Interprofessional Academic Patient Aligned Care Team Panel Management Model

Success Factors

A key success factor includes CoEPCE faculty’s ability to develop and operationalize a panel management model that simultaneously aligns with the educational goals of an interprofessional education training program and supports VA adoption of the medical home or patient aligned care teams (PACT). The CoEPCE contributes staff expertise in accessing and reporting patient data, accessing appropriate teaching space, managing panels of patients with chronic diseases, and facilitating a team-based approach to care. Additionally, the CoEPCE brand is helpful for getting buy-in from the clinical and academic stakeholders necessary for moving PM forward.

Colocating CoEPCE trainees and faculty in the primary care clinic promotes team identity around the RN care managers and facilitated communications with non-CoEPCE clinical teams that have trainees from other professions. RN care managers serve as the locus of highquality PM since they share patient panels with the trainees and already track admissions, ED visits, and numerous chronic health care metrics. RN care managers offer a level of insight into chronic disease that other providers may not possess, such as the specific details on medication adherence and the impact of adverse effects (AEs) for that particular patient. RN care managers are able to teach about their team role and responsibilities, strengthening the model.

PM is an opportunity to expand CoEPCE interprofessional education capacity by creating colocation of different trainee and faculty professions during the PM sessions; the sharing of data with trainees; and sharing and reflecting on data, strengthening communications between professions and within the PACT. The Seattle CoEPCE now has systems in place that allow the RN care manager to send notes to a physician and DNP resident, and the resident is expected to respond. In addition, the PM approach provides experience with analyzing data to improve care in an interprofessional team setting, which is a requirement of the Accreditation Council for Graduate Medical Education.

Interprofessional Collaboration

PM sessions are intentionally designed to improve communication among team members and foster a team approach to care. PM sessions provide an opportunity for trainees and clinician faculty to be together and learn about each profession’s perspectives. For example, early in the process physician and DNP trainees learn about the importance of clinical pharmacists to the team who prescribe and make medication adjustments within their scope of practice as well as the importance of making appropriate pharmacy referrals. Additionally, the RN care manager and clinical pharmacy specialists who serve as faculty in the CoEPCE provide pertinent information on individual patients, increasing integration with the PACT. Finally, there is anecdotal evidence that faculty also are learning more about interprofessional education and expanding their own skills.

Clinical Performance

CoEPCE trainees, non-CoEPCE physician residents, and CoEPCE faculty participants regularly receive patient data with which they can proactively develop or amend a treatment plan between visits. PM has resulted in improved data sharing with providers. Instead of once a year, providers and clinic staff now receive patient data monthly on chronic conditions from the clinic director. Trainees on ambulatory rotations are expected to review their panel data at least a half day per week. CoEPCE staff evaluate trainee likelihood to use PM and ability to identify patients who benefit from team-based care.