Training the Next Generation of Primary Care Providers

At the San Francisco VA Medical Center’s primary care clinic, nurse practitioners and medical residents are training together in teams in an emerging trend in health care known as patient-centered medical homes.

On a typical day at the clinic, just before 8 a.m. Nurse Practitioner (NP) student Jonathan Van Nuys is handing out pastries to celebrate his birthday in a cramped exam room.

Van Nuys – a lean, kind-faced man in shirt and tie and white lab coat – is surrounded by his nurse practitioner preceptor, a second-year medical resident, an RN and an LVN. After a few short minutes of eating and making small talk, the group settles into a discussion of the day’s appointments.

Van Nuys is concerned about a patient who suffers from a spinal deformity and is showing signs of being suicidal and another patient who struggles with alcoholism. Over the next 15 minutes the team discusses a number of similarly complex patients, each time arriving at a plan for the day’s appointment and follow-up care.

But this morning’s “huddle” is about more than planning the day. For one, it aims to foster better communication and closer care coordination among a team of professionals responsible for maintaining and improving the health of about 1,200 patients.

At the UCSF-affiliated SFVAMC, the patient-focused team concept is called PACT, which stands for Patient Aligned Care Teams. Numerous entities – with incentives from the Centers for Medicare & Medicaid Services (CMS) and the Affordable Care Act (ACA) – are implementing a similar concept and calling it a “patient-centered medical home” (PCMH).

Recognizing the Future is Team-Based Care

A second purpose is to advance an innovative experiment in the training of primary care providers at a time when it’s crucial to fill the pipeline. The SFVAMC’s training program gives second-year NP students their own longitudinal panel of patients, trains the NPs alongside second-year medical residents and gives staff NPs dedicated precepting time – all three concepts virtually unheard of outside of the VA.

“The VA recognized that the future is team-based care and that in order to perform effectively as a team, students need to learn on a team,” says NP Susan Janson, RN, PhD, a faculty member at UCSF School of Nursing and co-director of the program.

“The literature suggests and we believe that patient care improves when the primary care team learns how to communicate, understands each others’ roles and utilizes team members effectively,” says physician and co-director Rebecca Shunk, MD, an associate professor at UCSF School of Medicine and director of the Center of Excellence in Primary Care Education.

The VA is transforming its primary care delivery system to improve coordination and continuity of care through PACTS. As part of this transformation the VA’s Office of Academic Affiliations has designated five Centers of Excellence (COE) in Primary Care Education to develop new educational models for residents and NP students.

“This rarely happens in other parts of the country and because physicians and nurse practitioners are trained separately – because, in particular, physicians don’t always know what nurse practitioners can do – they're not always an effective team. In the VA scenario, where people work side by side, they know,” says Susan Hassmiller, senior adviser in nursing at the Robert Wood Johnson Foundation (RWJF).

To help spur the effort, the RWJF foundation recently joined three companion organizations – Josiah Macy Jr. Foundation, John A. Hartford Foundation and Gordon and Betty Moore Foundation – and the Health Resources and Services Administration to fund the National Coordinating Center for Interprofessional Education and Collaborative Practice at the University of Minnesota.

At UCSF, Scott Reeves, PhD, – a world-renowned British social scientist – directs the Center for Innovation in Interprofessional Healthcare Education, which has participation from all four schools at UCSF: dentistry, medicine, nursing and pharmacy.

Ensuring Greater Continuity of Care

For a full year, at the SFVA’s three local primary care clinics (two in San Francisco and one in San Bruno), an NP student and two residents have their own primary care patients, and share the entire panel to ensure greater continuity of care while receiving guidance from both physician and NP preceptors. The NP student is the continuous clinical presence, while the residents alternate every two months between inpatient and outpatient care.

Known as EdPACT (for Education in Patient Aligned Care Teams) and now in its second year, the educational program is a collaboration among the VA, the UCSF schools of medicine and nursing and the UCSF Office of Graduate Medical Education. Janson and Shunk run the program along with a team of experts in evaluation, communication, clinical care and quality improvement. In 2012, the team applied and was selected as one of only five VAs nationwide to receive a five-year, $5 million grant as a designated Center of Excellence in Primary Care Education.

In the program’s first year, seven NP students participated, even as they continued with their full academic load. This year there are nine NP students. In addition, the Center secured funding for NP fellowships that enabled three of last year’s students – now newly minted NPs – to continue their work and training at the VA.

“Our starting point was trying to understand how people learn and improve practice in the context of a team,” says Bridget O’Brien of the UCSF Office of Medical Education, who along with Shunk and Janson took the lead in designing the curriculum.

Janson was a logical choice to represent the School of Nursing, because she has deep experience in interprofessional work and training, through a long-standing partnership in pulmonary care with physician Homer Boushey and through an interprofessional training program she helped create at UCSF Medical Center with physicians Molly Cooke and Bobby Baron. Her colleagues JoAnne Saxe and Suzan Stringari-Murray, both of whom are NP faculty from UCSF School of Nursing and NPs at the San Francisco VA, helped design the NP curriculum.

Synching the Training of NPs and MDs

It wasn’t easy. “For one, neither the NPs or MDs had a strong understanding of one another’s model of training,” says O’Brien. Perhaps most challenging, the group had to figure out how to sync the training of the medical residents, who have had four years of medical education and a year of internship, with that of the NPs, who had their RN training and experience, as well as one year of NP education.

“Some of the NPs had a lot of practical experience from being RNs, but we didn’t really know exactly where they were in the learning trajectory until preceptors began working with them and identifying their strengths as well as their gaps,” says O’Brien.

Eventually, it became clear that while NP students had much of the vocabulary and practical experience, they didn’t always have the knowledge base that would enable them to understand underlying biomedical concerns.

“It’s definitely been a challenge and, at times, intimidating,” says NP student Varsha Singh, who like Van Nuys began the program in July 2012. “It’s kind of surreal that I’m having to make some of these clinical decisions, but at the same time, we’re very well supported by nursing and medical faculty.”

“We give them resources and remind them there is clinical decision support and ways to research many of the things they’re expected to know,” says Janson.

“Seeing the NP fellows has helped,” says Singh. “The intimidation I feel, I don’t see in them. They’re there, making valuable statements about care. If I can become the same, I’ll be ecstatic.”

The residents, on the other hand, had to learn about what NPs bring to the delivery of primary care.

Resident Melisa Wong is working closely with NP students for the first time this year. “I do find that they look at a broader picture. In general, when they talk about a patient, they’re often interested in what are the things going on in the patient’s family life, their caregivers, other things that might affect how patients are doing with their health.”

The NP students and medical residents also learn about the roles and skills of their other team members: RNs, LVNs, medical assistants and, at times, pharmacists, psychologists, social workers and dietitians. Shunk and Janson emphasize that this is important, because care improvement often depends on team members building productive working relationships – a skill that can be taught. Huddles are part of that process – the sharing of birthday pastries is not insignificant – as are daylong retreats.

“It’s hard to ask a colleague to do extra work or give them productive feedback if you don’t really know them,” says Shunk. “The team has to have each other’s back, and flattening the hierarchy helps.”

To read the full story, visit the UCSF School of Nursing’s Science of Caring website.