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Care coordination is facilitated when health professionals, both within and across care teams, have an immediate and rich understanding of what others can bring to a patient’s care. In the VA Centers of Excellence for Primary Care Education (CoEPCE), trainees from medicine, advanced practice nursing, health psychology, pharmacy, and social work complete their training in an inter-professional context where both didactic and practice-based learning approaches focus on honing the skills needed for effective team-based care. Since 2015, QUERI’s Action-Oriented Evaluation of the Inter-professional Learning Efforts in the CoEPCE and IAPACT Environments has partnered with the VA Office of Academic Affiliations to evaluate the performance of the CoEPCE. The evaluation has used an innovative realist evaluation approach to identify both qualitative and quantitative impacts of the program. This mixed-methods approach is a good fit for complex adaptive interventions like the CoEPCE, where understanding how context and mechanisms support or hinder multiple simultaneous desired outcomes is a critical evaluation goal.
In relation to care coordination, teams in CoEPCE clinics showed improvement in primary care and mental health integration. A recent retrospective analysis of mental health utilization associated with CoEPCE implementation showed that the proportion of patients that had a timely mental health visit increased among CoEPCE patients by 1.8 percentage points vs. control patients, an 11% increase from the pre-COEPCE mean (17%). Similarly, the likelihood of an integrated primary care-mental health visit increased by 1.4% per patient year among CoEPCE patients, a 27% increase from the pre-CoEPCE mean (5%).
Interviews with faculty, trainees, and staff have generated insights into how inter-professionally trained providers create new norms and expectations that contribute to care coordination. For example, interviews with 36 program graduates from 5 sites found that one of the main program strengths identified by graduates was an increased comfort initiating conversations across professional boundaries, particularly among non-medicine professionals. Training increased awareness of services provided by other disciplines and also increased their perceived ability to connect patients to these services. A deeper understanding of other professions was created through the extended time with their inter-professional cohorts, integration into VA PACT teams (also inter-professional), and sessions designed to expose implicit barriers to collaboration. Graduates felt the programs helped them develop habits that strengthen interdisciplinary collaboration, such as inviting collaboration through workgroups and regular meetings.
Collectively, these insights help faculty implementing the CoEPCE programs to focus their efforts on the practices that make the strongest impact on trainee and team behavior. This has positive impacts for care coordination not only in the care being offered daily to Veterans in COEPCE clinics right now, but also in the future, as program graduates take up practice throughout the VA healthcare system and US healthcare more broadly.
For more information about this project, please contact Anais Tuepker, PhD, MPH, at Anais.Tuepker@va.gov.