MSN

APP Intersection

Postgraduate training for advanced practice providers (APPs) has existed in one form or another since the genesis of the allied professions. They are typically referred to as residencies, fellowships, postgraduate programs, and transition-to-practice.

The desire and necessity for these programs has increased in the past decade with workforce changes; namely the increasing number of nurse practitioners (NPs) graduating with fewer years of experience at the bedside compared with previous eras, a similar decrease in patient contact hours for graduating PAs, the transition of physician colleagues from employers to employees and the subsequent change in priorities in training new graduate APPs, and resident work hour restrictions necessitating more APPs to staff inpatient units and work in various specialties.

CHEST

The goal of these programs is to provide postgraduate training to physician assistants/associates (PAs) and NPs across myriad medical specialties to both newly graduated APPs and those looking to transition specialties. Current programs exist in family medicine, emergency medicine, urgent care, critical care medicine, pulmonary medicine, oncology, surgery, and various surgical subspecialties, to name a few. Program length is highly variable, though most programs advertise as lasting around 12 months, with varying ratios of clinical and didactic education. Postgraduate APP programs are largely advertise as salaried, benefitted positions, though usually at a rate below that of a so-called “direct hire” due to the protected learning time associated with the postgraduate training year.

CHEST

Accreditation for these programs is still disjointed, although unifying efforts have been made as of late, and is currently available through the Advanced Practice Provider Fellowship Accreditation, Association of Postgraduate Physician Assistant Programs, ARC-PA, the Accreditation Commission for Education in Nursing, and the Consortium for Advanced Practice Providers. Other organizations, such as the Association of Post Graduate APRN Programs, host regular conferences to discuss the formulation of postgraduate APP education curricula and program development.

While accreditation offers guidance for fledgling programs, many utilize the standards published by the American College of Graduate Medical Education to ensure that appropriate clinical milestones are being met and that a common language among APPs and physicians who are involved in the evaluation of the postgraduate APP trainee is being used. Programs also seek to utilize other well-established curricula and certification programs published by various national and international organizations. A key distinction from physician postgraduate training is that there is currently no fiscal or legislative support for postgraduate APP programs; these issues have been cited as reasons for the limited scope and number of programs.

When starting APP Fellowship programs, it is important to consider why this would be beneficial to a specific division and health care organization. Usually, fellowship programs develop out of a need to train and retain APPs. It is no secret that turnover and retention of skilled APPs is a nationwide problem associated with significant costs to organizations. The ability to retain fellowship-trained APPs will result in cost savings due to the reduction in onboarding time and orientation costs, as these APP fellows finish their programs ready to be fully productive team members.

Additional considerations for the development of an APP fellowship include improving access to care and increasing the quality of the care provided. Fellowship programs encourage a smoother transition to practice by offering more support through education, closer evaluation, and frequent feedback, which improves competence and confidence of these providers. A supported APP is more likely to practice to the fullest extent of their license and have improved personal and professional satisfaction, leading to employee retention and better patient care.

When developing a budget for these types of programs, it is important to include the full-time equivalent (FTE) for the fellow, benefits, onboarding/licensure, simulations, and fellowship faculty costs.

Faculty compensation varies by institution but can include salary support, FTE reduction, and nonclinical appointments. Tracking metrics such as fellow billing, length of stay, and access to care during the fellowship year are helpful to highlight the benefit of these programs to the organization.

Initiating a program like those described may seem like a Herculean feat, but motivated individuals have been able to accomplish similar goals in both adequately and poorly resourced areas. For those aspiring to start a postgraduate APP program at their instruction, these authors suggest the following approach.

First, identify your institution’s need for such a program. Next, define your curriculum, evaluation process, and expectations. Then, create buy-in from stakeholders, including administrative and clinical personnel. Finally, focus on recruitment. Seeking accreditation may be challenging for new programs, but identifying the accreditation standard you plan to pursue early will pay dividends when the time comes for the program to apply. Those starting down this path should realistically expect an 18- to 24-month period between their first efforts and the start of the first class.

“APP Intersection” is a new quarterly column focusing on areas of interest for the entire chest medicine health care team.

APP Intersection

Postgraduate training for advanced practice providers (APPs) has existed in one form or another since the genesis of the allied professions. They are typically referred to as residencies, fellowships, postgraduate programs, and transition-to-practice.

The desire and necessity for these programs has increased in the past decade with workforce changes; namely the increasing number of nurse practitioners (NPs) graduating with fewer years of experience at the bedside compared with previous eras, a similar decrease in patient contact hours for graduating PAs, the transition of physician colleagues from employers to employees and the subsequent change in priorities in training new graduate APPs, and resident work hour restrictions necessitating more APPs to staff inpatient units and work in various specialties.

CHEST

The goal of these programs is to provide postgraduate training to physician assistants/associates (PAs) and NPs across myriad medical specialties to both newly graduated APPs and those looking to transition specialties. Current programs exist in family medicine, emergency medicine, urgent care, critical care medicine, pulmonary medicine, oncology, surgery, and various surgical subspecialties, to name a few. Program length is highly variable, though most programs advertise as lasting around 12 months, with varying ratios of clinical and didactic education. Postgraduate APP programs are largely advertise as salaried, benefitted positions, though usually at a rate below that of a so-called “direct hire” due to the protected learning time associated with the postgraduate training year.

CHEST

Accreditation for these programs is still disjointed, although unifying efforts have been made as of late, and is currently available through the Advanced Practice Provider Fellowship Accreditation, Association of Postgraduate Physician Assistant Programs, ARC-PA, the Accreditation Commission for Education in Nursing, and the Consortium for Advanced Practice Providers. Other organizations, such as the Association of Post Graduate APRN Programs, host regular conferences to discuss the formulation of postgraduate APP education curricula and program development.

While accreditation offers guidance for fledgling programs, many utilize the standards published by the American College of Graduate Medical Education to ensure that appropriate clinical milestones are being met and that a common language among APPs and physicians who are involved in the evaluation of the postgraduate APP trainee is being used. Programs also seek to utilize other well-established curricula and certification programs published by various national and international organizations. A key distinction from physician postgraduate training is that there is currently no fiscal or legislative support for postgraduate APP programs; these issues have been cited as reasons for the limited scope and number of programs.

When starting APP Fellowship programs, it is important to consider why this would be beneficial to a specific division and health care organization. Usually, fellowship programs develop out of a need to train and retain APPs. It is no secret that turnover and retention of skilled APPs is a nationwide problem associated with significant costs to organizations. The ability to retain fellowship-trained APPs will result in cost savings due to the reduction in onboarding time and orientation costs, as these APP fellows finish their programs ready to be fully productive team members.

Additional considerations for the development of an APP fellowship include improving access to care and increasing the quality of the care provided. Fellowship programs encourage a smoother transition to practice by offering more support through education, closer evaluation, and frequent feedback, which improves competence and confidence of these providers. A supported APP is more likely to practice to the fullest extent of their license and have improved personal and professional satisfaction, leading to employee retention and better patient care.

When developing a budget for these types of programs, it is important to include the full-time equivalent (FTE) for the fellow, benefits, onboarding/licensure, simulations, and fellowship faculty costs.

Faculty compensation varies by institution but can include salary support, FTE reduction, and nonclinical appointments. Tracking metrics such as fellow billing, length of stay, and access to care during the fellowship year are helpful to highlight the benefit of these programs to the organization.

Initiating a program like those described may seem like a Herculean feat, but motivated individuals have been able to accomplish similar goals in both adequately and poorly resourced areas. For those aspiring to start a postgraduate APP program at their instruction, these authors suggest the following approach.

First, identify your institution’s need for such a program. Next, define your curriculum, evaluation process, and expectations. Then, create buy-in from stakeholders, including administrative and clinical personnel. Finally, focus on recruitment. Seeking accreditation may be challenging for new programs, but identifying the accreditation standard you plan to pursue early will pay dividends when the time comes for the program to apply. Those starting down this path should realistically expect an 18- to 24-month period between their first efforts and the start of the first class.

“APP Intersection” is a new quarterly column focusing on areas of interest for the entire chest medicine health care team.

APP Intersection

Postgraduate training for advanced practice providers (APPs) has existed in one form or another since the genesis of the allied professions. They are typically referred to as residencies, fellowships, postgraduate programs, and transition-to-practice.

The desire and necessity for these programs has increased in the past decade with workforce changes; namely the increasing number of nurse practitioners (NPs) graduating with fewer years of experience at the bedside compared with previous eras, a similar decrease in patient contact hours for graduating PAs, the transition of physician colleagues from employers to employees and the subsequent change in priorities in training new graduate APPs, and resident work hour restrictions necessitating more APPs to staff inpatient units and work in various specialties.

CHEST

The goal of these programs is to provide postgraduate training to physician assistants/associates (PAs) and NPs across myriad medical specialties to both newly graduated APPs and those looking to transition specialties. Current programs exist in family medicine, emergency medicine, urgent care, critical care medicine, pulmonary medicine, oncology, surgery, and various surgical subspecialties, to name a few. Program length is highly variable, though most programs advertise as lasting around 12 months, with varying ratios of clinical and didactic education. Postgraduate APP programs are largely advertise as salaried, benefitted positions, though usually at a rate below that of a so-called “direct hire” due to the protected learning time associated with the postgraduate training year.

CHEST

Accreditation for these programs is still disjointed, although unifying efforts have been made as of late, and is currently available through the Advanced Practice Provider Fellowship Accreditation, Association of Postgraduate Physician Assistant Programs, ARC-PA, the Accreditation Commission for Education in Nursing, and the Consortium for Advanced Practice Providers. Other organizations, such as the Association of Post Graduate APRN Programs, host regular conferences to discuss the formulation of postgraduate APP education curricula and program development.

While accreditation offers guidance for fledgling programs, many utilize the standards published by the American College of Graduate Medical Education to ensure that appropriate clinical milestones are being met and that a common language among APPs and physicians who are involved in the evaluation of the postgraduate APP trainee is being used. Programs also seek to utilize other well-established curricula and certification programs published by various national and international organizations. A key distinction from physician postgraduate training is that there is currently no fiscal or legislative support for postgraduate APP programs; these issues have been cited as reasons for the limited scope and number of programs.

When starting APP Fellowship programs, it is important to consider why this would be beneficial to a specific division and health care organization. Usually, fellowship programs develop out of a need to train and retain APPs. It is no secret that turnover and retention of skilled APPs is a nationwide problem associated with significant costs to organizations. The ability to retain fellowship-trained APPs will result in cost savings due to the reduction in onboarding time and orientation costs, as these APP fellows finish their programs ready to be fully productive team members.

Additional considerations for the development of an APP fellowship include improving access to care and increasing the quality of the care provided. Fellowship programs encourage a smoother transition to practice by offering more support through education, closer evaluation, and frequent feedback, which improves competence and confidence of these providers. A supported APP is more likely to practice to the fullest extent of their license and have improved personal and professional satisfaction, leading to employee retention and better patient care.

When developing a budget for these types of programs, it is important to include the full-time equivalent (FTE) for the fellow, benefits, onboarding/licensure, simulations, and fellowship faculty costs.

Faculty compensation varies by institution but can include salary support, FTE reduction, and nonclinical appointments. Tracking metrics such as fellow billing, length of stay, and access to care during the fellowship year are helpful to highlight the benefit of these programs to the organization.

Initiating a program like those described may seem like a Herculean feat, but motivated individuals have been able to accomplish similar goals in both adequately and poorly resourced areas. For those aspiring to start a postgraduate APP program at their instruction, these authors suggest the following approach.

First, identify your institution’s need for such a program. Next, define your curriculum, evaluation process, and expectations. Then, create buy-in from stakeholders, including administrative and clinical personnel. Finally, focus on recruitment. Seeking accreditation may be challenging for new programs, but identifying the accreditation standard you plan to pursue early will pay dividends when the time comes for the program to apply. Those starting down this path should realistically expect an 18- to 24-month period between their first efforts and the start of the first class.

“APP Intersection” is a new quarterly column focusing on areas of interest for the entire chest medicine health care team.

The Veterans Health Administration (VHA)—along with systems across the world—has spent the past 2 years continuously adapting to meet the emerging needs of persons infected with COVID-19. With the development of effective vaccines and global efforts to mitigate transmission, attention has now shifted to long COVID care as the need for further outpatient health care becomes increasingly apparent.^1,2

Background

Multiple terms describe the lingering, multisystem sequelae of COVID-19 that last longer than 4 weeks: long COVID, postacute COVID-19 syndrome, post-COVID condition, postacute sequalae of COVID-19, and COVID long hauler.^1,3 Common symptoms include fatigue, shortness of breath, cough, sleep disorders, brain fog or cognitive dysfunction, depression, anxiety, pain, and changes in taste or smell that impact a person’s functioning.^4,5 The multisystem nature of the postacute course of COVID-19 necessitates an interdisciplinary approach to devise comprehensive and individualized care plans.^6-9 Research is needed to better understand this postacute state (eg, prevalence, underlying effects, characteristics of those who experience long COVID) to establish and evaluate cost-effective treatment approaches.

Many patients who are experiencing symptoms beyond the acute course of COVID-19 have been referred to general outpatient clinics or home health, which may lack the capacity and knowledge of this novel disease to effectively manage complex long COVID cases.^2,3 To address this growing need, clinicians and leadership across a variety of disciplines and settings in the VHA created a community of practice (CoP) to create a mechanism for cross-facility communication, identify gaps in long COVID care and research, and cocreate knowledge on best practices for care delivery.

In this spirit, we are embracing a learning health system (LHS) approach that uses rapid-cycle methods to integrate data and real-world experience to iteratively evaluate and adapt models of long COVID care.¹⁰ Our clinically identified and data-driven objective is to provide high value health care to patients with long COVID sequalae by creating a framework to learn about this novel condition and develop innovative care models. This article provides an overview of our emerging LHS approach to the study of long COVID care that is fostering innovation and adaptability within the VHA. We describe 3 aspects of our engagement approach central to LHS: the ongoing development of a long COVID CoP dedicated to iteratively informing the bidirectional cycle of data from practice to research, results of a broad environmental scan of VHA long COVID care, and results of a survey administered to CoP members to inform ongoing needs of the community and identify early successful outcomes from participation.

Learning Health System Approach

The VHA is one of the largest integrated health care systems in the United States serving more than 9 million veterans.¹¹ Since 2017, the VHA has articulated a vision to become an LHS that informs and improves patient-centered care through practice-based and data-driven research (eAppendix).¹² During the early COVID-19 pandemic, an LHS approach in the VHA was critical to rapidly establishing a data infrastructure for disease surveillance, coordinating data-driven solutions, leveraging use of technology, collaborating across the globe to identify best practices, and implementing systematic responses (eg, policies, workforce adjustments).

Our long COVID CoP was developed as clinical observations and ongoing conversations with stakeholders (eg, veterans, health care practitioners [HCPs], leadership) identified a need to effectively identify and treat the growing number of veterans with long COVID. This clinical issue is compounded by the limited but emerging evidence on the clinical presentation of prolonged COVID-19 symptoms, treatment, and subsequent care pathways. The VHA’s efforts and lessons learned within the lens of an LHS are applicable to other systems confronting the complex identification and management of patients with persistent and encumbering long COVID symptoms. The VHA is building upon the LHS approach to proactively prepare for and address future clinical or public health challenges that require cross-system and sector collaborations, expediency, inclusivity, and patient/family centeredness.¹¹

Community of Practice

As of January 25, 2022, our workgroup consisted of 128 VHA employees representing 29 VHA medical centers. Members of the multidisciplinary workgroup have diverse backgrounds with HCPs from primary care (eg, physicians, nurse practitioners), rehabilitation (eg, physical therapists), specialty care (eg, pulmonologists, physiatrists), mental health (eg, psychologists), and complementary and integrated health/Whole Health services (eg, practitoners of services such as yoga, tai chi, mindfulness, acupuncture). Members also include clinical, operations, and research leadership at local, regional, and national VHA levels. Our first objective as a large, diverse group was to establish shared goals, which included: (1) determining efficient communication pathways; (2) identifying gaps in care or research; and (3) cocreating knowledge to provide solutions to identified gaps.

Communication Mechanisms

Our first goal was to create an efficient mechanism for cross-facility communication. The initial CoP was formed in April 2021 and the first virtual meeting focused on reaching a consensus regarding the best way to communicate and proceed. We agreed to convene weekly at a consistent time, created a standard agenda template, and elected a lead facilitator of meeting proceedings. In addition, a member of the CoP recorded and took extensive meeting notes, which were later distributed to the entire CoP to accommodate varying schedules and ability to attend live meetings. Approximately 20 to 30 participants attend the meetings in real-time.

To consolidate working documents, information, and resources in one location, we created a platform to communicate via a Microsoft Teams channel. All CoP members are given access to the folders and allowed to add to the growing library of resources. Resources include clinical assessment and note templates for electronic documentation of care, site-specific process maps, relevant literature on screening and interventions identified by practice members, and meeting notes along with the recordings. A chat feature alerts CoP members to questions posed by other members. Any resources or information shared on the chat discussion are curated by CoP leaders to disseminate to all members. Importantly, this platform allowed us to communicate efficiently within the VHA organization by creating a centralized space for documents and the ability to correspond with all or select members of the CoP. Additional VHA employees can easily be referred and request access.

To increase awareness of the CoP, expand reach, and diversify perspectives, every participant was encouraged to invite colleagues and stakeholders with interest or experience in long COVID care to join. While patients are not included in this CoP, we are working closely with the VHA user experience workgroup (many members overlap) that is gathering patient and caregiver perspectives on their COVID-19 experience and long COVID care. Concurrently, CoP members and leadership facilitate communication and set up formal collaborations with other non-VHA health care systems to create an intersystem network of collaboration for long COVID care. This approach further enhances the speed at which we can work together to share lessons learned and stay up-to-date on emerging evidence surrounding long COVID care.

Identifying Gaps in Care and Research

Our second goal was to identify gaps in care or knowledge to inform future research and quality improvement initiatives, while also creating a foundation to cocreate knowledge about safe, effective care management of the novel long COVID sequelae. To translate knowledge, we must first identify and understand the gaps between the current, best available evidence and current care practices or policies impacting that delivery.¹³ As such, the structured meeting agenda and facilitated meeting discussions focused on understanding current clinical decision making and the evidence base. We shared VHA evidence synthesis reports and living rapid reviews on complications following COVID-19 illness (ie, major organ damage and posthospitalization health care use) that provided an objective evidence base on common long COVID complications.^14,15

Since long COVID is a novel condition, we drew from literature in similar patient populations and translated that information in the context of our current knowledge of this unique syndrome. For example, we discussed the predominant and persistent symptom of fatigue post-COVID.⁵ In particular, the CoP discussed challenges in identifying and treating post-COVID fatigue, which is often a vague symptom with multiple or interacting etiologies that require a comprehensive, interdisciplinary approach. As such, we reviewed, adapted, and translated identification and treatment strategies from the literature on chronic fatigue syndrome to patients with post-COVID syndrome.^16,17 We continue to work collaboratively and engage the appropriate stakeholders to provide input on the gaps to prioritize targeting.

Cocreate Knowledge

Our third goal was to cocreate knowledge regarding the care of patients with long COVID. To accomplish this, our structured meetings and communication pathways invited members to share experiences on the who (delivers and receives care), what (type of care or HCPs), when (identification of post-COVID and access), and how (eg, telehealth) of care to patients post-COVID. As part of the workgroup, we identified and shared resources on standardized, facility-level practices to reduce variability across the VHA system. These resources included intake/assessment forms, care processes, and batteries of tests/measures used for screening and assessment. The knowledge obtained from outside the CoP and cocreated within is being used to inform data-driven tools to support and evaluate care for patients with long COVID. As such, members of the workgroup are in the formative stages of participating in quality improvement innovation pilots to test technologies and processes designed to improve and validate long COVID care pathways. These technologies include screening tools, clinical decision support tools, and population health management technologies. In addition, we are developing a formal collaboration with the VHA Office of Research and Development to create standardized intake forms across VHA long COVID clinics to facilitate both clinical monitoring and research.

Surveys

The US Department of Veterans Affairs Central Office collaborated with our workgroup to draft an initial set of survey questions designed to understand how each VHA facility defines, identifies, and provides care to veterans experiencing post-COVID sequalae. The 41-question survey was distributed through regional directors and chief medical officers at 139 VHA facilities in August 2021. One hundred nineteen responses (86%) were received. Sixteen facilities indicated they had established programs and 26 facilities were considering a program. Our CoP had representation from the 16 facilities with established programs indicating the deep and well-connected nature of our grassroots efforts to bring together stakeholders to learn as part of a CoP.

A separate, follow-up survey generated responses from 18 facilities and identified the need to capture evolving innovations and to develop smaller workstreams (eg, best practices, electronic documentation templates, pathway for referrals, veteran engagement, outcome measures). The survey not only exposed ongoing challenges to providing long COVID care, but importantly, outlined the ways in which CoP members were leveraging community knowledge and resources to inform innovations and processes of care changes at their specific sites. Fourteen of 18 facilities with long COVID programs in place explicitly identified the CoP as a resource they have found most beneficial when employing such innovations. Specific innovations reported included changes in care delivery, engagement in active outreach with veterans and local facility, and infrastructure development to sustain local long COVID clinics (Table).

Future Directions

Our CoP strives to contribute to an evidence base for long COVID care. At the system level, the CoP has the potential to impact access and continuity of care by identifying appropriate processes and ensuring that VHA patients receive outreach and an opportunity for post-COVID care. Comprehensive care requires input from HCP, clinical leadership, and operations levels. In this sense, our CoP provides an opportunity for diverse stakeholders to come together, discuss barriers to screening and delivering post-COVID care, and create an action plan to remove or lessen such barriers.¹⁸ Part of the process to remove barriers is to identify and support efficient resource allocation. Our CoP has worked to address issues in resource allocation (eg, space, personnel) for post-COVID care. For example, one facility is currently implementing interdisciplinary virtual post-COVID care. Another facility identified and restructured working assignments for psychologists who served in different capacities throughout the system to fill the need within the long COVID team.

At the HCP level, the CoP is currently developing workshops, media campaigns, written clinical resources, skills training, publications, and webinars/seminars with continuing medical education credits.¹⁹ The CoP may also provide learning and growth opportunities, such as clinical or VHA operational fellowships and research grants.

We are still in the formative stages of post-COVID care and future efforts will explore patient-centered outcomes. We are drawing on the Centers for Disease Control and Prevention’s guidance for evaluating patients with long COVID symptoms and examining the feasibility within VHA, as well as patient perspectives on post-COVID sequalae, to ensure we are selecting assessments that measure patient-centered constructs.¹⁸

Conclusions

A VHA-wide LHS approach is identifying issues related to the identification, delivery, and evaluation of long COVID care. This long COVID CoP has developed an infrastructure for communication, identified gaps in care, and cocreated knowledge related to best current practices for post-COVID care. This work is contributing to systemwide LHS efforts dedicated to creating a culture of quality care and innovation and is a process that is transferrable to other areas of care in the VHA, as well as other health care systems. The LHS approach continues to be highly relevant as we persist through the COVID-19 pandemic and reimagine a postpandemic world.

Acknowledgments

We thank all the members of the Veterans Health Administration long COVID Community of Practice who participate in the meetings and contribute to the sharing and spread of knowledge.

The Veterans Health Administration (VHA)—along with systems across the world—has spent the past 2 years continuously adapting to meet the emerging needs of persons infected with COVID-19. With the development of effective vaccines and global efforts to mitigate transmission, attention has now shifted to long COVID care as the need for further outpatient health care becomes increasingly apparent.^1,2

Background

Multiple terms describe the lingering, multisystem sequelae of COVID-19 that last longer than 4 weeks: long COVID, postacute COVID-19 syndrome, post-COVID condition, postacute sequalae of COVID-19, and COVID long hauler.^1,3 Common symptoms include fatigue, shortness of breath, cough, sleep disorders, brain fog or cognitive dysfunction, depression, anxiety, pain, and changes in taste or smell that impact a person’s functioning.^4,5 The multisystem nature of the postacute course of COVID-19 necessitates an interdisciplinary approach to devise comprehensive and individualized care plans.^6-9 Research is needed to better understand this postacute state (eg, prevalence, underlying effects, characteristics of those who experience long COVID) to establish and evaluate cost-effective treatment approaches.

Many patients who are experiencing symptoms beyond the acute course of COVID-19 have been referred to general outpatient clinics or home health, which may lack the capacity and knowledge of this novel disease to effectively manage complex long COVID cases.^2,3 To address this growing need, clinicians and leadership across a variety of disciplines and settings in the VHA created a community of practice (CoP) to create a mechanism for cross-facility communication, identify gaps in long COVID care and research, and cocreate knowledge on best practices for care delivery.

In this spirit, we are embracing a learning health system (LHS) approach that uses rapid-cycle methods to integrate data and real-world experience to iteratively evaluate and adapt models of long COVID care.¹⁰ Our clinically identified and data-driven objective is to provide high value health care to patients with long COVID sequalae by creating a framework to learn about this novel condition and develop innovative care models. This article provides an overview of our emerging LHS approach to the study of long COVID care that is fostering innovation and adaptability within the VHA. We describe 3 aspects of our engagement approach central to LHS: the ongoing development of a long COVID CoP dedicated to iteratively informing the bidirectional cycle of data from practice to research, results of a broad environmental scan of VHA long COVID care, and results of a survey administered to CoP members to inform ongoing needs of the community and identify early successful outcomes from participation.

Learning Health System Approach

The VHA is one of the largest integrated health care systems in the United States serving more than 9 million veterans.¹¹ Since 2017, the VHA has articulated a vision to become an LHS that informs and improves patient-centered care through practice-based and data-driven research (eAppendix).¹² During the early COVID-19 pandemic, an LHS approach in the VHA was critical to rapidly establishing a data infrastructure for disease surveillance, coordinating data-driven solutions, leveraging use of technology, collaborating across the globe to identify best practices, and implementing systematic responses (eg, policies, workforce adjustments).

Our long COVID CoP was developed as clinical observations and ongoing conversations with stakeholders (eg, veterans, health care practitioners [HCPs], leadership) identified a need to effectively identify and treat the growing number of veterans with long COVID. This clinical issue is compounded by the limited but emerging evidence on the clinical presentation of prolonged COVID-19 symptoms, treatment, and subsequent care pathways. The VHA’s efforts and lessons learned within the lens of an LHS are applicable to other systems confronting the complex identification and management of patients with persistent and encumbering long COVID symptoms. The VHA is building upon the LHS approach to proactively prepare for and address future clinical or public health challenges that require cross-system and sector collaborations, expediency, inclusivity, and patient/family centeredness.¹¹

Community of Practice

As of January 25, 2022, our workgroup consisted of 128 VHA employees representing 29 VHA medical centers. Members of the multidisciplinary workgroup have diverse backgrounds with HCPs from primary care (eg, physicians, nurse practitioners), rehabilitation (eg, physical therapists), specialty care (eg, pulmonologists, physiatrists), mental health (eg, psychologists), and complementary and integrated health/Whole Health services (eg, practitoners of services such as yoga, tai chi, mindfulness, acupuncture). Members also include clinical, operations, and research leadership at local, regional, and national VHA levels. Our first objective as a large, diverse group was to establish shared goals, which included: (1) determining efficient communication pathways; (2) identifying gaps in care or research; and (3) cocreating knowledge to provide solutions to identified gaps.

Communication Mechanisms

Our first goal was to create an efficient mechanism for cross-facility communication. The initial CoP was formed in April 2021 and the first virtual meeting focused on reaching a consensus regarding the best way to communicate and proceed. We agreed to convene weekly at a consistent time, created a standard agenda template, and elected a lead facilitator of meeting proceedings. In addition, a member of the CoP recorded and took extensive meeting notes, which were later distributed to the entire CoP to accommodate varying schedules and ability to attend live meetings. Approximately 20 to 30 participants attend the meetings in real-time.

To consolidate working documents, information, and resources in one location, we created a platform to communicate via a Microsoft Teams channel. All CoP members are given access to the folders and allowed to add to the growing library of resources. Resources include clinical assessment and note templates for electronic documentation of care, site-specific process maps, relevant literature on screening and interventions identified by practice members, and meeting notes along with the recordings. A chat feature alerts CoP members to questions posed by other members. Any resources or information shared on the chat discussion are curated by CoP leaders to disseminate to all members. Importantly, this platform allowed us to communicate efficiently within the VHA organization by creating a centralized space for documents and the ability to correspond with all or select members of the CoP. Additional VHA employees can easily be referred and request access.

To increase awareness of the CoP, expand reach, and diversify perspectives, every participant was encouraged to invite colleagues and stakeholders with interest or experience in long COVID care to join. While patients are not included in this CoP, we are working closely with the VHA user experience workgroup (many members overlap) that is gathering patient and caregiver perspectives on their COVID-19 experience and long COVID care. Concurrently, CoP members and leadership facilitate communication and set up formal collaborations with other non-VHA health care systems to create an intersystem network of collaboration for long COVID care. This approach further enhances the speed at which we can work together to share lessons learned and stay up-to-date on emerging evidence surrounding long COVID care.

Identifying Gaps in Care and Research

Our second goal was to identify gaps in care or knowledge to inform future research and quality improvement initiatives, while also creating a foundation to cocreate knowledge about safe, effective care management of the novel long COVID sequelae. To translate knowledge, we must first identify and understand the gaps between the current, best available evidence and current care practices or policies impacting that delivery.¹³ As such, the structured meeting agenda and facilitated meeting discussions focused on understanding current clinical decision making and the evidence base. We shared VHA evidence synthesis reports and living rapid reviews on complications following COVID-19 illness (ie, major organ damage and posthospitalization health care use) that provided an objective evidence base on common long COVID complications.^14,15

Since long COVID is a novel condition, we drew from literature in similar patient populations and translated that information in the context of our current knowledge of this unique syndrome. For example, we discussed the predominant and persistent symptom of fatigue post-COVID.⁵ In particular, the CoP discussed challenges in identifying and treating post-COVID fatigue, which is often a vague symptom with multiple or interacting etiologies that require a comprehensive, interdisciplinary approach. As such, we reviewed, adapted, and translated identification and treatment strategies from the literature on chronic fatigue syndrome to patients with post-COVID syndrome.^16,17 We continue to work collaboratively and engage the appropriate stakeholders to provide input on the gaps to prioritize targeting.

Cocreate Knowledge

Our third goal was to cocreate knowledge regarding the care of patients with long COVID. To accomplish this, our structured meetings and communication pathways invited members to share experiences on the who (delivers and receives care), what (type of care or HCPs), when (identification of post-COVID and access), and how (eg, telehealth) of care to patients post-COVID. As part of the workgroup, we identified and shared resources on standardized, facility-level practices to reduce variability across the VHA system. These resources included intake/assessment forms, care processes, and batteries of tests/measures used for screening and assessment. The knowledge obtained from outside the CoP and cocreated within is being used to inform data-driven tools to support and evaluate care for patients with long COVID. As such, members of the workgroup are in the formative stages of participating in quality improvement innovation pilots to test technologies and processes designed to improve and validate long COVID care pathways. These technologies include screening tools, clinical decision support tools, and population health management technologies. In addition, we are developing a formal collaboration with the VHA Office of Research and Development to create standardized intake forms across VHA long COVID clinics to facilitate both clinical monitoring and research.

Surveys

The US Department of Veterans Affairs Central Office collaborated with our workgroup to draft an initial set of survey questions designed to understand how each VHA facility defines, identifies, and provides care to veterans experiencing post-COVID sequalae. The 41-question survey was distributed through regional directors and chief medical officers at 139 VHA facilities in August 2021. One hundred nineteen responses (86%) were received. Sixteen facilities indicated they had established programs and 26 facilities were considering a program. Our CoP had representation from the 16 facilities with established programs indicating the deep and well-connected nature of our grassroots efforts to bring together stakeholders to learn as part of a CoP.

A separate, follow-up survey generated responses from 18 facilities and identified the need to capture evolving innovations and to develop smaller workstreams (eg, best practices, electronic documentation templates, pathway for referrals, veteran engagement, outcome measures). The survey not only exposed ongoing challenges to providing long COVID care, but importantly, outlined the ways in which CoP members were leveraging community knowledge and resources to inform innovations and processes of care changes at their specific sites. Fourteen of 18 facilities with long COVID programs in place explicitly identified the CoP as a resource they have found most beneficial when employing such innovations. Specific innovations reported included changes in care delivery, engagement in active outreach with veterans and local facility, and infrastructure development to sustain local long COVID clinics (Table).

Future Directions

Our CoP strives to contribute to an evidence base for long COVID care. At the system level, the CoP has the potential to impact access and continuity of care by identifying appropriate processes and ensuring that VHA patients receive outreach and an opportunity for post-COVID care. Comprehensive care requires input from HCP, clinical leadership, and operations levels. In this sense, our CoP provides an opportunity for diverse stakeholders to come together, discuss barriers to screening and delivering post-COVID care, and create an action plan to remove or lessen such barriers.¹⁸ Part of the process to remove barriers is to identify and support efficient resource allocation. Our CoP has worked to address issues in resource allocation (eg, space, personnel) for post-COVID care. For example, one facility is currently implementing interdisciplinary virtual post-COVID care. Another facility identified and restructured working assignments for psychologists who served in different capacities throughout the system to fill the need within the long COVID team.

At the HCP level, the CoP is currently developing workshops, media campaigns, written clinical resources, skills training, publications, and webinars/seminars with continuing medical education credits.¹⁹ The CoP may also provide learning and growth opportunities, such as clinical or VHA operational fellowships and research grants.

We are still in the formative stages of post-COVID care and future efforts will explore patient-centered outcomes. We are drawing on the Centers for Disease Control and Prevention’s guidance for evaluating patients with long COVID symptoms and examining the feasibility within VHA, as well as patient perspectives on post-COVID sequalae, to ensure we are selecting assessments that measure patient-centered constructs.¹⁸

Conclusions

A VHA-wide LHS approach is identifying issues related to the identification, delivery, and evaluation of long COVID care. This long COVID CoP has developed an infrastructure for communication, identified gaps in care, and cocreated knowledge related to best current practices for post-COVID care. This work is contributing to systemwide LHS efforts dedicated to creating a culture of quality care and innovation and is a process that is transferrable to other areas of care in the VHA, as well as other health care systems. The LHS approach continues to be highly relevant as we persist through the COVID-19 pandemic and reimagine a postpandemic world.

Acknowledgments

We thank all the members of the Veterans Health Administration long COVID Community of Practice who participate in the meetings and contribute to the sharing and spread of knowledge.

The Veterans Health Administration (VHA)—along with systems across the world—has spent the past 2 years continuously adapting to meet the emerging needs of persons infected with COVID-19. With the development of effective vaccines and global efforts to mitigate transmission, attention has now shifted to long COVID care as the need for further outpatient health care becomes increasingly apparent.^1,2

Background

Multiple terms describe the lingering, multisystem sequelae of COVID-19 that last longer than 4 weeks: long COVID, postacute COVID-19 syndrome, post-COVID condition, postacute sequalae of COVID-19, and COVID long hauler.^1,3 Common symptoms include fatigue, shortness of breath, cough, sleep disorders, brain fog or cognitive dysfunction, depression, anxiety, pain, and changes in taste or smell that impact a person’s functioning.^4,5 The multisystem nature of the postacute course of COVID-19 necessitates an interdisciplinary approach to devise comprehensive and individualized care plans.^6-9 Research is needed to better understand this postacute state (eg, prevalence, underlying effects, characteristics of those who experience long COVID) to establish and evaluate cost-effective treatment approaches.

Many patients who are experiencing symptoms beyond the acute course of COVID-19 have been referred to general outpatient clinics or home health, which may lack the capacity and knowledge of this novel disease to effectively manage complex long COVID cases.^2,3 To address this growing need, clinicians and leadership across a variety of disciplines and settings in the VHA created a community of practice (CoP) to create a mechanism for cross-facility communication, identify gaps in long COVID care and research, and cocreate knowledge on best practices for care delivery.

In this spirit, we are embracing a learning health system (LHS) approach that uses rapid-cycle methods to integrate data and real-world experience to iteratively evaluate and adapt models of long COVID care.¹⁰ Our clinically identified and data-driven objective is to provide high value health care to patients with long COVID sequalae by creating a framework to learn about this novel condition and develop innovative care models. This article provides an overview of our emerging LHS approach to the study of long COVID care that is fostering innovation and adaptability within the VHA. We describe 3 aspects of our engagement approach central to LHS: the ongoing development of a long COVID CoP dedicated to iteratively informing the bidirectional cycle of data from practice to research, results of a broad environmental scan of VHA long COVID care, and results of a survey administered to CoP members to inform ongoing needs of the community and identify early successful outcomes from participation.

Learning Health System Approach

The VHA is one of the largest integrated health care systems in the United States serving more than 9 million veterans.¹¹ Since 2017, the VHA has articulated a vision to become an LHS that informs and improves patient-centered care through practice-based and data-driven research (eAppendix).¹² During the early COVID-19 pandemic, an LHS approach in the VHA was critical to rapidly establishing a data infrastructure for disease surveillance, coordinating data-driven solutions, leveraging use of technology, collaborating across the globe to identify best practices, and implementing systematic responses (eg, policies, workforce adjustments).

Our long COVID CoP was developed as clinical observations and ongoing conversations with stakeholders (eg, veterans, health care practitioners [HCPs], leadership) identified a need to effectively identify and treat the growing number of veterans with long COVID. This clinical issue is compounded by the limited but emerging evidence on the clinical presentation of prolonged COVID-19 symptoms, treatment, and subsequent care pathways. The VHA’s efforts and lessons learned within the lens of an LHS are applicable to other systems confronting the complex identification and management of patients with persistent and encumbering long COVID symptoms. The VHA is building upon the LHS approach to proactively prepare for and address future clinical or public health challenges that require cross-system and sector collaborations, expediency, inclusivity, and patient/family centeredness.¹¹

Community of Practice

As of January 25, 2022, our workgroup consisted of 128 VHA employees representing 29 VHA medical centers. Members of the multidisciplinary workgroup have diverse backgrounds with HCPs from primary care (eg, physicians, nurse practitioners), rehabilitation (eg, physical therapists), specialty care (eg, pulmonologists, physiatrists), mental health (eg, psychologists), and complementary and integrated health/Whole Health services (eg, practitoners of services such as yoga, tai chi, mindfulness, acupuncture). Members also include clinical, operations, and research leadership at local, regional, and national VHA levels. Our first objective as a large, diverse group was to establish shared goals, which included: (1) determining efficient communication pathways; (2) identifying gaps in care or research; and (3) cocreating knowledge to provide solutions to identified gaps.

Communication Mechanisms

Our first goal was to create an efficient mechanism for cross-facility communication. The initial CoP was formed in April 2021 and the first virtual meeting focused on reaching a consensus regarding the best way to communicate and proceed. We agreed to convene weekly at a consistent time, created a standard agenda template, and elected a lead facilitator of meeting proceedings. In addition, a member of the CoP recorded and took extensive meeting notes, which were later distributed to the entire CoP to accommodate varying schedules and ability to attend live meetings. Approximately 20 to 30 participants attend the meetings in real-time.

To consolidate working documents, information, and resources in one location, we created a platform to communicate via a Microsoft Teams channel. All CoP members are given access to the folders and allowed to add to the growing library of resources. Resources include clinical assessment and note templates for electronic documentation of care, site-specific process maps, relevant literature on screening and interventions identified by practice members, and meeting notes along with the recordings. A chat feature alerts CoP members to questions posed by other members. Any resources or information shared on the chat discussion are curated by CoP leaders to disseminate to all members. Importantly, this platform allowed us to communicate efficiently within the VHA organization by creating a centralized space for documents and the ability to correspond with all or select members of the CoP. Additional VHA employees can easily be referred and request access.

To increase awareness of the CoP, expand reach, and diversify perspectives, every participant was encouraged to invite colleagues and stakeholders with interest or experience in long COVID care to join. While patients are not included in this CoP, we are working closely with the VHA user experience workgroup (many members overlap) that is gathering patient and caregiver perspectives on their COVID-19 experience and long COVID care. Concurrently, CoP members and leadership facilitate communication and set up formal collaborations with other non-VHA health care systems to create an intersystem network of collaboration for long COVID care. This approach further enhances the speed at which we can work together to share lessons learned and stay up-to-date on emerging evidence surrounding long COVID care.

Identifying Gaps in Care and Research

Our second goal was to identify gaps in care or knowledge to inform future research and quality improvement initiatives, while also creating a foundation to cocreate knowledge about safe, effective care management of the novel long COVID sequelae. To translate knowledge, we must first identify and understand the gaps between the current, best available evidence and current care practices or policies impacting that delivery.¹³ As such, the structured meeting agenda and facilitated meeting discussions focused on understanding current clinical decision making and the evidence base. We shared VHA evidence synthesis reports and living rapid reviews on complications following COVID-19 illness (ie, major organ damage and posthospitalization health care use) that provided an objective evidence base on common long COVID complications.^14,15

Since long COVID is a novel condition, we drew from literature in similar patient populations and translated that information in the context of our current knowledge of this unique syndrome. For example, we discussed the predominant and persistent symptom of fatigue post-COVID.⁵ In particular, the CoP discussed challenges in identifying and treating post-COVID fatigue, which is often a vague symptom with multiple or interacting etiologies that require a comprehensive, interdisciplinary approach. As such, we reviewed, adapted, and translated identification and treatment strategies from the literature on chronic fatigue syndrome to patients with post-COVID syndrome.^16,17 We continue to work collaboratively and engage the appropriate stakeholders to provide input on the gaps to prioritize targeting.

Cocreate Knowledge

Our third goal was to cocreate knowledge regarding the care of patients with long COVID. To accomplish this, our structured meetings and communication pathways invited members to share experiences on the who (delivers and receives care), what (type of care or HCPs), when (identification of post-COVID and access), and how (eg, telehealth) of care to patients post-COVID. As part of the workgroup, we identified and shared resources on standardized, facility-level practices to reduce variability across the VHA system. These resources included intake/assessment forms, care processes, and batteries of tests/measures used for screening and assessment. The knowledge obtained from outside the CoP and cocreated within is being used to inform data-driven tools to support and evaluate care for patients with long COVID. As such, members of the workgroup are in the formative stages of participating in quality improvement innovation pilots to test technologies and processes designed to improve and validate long COVID care pathways. These technologies include screening tools, clinical decision support tools, and population health management technologies. In addition, we are developing a formal collaboration with the VHA Office of Research and Development to create standardized intake forms across VHA long COVID clinics to facilitate both clinical monitoring and research.

Surveys

The US Department of Veterans Affairs Central Office collaborated with our workgroup to draft an initial set of survey questions designed to understand how each VHA facility defines, identifies, and provides care to veterans experiencing post-COVID sequalae. The 41-question survey was distributed through regional directors and chief medical officers at 139 VHA facilities in August 2021. One hundred nineteen responses (86%) were received. Sixteen facilities indicated they had established programs and 26 facilities were considering a program. Our CoP had representation from the 16 facilities with established programs indicating the deep and well-connected nature of our grassroots efforts to bring together stakeholders to learn as part of a CoP.

A separate, follow-up survey generated responses from 18 facilities and identified the need to capture evolving innovations and to develop smaller workstreams (eg, best practices, electronic documentation templates, pathway for referrals, veteran engagement, outcome measures). The survey not only exposed ongoing challenges to providing long COVID care, but importantly, outlined the ways in which CoP members were leveraging community knowledge and resources to inform innovations and processes of care changes at their specific sites. Fourteen of 18 facilities with long COVID programs in place explicitly identified the CoP as a resource they have found most beneficial when employing such innovations. Specific innovations reported included changes in care delivery, engagement in active outreach with veterans and local facility, and infrastructure development to sustain local long COVID clinics (Table).

Future Directions

Our CoP strives to contribute to an evidence base for long COVID care. At the system level, the CoP has the potential to impact access and continuity of care by identifying appropriate processes and ensuring that VHA patients receive outreach and an opportunity for post-COVID care. Comprehensive care requires input from HCP, clinical leadership, and operations levels. In this sense, our CoP provides an opportunity for diverse stakeholders to come together, discuss barriers to screening and delivering post-COVID care, and create an action plan to remove or lessen such barriers.¹⁸ Part of the process to remove barriers is to identify and support efficient resource allocation. Our CoP has worked to address issues in resource allocation (eg, space, personnel) for post-COVID care. For example, one facility is currently implementing interdisciplinary virtual post-COVID care. Another facility identified and restructured working assignments for psychologists who served in different capacities throughout the system to fill the need within the long COVID team.

At the HCP level, the CoP is currently developing workshops, media campaigns, written clinical resources, skills training, publications, and webinars/seminars with continuing medical education credits.¹⁹ The CoP may also provide learning and growth opportunities, such as clinical or VHA operational fellowships and research grants.

We are still in the formative stages of post-COVID care and future efforts will explore patient-centered outcomes. We are drawing on the Centers for Disease Control and Prevention’s guidance for evaluating patients with long COVID symptoms and examining the feasibility within VHA, as well as patient perspectives on post-COVID sequalae, to ensure we are selecting assessments that measure patient-centered constructs.¹⁸

Conclusions

A VHA-wide LHS approach is identifying issues related to the identification, delivery, and evaluation of long COVID care. This long COVID CoP has developed an infrastructure for communication, identified gaps in care, and cocreated knowledge related to best current practices for post-COVID care. This work is contributing to systemwide LHS efforts dedicated to creating a culture of quality care and innovation and is a process that is transferrable to other areas of care in the VHA, as well as other health care systems. The LHS approach continues to be highly relevant as we persist through the COVID-19 pandemic and reimagine a postpandemic world.

Acknowledgments

We thank all the members of the Veterans Health Administration long COVID Community of Practice who participate in the meetings and contribute to the sharing and spread of knowledge.

Looking across a hospital ward, emergency department, or primary care clinic aligned side by side, you may not see any differences between an advanced practice nurse (APN) or physician assistant (PA). However, if you took a closer look at their education programs and credentialing, you would find considerable differences.

Although both professions hold advanced degrees, the approach to patient care differs, as well as the training they receive, including different models of practice. The APN is trained according to the nursing model, while the PA attends programs that are more in line with the medical model. The APN has a patient-centered model, while the PA adheres to a disease-centered model. Consequently, their approach to caring for the same patient population differs in viewpoint and philosophy.

Ms. Thew is a certified family nurse practitioner in the division of adolescent medicine at the Medical College of Wisconsin, Milwaukee. Email her at pdnews@mdedge.com

Looking across a hospital ward, emergency department, or primary care clinic aligned side by side, you may not see any differences between an advanced practice nurse (APN) or physician assistant (PA). However, if you took a closer look at their education programs and credentialing, you would find considerable differences.

Although both professions hold advanced degrees, the approach to patient care differs, as well as the training they receive, including different models of practice. The APN is trained according to the nursing model, while the PA attends programs that are more in line with the medical model. The APN has a patient-centered model, while the PA adheres to a disease-centered model. Consequently, their approach to caring for the same patient population differs in viewpoint and philosophy.

Ms. Thew is a certified family nurse practitioner in the division of adolescent medicine at the Medical College of Wisconsin, Milwaukee. Email her at pdnews@mdedge.com

Looking across a hospital ward, emergency department, or primary care clinic aligned side by side, you may not see any differences between an advanced practice nurse (APN) or physician assistant (PA). However, if you took a closer look at their education programs and credentialing, you would find considerable differences.

Although both professions hold advanced degrees, the approach to patient care differs, as well as the training they receive, including different models of practice. The APN is trained according to the nursing model, while the PA attends programs that are more in line with the medical model. The APN has a patient-centered model, while the PA adheres to a disease-centered model. Consequently, their approach to caring for the same patient population differs in viewpoint and philosophy.

Ms. Thew is a certified family nurse practitioner in the division of adolescent medicine at the Medical College of Wisconsin, Milwaukee. Email her at pdnews@mdedge.com

From Wheaton Franciscan Healthcare (Ms. Fedel), Aspirus (Ms. Hackbarth), and Aurora Health Care (Mr. Malsch and Ms. Pagel).

Abstract

• Background: There is a nationwide shortage of geriatric prepared providers. Caring for complex older adults is challenging.
• Objective: To develop an efficient and affordable way to educate members of the interdisciplinary team involved in the care of geriatric patients.
• Methods: A team from 3 area health systems developed a plan to present monthly case studies via teleconference. Cases are presented by a direct caregiver using the Wisconsin Star Method to facilitate analysis of the case. A geriatric expert and another member of the team presents teaching points, and questions are elicited and discussed.
• Results: The team has completed 18 consecutive monthly teleconferences. Participant satisfaction has been favorable. Participation on the call has increased approximately 300% since the initiation of the program.
• Conclusion: The case teleconference provides an accessible and affordable educational forum that provides learners an opportunity to improve their knowledge in care of older adults.

The number of older adults in the United States will nearly double between 2005 and 2030 [1] as the baby boom generation begins turning 65 and as life expectancy for older Americans increases. The Institute of Medicine’s (IOM) landmark report Retooling for an Aging America: Building the Health Care Workforce states that “unless action is taken immediately, the health care workforce will lack the capacity (in both size and ability) to meet the needs of older patients in the future [1].” One of their recommendations is to explore ways to widen the duties and responsibilities of workers at various levels of training. More health care providers need to be trained in the basics of geriatric care and should be capable of caring for older patients.

Team-based care is becoming more prevalent. Care delivered by interdisciplinary teams have been shown to improve patient outcomes [2]. A team led by one of the authors (PF) developed an intervention to increase the geriatric and teamwork competencies of interdisciplinary teams who serve patients throughout Wisconsin. The Interdisciplinary Geriatric Difficult Case Conference Call (IGDCC) is sponsored monthly by 3 Wisconsin health systems. The purpose is to provide opportunities to discuss clinical cases, to learn from one another and from experts, and to elevate the level of geriatric care in the states of Wisconsin, Michigan, and beyond. Each month a difficult case is presented by a clinician involved in that patient’s care. Time is allotted for participants to ask questions, and teaching points are shared by a clinical expert to highlight concepts and provide additional context. The IGDCC is meant to be a joint learning exercise to explore a specific difficult patient situation and learn skills and knowledge to improve care and transitions for older adults. The conference call is not a critique of the care, but rather an opportunity to jointly learn from the challenging situations all experience.

Background

The IGDCC was created by four members of 3 health systems in Wisconsin: Wheaton Franciscan Healthcare, Aspirus, and Aurora Health Care. The health systems serve and partially overlap on a broad geographic and demographic area of Wisconsin. The 4 members collaborated on numerous projects in the past, including Nurses Improving Case for Health System Elders (NICHE) implementation [3]. A common concern among the team is the management of challenging geriatric clinical patients and having a prepared workforce to meet those challenges.

Problem/Issue

As mentioned above, the older adult population is increasing, and these statistics are reflected in our service area [4]. Exacerbating these demographic changes is a shortage of health care workers in all disciplines, inadequate geriatric training, and the increased prevalence of multiple chronic conditions. Older adults also have higher rates of 30-day readmissions as well as higher rates of functional decline and medical errors during hospital stays [5,6]. Effective interprofessional teamwork is essential for the delivery of high-quality patient care in an increasingly complex health environment [7]. The IOM’s Future of Nursing report recommends that nurses, who represent the largest segment of the US health workforce, should achieve higher levels of training and be full partners in redesigning health care [8]. Unfortunately, effective care is hampered by poor coordination, limited communication, boundary infringement, and lack of understanding of roles [9]. Meta-analyses have demonstrated that there is a positive relationship between team training interventions and outcomes [10,11].

Objectives

The objective of the IGDCC is to elevate the level of geriatric care in the region by providing an accessible and affordable forum for the education of health care workers involved in the care of our most vulnerable population. To meet this challenge, the 4 founding members of IGDCC utilized the Aurora Health Care Geriatric Fellow’s Most Difficult Case (GFMCC) conference format as a model [12,13]. All disciplines are encouraged to participate, with announcements sent out via the leadership at the participating hospital systems. Participants have the option to call into the conference and teleconference via their own personal telephone and computer; in addition, each participating hospital system frequently hosts an open forum teleconference room where participants also may join a group.

Conference Components

The team uses the Wisconsin Star Method framework for presentation and discussion of the case. The Star Method, developed by Timothy Howell, enables clinical data about a person to be mapped out onto a single field with 5 domains: medications, medical, behavioral, personal, and social [14], creating a visual representation of the complicated and interacting physical, emotional, and social issues of older adults (Figure). By becoming comfortable using this method, the learner can use a similar approach in their clinical practice to address the needs of the patient in a holistic manner.

The case call concludes with expert teaching points from both a geriatric expert and a member of the interdisciplinary team. The interdisciplinary team member is chosen based on the key issues raised by the case. For example, cases that are made complex due to polypharmacy and adverse drug reactions might have a pharmacist presenting pertinent take-home message for the learner. In addition, geriatric teaching experts (ie, a geriatrician or advanced practice geriatric nursing specialist) provide the learner with insights that they can apply to their future practice. Often times the teaching points consist of an analysis of the various geriatric syndromes and how they can be managed in the complex older adult.

Implementation

Implementation of the IGDCC is coordinated by an oversight team with representation from each of the 3 sponsoring health systems. The oversight team currently includes 4 members: 3 geriatric clinical nurse specialists and a geriatric service line administrator. The team is responsible for:

• Planning the conference call schedule
• Making arrangements for case presenters and experts to contribute teaching points
• Registering participants and sharing written materials with participants
• Publicizing and encouraging attendance
• Soliciting feedback for continual improvement
• Exploring and implementing new ways to maximize learning.

Team members share duties and rotate case presentations. The Aurora and Wheaton Franciscan systems provide the geriatric specialists who provide the expert teaching points. The Aspirus system provides the conference line and webinar application and supports publicity and evaluations. All 3 systems are supported by a geriatric clinical nurse specialist who identifies and helps prepare presenters, case presentations, and call participants. Over time, the conference call format has evolved into a webinar format, allowing participants to either phone into the call for audio only or participate via both audio and visual. The visual allows participants to watch on their computer screens while the case is presented using the Star Method. During the call, a member of the oversight team adds clinical details by typing into a Word template of a blank star, adding information for each of the 5 domains in real-time as the case is discussed. Another member of the team facilitates the call, introducing presenters and experts, describing the Star Method, and offering “housekeeping” announcements. The facilitator also watches the timing to make certain the agenda is followed and the call begins and ends on time. During the call, another member of the team updates the attendance spreadsheet and makes a recording of each session.

Some participating facilities reserve a meeting room and project the webinar onto a screen for shared viewing. One of the participating sites has done this quite successfully with a growing group of participants coming together to watch the case during their lunch hour. This allows an opportunity for group discussion—when the conference call is on “mute” so as not to disrupt learners at other locations.

Measurement/Analysis

Attendance has steadily increased. In CY2015 from January to September, the mean attendance per month was 29.1 (mode, 17). The maximum per month was 62 (September 2015). The program enjoyed a boost in attendance beginning in July 2015 when Nurses Improving Care of Healthsystem Elders (NICHE) [3] began promoting the call-in opportunity to its NICHE Coordinators at member health systems. In June 2015, the technology was improved to allow for recorded sessions, and the recordings are growing in popularity from 2 listeners per month in July 2014 to 23 listeners per month in September 2015.

Lessons Learned

In comparing the IGDCC with similar conference call educational offerings, the team found that the program was unique in 2 areas. First, in addition to having a rich discussion in the care of frail older adults with experts in the field, the team also sought to help our staff learn how to present a difficult case to their peers. Three of our 4 committee members are geriatric clinical nurse specialists (a fourth is a clinical nurse specialist from Aspirus who assists periodically) who have been able to mentor, guide, and encourage interdisciplinary team members to present a challenging case. Many presenters had never presented a difficult case in this format. Presenters found the process fun and rewarding and have offered to present cases again in the future.

A second unique feature was utilizing the Wisconsin Star Method rather than focusing on a typical medical model framework for discussing a challenging case. The Star Method allows participants to increase their proficiency in providing comprehensive care while being more confident and mindful in addressing the complicated interacting physical, emotional and social issues of older adults [13].

A monthly post-call debriefing with committee members to review the strengths and weakness of the call was key to growing the program. The committee was able to critically review the process of the call, review participant surveys and discuss next steps. Adding a webinar approach, automatic email notification of calls, participant electronic survey, recording the call, and the addition of offering contact hours were some of the action items that were a result of monthly debriefing calls.

The team also found the 3-system collaboration to be beneficial. Aspirus has a large rural population, and Wheaton and Aurora have a diverse population, and each adds to the participant’s experience. Each IGDCC was rotated between the systems, which did not put the burden on any one health system. An annual call assignment listing was maintained for noting which system was responsible for the case each month and whether the geriatric expert was assigned/confirmed. Identifying the committee’s individual and collective group expertise was helpful in the overall project planning. The committee also developed a standard presenter guide and template and an expert teaching guide so the monthly IGDCC were consistent.

Challenges

The committee did not have a budget. Participation on the committee was in-kind funding from each system. Aspirus used its electronic system in place at the time to support the project. Interactive conference call education platform can be challenging with multiple participants on an open line who may not mute their phone. Often times, when a group of participants are calling in from one phone line it is difficult to know how many people are attending the IGDCC. It can be challenging at times to facilitate the call during the discussion component as participants occasionally talk over each other.

Current Status/Future Directions

The team has completed 18 consecutive monthly IGDCCs. Our participation rate has tripled. Participant satisfaction remains favorable. The team is now offering 1 contact hour to participants, and our invitations to participate have been extended to national health care groups. Challenging cases will be presented from community sources outside the hospital. Focusing attention on elevating the level of geriatric care in our region using a community educational approach will give us new opportunities for collaborating on best practice in multiple settings across the care continuum.

Acknowledgment: The planning team acknowledges Evalyn Michira, MSN, RN, PHN, AGCNS-BC, for her assistance in call presentations.

Corresponding author: Margie Hackbarth, MBA, margie.hackbarth@aspirus.org.

Financial disclosures: none.

From Wheaton Franciscan Healthcare (Ms. Fedel), Aspirus (Ms. Hackbarth), and Aurora Health Care (Mr. Malsch and Ms. Pagel).

Abstract

• Background: There is a nationwide shortage of geriatric prepared providers. Caring for complex older adults is challenging.
• Objective: To develop an efficient and affordable way to educate members of the interdisciplinary team involved in the care of geriatric patients.
• Methods: A team from 3 area health systems developed a plan to present monthly case studies via teleconference. Cases are presented by a direct caregiver using the Wisconsin Star Method to facilitate analysis of the case. A geriatric expert and another member of the team presents teaching points, and questions are elicited and discussed.
• Results: The team has completed 18 consecutive monthly teleconferences. Participant satisfaction has been favorable. Participation on the call has increased approximately 300% since the initiation of the program.
• Conclusion: The case teleconference provides an accessible and affordable educational forum that provides learners an opportunity to improve their knowledge in care of older adults.

The number of older adults in the United States will nearly double between 2005 and 2030 [1] as the baby boom generation begins turning 65 and as life expectancy for older Americans increases. The Institute of Medicine’s (IOM) landmark report Retooling for an Aging America: Building the Health Care Workforce states that “unless action is taken immediately, the health care workforce will lack the capacity (in both size and ability) to meet the needs of older patients in the future [1].” One of their recommendations is to explore ways to widen the duties and responsibilities of workers at various levels of training. More health care providers need to be trained in the basics of geriatric care and should be capable of caring for older patients.

Team-based care is becoming more prevalent. Care delivered by interdisciplinary teams have been shown to improve patient outcomes [2]. A team led by one of the authors (PF) developed an intervention to increase the geriatric and teamwork competencies of interdisciplinary teams who serve patients throughout Wisconsin. The Interdisciplinary Geriatric Difficult Case Conference Call (IGDCC) is sponsored monthly by 3 Wisconsin health systems. The purpose is to provide opportunities to discuss clinical cases, to learn from one another and from experts, and to elevate the level of geriatric care in the states of Wisconsin, Michigan, and beyond. Each month a difficult case is presented by a clinician involved in that patient’s care. Time is allotted for participants to ask questions, and teaching points are shared by a clinical expert to highlight concepts and provide additional context. The IGDCC is meant to be a joint learning exercise to explore a specific difficult patient situation and learn skills and knowledge to improve care and transitions for older adults. The conference call is not a critique of the care, but rather an opportunity to jointly learn from the challenging situations all experience.

Background

The IGDCC was created by four members of 3 health systems in Wisconsin: Wheaton Franciscan Healthcare, Aspirus, and Aurora Health Care. The health systems serve and partially overlap on a broad geographic and demographic area of Wisconsin. The 4 members collaborated on numerous projects in the past, including Nurses Improving Case for Health System Elders (NICHE) implementation [3]. A common concern among the team is the management of challenging geriatric clinical patients and having a prepared workforce to meet those challenges.

Problem/Issue

As mentioned above, the older adult population is increasing, and these statistics are reflected in our service area [4]. Exacerbating these demographic changes is a shortage of health care workers in all disciplines, inadequate geriatric training, and the increased prevalence of multiple chronic conditions. Older adults also have higher rates of 30-day readmissions as well as higher rates of functional decline and medical errors during hospital stays [5,6]. Effective interprofessional teamwork is essential for the delivery of high-quality patient care in an increasingly complex health environment [7]. The IOM’s Future of Nursing report recommends that nurses, who represent the largest segment of the US health workforce, should achieve higher levels of training and be full partners in redesigning health care [8]. Unfortunately, effective care is hampered by poor coordination, limited communication, boundary infringement, and lack of understanding of roles [9]. Meta-analyses have demonstrated that there is a positive relationship between team training interventions and outcomes [10,11].

Objectives

The objective of the IGDCC is to elevate the level of geriatric care in the region by providing an accessible and affordable forum for the education of health care workers involved in the care of our most vulnerable population. To meet this challenge, the 4 founding members of IGDCC utilized the Aurora Health Care Geriatric Fellow’s Most Difficult Case (GFMCC) conference format as a model [12,13]. All disciplines are encouraged to participate, with announcements sent out via the leadership at the participating hospital systems. Participants have the option to call into the conference and teleconference via their own personal telephone and computer; in addition, each participating hospital system frequently hosts an open forum teleconference room where participants also may join a group.

Conference Components

The team uses the Wisconsin Star Method framework for presentation and discussion of the case. The Star Method, developed by Timothy Howell, enables clinical data about a person to be mapped out onto a single field with 5 domains: medications, medical, behavioral, personal, and social [14], creating a visual representation of the complicated and interacting physical, emotional, and social issues of older adults (Figure). By becoming comfortable using this method, the learner can use a similar approach in their clinical practice to address the needs of the patient in a holistic manner.

The case call concludes with expert teaching points from both a geriatric expert and a member of the interdisciplinary team. The interdisciplinary team member is chosen based on the key issues raised by the case. For example, cases that are made complex due to polypharmacy and adverse drug reactions might have a pharmacist presenting pertinent take-home message for the learner. In addition, geriatric teaching experts (ie, a geriatrician or advanced practice geriatric nursing specialist) provide the learner with insights that they can apply to their future practice. Often times the teaching points consist of an analysis of the various geriatric syndromes and how they can be managed in the complex older adult.

Implementation

Implementation of the IGDCC is coordinated by an oversight team with representation from each of the 3 sponsoring health systems. The oversight team currently includes 4 members: 3 geriatric clinical nurse specialists and a geriatric service line administrator. The team is responsible for:

• Planning the conference call schedule
• Making arrangements for case presenters and experts to contribute teaching points
• Registering participants and sharing written materials with participants
• Publicizing and encouraging attendance
• Soliciting feedback for continual improvement
• Exploring and implementing new ways to maximize learning.

Team members share duties and rotate case presentations. The Aurora and Wheaton Franciscan systems provide the geriatric specialists who provide the expert teaching points. The Aspirus system provides the conference line and webinar application and supports publicity and evaluations. All 3 systems are supported by a geriatric clinical nurse specialist who identifies and helps prepare presenters, case presentations, and call participants. Over time, the conference call format has evolved into a webinar format, allowing participants to either phone into the call for audio only or participate via both audio and visual. The visual allows participants to watch on their computer screens while the case is presented using the Star Method. During the call, a member of the oversight team adds clinical details by typing into a Word template of a blank star, adding information for each of the 5 domains in real-time as the case is discussed. Another member of the team facilitates the call, introducing presenters and experts, describing the Star Method, and offering “housekeeping” announcements. The facilitator also watches the timing to make certain the agenda is followed and the call begins and ends on time. During the call, another member of the team updates the attendance spreadsheet and makes a recording of each session.

Some participating facilities reserve a meeting room and project the webinar onto a screen for shared viewing. One of the participating sites has done this quite successfully with a growing group of participants coming together to watch the case during their lunch hour. This allows an opportunity for group discussion—when the conference call is on “mute” so as not to disrupt learners at other locations.

Measurement/Analysis

Attendance has steadily increased. In CY2015 from January to September, the mean attendance per month was 29.1 (mode, 17). The maximum per month was 62 (September 2015). The program enjoyed a boost in attendance beginning in July 2015 when Nurses Improving Care of Healthsystem Elders (NICHE) [3] began promoting the call-in opportunity to its NICHE Coordinators at member health systems. In June 2015, the technology was improved to allow for recorded sessions, and the recordings are growing in popularity from 2 listeners per month in July 2014 to 23 listeners per month in September 2015.

Lessons Learned

In comparing the IGDCC with similar conference call educational offerings, the team found that the program was unique in 2 areas. First, in addition to having a rich discussion in the care of frail older adults with experts in the field, the team also sought to help our staff learn how to present a difficult case to their peers. Three of our 4 committee members are geriatric clinical nurse specialists (a fourth is a clinical nurse specialist from Aspirus who assists periodically) who have been able to mentor, guide, and encourage interdisciplinary team members to present a challenging case. Many presenters had never presented a difficult case in this format. Presenters found the process fun and rewarding and have offered to present cases again in the future.

A second unique feature was utilizing the Wisconsin Star Method rather than focusing on a typical medical model framework for discussing a challenging case. The Star Method allows participants to increase their proficiency in providing comprehensive care while being more confident and mindful in addressing the complicated interacting physical, emotional and social issues of older adults [13].

A monthly post-call debriefing with committee members to review the strengths and weakness of the call was key to growing the program. The committee was able to critically review the process of the call, review participant surveys and discuss next steps. Adding a webinar approach, automatic email notification of calls, participant electronic survey, recording the call, and the addition of offering contact hours were some of the action items that were a result of monthly debriefing calls.

The team also found the 3-system collaboration to be beneficial. Aspirus has a large rural population, and Wheaton and Aurora have a diverse population, and each adds to the participant’s experience. Each IGDCC was rotated between the systems, which did not put the burden on any one health system. An annual call assignment listing was maintained for noting which system was responsible for the case each month and whether the geriatric expert was assigned/confirmed. Identifying the committee’s individual and collective group expertise was helpful in the overall project planning. The committee also developed a standard presenter guide and template and an expert teaching guide so the monthly IGDCC were consistent.

Challenges

The committee did not have a budget. Participation on the committee was in-kind funding from each system. Aspirus used its electronic system in place at the time to support the project. Interactive conference call education platform can be challenging with multiple participants on an open line who may not mute their phone. Often times, when a group of participants are calling in from one phone line it is difficult to know how many people are attending the IGDCC. It can be challenging at times to facilitate the call during the discussion component as participants occasionally talk over each other.

Current Status/Future Directions

The team has completed 18 consecutive monthly IGDCCs. Our participation rate has tripled. Participant satisfaction remains favorable. The team is now offering 1 contact hour to participants, and our invitations to participate have been extended to national health care groups. Challenging cases will be presented from community sources outside the hospital. Focusing attention on elevating the level of geriatric care in our region using a community educational approach will give us new opportunities for collaborating on best practice in multiple settings across the care continuum.

Acknowledgment: The planning team acknowledges Evalyn Michira, MSN, RN, PHN, AGCNS-BC, for her assistance in call presentations.

Corresponding author: Margie Hackbarth, MBA, margie.hackbarth@aspirus.org.

Financial disclosures: none.

From Wheaton Franciscan Healthcare (Ms. Fedel), Aspirus (Ms. Hackbarth), and Aurora Health Care (Mr. Malsch and Ms. Pagel).

Abstract

• Background: There is a nationwide shortage of geriatric prepared providers. Caring for complex older adults is challenging.
• Objective: To develop an efficient and affordable way to educate members of the interdisciplinary team involved in the care of geriatric patients.
• Methods: A team from 3 area health systems developed a plan to present monthly case studies via teleconference. Cases are presented by a direct caregiver using the Wisconsin Star Method to facilitate analysis of the case. A geriatric expert and another member of the team presents teaching points, and questions are elicited and discussed.
• Results: The team has completed 18 consecutive monthly teleconferences. Participant satisfaction has been favorable. Participation on the call has increased approximately 300% since the initiation of the program.
• Conclusion: The case teleconference provides an accessible and affordable educational forum that provides learners an opportunity to improve their knowledge in care of older adults.

The number of older adults in the United States will nearly double between 2005 and 2030 [1] as the baby boom generation begins turning 65 and as life expectancy for older Americans increases. The Institute of Medicine’s (IOM) landmark report Retooling for an Aging America: Building the Health Care Workforce states that “unless action is taken immediately, the health care workforce will lack the capacity (in both size and ability) to meet the needs of older patients in the future [1].” One of their recommendations is to explore ways to widen the duties and responsibilities of workers at various levels of training. More health care providers need to be trained in the basics of geriatric care and should be capable of caring for older patients.

Team-based care is becoming more prevalent. Care delivered by interdisciplinary teams have been shown to improve patient outcomes [2]. A team led by one of the authors (PF) developed an intervention to increase the geriatric and teamwork competencies of interdisciplinary teams who serve patients throughout Wisconsin. The Interdisciplinary Geriatric Difficult Case Conference Call (IGDCC) is sponsored monthly by 3 Wisconsin health systems. The purpose is to provide opportunities to discuss clinical cases, to learn from one another and from experts, and to elevate the level of geriatric care in the states of Wisconsin, Michigan, and beyond. Each month a difficult case is presented by a clinician involved in that patient’s care. Time is allotted for participants to ask questions, and teaching points are shared by a clinical expert to highlight concepts and provide additional context. The IGDCC is meant to be a joint learning exercise to explore a specific difficult patient situation and learn skills and knowledge to improve care and transitions for older adults. The conference call is not a critique of the care, but rather an opportunity to jointly learn from the challenging situations all experience.

Background

The IGDCC was created by four members of 3 health systems in Wisconsin: Wheaton Franciscan Healthcare, Aspirus, and Aurora Health Care. The health systems serve and partially overlap on a broad geographic and demographic area of Wisconsin. The 4 members collaborated on numerous projects in the past, including Nurses Improving Case for Health System Elders (NICHE) implementation [3]. A common concern among the team is the management of challenging geriatric clinical patients and having a prepared workforce to meet those challenges.

Problem/Issue

As mentioned above, the older adult population is increasing, and these statistics are reflected in our service area [4]. Exacerbating these demographic changes is a shortage of health care workers in all disciplines, inadequate geriatric training, and the increased prevalence of multiple chronic conditions. Older adults also have higher rates of 30-day readmissions as well as higher rates of functional decline and medical errors during hospital stays [5,6]. Effective interprofessional teamwork is essential for the delivery of high-quality patient care in an increasingly complex health environment [7]. The IOM’s Future of Nursing report recommends that nurses, who represent the largest segment of the US health workforce, should achieve higher levels of training and be full partners in redesigning health care [8]. Unfortunately, effective care is hampered by poor coordination, limited communication, boundary infringement, and lack of understanding of roles [9]. Meta-analyses have demonstrated that there is a positive relationship between team training interventions and outcomes [10,11].

Objectives

The objective of the IGDCC is to elevate the level of geriatric care in the region by providing an accessible and affordable forum for the education of health care workers involved in the care of our most vulnerable population. To meet this challenge, the 4 founding members of IGDCC utilized the Aurora Health Care Geriatric Fellow’s Most Difficult Case (GFMCC) conference format as a model [12,13]. All disciplines are encouraged to participate, with announcements sent out via the leadership at the participating hospital systems. Participants have the option to call into the conference and teleconference via their own personal telephone and computer; in addition, each participating hospital system frequently hosts an open forum teleconference room where participants also may join a group.

Conference Components

The team uses the Wisconsin Star Method framework for presentation and discussion of the case. The Star Method, developed by Timothy Howell, enables clinical data about a person to be mapped out onto a single field with 5 domains: medications, medical, behavioral, personal, and social [14], creating a visual representation of the complicated and interacting physical, emotional, and social issues of older adults (Figure). By becoming comfortable using this method, the learner can use a similar approach in their clinical practice to address the needs of the patient in a holistic manner.

The case call concludes with expert teaching points from both a geriatric expert and a member of the interdisciplinary team. The interdisciplinary team member is chosen based on the key issues raised by the case. For example, cases that are made complex due to polypharmacy and adverse drug reactions might have a pharmacist presenting pertinent take-home message for the learner. In addition, geriatric teaching experts (ie, a geriatrician or advanced practice geriatric nursing specialist) provide the learner with insights that they can apply to their future practice. Often times the teaching points consist of an analysis of the various geriatric syndromes and how they can be managed in the complex older adult.

Implementation

Implementation of the IGDCC is coordinated by an oversight team with representation from each of the 3 sponsoring health systems. The oversight team currently includes 4 members: 3 geriatric clinical nurse specialists and a geriatric service line administrator. The team is responsible for:

• Planning the conference call schedule
• Making arrangements for case presenters and experts to contribute teaching points
• Registering participants and sharing written materials with participants
• Publicizing and encouraging attendance
• Soliciting feedback for continual improvement
• Exploring and implementing new ways to maximize learning.

Team members share duties and rotate case presentations. The Aurora and Wheaton Franciscan systems provide the geriatric specialists who provide the expert teaching points. The Aspirus system provides the conference line and webinar application and supports publicity and evaluations. All 3 systems are supported by a geriatric clinical nurse specialist who identifies and helps prepare presenters, case presentations, and call participants. Over time, the conference call format has evolved into a webinar format, allowing participants to either phone into the call for audio only or participate via both audio and visual. The visual allows participants to watch on their computer screens while the case is presented using the Star Method. During the call, a member of the oversight team adds clinical details by typing into a Word template of a blank star, adding information for each of the 5 domains in real-time as the case is discussed. Another member of the team facilitates the call, introducing presenters and experts, describing the Star Method, and offering “housekeeping” announcements. The facilitator also watches the timing to make certain the agenda is followed and the call begins and ends on time. During the call, another member of the team updates the attendance spreadsheet and makes a recording of each session.

Some participating facilities reserve a meeting room and project the webinar onto a screen for shared viewing. One of the participating sites has done this quite successfully with a growing group of participants coming together to watch the case during their lunch hour. This allows an opportunity for group discussion—when the conference call is on “mute” so as not to disrupt learners at other locations.

Measurement/Analysis

Attendance has steadily increased. In CY2015 from January to September, the mean attendance per month was 29.1 (mode, 17). The maximum per month was 62 (September 2015). The program enjoyed a boost in attendance beginning in July 2015 when Nurses Improving Care of Healthsystem Elders (NICHE) [3] began promoting the call-in opportunity to its NICHE Coordinators at member health systems. In June 2015, the technology was improved to allow for recorded sessions, and the recordings are growing in popularity from 2 listeners per month in July 2014 to 23 listeners per month in September 2015.

Lessons Learned

In comparing the IGDCC with similar conference call educational offerings, the team found that the program was unique in 2 areas. First, in addition to having a rich discussion in the care of frail older adults with experts in the field, the team also sought to help our staff learn how to present a difficult case to their peers. Three of our 4 committee members are geriatric clinical nurse specialists (a fourth is a clinical nurse specialist from Aspirus who assists periodically) who have been able to mentor, guide, and encourage interdisciplinary team members to present a challenging case. Many presenters had never presented a difficult case in this format. Presenters found the process fun and rewarding and have offered to present cases again in the future.

A second unique feature was utilizing the Wisconsin Star Method rather than focusing on a typical medical model framework for discussing a challenging case. The Star Method allows participants to increase their proficiency in providing comprehensive care while being more confident and mindful in addressing the complicated interacting physical, emotional and social issues of older adults [13].

A monthly post-call debriefing with committee members to review the strengths and weakness of the call was key to growing the program. The committee was able to critically review the process of the call, review participant surveys and discuss next steps. Adding a webinar approach, automatic email notification of calls, participant electronic survey, recording the call, and the addition of offering contact hours were some of the action items that were a result of monthly debriefing calls.

The team also found the 3-system collaboration to be beneficial. Aspirus has a large rural population, and Wheaton and Aurora have a diverse population, and each adds to the participant’s experience. Each IGDCC was rotated between the systems, which did not put the burden on any one health system. An annual call assignment listing was maintained for noting which system was responsible for the case each month and whether the geriatric expert was assigned/confirmed. Identifying the committee’s individual and collective group expertise was helpful in the overall project planning. The committee also developed a standard presenter guide and template and an expert teaching guide so the monthly IGDCC were consistent.

Challenges

The committee did not have a budget. Participation on the committee was in-kind funding from each system. Aspirus used its electronic system in place at the time to support the project. Interactive conference call education platform can be challenging with multiple participants on an open line who may not mute their phone. Often times, when a group of participants are calling in from one phone line it is difficult to know how many people are attending the IGDCC. It can be challenging at times to facilitate the call during the discussion component as participants occasionally talk over each other.

Current Status/Future Directions

The team has completed 18 consecutive monthly IGDCCs. Our participation rate has tripled. Participant satisfaction remains favorable. The team is now offering 1 contact hour to participants, and our invitations to participate have been extended to national health care groups. Challenging cases will be presented from community sources outside the hospital. Focusing attention on elevating the level of geriatric care in our region using a community educational approach will give us new opportunities for collaborating on best practice in multiple settings across the care continuum.

Acknowledgment: The planning team acknowledges Evalyn Michira, MSN, RN, PHN, AGCNS-BC, for her assistance in call presentations.

Corresponding author: Margie Hackbarth, MBA, margie.hackbarth@aspirus.org.

Financial disclosures: none.