Chronic conditions contribute to increasing health care expenditures, and a small number of patients with chronic medical conditions consume a disproportionately larger amount of health care resources.1,2 Naessens and colleagues showed that 2.6% of adult patients accounted for 20.7% of all primary care clinic visits during a calendar year.2 These high-risk patients may be using much of the health care resources but have unmet needs even with the increased amount of health care services they receive.
The impact of interprofessional forms of chronic disease management on patient outcomes is unclear.3-5 Definitions for high-risk patients and interprofessional care are broad, making comparison of studies difficult. In a team setting, it is difficult to discern the exact contributions of a single member of the team. Katon and colleagues concluded in a randomized, controlled trial that a nurse care manager collaborative treatment program added additional depression-free days and quality-adjusted life-years in adults with depression and poorly controlled diabetes mellitus (DM), coronary artery disease, or both.3 The intervention also resulted in improvements in a composite outcome of hemoglobin A1c (A1c), low-densitylipoprotein cholesterol, systolic blood pressure (BP) levels, and depression symptoms at 12 months, but these improvements were not sustained at 24 months.3,4
A study looked at interprofessional team care provided by primary care internal medicine residents, nurse practitioner students, and pharmacy students, compared with usual care by only internal medicine residents. The study showed improvements in patient assessments and a trend toward the decreased use of urgent care in patients with type 2 DM over 18 months but no significant improvements in A1c or BP values.5 The impact of pharmacists participating in team-based care and patient-centered medical home models has also been shown to be positive regarding metabolic parameters.6,7Patient aligned care teams (PACT), the VA patient-centered medical home model initiative, seek to optimize patient care through provision of interprofessional, team-based care. At the Boise VAMC in Idaho, PACT training occurs at a primary care academic training clinic that includes 40 primary care providers, supervisors, and trainees in internal medicine, nurse practitioner programs, pharmacy, and behavioral health.
The Boise VAMC is also 1 of 5 VA Centers of Excellence in Primary Care Education (CoEPCE), institutions that prepare health care trainees from many disciplines to participate in interprofessional PACTs, provide patient-centered, team-based care, and learn and understand the roles of other team members.8 This VAMC CoEPCE, implemented in 2010, is an academic partnership with area professional schools of medicine, nursing, and pharmacy.
At the Boise VAMC CoEPCE, primary care trainees are taught a team-based approach to providing more effective care for high-risk patients through a complex curriculum that includes interprofessional case conferences called PACT interprofessional care updates (ICU). During these case conferences, high-risk patients on a primary care trainee’s panel are presented to an interprofessional group of health care professionals (HCPs) for recommendations to improve care. Trainees from the various disciplines participate in these PACT ICU presentations during time spent rotating through the institution’s academic clinic.
The CoEPCE activities include PACT ICU, interprofessional didactic sessions, and provision of primary care to patients in an interprofessional clinic. Physician trainees participate in one-half day per week of ambulatory didactics and conferences during a 2-week clinic block, which occurs every 2 months. Other health care disciplines participate in PACT ICU during longitudinal experiences (ranging from 4 to 12 months) in the primary care training clinic throughout the academic year.
The PACT ICU case conferences occur weekly at the academic clinic with 2 patient cases presented and discussed at each meeting. Prior to each conference, a primary care trainee, generally an internal medicine resident, is given a list of the top 5 high-risk patients from their panel, determined by a care assessment needs score that is based on high health care use and risk of hospitalization or death within 90 days. To determine care assessment needs scores, patient electronic health records (EHRs) are scanned weekly to review more than 150 data elements, including vital signs; recent clinic, urgent care, and emergency department (ED) visits; medications; laboratory values; and the number and types of illnesses. Statistical analyses are run on the EHR data to provide up-to-date estimates of likelihood of hospital admission or death.
Trainees may also select any patient on their panel whose health care they feel would benefit from a case conference discussion. The trainee presents all medical and social problems related to the selected patient to a team of HCPs, including other trainees and their supervisors, from multiple different disciplines, such as medicine, nursing, pharmacy, behavioral health, and social work. The interprofessional team then provides recommendations.