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Initiative to Minimize Pharmaceutical Risk in Older Veterans (IMPROVE) Polypharmacy Clinic

An interprofessional polypharmacy clinic for intensive management of medication regimens helps high-risk patients manage their medications.
Federal Practitioner. 2018 November;35(11)a:40-47
November 5, 2018|Federal Practitioner
Annette L. Gardner, PhD, MPH;John M. Thomas, MD;Marcia C. Mecca, MD;Anne Hyson, MD, MSc;Kristina M. Niehoff, PharmD, BCPS;Sean Jeffery, PharmD, GCP;John Sellinger, PhD;Rebecca Brienza, MD, MPH;West Haven VA Center of Excellence in Primary Care Education (CoEPCE) Interprofessional Academic Patient Aligned Care Team (iAPACT)
Author and Disclosure Information

John Thomas and Anne Hyson are Physicians, John Sellinger is a Psychologist, Marcia Mecca is a Geriatrician and the Medical Director of the IMPROVE Clinic, and Rebecca Brienza is a Physician and Director of the West Haven CoEPCE at VA Connecticut Health Care System. Annette Gardner is an Assistant Professor at the University of California, San Francisco. Kristina Niehoff is a Pharmacist at Vanderbilt University in Nashville, Tennessee. Sean Jeffery is a Clinical Professor of Pharmacy Practice at the University of Connecticut School of Pharmacy in Storrs. Marcia Mecca and Rebecca Brienza are Assistant Professors at Yale University School of Medicine in New Haven, Connecticut.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.

This article is part of a series that illustrates strategies intended to redesign primary care education at the Veterans Health Administration (VHA), using interprofessional workplace learning. All have been implemented in the VA Centers of Excellence in Primary Care Education (CoEPCE). These models embody visionary transformation of clinical and educational environments that have potential for replication and dissemination throughout VA and other primary care clinical educational environments. For an introduction to the series see Klink K. Transforming primary care clinical learning environments to optimize education, outcomes, and satisfaction. Fed Pract. 2018;35(9):8-10.

Accomplishments and Benefits

Trainees are using team skills to provide patient-centered care. They are strengthening their clinical skills through exposure to patients in a group visit and 1:1 clinic visit. There have been significant improvements in the trainees’ provision of individual patient care. Key IMPROVE outcomes are outlined below.

Interprofessional Education

Unlike a traditional didactic, IMPROVE is an opportunity for health care professionals to work together to provide care in a clinic setting. It also expands CoEPCE interprofessional education capacity through colocation of different trainee and faculty professions during the conference session. This combination trains participants to work as a team and reflect on patients together, which has strengthened communications among professions. The model provides sufficient time and expertise to discuss the medications in detail and as a team, something that would not normally happen during a regular primary care visit.

CoEPCE trainees learn about medication management, its importance in preventing complications and improving patient health outcomes. Trainees of all professions learn to translate the skills they learn in IMPROVE to other patients, such as how to perform a complete medication reconciliation or lead a discussion using SDM. IMPROVE also provides techniques useful in other contexts, such as group visits and consideration of different medication options for patients who have been cared for by other (VA and non-VA) providers.

Interprofessional Collaboration

Understanding and leveraging the expertise of trainees and faculty from different professions is a primary goal of IMPROVE. Education sessions, the group visit, and precepting model are intentionally designed to break down silos and foster a team approach to care, which supports the PACT team model. Trainees and faculty all have their unique strengths and look at the issue from a different perspective, which increases the likelihood that the patient will hear a cohesive solution or strategy. The result is that trainees are more well rounded and become better practitioners who seek advice from other professions and work well in teams.

Trainees are expected to learn about other professions and their skill sets. For example, trainees learn early about the roles and scopes of practice of pharmacists and health psychologists for more effective referrals. Discussions during the session before the group visit may bring conditions like depression or dementia to the trainees’ attention. This is significant because issues like patient motivation may be better handled from a behavioral perspective.

Expanded Clinical Performance

IMPROVE is an opportunity for CoEPCE trainees to expand their clinical expertise. It provides exposure to a variety of patients and patient care needs and is an opportunity to present a high-risk patient to colleagues of various professions. As of December 2015, about 30 internal medicine residents and 6 NP residents have seen patients in the polypharmacy clinic. Each year, 4 NP residents, 2 health psychology residents, 4 clinical pharmacy residents, and 1 geriatric pharmacy resident participate in the IMPROVE clinic during their yearlong training program. During their 3-year training program, 17 to 19 internal medicine residents participate in IMPROVE.

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