Promoting the “Triple Aim” - · PDF fileGeorge Thibault, 2013. ... – NP...

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Promoting the “Triple Aim” Aligning Interprofessional Education and Health System Redesign

CAB VI Conference October 3, 2017 Banff, Canada

Malcolm Cox, MD Adjunct Professor

Perelman School of Medicine University of Pennsylvania

What Actions Should be Taken To More Closely Link Educational and Practice Reform …Educational enterprises and healthcare delivery systems have evolved with different structures, incentives, and cultures. There have been insufficient opportunities for them to work and plan together, and it has not been as clear as it should be that both have the same goals – better patient outcomes and better health for society. George Thibault, 2013.

Agenda

• Defining the Journey – What matters?

• Considering the Context – IPE ecosystems – Leadership – Conceptual models – Evidence – Learning

• Enabling Collaborative Practice – Practice redesign – Education reform

• Reaping the Rewards – Better health &

enhanced value

Per Capita Cost of Healthcare

IPE and the Triple Aim

Number of Aims

Number of Publications

Percentage of

Publications Specific Triple Aim Focus

0 108/133 81.2 None

1 22/133 18.5 Experiences of Care

2 3/133 2.3 Population Health + Experiences of Care

3 0/133 0 Per Capita Cost of Healthcare

IPE Ecology

• We’ve tended to focus on the guest (the curriculum and its associated pedagogy) but it is the host (the clinical learning environment and its myriad relationships and interactions) that dominates in determining whether IPE will flourish

• An understanding of Health Delivery and Education Systems is central to the rational use of IPE and the demonstration of its effectiveness

Educational Reform

Practice Redesign

Learning

Patient

Caring

MACROSYSTEM

Structure Financing

MICROSYSTEM

System Alignment

Without a purposeful and more comprehensive system of engagement between the education and health care delivery systems, evaluating the impact of IPE interventions on health and system outcomes will be difficult.

Plan and

Control

Zone of

Complexity

Professional Agreement

About Outcomes

High Low

Certainty About Outcomes

Strategic Lessons

• Redesigning the process of care is about culture change

• Moving educational and delivery systems requires a compelling vision and case statement

• Efforts must be appropriately resourced • Leadership at all levels is essential

Cultural Challenges

• Individual inertia – “What’s wrong with the old system? It produced

me and I’m terrific.” • Organizational inertia

– “When you really don’t want to do something, one reason is as good as another.”

• National inertia – “There’s no greater barrier to change than past

success.”

Enabling or Interfering Factors Foundational

Education Graduate Education

Continuing Professional

Development

Reaction

Attitudes/perceptions Knowledge/skills

Collaborative behavior Performance in practice

Interprofessional Education

Professional culture Institutional culture

Workforce policy Financing policy

Learning Outcomes Health and System Outcomes

Learning Continuum (Formal and Informal)

Individual health Population/public health

Organizational change System efficiencies Cost effectiveness

Value of Conceptual Models

• Communication & Standardization – Foster adoption of consistent terminology and

standardized frameworks • Contextual Analysis

– Define inputs/outputs and enabling and interfering factors • Evaluation & Assessment

– Guide future studies & promote robust experimental designs

• Creativity & Innovation – Guide programmatic, institutional & system-wide

transformation

Value of Team Training

Reactions

Learning

Transfer

Results

Healthcare Team Training

0.33 , 0.73

0.66 , 1.11

0.52 , 0.82

0.21 , 0.52

Analysis of Outcome Studies

• Emphasis on “early” learning outcomes – Attitudes, knowledge, clinical skills

• Limited evidence for “higher level” outcomes – Behavior, performance in practice – Patient or population benefits, system outcomes

• Significant methodological weaknesses – Absence of control groups

• Lack of attention to long-term impact

Educational Transformation

Acting your way into

new thinking

Thinking your way into

new acting

Workplace Learning

• Unscripted: Requires workers to go beyond approaches learned previously in order to resolve novel and poorly defined work challenges

• Collaborative: Requires workers to enhance or replace their collective expertise as changes in technology and work processes necessitate the development of new skills

• Distributive: Requires team leadership to be determined by expertise germane to the question at hand rather than artificial hierarchies

Learning Domains

each profession’s curriculum

“nested” within

“nested” within clinical site

transformation

within and between professions

IPE Learning Domains

Collaborative Practice Strategies

• Hierarchical models – Clinician “extension” models (using support personnel

with more limited qualifications) • Independent models

– “Parallel play” by qualified clinicians (e.g., primary care physicians, nurse practitioners, physician assistants)

• Integrated models – “Series play” organized around existing health issues

and provider expertise and availability

Moving to Integrated Models • Explicitly recognize the power of collaboration

– Leadership Is Job One! • Demonstrate a positive value proposition for

interprofessional team-based care – Evidence Is Power!

• Realign institutional resources to support interprofessional team-based care – If You Build It, They Will Come!

• Recognize that practice redesign is a prerequisite for clinical education reform – The Tail Does NOT Wag the Dog!

VA as a Vehicle for IPE

• Alignment between education and health delivery system

• Joint planning and investment by academic and practice communities

• Broad-based, multi-professional public financing of health professions education

• Organizational seed support based on potential health and societal benefits

• Infusion of public funds based on documented health and societal benefits

FA M I LY

C L I N I C A L A S S O C I AT E

P C P R O V I D E R

C L E R K RN C A R E M A N A G E R

R E S I D E N T

PACT Implementation

PATIENT-ALIGNED CARE TEAMS (PACTS) National Policy Fully Resourced

ADOPTION & DISSEMINATION

Leadership Support Project Management

EDUCATION & TRAINING Learning Collaboratives

Consultation Teams

Learning Center

IMPLEMENTATION GUIDANCE

PACT Handbook Workload Analysis

Staffing Ratios

COMMUNICATION

IT ENHANCEMENTS PCMM

VISTA/CPRS Registry functionality

ASSESSMENT ACP Medical Home

Builder PACT Certification

DEMONSTRATION LABORATORIES

System Outcomes

COE IN PRIMARY CARE EDUCATION (COE-PCE) Academic Partnerships Demonstration Projects

PACT Implementation Index (PI2) PACT Goals PI2 Domains Data Source

Accessible, continuous and coordinated care

Access VA Corporate Data Warehouse and

CAHPS-PCMH Survey (n=75,101)

Continuity of care

Coordination of care

Team-based care Delegation, staffing, team functioning, working to top of competency

VA PACT Personnel Survey (n= 5,404)

Patient-centered care

Comprehensiveness

CAHPS-PCMH Survey (n=75,101)

Self-management support

Patient-centered care and communication

Shared decision making 27

PACT Domain Correlations

• Higher Patient Satisfaction • Lower Staff Burnout • Lower ED Use • Lower Hospitalization Rates • Better Clinical Quality

Sites with

Higher PI2

Score had:

Changes in Utilization, 2010-2012 % Change in utilization

due to PACT

Age <65

Age 65+

Hospitalizations for ambulatory care-sensitive conditions

-4.2% -0.2% -1.7%

Outpatient primary care visits -1.2% 3.5% 1.0%

Outpatient specialty mental health visits

-7.8% -5.2% -7.3%

Return on Investment, 2010-2012

2010 2011 2012 Total Discounted

Costs avoided $96 $264 $280 $639 $596

PACT investment $258 $279 $285 $822 $774

Net loss -$162 -$15 -$5 -$183 -$178

VA COE-PCE

Core Requirements • Innovative approaches • Joint sponsorship

(medicine, nursing, others)

• 30% time commitment • Robust evaluation

Key Features • Shared Decision Making • Sustained Relationships • Interprofessional

Collaboration • Performance

Improvement

COE-PCE Inaugural Sites

Co-Directors: C. Scott Smith, MD and Melanie Nash, MSN, ANP

Academic Partners: Gonzaga University School of Nursing

University of Washington School of Medicine Idaho State University Schools of Pharmacy and Nursing

Co-Directors: Joyce Wipf, MD and Kameka Brown, PhD, APN

Academic Partner: University of Washington

Schools of Medicine and Nursing

Co-Directors: Rebecca Brienza, MD, MPH and Susan Zapatka, MSN, APN

Academic Partners: Fairfield University School of Nursing

Quinnipiac University School of Nursing Yale University Schools of Medicine and Nursing

University of Connecticut School of Medicine

Co-Directors: Mimi Singh, MD, MS and Mary Dolansky, PhD, RN

Academic Partners: Case Western Reserve University School of Nursing

Ursuline College School of Nursing Cleveland Clinic Foundation

Co-Directors: Rebecca Shunk, MD and Terry Keane, DNP, APN

Academic Partner: University of California at San Francisco

Schools of Medicine and Nursing

Trainee Engagement

When I first read the five cases, what impressed me was the reflection, the deeper story behind the story. We have the opportunity to learn about context and developmental issues from a national larger-scale complex adaptive systems perspective.

Barbara F. Brandt, PhD

Key Outcome Questions

• Does interprofessional team training enhance learning outcomes? – NP residents – IM residents

• Does interprofessional team training influence practice performance? – Patient, staff and trainee satisfaction – Quality of care outcomes – Utilization outcomes

Learning Outcomes – NP Residents

Learning Domain

Competency Item

Mentor Assessment Mean (SD)

Month 1 Month 12 Interprofessional Collaboration

Safely transition patients among team 3.0 (1.4) 4.5 (0.56)

Shared Decision Making

Facilitate patient participation in health care decisions 3.1 (1.0) 4.5 (0.94)

Sustained Relationships

Devise, follow, review and adjust longitudinal care plan 3.0 (1.0) 4.6 (0.6)

Performance Improvement

Perform root cause analysis and reflect on critical incidents 1.2 (1.3) 3.2 (1.8)

p<0.001 for all items

Placeholder 1

Learning Outcomes – IM Residents For information about this study, please contact:

Scott.Smith2@va.gov

Placeholder 2

Learning Outcomes – IM Residents For information about this study, please contact:

Scott.Smith2@va.gov

Placeholder 3

Qualitative Outcomes – Patient Satisfaction For information about this study, please contact:

Anais.Tuepker@va.gov

Placeholder 4

Quality and Utilization Outcomes For information about this study, please contact:

Samuel.Edwards@va.gov

Placeholder 5

Placeholder 6

Placeholder 7

Burning platform

Pockets of Success

Linked Success

Learning Organization

•Awareness •Education

•Learn •Do

•Connect Success •Engage Value Stream

•Leaders as Teachers •Empowered Teams •Self-sustaining Culture of Improvement

Engagement of People in Re-Designing Work

New Rules • Practice redesign is foundational!

– Delivering safe, satisfying, effective and efficient care is the end game

• Alignment of education reform with health system redesign is vital! – Without it resources will be hard to find

• Learning by doing is essential! – Workplace learning trumps formal instruction – Reflection on and in action are critical

• Context matters (a whole lot)! – Evidence-based blueprints are important, but local

modifications are essential for maximum effectiveness and sustainability

More New Rules • Outcomes are persuasive (but still largely missing)!

– Even traditionalists will yield to evidence of positive outcomes • Demonstrating a financial and/or social return on

investment is critical! – Health and system outcomes are more meaningful than learning

outcomes alone • Understanding what works (and when and why) is as

important as demonstrating enhanced educational, clinical and system outcomes! – Without such information generalizability is unknowable

• Culture matters most of all! – Leadership, leadership, leadership…

Give Up Professional Prerogative When It Hurts the Whole

…the romantic image of the totally self sufficient physician [clinician] no longer serves professionals or patients well. The most important question a modern professional can ask is not “What do I do?” but “What am I part of?” Those who prepare young professionals should nurture that redirection from prerogative to citizenship. Don Berwick, 2016.

Promoting the “Triple Aim” - · PDF fileGeorge Thibault, 2013. ... – NP...

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