score by respondents’ workgroup. Post hoc analyses examined relational coordination survey differences among the 4 respondent groups.

Results

Thirty-nine survey respondents participated in the semistructured interviews. C&P examiners expressed varying degrees of comfort with their role in extending access to pain care for veterans. Some of the examiners strongly believed that their role was purely forensic, and going beyond this forensic role to refer or recommend treatment to veterans would be a violation of their role to conduct a forensic examination. “We don’t have an ongoing therapeutic relationship with any of the patients,” a C&P examiner explained: “We see them once; they’re out the door. It’s forensic. We’re investigating the person as a claimant, we’re investigating it and using our tools to go and review information from 30, 40 years ago.”

Other examiners had a less strict approach for working with veterans in C&P, even though examiners are asked not to provide advice or therapy. One C&P examiner noted that because he “can’t watch people in pain,” during the examination this doctor recommends that patients go to the office that determines whether they are eligible for benefits and choose a PCP. Another C&P examiner concurred with this approach. “I certainly spend a little time with the veteran talking to them about their personal life, who they are, what they do, what they’ve done, what they’re going to do to kind of break the ice between us,” the second examiner explained. “At the end, I will make some suggestions to them. I’m comfortable doing that. I don’t know that everybody is.”

Many of the VHA providers we interviewed had little knowledge of the C&P process or whether C&P examiners had any role or responsibilities in referring veterans for pain care. Most VHA providers could not name any C&P examiners at their facility and were generally unfamiliar with the content of C&P examinations. One provider bluntly said, “I’ve never communicated with anyone in comp and pen [C&P].”

Another PCP also expressed concerns with referrals, suggesting that C&P and primary care “are totally separate and should remain separate,” the PCP explained. “My concern with getting referral from comp and pen is that is it then they’re seeking all sorts of treatment that they wouldn’t necessarily need or ask for otherwise.”

Conversely a different PCP had a positive outlook on how C&P examiners might help ease the transition into the VHA for veterans with pain, especially for newly discharged veterans. “Having comp and pen address these issues is really going to be helpful. I think it could be significant that the topic is introduced early on.”

Relational Coordination Survey

Relational coordination surveys were sent to 83 participants of whom 66 responded. Respondents were from C&P (n = 7), primary care (n = 16), pain medicine (n = 32), and administration (n = 11). Of the 66 respondents, 18 indicated a secondary workgroup. Respondents on 2 teams (primary/secondary) were primary care/administrative (n = 4), pain management/primary care (n = 4), primary care/pain management (n = 3), administrative/primary care (n = 3), and C&P/administrative (n = 1).

The relational coordination composite scores were lowest for C&P. This finding remained whether C&P staff surveys were included or removed from the C&P responses. As demonstrated by the 95% CI, when team members’ surveys were included, C&P scores (95% CI, 2.01-2.42) were significantly lower than the primary care (95% CI, 3.34-3.64) and pain management (95% CI, 3.61-3.96) groups. All the relational coordination composite scores were slightly lower when staff who described their own workgroup were removed (ie, respondents rated their own workgroups as having higher relational coordination than others did). Using the composite scores excluding same workgroup members, the composite scores of the C&P remained significantly lower than all 3 other workgroups (Table). Means values for each individual item in the C&P group were significantly less than all other group means for each item except for the question on responses to problems providing pain services (data not shown). On this item only, the mean C&P rating was > 3 (3.19), but this was still lower than the means of the primary care and pain management workgroups.

Further analyses were undertaken to understand the importance of stakeholders’ ratings of their own workgroup compared with ratings by others of that workgroup. A 1-way ANOVA of workgroup was conducted and displayed significant workgroup differences between member and nonmember relational coordination ratings on 3 of the 4 workgroup’s scores C&P (F = 5.75, 3, 62 df; P < .01) primary care (F = 4.30, 3, 62 df; P < .008) and pain management (F = 8.22, 3, 62 df; P < .001). Post hoc contrasts between the different workgroups doing the rating revealed: (1) significant differences in the assessment of the C&P workgroup between the C&P workgroup and both the primary care (P < .01) and pain management groups (P < .001) with C&P rating their own workgroup significantly higher; (2) a significant difference in the scoring of the primary care workgroup with the primary care group rating themselves significantly higher than the C&P group; and (3) significant differences in the scoring of the pain management workgroup with both pain management and primary care groups rating the pain management group significantly higher than the C&P group. The results were not substantially changed by removing the 18 respondents who identified themselves as being part of > 1 workgroup .

Discussion

Mixed methods revealed disparate viewpoints about the role of C&P in referring veterans to pain care services. Overall, C&P teams coordinated less with other workgroups than the other groups coordinated with each other, and the C&P clinics took only limited steps to engage veterans in VHA treatment. The relational coordination results appeared to be valid. The mean scores were near the middle of the relational coordination rating scale, with standard deviations indicating a range of responses. The lower relational coordination scores of the C&P group remained after removing stakeholders who were rating their own workgroup. Further support for the validity of the relational coordination survey results is that they were consistent with the reports of C&P clinic isolation in the semistructured interviews.

The interview data suggest that one reason the C&P teams had low relational coordination scores is that VA staff interpret the emphasis on evaluative rather than therapeutic examinations to preclude other attempts to engage veterans into VHA treatment, even though such treatment engagement is permitted within existing guidelines. VBA referrals for examinations say nothing, either way, about engaging veterans in VHA care. The relational coordination results suggest that an intervention that might increase treatment referrals from the C&P clinics would be to explain the (existing) policy allowing for outreach around the time of compensation examinations to VHA staff so this goal is clearly agreed-upon. Another approach to facilitating treatment engagement at the C&P examination is to use other interventions that have been associated with better relational coordination such as intergroup meetings, horizontal integration more generally, and an atmosphere is which people from different backgrounds feel empowered to speak frankly to each other.^15,18,19 An important linkage to forge is between C&P teams and the administrative workgroups responsible for verifying a veteran’s eligibility for VHA care and enrolling eligible veterans in VHA treatment. Having C&P clinicians who are familiar with the eligibility and treatment engagement processes would facilitate providing that information to veterans, without compromising the evaluative format of the compensation examination.

An interesting ancillary finding is that relational coordination ratings by members of 3 of the 4 workgroups were higher than ratings by other staff of that workgroup. A possible explanation for this finding is that workgroup members are more aware of the relational coordination efforts made by their own workgroup than those by other workgroups, and therefore rate their own workgroup higher. This also might be part of a broader self-aggrandizement heuristic that has been described in multiple domains.²⁰ Staff may apply this heuristic in reporting that their staff engage in more relational coordination, reflecting the social desirability of being cooperative.

There are simple facility-level interventions that would facilitate veterans access to care such as conducting C&P examinations for potentially treatment-eligible veterans at VHA facilities (vs conducted outside VHA) and having access to materials that explain the treatment options to veterans when they check in for their compensation examinations. The approach to C&P-based treatment engagement that was successfully employed in 2 clinical trials involved having counselors not connected with the C&P clinic contact veterans around the time of their compensation examination to explain VA treatment options and motivate veterans to pursue treatment.^8,9 This independent counselor approach is being evaluated in a larger study.

Limitations

These data are from a small number of VA staff evaluating veterans in a single region of the US. They do not show causation, and it is possible that relational coordination is not necessary for referrals from C&P clinics. Relational coordination might not be necessary when referral processes can be simply routinized with little need for communication.¹¹ However, other analyses in these clinics have found that pain treatment referrals in fact are not routinized, with substantial variability within and across institutions. Another possibility is that features that have been associated with less relational coordination, such as male gender and medical specialist guild, were disproportionately present in C&P clinics compared to the other clinics.²¹Finally, veterans may be eligible for priority VA care for reasons that do not involve service-connection claims (38 CFR § 17.37).

Conclusions

There have been public calls to improve the evaluation of service-connection claims such that this process includes approaches to engage veterans in treatment.²² Referring veterans to treatment when they come for C&P examinations will likely involve improving relational coordination between the C&P service and other parts of VHA. Nationwide, sites that integrate C&P more fully may have valuable lessons to impart about the benefits of such integration. An important step towards better relational coordination will be clarifying that engaging veterans in VHA care around the time of their C&P examinations is a facility-wide goal.

Acknowledgments

The authors thank Brian Linde and Efia James for their perspectives on C&P procedures. This work was supported by the Veterans Integrated Service Network 1 Mental Illness Research Education and Clinical Center (MIRECC) and National Institute of Health, National Center for Complementary and Integrative Health Project # 5UG3AT009758-02. (MIR, SM mPIs).

Chronic pain is common in veterans, and early engagement in pain treatment is recommended to forestall consequences of untreated pain, including depression, disability, and substance use disorders. The Veterans Health Administration (VHA) employs a stepped care model of pain treatment, with the majority of pain care based in primary care (step 1), and an array of specialty/multimodal treatment options made available at each step in the model for patients with more complex problems, or those who do not respond to more conservative interventions.¹

Recognizing the need for comprehensive pain care, the US Congress passed the Comprehensive Addiction and Recovery Act, 21 USC §1521 (2016), which included provisions for VHA facilities to offer multimodal pain treatment and to report the availability of pain care options at each step in the stepped care model.^2, With the passage of the Veterans Access, Choice, and Accountability Act of 2014, 38 USC §101 (2014) and now the MISSION Act of 2018, 38 USC §703 (2018) veterans whose VHA facilities are too distant, who require care unavailable at that facility, or who have to wait too long to receive care are eligible for treatment at either VHA or non-VHA facilities.³ These laws allocate the same pool of funds to both VHA and community care and thus create an incentive to engage veterans in care within the VHA network so the funds are not spent out of network.⁴

An opportunity to connect veterans with VHA care arises at specialized VHA Compensation and Pension (C&P) clinics during examinations that determine whether a veteran’s health conditions were caused or exacerbated by their military service. Veterans file claims with the US Department of Veterans Affairs (VA) Veterans Benefits Administration (VBA), which sends the patient to either a VHA facility or private practitioners for these examinations. Although the number of examinations conducted each year is not available, there were 274,528 veterans newly awarded compensation in fiscal year 2018, and a substantial number of the total of 4,743,108 veterans with C&P awards had reevaluation examinations for at least 1 of their conditions during that year.⁵ Based largely on the compensation examination results, military service records, and medical records, veterans are granted a service-connected rating for conditions deemed related to military service. A service-connection rating between 0% and 100% is assigned by the VBA, with higher ratings indicating more impairment and, consequently, more financial compensation. Service-connection ratings also are used to decide which veterans are in the highest priority groups for receipt of VHA health care services and are exempt from copayments.

Although traditionally thought of as a forensic evaluation with no clinical purpose, the C&P examination process affords many opportunities to explain VHA care to veterans in distress who file claims.⁶ A randomized clinical trials (RCT) involving veterans with mental health claims and a second RCT including veterans with musculoskeletal claims each found that veterans use more VHA services if offered outreach at the time of the C&P examination.^7,8 In addition to clinical benefits, outreach around the time of C&P examinations also might mitigate the well documented adversarial aspects of the service-connection claims process.^6,9,10 Currently, such outreach is not part of routine VHA procedures. Ironically, it is the VBA and not VHA that contacts veterans who are awarded service-connection with information about their eligibility for VHA care based on their award.

Connecting veterans to pain treatment can involve clarifying eligibility for VHA care for veterans in whom eligibility is unknown, involving primary care providers (PCPs) who are the fulcrum of VHA pain care referrals, and motivating veterans to seek specific pain treatment modalities. Connecting veterans to treatment at the time of their compensation examinations also likely involves bidirectional cooperation between the specialized C&P clinics where veterans are examined and the clinics that provide treatment.

Relational coordination is a theoretical framework that can describe the horizontal relationships between different teams within the same medical facility. Relational coordination theorizes that communication between workgroups is related synergistically to the quality of relationships between workgroups. Relational coordination is better between workgroups that share goals and often have high levels of relational coordination, which is thought to be especially important when activities are ambiguous, require cooperation, and are conducted under time pressure.¹¹ High relational coordination also has been associated with high staff job satisfaction, high satisfaction with delivered services, and adherence to treatment guidelines.^12-14 An observational cohort study suggested that relational coordination can be improved by targeted interventions that bring workgroups together and facilitate intercommunication.¹⁵

To better understand referral and engagement for pain treatment at compensation examinations, VA staff from primary care, mental health, pain management, and C&P teams at the 8 VHA medical centers in New England were invited to complete a validated relational coordination survey.^11,16 A subset of invited staff participated in a semistructured interview about pain treatment referral practices within their medical centers.

Methods

Assessments were conducted as part of a mixed methods formative evaluation involving quantitative and qualitative methods for a clinical trial at the 8 VHA medical centers in New England. The trial is testing an intervention in which veterans presenting for service-connection examinations for musculoskeletal conditions receive brief counseling to engage them in nonopioid pain treatments. The VHA Central Institutional Review Board approved this formative evaluation and the clinical trial has begun (ClinicalTrials.gov NCT04062214).

Potential interviewees were involved in referrals to and provision of nonpharmacologic pain treatment and were identified by site investigators in the randomized trial. Identified interviewees were clinical and administrative staff belonging to VHA Primary Care, Pain Management, and Compensation and Pension clinics. A total of 83 staff were identified.

Semistructured Interviews

A subset of the 83 staff were invited to participate in a semistructured interview because their position impacted coordination of pain care at their facilities or they worked in C&P. Staff at a site were interviewed until no new themes emerged from additional interviews, and each of the 8 sites was represented. Interviews were conducted between June and August 2018. Standardized scripts describing the study and inviting participation in a semistructured interview were e-mailed to VA staff. At the time of the interview the study purpose was restated and consent for audiotaping was obtained. The interviews followed a guide designed to assess a relational coordination framework among various workgroups. The data in this manuscript were elicited by specific prompts concerning: (1) How veterans learn about pain care when they come through C&P; and (2) How staff in C&P communicate with treatment providers about veterans who have chronic pain. Each interview lasted about 30 minutes.

Relational Coordination Survey

All identified staff were invited to participate in a relational coordination survey. The survey was administered through VA REDCap. Survey invitations were e-mailed from REDCap to VA staff and included a description of the study and assurances of the confidentiality of data collected. Surveys took < 10 minutes to complete. To begin, respondents identified their primary workgroup (C&P, primary care, pain management, or administrative leadership or staff), secondary workgroup (if they were in > 1), and site. Respondents provided no other identifying information and were assured their responses would be confidential.

The survey consisted of 7 questions regarding beliefs about the quality of communication and interactions among workgroup members in obtaining a shared goal.¹¹ The shared goal in the survey used in this study was providing pain care services for veterans with musculoskeletal conditions. Using a 5-point Likert scale, the 7 questions concerned frequency, timeliness, and accuracy of communication; response to problems providing pain services; sharing goals; and knowledge and respect for respondent’s job function. Higher scores indicated better relational coordination among members of a workgroup. Using the survey’s 7 items, composite mean relational coordination scores were calculated for each of the 4 primary workgroups. To account for the possibility that a member rated their own workgroups, 2 scores were created for each workgroup; one included members of the workgroup and another excluded them.

Data Analysis

The audio-recorded semistructured interviews were transcribed and entered into Atlas.ti qualitative data analysis software. To identify cross-cutting themes, a semistructured telephone interview guide was developed by the qualitative study team that emphasized interrelationships between different clinical teams. The transcripts were then analyzed using the grounded theory approach, a systematic methodology to reduce themes from collected qualitative data. Two research staff read each transcript twice; first to familiarize themselves with the text and then, using open coding, to identify important concepts that emerged from the language and assign codes to segments of text. To ensure accuracy, researchers included suitable contextual information in the coding. Using the constant comparative method, research staff then met to examine the themes that emerged in the interviews, discuss and coalesce coding discrepancies, and compare perspectives.¹⁷

The composite score (mean of the 7 items and 95% CI) of the survey responses was analyzed to identify significant differences in coordination across the 4 workgroups. Analysis of variance (ANOVA) was used to examine each relational coordination score by respondents’ workgroup. Post hoc analyses examined relational coordination survey differences among the 4 respondent groups.

Results

Thirty-nine survey respondents participated in the semistructured interviews. C&P examiners expressed varying degrees of comfort with their role in extending access to pain care for veterans. Some of the examiners strongly believed that their role was purely forensic, and going beyond this forensic role to refer or recommend treatment to veterans would be a violation of their role to conduct a forensic examination. “We don’t have an ongoing therapeutic relationship with any of the patients,” a C&P examiner explained: “We see them once; they’re out the door. It’s forensic. We’re investigating the person as a claimant, we’re investigating it and using our tools to go and review information from 30, 40 years ago.”

Other examiners had a less strict approach for working with veterans in C&P, even though examiners are asked not to provide advice or therapy. One C&P examiner noted that because he “can’t watch people in pain,” during the examination this doctor recommends that patients go to the office that determines whether they are eligible for benefits and choose a PCP. Another C&P examiner concurred with this approach. “I certainly spend a little time with the veteran talking to them about their personal life, who they are, what they do, what they’ve done, what they’re going to do to kind of break the ice between us,” the second examiner explained. “At the end, I will make some suggestions to them. I’m comfortable doing that. I don’t know that everybody is.”

Many of the VHA providers we interviewed had little knowledge of the C&P process or whether C&P examiners had any role or responsibilities in referring veterans for pain care. Most VHA providers could not name any C&P examiners at their facility and were generally unfamiliar with the content of C&P examinations. One provider bluntly said, “I’ve never communicated with anyone in comp and pen [C&P].”

Another PCP also expressed concerns with referrals, suggesting that C&P and primary care “are totally separate and should remain separate,” the PCP explained. “My concern with getting referral from comp and pen is that is it then they’re seeking all sorts of treatment that they wouldn’t necessarily need or ask for otherwise.”

Conversely a different PCP had a positive outlook on how C&P examiners might help ease the transition into the VHA for veterans with pain, especially for newly discharged veterans. “Having comp and pen address these issues is really going to be helpful. I think it could be significant that the topic is introduced early on.”

Relational Coordination Survey

Relational coordination surveys were sent to 83 participants of whom 66 responded. Respondents were from C&P (n = 7), primary care (n = 16), pain medicine (n = 32), and administration (n = 11). Of the 66 respondents, 18 indicated a secondary workgroup. Respondents on 2 teams (primary/secondary) were primary care/administrative (n = 4), pain management/primary care (n = 4), primary care/pain management (n = 3), administrative/primary care (n = 3), and C&P/administrative (n = 1).

The relational coordination composite scores were lowest for C&P. This finding remained whether C&P staff surveys were included or removed from the C&P responses. As demonstrated by the 95% CI, when team members’ surveys were included, C&P scores (95% CI, 2.01-2.42) were significantly lower than the primary care (95% CI, 3.34-3.64) and pain management (95% CI, 3.61-3.96) groups. All the relational coordination composite scores were slightly lower when staff who described their own workgroup were removed (ie, respondents rated their own workgroups as having higher relational coordination than others did). Using the composite scores excluding same workgroup members, the composite scores of the C&P remained significantly lower than all 3 other workgroups (Table). Means values for each individual item in the C&P group were significantly less than all other group means for each item except for the question on responses to problems providing pain services (data not shown). On this item only, the mean C&P rating was > 3 (3.19), but this was still lower than the means of the primary care and pain management workgroups.

Further analyses were undertaken to understand the importance of stakeholders’ ratings of their own workgroup compared with ratings by others of that workgroup. A 1-way ANOVA of workgroup was conducted and displayed significant workgroup differences between member and nonmember relational coordination ratings on 3 of the 4 workgroup’s scores C&P (F = 5.75, 3, 62 df; P < .01) primary care (F = 4.30, 3, 62 df; P < .008) and pain management (F = 8.22, 3, 62 df; P < .001). Post hoc contrasts between the different workgroups doing the rating revealed: (1) significant differences in the assessment of the C&P workgroup between the C&P workgroup and both the primary care (P < .01) and pain management groups (P < .001) with C&P rating their own workgroup significantly higher; (2) a significant difference in the scoring of the primary care workgroup with the primary care group rating themselves significantly higher than the C&P group; and (3) significant differences in the scoring of the pain management workgroup with both pain management and primary care groups rating the pain management group significantly higher than the C&P group. The results were not substantially changed by removing the 18 respondents who identified themselves as being part of > 1 workgroup .

Discussion

Mixed methods revealed disparate viewpoints about the role of C&P in referring veterans to pain care services. Overall, C&P teams coordinated less with other workgroups than the other groups coordinated with each other, and the C&P clinics took only limited steps to engage veterans in VHA treatment. The relational coordination results appeared to be valid. The mean scores were near the middle of the relational coordination rating scale, with standard deviations indicating a range of responses. The lower relational coordination scores of the C&P group remained after removing stakeholders who were rating their own workgroup. Further support for the validity of the relational coordination survey results is that they were consistent with the reports of C&P clinic isolation in the semistructured interviews.

The interview data suggest that one reason the C&P teams had low relational coordination scores is that VA staff interpret the emphasis on evaluative rather than therapeutic examinations to preclude other attempts to engage veterans into VHA treatment, even though such treatment engagement is permitted within existing guidelines. VBA referrals for examinations say nothing, either way, about engaging veterans in VHA care. The relational coordination results suggest that an intervention that might increase treatment referrals from the C&P clinics would be to explain the (existing) policy allowing for outreach around the time of compensation examinations to VHA staff so this goal is clearly agreed-upon. Another approach to facilitating treatment engagement at the C&P examination is to use other interventions that have been associated with better relational coordination such as intergroup meetings, horizontal integration more generally, and an atmosphere is which people from different backgrounds feel empowered to speak frankly to each other.^15,18,19 An important linkage to forge is between C&P teams and the administrative workgroups responsible for verifying a veteran’s eligibility for VHA care and enrolling eligible veterans in VHA treatment. Having C&P clinicians who are familiar with the eligibility and treatment engagement processes would facilitate providing that information to veterans, without compromising the evaluative format of the compensation examination.

An interesting ancillary finding is that relational coordination ratings by members of 3 of the 4 workgroups were higher than ratings by other staff of that workgroup. A possible explanation for this finding is that workgroup members are more aware of the relational coordination efforts made by their own workgroup than those by other workgroups, and therefore rate their own workgroup higher. This also might be part of a broader self-aggrandizement heuristic that has been described in multiple domains.²⁰ Staff may apply this heuristic in reporting that their staff engage in more relational coordination, reflecting the social desirability of being cooperative.

There are simple facility-level interventions that would facilitate veterans access to care such as conducting C&P examinations for potentially treatment-eligible veterans at VHA facilities (vs conducted outside VHA) and having access to materials that explain the treatment options to veterans when they check in for their compensation examinations. The approach to C&P-based treatment engagement that was successfully employed in 2 clinical trials involved having counselors not connected with the C&P clinic contact veterans around the time of their compensation examination to explain VA treatment options and motivate veterans to pursue treatment.^8,9 This independent counselor approach is being evaluated in a larger study.

Limitations

These data are from a small number of VA staff evaluating veterans in a single region of the US. They do not show causation, and it is possible that relational coordination is not necessary for referrals from C&P clinics. Relational coordination might not be necessary when referral processes can be simply routinized with little need for communication.¹¹ However, other analyses in these clinics have found that pain treatment referrals in fact are not routinized, with substantial variability within and across institutions. Another possibility is that features that have been associated with less relational coordination, such as male gender and medical specialist guild, were disproportionately present in C&P clinics compared to the other clinics.²¹Finally, veterans may be eligible for priority VA care for reasons that do not involve service-connection claims (38 CFR § 17.37).

Conclusions

There have been public calls to improve the evaluation of service-connection claims such that this process includes approaches to engage veterans in treatment.²² Referring veterans to treatment when they come for C&P examinations will likely involve improving relational coordination between the C&P service and other parts of VHA. Nationwide, sites that integrate C&P more fully may have valuable lessons to impart about the benefits of such integration. An important step towards better relational coordination will be clarifying that engaging veterans in VHA care around the time of their C&P examinations is a facility-wide goal.

Acknowledgments

The authors thank Brian Linde and Efia James for their perspectives on C&P procedures. This work was supported by the Veterans Integrated Service Network 1 Mental Illness Research Education and Clinical Center (MIRECC) and National Institute of Health, National Center for Complementary and Integrative Health Project # 5UG3AT009758-02. (MIR, SM mPIs).

In 2011, 5 VA medical centers (VAMCs) were selected by the Office of Academic Affiliations (OAA) to establish CoEPCE. Part of the VA New Models of Care initiative, the 5 Centers of Excellence (CoE) in Boise, Idaho; Cleveland, Ohio; San Francisco, California; Seattle, Washington; and West Haven, Connecticut, 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 (eg, pharmacy, social work, psychology, physician assistants [PAs], physical therapists) for primary care practice in the 21st century. The CoEs 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 CoEs must address 4 core domains (Table).

Health care professional education programs do not have many opportunities for workplace learning where trainees from different professions can learn and work together to provide care to patients in real time. 

The VA Connecticut Healthcare System CoEPCE developed and implemented an education and practice-based immersion learning model with physician residents, nurse practitioner (NP) residents and NP students, pharmacy residents, postdoctorate psychology learners, and PA and physical therapy learners and faculty. This interprofessional, collaborative team model breaks from the traditional independent model of siloed primary care providers (PCPs) caring for a panel of patients.

Methods

In 2015, OAA evaluators 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 Initiative to Minimize Pharmaceutical Risk in Older Veterans (IMPROVE) program to trainees, veterans, and the VA.

Lack of Clinical Approaches to Interprofessional Education and Care

Polypharmacy is a common problem among older adults with multiple chronic conditions, which places patients at higher risk for multiple negative health outcomes.^2,3 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 team-based approach.

Team Approach to Medication Needs

A key CoEPCE program aim is to expand workplace 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 IMPROVE to focus on high-need 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 adverse effects (AEs). These goals are 2-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.

Related: Pharmacist Interventions to Reduce Modifiable Bleeding Risk Factors Using HAS-BLED in Patients Taking Warfarin (FULL)

Planning and Implementation

IMPROVE has its origins in a scholarly project developed by a West Haven CoE physician resident trainee. Development of the IMPROVE program involved VA health psychology, internal medicine faculty, geriatric medicine faculty, NP faculty, and geriatric pharmacy residents and faculty. Planning started in 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 West Haven primary care clinic.

Curriculum

IMPROVE is an educational, workplace learning, and clinical activity that combines a 1-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 nonpharmacologic 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 sees one of their patients at least 3 times per year in the program. Up to 5 trainees participate in each IMPROVE session. Trainees are responsible for reviewing their 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 VAMC providers.⁴ They also work with a protocol for medication discontinuation, which was compiled by West Haven VAMC clinicians. The teams use a variety of tools that guide appropriate prescribing in older adult populations.^5,6 During a preclinic conference, trainees present their patients to the interprofessional team for discussion and participate in a short discussion led by a pharmacist, geriatrician, or health psychologist on a topic related to prescribing safety in older adults or nonpharmacologic treatments.

IMPROVE emphasizes a patient-centered approach to develop, execute, and monitor medication plans. Patients and their family members are invited by their trainee clinician to participate in a group visit. Typically, trainees invite patients aged ≥ 65 years who have ≥ 10 medications and are considered appropriate for a group visit. 

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.⁷ 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 perceptions and share concerns and treatment goals. There is shared responsibility among the trainees to address the educational material as well as involve their respective patients during the sessions.

Immediately following the group visit, trainees conduct a 1-hour clinic session that includes medication reconciliation, a review of an IMPROVE questionnaire, orthostatic vital signs, and the St. Louis University Mental Status (SLUMS) exam to assess changes in cognition.^7,8 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, feelings about the medications, which medications they would like to stop, and AEs 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. In the session they may 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 4 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 shared decision making (SDM).

Related: Reducing Benzodiazepine Prescribing in Older Veterans: A Direct-to-Consumer Educational Brochure

The IMPROVE model continues to evolve. The original curriculum involved an hour-long preclinic preparation session before the group visit in which trainees and faculty discussed the medication review for each patient scheduled that day. This preparation session was later shortened to 40 minutes, and a 20-minute didactic component was added to create the current preclinic session. The didactic component focused on a specific topic in appropriate prescribing for older patients. For example, one didactic lesson is on a particular class of medications, its common AEs, 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 patients from their 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 patients to continue to optimize the medication regimen even after the IMPROVE visit. Another significant change was the inclusion of veterans who are comanaged with PCPs outside the VA, because we found that patients with multiple providers could benefit from improved coordination of care.

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 patients’ health records before the patients come into the clinic, participates in the group visit, and coprecepts during the 1:1 patient visits. Collaboration is inherent in IMPROVE. For example, the geriatrician works with the geriatric pharmacist to identify and teach an 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 patient aligned care team (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 1 to 3 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 preclinic session (about an hour of preparation per session). Sufficient space also is required: a room large enough to accommodate up to 10 people for both didactic lessons and preclinic sessions, a facility patient education conference room for the group visit, and up to 5 clinic exam rooms. CoEPCE staff developed a templated note in the VA Computerized Patient Record System (CPRS), the VA electronic health record system to guide trainees step-by-step through the clinic visit and allow them to directly enter information into the system.⁷

Monitoring and Assessment

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 NP trainees.

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 also have 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 the Accreditation Council for Graduate Medical Education interprofessional milestones, and promote individual trainee scholarship and performance improvement in areas of broad applicability. IMPROVE also is 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 complex 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 training priority. The CoEPCE has tried different configurations to increase the number of patients being seen, such as having ≥ 1 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 some of these patients needed the most help, it developed a process for reaching out to non-VA providers and coordinating care. Additionally, there is significant diversity in patient polypharmacy needs. These can range from adherence problems to the challenge of complex psychosocial needs that are more easily (but less effectively) addressed with medications. The issue of polypharmacy is further complicated by evolving understanding of medications’ relative risks and benefits in older adults with multiple chronic conditions. IMPROVE is an effective vehicle for synthesizing current science in medications and their management, especially in complex older patients with multiple chronic conditions.

Other challenges include developing a templated CPRS electronic note that interfaces with the VA information technology system. The process of creating a template, obtaining approval from the forms committee, and working with information technology personnel to implement the template was more time intensive than anticipated and required multiple iterations of proofreading and editing.

Related: Effect of High-Dose Ergocalciferol on Rate of Falls in a Community-Dwelling, Home-Based Primary Care Veteran Population: A Case-Crossover Study

Factors for Success

The commitment to support new models of trainee education by West Haven CoEPCE faculty and leadership, and West Haven VAMC and primary care clinic leadership facilitated the implementation of IMPROVE. Additionally, there is strong CoEPCE collaboration at all levels—codirectors, faculty, and trainees—for the program. High interprofessional trainee interest, organizational insight, and an academic orientation were critical for developing and launching IMPROVE.

Additionally, there is synergy with other team-based professions. Geriatrics has a tradition of working in multidisciplinary 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 2 specialties complement each other and address the complex health needs of participating veterans. Health psychologists transition patients to nonpharmacologic 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 within the VA from 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 mellitus 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 are outlined below.

Interprofessional Education

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 colocation 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.

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 who have been cared for by other (VA and non-VA) providers.

Interprofessional Collaboration

Understanding and leveraging the expertise of trainees and faculty from different professions is a primary goal of 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 cohesive solution or strategy. The result is that trainees are more well rounded and become better practitioners who seek advice from other professions and work well in teams.

Trainees are expected to learn about other professions and their skill sets. For example, trainees learn early about 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 or dementia to the trainees’ attention. This is significant because issues like patient motivation may be better handled from a behavioral perspective.

Expanded 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, about 30 internal medicine residents and 6 NP residents have seen patients in the polypharmacy clinic. Each year, 4 NP residents, 2 health psychology residents, 4 clinical pharmacy residents, and 1 geriatric pharmacy resident participate in the IMPROVE clinic during their yearlong training program. During their 3-year training program, 17 to 19 internal medicine residents participate in IMPROVE.

A structured forum for discussing patients and their care options supports professionals’ utilization of the full scope of their practice. Trainees learn and apply team skills, such as communication and the warm handoff, which can be used in other clinic settings. 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.”⁹ An interprofessional care plan supports trainee clinical performance, providing a more robust approach to patient care than individual providers might on their own.

Patient Outcomes

IMPROVE is an enriched care plan informed by multiple professions with the potential to improve medication use and provide better care. Veterans also are 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, 5 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 also are 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 suggest that in some patients, cognition (as measured with SLUMS after 6 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 faculty try to ensure that everyone knows about and concurs with medication changes, including outside providers and family members.

Satisfaction Questionnaire

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.

Results of postvisit patient satisfaction questionnaires are encouraging and result in 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.

CoEPCE Benefits

IMPROVE expands the prevention and treatment options for populations at risk of hospitalization and adverse outcomes from medication complications, such as AEs and drug-drug or drug-disease 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.

IMPROVE also 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 not only has strengthened CoEPCE partnerships with other VA departments and specialties, but also revealed opportunities for collaboration with academic affiliates as a means to break down traditional silos among medicine, nursing, pharmacy, geriatrics, and psychology.

IMPROVE combines key components of interprofessional education, including all 4 CoEPCE core domains, to provide hands-on experience with knowledge learned in other aspects of the CoEPCE training program (eg, shared decision-making strategies for eliciting patient goals, weighing risks and benefits in complex clinical situations). Physician and NP trainees work together with trainees in pharmacy and health psychology in the complex approach to polypharmacy. IMPROVE provides the framework for an interprofessional clinic that could be used in the treatment of other complex or high-risk chronic conditions.

The Future

An opportunity for improvement and expansion includes increased patient involvement (as patients continue to learn they have a team working on their behalf). Opportunities exist to connect with patients who have several clinicians prescribing medications outside 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 an implementation kit that describes the training process and includes the medication worksheet, 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 other health professional training sites at Yale University in New Haven, Connecticut. Additionally, the West Haven CoEPCE is planning to partner with the other original CoEPCE program sites to implement similar interprofessional polypharmacy clinics.

In 2011, 5 VA medical centers (VAMCs) were selected by the Office of Academic Affiliations (OAA) to establish CoEPCE. Part of the VA New Models of Care initiative, the 5 Centers of Excellence (CoE) in Boise, Idaho; Cleveland, Ohio; San Francisco, California; Seattle, Washington; and West Haven, Connecticut, 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 (eg, pharmacy, social work, psychology, physician assistants [PAs], physical therapists) for primary care practice in the 21st century. The CoEs 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 CoEs must address 4 core domains (Table).

Health care professional education programs do not have many opportunities for workplace learning where trainees from different professions can learn and work together to provide care to patients in real time. 

The VA Connecticut Healthcare System CoEPCE developed and implemented an education and practice-based immersion learning model with physician residents, nurse practitioner (NP) residents and NP students, pharmacy residents, postdoctorate psychology learners, and PA and physical therapy learners and faculty. This interprofessional, collaborative team model breaks from the traditional independent model of siloed primary care providers (PCPs) caring for a panel of patients.

Methods

In 2015, OAA evaluators 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 Initiative to Minimize Pharmaceutical Risk in Older Veterans (IMPROVE) program to trainees, veterans, and the VA.

Lack of Clinical Approaches to Interprofessional Education and Care

Polypharmacy is a common problem among older adults with multiple chronic conditions, which places patients at higher risk for multiple negative health outcomes.^2,3 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 team-based approach.

Team Approach to Medication Needs

A key CoEPCE program aim is to expand workplace 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 IMPROVE to focus on high-need 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 adverse effects (AEs). These goals are 2-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.

Related: Pharmacist Interventions to Reduce Modifiable Bleeding Risk Factors Using HAS-BLED in Patients Taking Warfarin (FULL)

Planning and Implementation

IMPROVE has its origins in a scholarly project developed by a West Haven CoE physician resident trainee. Development of the IMPROVE program involved VA health psychology, internal medicine faculty, geriatric medicine faculty, NP faculty, and geriatric pharmacy residents and faculty. Planning started in 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 West Haven primary care clinic.

Curriculum

IMPROVE is an educational, workplace learning, and clinical activity that combines a 1-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 nonpharmacologic 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 sees one of their patients at least 3 times per year in the program. Up to 5 trainees participate in each IMPROVE session. Trainees are responsible for reviewing their 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 VAMC providers.⁴ They also work with a protocol for medication discontinuation, which was compiled by West Haven VAMC clinicians. The teams use a variety of tools that guide appropriate prescribing in older adult populations.^5,6 During a preclinic conference, trainees present their patients to the interprofessional team for discussion and participate in a short discussion led by a pharmacist, geriatrician, or health psychologist on a topic related to prescribing safety in older adults or nonpharmacologic treatments.

IMPROVE emphasizes a patient-centered approach to develop, execute, and monitor medication plans. Patients and their family members are invited by their trainee clinician to participate in a group visit. Typically, trainees invite patients aged ≥ 65 years who have ≥ 10 medications and are considered appropriate for a group visit. 

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.⁷ 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 perceptions and share concerns and treatment goals. There is shared responsibility among the trainees to address the educational material as well as involve their respective patients during the sessions.

Immediately following the group visit, trainees conduct a 1-hour clinic session that includes medication reconciliation, a review of an IMPROVE questionnaire, orthostatic vital signs, and the St. Louis University Mental Status (SLUMS) exam to assess changes in cognition.^7,8 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, feelings about the medications, which medications they would like to stop, and AEs 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. In the session they may 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 4 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 shared decision making (SDM).

Related: Reducing Benzodiazepine Prescribing in Older Veterans: A Direct-to-Consumer Educational Brochure

The IMPROVE model continues to evolve. The original curriculum involved an hour-long preclinic preparation session before the group visit in which trainees and faculty discussed the medication review for each patient scheduled that day. This preparation session was later shortened to 40 minutes, and a 20-minute didactic component was added to create the current preclinic session. The didactic component focused on a specific topic in appropriate prescribing for older patients. For example, one didactic lesson is on a particular class of medications, its common AEs, 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 patients from their 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 patients to continue to optimize the medication regimen even after the IMPROVE visit. Another significant change was the inclusion of veterans who are comanaged with PCPs outside the VA, because we found that patients with multiple providers could benefit from improved coordination of care.

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 patients’ health records before the patients come into the clinic, participates in the group visit, and coprecepts during the 1:1 patient visits. Collaboration is inherent in IMPROVE. For example, the geriatrician works with the geriatric pharmacist to identify and teach an 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 patient aligned care team (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 1 to 3 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 preclinic session (about an hour of preparation per session). Sufficient space also is required: a room large enough to accommodate up to 10 people for both didactic lessons and preclinic sessions, a facility patient education conference room for the group visit, and up to 5 clinic exam rooms. CoEPCE staff developed a templated note in the VA Computerized Patient Record System (CPRS), the VA electronic health record system to guide trainees step-by-step through the clinic visit and allow them to directly enter information into the system.⁷

Monitoring and Assessment

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 NP trainees.

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 also have 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 the Accreditation Council for Graduate Medical Education interprofessional milestones, and promote individual trainee scholarship and performance improvement in areas of broad applicability. IMPROVE also is 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 complex 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 training priority. The CoEPCE has tried different configurations to increase the number of patients being seen, such as having ≥ 1 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 some of these patients needed the most help, it developed a process for reaching out to non-VA providers and coordinating care. Additionally, there is significant diversity in patient polypharmacy needs. These can range from adherence problems to the challenge of complex psychosocial needs that are more easily (but less effectively) addressed with medications. The issue of polypharmacy is further complicated by evolving understanding of medications’ relative risks and benefits in older adults with multiple chronic conditions. IMPROVE is an effective vehicle for synthesizing current science in medications and their management, especially in complex older patients with multiple chronic conditions.

Other challenges include developing a templated CPRS electronic note that interfaces with the VA information technology system. The process of creating a template, obtaining approval from the forms committee, and working with information technology personnel to implement the template was more time intensive than anticipated and required multiple iterations of proofreading and editing.

Related: Effect of High-Dose Ergocalciferol on Rate of Falls in a Community-Dwelling, Home-Based Primary Care Veteran Population: A Case-Crossover Study

Factors for Success

The commitment to support new models of trainee education by West Haven CoEPCE faculty and leadership, and West Haven VAMC and primary care clinic leadership facilitated the implementation of IMPROVE. Additionally, there is strong CoEPCE collaboration at all levels—codirectors, faculty, and trainees—for the program. High interprofessional trainee interest, organizational insight, and an academic orientation were critical for developing and launching IMPROVE.

Additionally, there is synergy with other team-based professions. Geriatrics has a tradition of working in multidisciplinary 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 2 specialties complement each other and address the complex health needs of participating veterans. Health psychologists transition patients to nonpharmacologic 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 within the VA from 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 mellitus 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 are outlined below.

Interprofessional Education

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 colocation 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.

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 who have been cared for by other (VA and non-VA) providers.

Interprofessional Collaboration

Understanding and leveraging the expertise of trainees and faculty from different professions is a primary goal of 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 cohesive solution or strategy. The result is that trainees are more well rounded and become better practitioners who seek advice from other professions and work well in teams.

Trainees are expected to learn about other professions and their skill sets. For example, trainees learn early about 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 or dementia to the trainees’ attention. This is significant because issues like patient motivation may be better handled from a behavioral perspective.

Expanded 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, about 30 internal medicine residents and 6 NP residents have seen patients in the polypharmacy clinic. Each year, 4 NP residents, 2 health psychology residents, 4 clinical pharmacy residents, and 1 geriatric pharmacy resident participate in the IMPROVE clinic during their yearlong training program. During their 3-year training program, 17 to 19 internal medicine residents participate in IMPROVE.

A structured forum for discussing patients and their care options supports professionals’ utilization of the full scope of their practice. Trainees learn and apply team skills, such as communication and the warm handoff, which can be used in other clinic settings. 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.”⁹ An interprofessional care plan supports trainee clinical performance, providing a more robust approach to patient care than individual providers might on their own.

Patient Outcomes

IMPROVE is an enriched care plan informed by multiple professions with the potential to improve medication use and provide better care. Veterans also are 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, 5 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 also are 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 suggest that in some patients, cognition (as measured with SLUMS after 6 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 faculty try to ensure that everyone knows about and concurs with medication changes, including outside providers and family members.

Satisfaction Questionnaire

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.

Results of postvisit patient satisfaction questionnaires are encouraging and result in 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.

CoEPCE Benefits

IMPROVE expands the prevention and treatment options for populations at risk of hospitalization and adverse outcomes from medication complications, such as AEs and drug-drug or drug-disease 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.

IMPROVE also 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 not only has strengthened CoEPCE partnerships with other VA departments and specialties, but also revealed opportunities for collaboration with academic affiliates as a means to break down traditional silos among medicine, nursing, pharmacy, geriatrics, and psychology.

IMPROVE combines key components of interprofessional education, including all 4 CoEPCE core domains, to provide hands-on experience with knowledge learned in other aspects of the CoEPCE training program (eg, shared decision-making strategies for eliciting patient goals, weighing risks and benefits in complex clinical situations). Physician and NP trainees work together with trainees in pharmacy and health psychology in the complex approach to polypharmacy. IMPROVE provides the framework for an interprofessional clinic that could be used in the treatment of other complex or high-risk chronic conditions.

The Future

An opportunity for improvement and expansion includes increased patient involvement (as patients continue to learn they have a team working on their behalf). Opportunities exist to connect with patients who have several clinicians prescribing medications outside 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 an implementation kit that describes the training process and includes the medication worksheet, 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 other health professional training sites at Yale University in New Haven, Connecticut. Additionally, the West Haven CoEPCE is planning to partner with the other original CoEPCE program sites to implement similar interprofessional polypharmacy clinics.

In 2011, 5 VA medical centers (VAMCs) were selected by the Office of Academic Affiliations (OAA) to establish CoEPCE. Part of the VA New Models of Care initiative, the 5 Centers of Excellence (CoE) in Boise, Idaho; Cleveland, Ohio; San Francisco, California; Seattle, Washington; and West Haven, Connecticut, 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 (eg, pharmacy, social work, psychology, physician assistants [PAs], physical therapists) for primary care practice in the 21st century. The CoEs 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 CoEs must address 4 core domains (Table).

Health care professional education programs do not have many opportunities for workplace learning where trainees from different professions can learn and work together to provide care to patients in real time. 

The VA Connecticut Healthcare System CoEPCE developed and implemented an education and practice-based immersion learning model with physician residents, nurse practitioner (NP) residents and NP students, pharmacy residents, postdoctorate psychology learners, and PA and physical therapy learners and faculty. This interprofessional, collaborative team model breaks from the traditional independent model of siloed primary care providers (PCPs) caring for a panel of patients.

Methods

In 2015, OAA evaluators 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 Initiative to Minimize Pharmaceutical Risk in Older Veterans (IMPROVE) program to trainees, veterans, and the VA.

Lack of Clinical Approaches to Interprofessional Education and Care

Polypharmacy is a common problem among older adults with multiple chronic conditions, which places patients at higher risk for multiple negative health outcomes.^2,3 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 team-based approach.

Team Approach to Medication Needs

A key CoEPCE program aim is to expand workplace 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 IMPROVE to focus on high-need 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 adverse effects (AEs). These goals are 2-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.

Related: Pharmacist Interventions to Reduce Modifiable Bleeding Risk Factors Using HAS-BLED in Patients Taking Warfarin (FULL)

Planning and Implementation

IMPROVE has its origins in a scholarly project developed by a West Haven CoE physician resident trainee. Development of the IMPROVE program involved VA health psychology, internal medicine faculty, geriatric medicine faculty, NP faculty, and geriatric pharmacy residents and faculty. Planning started in 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 West Haven primary care clinic.

Curriculum

IMPROVE is an educational, workplace learning, and clinical activity that combines a 1-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 nonpharmacologic 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 sees one of their patients at least 3 times per year in the program. Up to 5 trainees participate in each IMPROVE session. Trainees are responsible for reviewing their 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 VAMC providers.⁴ They also work with a protocol for medication discontinuation, which was compiled by West Haven VAMC clinicians. The teams use a variety of tools that guide appropriate prescribing in older adult populations.^5,6 During a preclinic conference, trainees present their patients to the interprofessional team for discussion and participate in a short discussion led by a pharmacist, geriatrician, or health psychologist on a topic related to prescribing safety in older adults or nonpharmacologic treatments.

IMPROVE emphasizes a patient-centered approach to develop, execute, and monitor medication plans. Patients and their family members are invited by their trainee clinician to participate in a group visit. Typically, trainees invite patients aged ≥ 65 years who have ≥ 10 medications and are considered appropriate for a group visit. 

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.⁷ 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 perceptions and share concerns and treatment goals. There is shared responsibility among the trainees to address the educational material as well as involve their respective patients during the sessions.

Immediately following the group visit, trainees conduct a 1-hour clinic session that includes medication reconciliation, a review of an IMPROVE questionnaire, orthostatic vital signs, and the St. Louis University Mental Status (SLUMS) exam to assess changes in cognition.^7,8 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, feelings about the medications, which medications they would like to stop, and AEs 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. In the session they may 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 4 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 shared decision making (SDM).

Related: Reducing Benzodiazepine Prescribing in Older Veterans: A Direct-to-Consumer Educational Brochure

The IMPROVE model continues to evolve. The original curriculum involved an hour-long preclinic preparation session before the group visit in which trainees and faculty discussed the medication review for each patient scheduled that day. This preparation session was later shortened to 40 minutes, and a 20-minute didactic component was added to create the current preclinic session. The didactic component focused on a specific topic in appropriate prescribing for older patients. For example, one didactic lesson is on a particular class of medications, its common AEs, 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 patients from their 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 patients to continue to optimize the medication regimen even after the IMPROVE visit. Another significant change was the inclusion of veterans who are comanaged with PCPs outside the VA, because we found that patients with multiple providers could benefit from improved coordination of care.

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 patients’ health records before the patients come into the clinic, participates in the group visit, and coprecepts during the 1:1 patient visits. Collaboration is inherent in IMPROVE. For example, the geriatrician works with the geriatric pharmacist to identify and teach an 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 patient aligned care team (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 1 to 3 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 preclinic session (about an hour of preparation per session). Sufficient space also is required: a room large enough to accommodate up to 10 people for both didactic lessons and preclinic sessions, a facility patient education conference room for the group visit, and up to 5 clinic exam rooms. CoEPCE staff developed a templated note in the VA Computerized Patient Record System (CPRS), the VA electronic health record system to guide trainees step-by-step through the clinic visit and allow them to directly enter information into the system.⁷

Monitoring and Assessment

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 NP trainees.

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 also have 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 the Accreditation Council for Graduate Medical Education interprofessional milestones, and promote individual trainee scholarship and performance improvement in areas of broad applicability. IMPROVE also is 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 complex 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 training priority. The CoEPCE has tried different configurations to increase the number of patients being seen, such as having ≥ 1 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 some of these patients needed the most help, it developed a process for reaching out to non-VA providers and coordinating care. Additionally, there is significant diversity in patient polypharmacy needs. These can range from adherence problems to the challenge of complex psychosocial needs that are more easily (but less effectively) addressed with medications. The issue of polypharmacy is further complicated by evolving understanding of medications’ relative risks and benefits in older adults with multiple chronic conditions. IMPROVE is an effective vehicle for synthesizing current science in medications and their management, especially in complex older patients with multiple chronic conditions.

Other challenges include developing a templated CPRS electronic note that interfaces with the VA information technology system. The process of creating a template, obtaining approval from the forms committee, and working with information technology personnel to implement the template was more time intensive than anticipated and required multiple iterations of proofreading and editing.

Related: Effect of High-Dose Ergocalciferol on Rate of Falls in a Community-Dwelling, Home-Based Primary Care Veteran Population: A Case-Crossover Study

Factors for Success

The commitment to support new models of trainee education by West Haven CoEPCE faculty and leadership, and West Haven VAMC and primary care clinic leadership facilitated the implementation of IMPROVE. Additionally, there is strong CoEPCE collaboration at all levels—codirectors, faculty, and trainees—for the program. High interprofessional trainee interest, organizational insight, and an academic orientation were critical for developing and launching IMPROVE.

Additionally, there is synergy with other team-based professions. Geriatrics has a tradition of working in multidisciplinary 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 2 specialties complement each other and address the complex health needs of participating veterans. Health psychologists transition patients to nonpharmacologic 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 within the VA from 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 mellitus 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 are outlined below.

Interprofessional Education

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 colocation 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.

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 who have been cared for by other (VA and non-VA) providers.

Interprofessional Collaboration

Understanding and leveraging the expertise of trainees and faculty from different professions is a primary goal of 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 cohesive solution or strategy. The result is that trainees are more well rounded and become better practitioners who seek advice from other professions and work well in teams.

Trainees are expected to learn about other professions and their skill sets. For example, trainees learn early about 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 or dementia to the trainees’ attention. This is significant because issues like patient motivation may be better handled from a behavioral perspective.

Expanded 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, about 30 internal medicine residents and 6 NP residents have seen patients in the polypharmacy clinic. Each year, 4 NP residents, 2 health psychology residents, 4 clinical pharmacy residents, and 1 geriatric pharmacy resident participate in the IMPROVE clinic during their yearlong training program. During their 3-year training program, 17 to 19 internal medicine residents participate in IMPROVE.

A structured forum for discussing patients and their care options supports professionals’ utilization of the full scope of their practice. Trainees learn and apply team skills, such as communication and the warm handoff, which can be used in other clinic settings. 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.”⁹ An interprofessional care plan supports trainee clinical performance, providing a more robust approach to patient care than individual providers might on their own.

Patient Outcomes

IMPROVE is an enriched care plan informed by multiple professions with the potential to improve medication use and provide better care. Veterans also are 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, 5 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 also are 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 suggest that in some patients, cognition (as measured with SLUMS after 6 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 faculty try to ensure that everyone knows about and concurs with medication changes, including outside providers and family members.

Satisfaction Questionnaire

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.

Results of postvisit patient satisfaction questionnaires are encouraging and result in 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.

CoEPCE Benefits

IMPROVE expands the prevention and treatment options for populations at risk of hospitalization and adverse outcomes from medication complications, such as AEs and drug-drug or drug-disease 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.

IMPROVE also 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 not only has strengthened CoEPCE partnerships with other VA departments and specialties, but also revealed opportunities for collaboration with academic affiliates as a means to break down traditional silos among medicine, nursing, pharmacy, geriatrics, and psychology.

IMPROVE combines key components of interprofessional education, including all 4 CoEPCE core domains, to provide hands-on experience with knowledge learned in other aspects of the CoEPCE training program (eg, shared decision-making strategies for eliciting patient goals, weighing risks and benefits in complex clinical situations). Physician and NP trainees work together with trainees in pharmacy and health psychology in the complex approach to polypharmacy. IMPROVE provides the framework for an interprofessional clinic that could be used in the treatment of other complex or high-risk chronic conditions.

The Future

An opportunity for improvement and expansion includes increased patient involvement (as patients continue to learn they have a team working on their behalf). Opportunities exist to connect with patients who have several clinicians prescribing medications outside 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 an implementation kit that describes the training process and includes the medication worksheet, 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 other health professional training sites at Yale University in New Haven, Connecticut. Additionally, the West Haven CoEPCE is planning to partner with the other original CoEPCE program sites to implement similar interprofessional polypharmacy clinics.