Mixed Topics

In 2011, 5 VA medical centers (VAMCs) were selected by the Office of Academic Affiliations (OAA) to establish CoEPCE. Part of the VA New Models of Care initiative, the 5 Centers of Excellence (CoE) in Boise, Idaho; Cleveland, Ohio; San Francisco, California; Seattle, Washington; and West Haven, Connecticut, are utilizing VA primary care settings to develop and test innovative approaches to prepare physician residents and students, advanced practice nurse residents and undergraduate nursing students, and other professions of health trainees (eg, pharmacy, social work, psychology, physician assistants [PAs], physical therapists) for primary care practice in the 21st century. The CoEs are developing, implementing, and evaluating curricula designed to prepare learners from relevant professions to practice in patient-centered, interprofessional team-based primary care settings. The curricula at all CoEs must address 4 core domains (Table).

Health care professional education programs do not have many opportunities for workplace learning where trainees from different professions can learn and work together to provide care to patients in real time. 

The VA Connecticut Healthcare System CoEPCE developed and implemented an education and practice-based immersion learning model with physician residents, nurse practitioner (NP) residents and NP students, pharmacy residents, postdoctorate psychology learners, and PA and physical therapy learners and faculty. This interprofessional, collaborative team model breaks from the traditional independent model of siloed primary care providers (PCPs) caring for a panel of patients.

Methods

In 2015, OAA evaluators reviewed background documents and conducted open-ended interviews with 12 West Haven CoEPCE staff, participating trainees, VA faculty, VA facility leadership, and affiliate faculty. Informants described their involvement, challenges encountered, and benefits of the Initiative to Minimize Pharmaceutical Risk in Older Veterans (IMPROVE) program to trainees, veterans, and the VA.

Lack of Clinical Approaches to Interprofessional Education and Care

Polypharmacy is a common problem among older adults with multiple chronic conditions, which places patients at higher risk for multiple negative health outcomes.^2,3 The typical primary care visit rarely allows for a thorough review of a patient’s medications, much less the identification of strategies to reduce polypharmacy and improve medication management. Rather, the complexity inherent to polypharmacy makes it an ideal challenge for a team-based approach.

Team Approach to Medication Needs

A key CoEPCE program aim is to expand workplace learning instruction strategies and to create more clinical opportunities for CoEPCE trainees to work together as a team to anticipate and address the health care needs of veterans. To address this training need, the West Haven CoEPCE developed IMPROVE to focus on high-need patients and provides a venue in which trainees and supervisors from different professions can collaborate on a specific patient case, using a patient-centered framework. IMPROVE can be easily applied to a range of medication-related aims, such as reducing medications, managing medications and adherence, and addressing adverse effects (AEs). These goals are 2-fold: (1) implement a trainee-led performance improvement project that reduces polypharmacy in elderly veterans; and (2) develop a hands-on, experiential geriatrics training program that enhances trainee skills and knowledge related to safe prescribing.

Related: Pharmacist Interventions to Reduce Modifiable Bleeding Risk Factors Using HAS-BLED in Patients Taking Warfarin (FULL)

Planning and Implementation

IMPROVE has its origins in a scholarly project developed by a West Haven CoE physician resident trainee. Development of the IMPROVE program involved VA health psychology, internal medicine faculty, geriatric medicine faculty, NP faculty, and geriatric pharmacy residents and faculty. Planning started in 2013 with a series of pilot clinics and became an official project of the West Haven CoE in September 2014. The intervention required no change in West Haven VAMC policy. However, the initiative required buy-in from West Haven CoE leadership and the director of the West Haven primary care clinic.

Curriculum

IMPROVE is an educational, workplace learning, and clinical activity that combines a 1-hour trainee teaching session, a 45-minute group visit, and a 60-minute individual clinic visit to address the complex problem of polypharmacy. It emphasizes the sharing of trainee and faculty backgrounds by serving as a venue for interprofessional trainees and providers to discuss pharmacologic and nonpharmacologic treatment in the elderly and brainstorm strategies to optimize treatment regimens, minimize risk, and execute medication plans with patients.

All CoEPCE trainees in West Haven are required to participate in IMPROVE and on average, each trainee presents and sees one of their patients at least 3 times per year in the program. Up to 5 trainees participate in each IMPROVE session. Trainees are responsible for reviewing their panels to identify patients who might benefit from participation, followed by inviting the patient to participate. Patients are instructed to bring their pill bottles to the visit. To prepare for the polypharmacy clinic, the trainees, the geriatrician, and the geriatric pharmacist perform an extensive medication chart review, using the medication review worksheet developed by West Haven VAMC providers.⁴ They also work with a protocol for medication discontinuation, which was compiled by West Haven VAMC clinicians. The teams use a variety of tools that guide appropriate prescribing in older adult populations.^5,6 During a preclinic conference, trainees present their patients to the interprofessional team for discussion and participate in a short discussion led by a pharmacist, geriatrician, or health psychologist on a topic related to prescribing safety in older adults or nonpharmacologic treatments.

IMPROVE emphasizes a patient-centered approach to develop, execute, and monitor medication plans. Patients and their family members are invited by their trainee clinician to participate in a group visit. Typically, trainees invite patients aged ≥ 65 years who have ≥ 10 medications and are considered appropriate for a group visit. 

The group visit process is based on health psychology strategies, which often incorporate group-based engagement with patients. The health psychologist can give advice to facilitate the visit and optimize participant involvement. There is a discussion facilitator guide that lists the education points to be covered by a designated trainee facilitator and sample questions to guide the discussion.⁷ A health psychology resident and other rotating trainees cofacilitate the group visit with a goal to reach out to each group member, including family members, and have them discuss perceptions and share concerns and treatment goals. There is shared responsibility among the trainees to address the educational material as well as involve their respective patients during the sessions.

Immediately following the group visit, trainees conduct a 1-hour clinic session that includes medication reconciliation, a review of an IMPROVE questionnaire, orthostatic vital signs, and the St. Louis University Mental Status (SLUMS) exam to assess changes in cognition.^7,8 Discussion involved the patient’s medication list as well as possible changes that could be made to the list. Using shared decision-making techniques, this conversation considers the patients’ treatment goals, feelings about the medications, which medications they would like to stop, and AEs they may be experiencing. After the individual visit is completed, the trainee participates in a 10-minute interprofessional precepting session, which may include a geriatrician, a pharmacist, and a health psychologist. In the session they may discuss adjustments to medications and a safe follow-up plan, including appropriate referrals. Trainees discuss the plan with the patient and send a letter describing the plan shortly after the visit.

IMPROVE combines didactic teaching with experiential education. It embodies the 4 core domains that shape the CoEPCE curriculum. First, trainees learn interprofessional collaboration concepts, including highlighting the roles of each profession and working with an interprofessional team to solve problems. Second, CoEPCE trainees learn performance improvement under the supervision of faculty. Third, IMPROVE allows trainees to develop sustained relationships with other team members while improving the quality of the clinic experience as well as with patients through increased continuity of care. Trainees see patients on their panel and are responsible for outreach before and after the visit. Finally, with a focus on personalized patient goals, trainees have the opportunity to further develop skills in shared decision making (SDM).

Related: Reducing Benzodiazepine Prescribing in Older Veterans: A Direct-to-Consumer Educational Brochure

The IMPROVE model continues to evolve. The original curriculum involved an hour-long preclinic preparation session before the group visit in which trainees and faculty discussed the medication review for each patient scheduled that day. This preparation session was later shortened to 40 minutes, and a 20-minute didactic component was added to create the current preclinic session. The didactic component focused on a specific topic in appropriate prescribing for older patients. For example, one didactic lesson is on a particular class of medications, its common AEs, and practical prescribing and “deprescribing” strategies for that class. Initially, the oldest patients or patients who could be grouped thematically, such as those taking both narcotics and benzodiazepines, were invited to participate, but that limited the number of appropriate patients within the CoEPCE. Currently, trainees identify patients from their panels who might benefit, based on age, number of medications, or potential medication-related concerns, such as falls, cognitive impairment, or other concerns for adverse drug effects. These trainees have the unique opportunity to apply learned strategies to their patients to continue to optimize the medication regimen even after the IMPROVE visit. Another significant change was the inclusion of veterans who are comanaged with PCPs outside the VA, because we found that patients with multiple providers could benefit from improved coordination of care.

Faculty Role

CoE faculty and non-CoE VA faculty participate in supervisory, consulting, teaching and precepting roles. Some faculty members such as the health psychologists are already located in or near the VA primary care clinic, so they can assist in curriculum development and execution during their regular clinic duties. The geriatrician reviews the patients’ health records before the patients come into the clinic, participates in the group visit, and coprecepts during the 1:1 patient visits. Collaboration is inherent in IMPROVE. For example, the geriatrician works with the geriatric pharmacist to identify and teach an educational topic. IMPROVE is characterized by a strong faculty/trainee partnership, with trainees playing roles as both teacher and facilitator in addition to learning how to take a team approach to polypharmacy.

Resources

IMPROVE requires administrative and academic support, especially faculty and trainee preparation of education sessions. The CoEPCE internal medicine resident and the internal medicine chief resident work with the health technicians for each patient aligned care team (PACT) to enter the information into the VA medical scheduling system. Trainee clinic time is blocked for their group visits in advance. Patients are scheduled 1 to 3 weeks in advance. Trainees and faculty are expected to review the medication review worksheet and resources prior to the visit. One CoEPCE faculty member reviews patients prior to the preclinic session (about an hour of preparation per session). Sufficient space also is required: a room large enough to accommodate up to 10 people for both didactic lessons and preclinic sessions, a facility patient education conference room for the group visit, and up to 5 clinic exam rooms. CoEPCE staff developed a templated note in the VA Computerized Patient Record System (CPRS), the VA electronic health record system to guide trainees step-by-step through the clinic visit and allow them to directly enter information into the system.⁷

Monitoring and Assessment

CoEPCE staff are evaluating IMPROVE by building a database for patient-level and trainee-level outcomes, including changes in trainee knowledge and attitudes over time. The CoEPCE also validated the polypharmacy knowledge assessment tool for medicine and NP trainees.

Partnerships

IMPROVE has greatly benefited from partnerships with facility department leadership, particularly involvement of pharmacy staff. In addition, we have partnered with both the health psychology and pharmacy faculty and trainees to participate in the program. Geriatrics faculty and trainees also have contributed extensively to IMPROVE. Future goals include offering the program to non-COEPCE patients throughout primary care.

The Yale Primary Care Internal Medicine Residency program and the Yale Categorical Internal Medicine Residency Program are integral partners to the CoEPCE. IMPROVE supports their mandate to encourage interprofessional teamwork in primary care, meet the Accreditation Council for Graduate Medical Education interprofessional milestones, and promote individual trainee scholarship and performance improvement in areas of broad applicability. IMPROVE also is an opportunity to share ideas across institutions and stimulate new collaborations and dissemination of the model to other primary care settings outside the VA.

Challenges and Solutions

The demand for increased direct patient care pressures programs like IMPROVE, which is a time-intensive process with high impact on a few complex patients. The assumption is that managing medications will save money in the long run, but in the short-term, a strong case has to be made for securing resources, particularly blocking provider time and securing an education room for group visits and clinic exam rooms for individual visits. First, decision makers need to be convinced that polypharmacy is important and should be a training priority. The CoEPCE has tried different configurations to increase the number of patients being seen, such as having ≥ 1 IMPROVE session in an afternoon, but trainees found this to be labor intensive and stressful.

Second, patients with medications prescribed by providers outside the VA require additional communication and coordination to reduce medications. The CoEPCE initially excluded these patients, but after realizing that some of these patients needed the most help, it developed a process for reaching out to non-VA providers and coordinating care. Additionally, there is significant diversity in patient polypharmacy needs. These can range from adherence problems to the challenge of complex psychosocial needs that are more easily (but less effectively) addressed with medications. The issue of polypharmacy is further complicated by evolving understanding of medications’ relative risks and benefits in older adults with multiple chronic conditions. IMPROVE is an effective vehicle for synthesizing current science in medications and their management, especially in complex older patients with multiple chronic conditions.

Other challenges include developing a templated CPRS electronic note that interfaces with the VA information technology system. The process of creating a template, obtaining approval from the forms committee, and working with information technology personnel to implement the template was more time intensive than anticipated and required multiple iterations of proofreading and editing.

Related: Effect of High-Dose Ergocalciferol on Rate of Falls in a Community-Dwelling, Home-Based Primary Care Veteran Population: A Case-Crossover Study

Factors for Success

The commitment to support new models of trainee education by West Haven CoEPCE faculty and leadership, and West Haven VAMC and primary care clinic leadership facilitated the implementation of IMPROVE. Additionally, there is strong CoEPCE collaboration at all levels—codirectors, faculty, and trainees—for the program. High interprofessional trainee interest, organizational insight, and an academic orientation were critical for developing and launching IMPROVE.

Additionally, there is synergy with other team-based professions. Geriatrics has a tradition of working in multidisciplinary teams as well as working with SDM concepts as part of care discussions. High interest and collaboration by a geriatrician and an experienced geriatric pharmacist has been key. The 2 specialties complement each other and address the complex health needs of participating veterans. Health psychologists transition patients to nonpharmacologic treatments, such as sleep hygiene education and cognitive behavioral therapy, in addition to exploring barriers to behavior change.

Another factor for success has been the CoEPCE framework and expertise in interprofessional education. While refining the model, program planners tapped into existing expertise in polypharmacy within the VA from the geriatrics, pharmacy, and clinical health psychology departments. The success of the individual components—the preparation session, the group visit, and the 1:1 patient visit—is in large part the result of a collective effort by CoEPCE staff and the integration of CoEPCE staff through coordination, communications, logistics, quality improvement, and faculty involvement from multiple professions.

The IMPROVE model is flexible and can accommodate diverse patient interests and issues. Model components are based on sound practices that have demonstrated success in other arenas, such as diabetes mellitus group visits. The model can also accommodate diverse trainee levels. Senior trainees can be more independent in developing their care plans, teaching the didactic topic, or precepting during the 1:1 patient exam.

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.

A structured forum for discussing patients and their care options supports professionals’ utilization of the full scope of their practice. Trainees learn and apply team skills, such as communication and the warm handoff, which can be used in other clinic settings. A warm handoff is often described as an intervention in which “a clinician directly introduces a patient to another clinician at the time of the patient’s visit and often a brief encounter between the patient and the health care professional occurs.”⁹ An interprofessional care plan supports trainee clinical performance, providing a more robust approach to patient care than individual providers might on their own.

Patient Outcomes

IMPROVE is an enriched care plan informed by multiple professions with the potential to improve medication use and provide better care. Veterans also are receiving better medication education as well as access to a health psychologist who can help them with goal setting and effective behavioral interventions. On average, 5 patients participate each month. As of December 2015, 68 patients have participated in IMPROVE.

The group visit and the 1:1 patient visits focus exclusively on medication issues and solutions, which would be less common in a typical primary care visit with a complex patient who brings a list of agenda items. In addition to taking a thorough look at their medications and related problems, it also educates patients on related issues such as sleep hygiene. Participating veterans also are encouraged to share their concerns, experiences, and solutions with the group, which may increase the saliency of the message beyond what is offered in counseling from a provider.

To date, preliminary data suggest that in some patients, cognition (as measured with SLUMS after 6 months) has modestly improved after decreasing their medications. Other outcomes being monitored in follow-up are utilization of care, reported history of falls, number of medications, and vital signs at initial and follow-up visits.

Patients experience increased continuity of care because the patient now has a team focusing on his or her care. Team members have a shared understanding of the patient’s situation and are better able to establish therapeutic rapport with patients during the group visit. Moreover, CoEPCE trainees and faculty try to ensure that everyone knows about and concurs with medication changes, including outside providers and family members.

Satisfaction Questionnaire

Patients that are presented at IMPROVE can be particularly challenging, and there may be a psychological benefit to working with a team to develop a new care plan. Providers are able to get input and look at the patient in a new light.

Results of postvisit patient satisfaction questionnaires are encouraging and result in a high level of patient satisfaction and perception of clinical benefit. Patients identify an improvement in the understanding of their medications, feel they are able to safely decrease their medications, and are interested in participating again.

CoEPCE Benefits

IMPROVE expands the prevention and treatment options for populations at risk of hospitalization and adverse outcomes from medication complications, such as AEs and drug-drug or drug-disease interactions. Embedding the polypharmacy clinic within the primary care setting rather than in a separate specialty clinic results in an increased likelihood of implementation of pharmacist and geriatrician recommendations for polypharmacy and allows for direct interprofessional education and collaboration.

IMPROVE also combines key components of interprofessional education—an enriched clinical training model and knowledge of medications in an elderly population—into a training activity that complements other CoEPCE activities. The model not only has strengthened CoEPCE partnerships with other VA departments and specialties, but also revealed opportunities for collaboration with academic affiliates as a means to break down traditional silos among medicine, nursing, pharmacy, geriatrics, and psychology.

IMPROVE combines key components of interprofessional education, including all 4 CoEPCE core domains, to provide hands-on experience with knowledge learned in other aspects of the CoEPCE training program (eg, shared decision-making strategies for eliciting patient goals, weighing risks and benefits in complex clinical situations). Physician and NP trainees work together with trainees in pharmacy and health psychology in the complex approach to polypharmacy. IMPROVE provides the framework for an interprofessional clinic that could be used in the treatment of other complex or high-risk chronic conditions.

The Future

An opportunity for improvement and expansion includes increased patient involvement (as patients continue to learn they have a team working on their behalf). Opportunities exist to connect with patients who have several clinicians prescribing medications outside the CoEPCE to provide comprehensive care and decrease medication complexity.

The CoEPCE has been proactive in increasing the visibility of IMPROVE through multiple presentations at local and national meetings, facilitating collaborations and greater adoption in primary care. Individual and collective IMPROVE components can be adapted to other contexts. For example, the 20-minute geriatrics education session and the forms completed prior and during the patient visit can be readily applied to other complex patients that trainees meet in clinic. Under stage 2 of the CoEPCE program, the CoEPCE is developing an implementation kit that describes the training process and includes the medication worksheet, assessment tools, and directions for conducting the group visit.

It is hoped that working collaboratively with the West Haven COEPCE polypharmacy faculty, a similar model of education and training will be implemented at other health professional training sites at Yale University in New Haven, Connecticut. Additionally, the West Haven CoEPCE is planning to partner with the other original CoEPCE program sites to implement similar interprofessional polypharmacy clinics.

In 2011, 5 VA medical centers (VAMCs) were selected by the Office of Academic Affiliations (OAA) to establish CoEPCE. Part of the VA New Models of Care initiative, the 5 Centers of Excellence (CoE) in Boise, Idaho; Cleveland, Ohio; San Francisco, California; Seattle, Washington; and West Haven, Connecticut, are utilizing VA primary care settings to develop and test innovative approaches to prepare physician residents and students, advanced practice nurse residents and undergraduate nursing students, and other professions of health trainees (eg, pharmacy, social work, psychology, physician assistants [PAs], physical therapists) for primary care practice in the 21st century. The CoEs are developing, implementing, and evaluating curricula designed to prepare learners from relevant professions to practice in patient-centered, interprofessional team-based primary care settings. The curricula at all CoEs must address 4 core domains (Table).

Health care professional education programs do not have many opportunities for workplace learning where trainees from different professions can learn and work together to provide care to patients in real time. 

The VA Connecticut Healthcare System CoEPCE developed and implemented an education and practice-based immersion learning model with physician residents, nurse practitioner (NP) residents and NP students, pharmacy residents, postdoctorate psychology learners, and PA and physical therapy learners and faculty. This interprofessional, collaborative team model breaks from the traditional independent model of siloed primary care providers (PCPs) caring for a panel of patients.

Methods

In 2015, OAA evaluators reviewed background documents and conducted open-ended interviews with 12 West Haven CoEPCE staff, participating trainees, VA faculty, VA facility leadership, and affiliate faculty. Informants described their involvement, challenges encountered, and benefits of the Initiative to Minimize Pharmaceutical Risk in Older Veterans (IMPROVE) program to trainees, veterans, and the VA.

Lack of Clinical Approaches to Interprofessional Education and Care

Polypharmacy is a common problem among older adults with multiple chronic conditions, which places patients at higher risk for multiple negative health outcomes.^2,3 The typical primary care visit rarely allows for a thorough review of a patient’s medications, much less the identification of strategies to reduce polypharmacy and improve medication management. Rather, the complexity inherent to polypharmacy makes it an ideal challenge for a team-based approach.

Team Approach to Medication Needs

A key CoEPCE program aim is to expand workplace learning instruction strategies and to create more clinical opportunities for CoEPCE trainees to work together as a team to anticipate and address the health care needs of veterans. To address this training need, the West Haven CoEPCE developed IMPROVE to focus on high-need patients and provides a venue in which trainees and supervisors from different professions can collaborate on a specific patient case, using a patient-centered framework. IMPROVE can be easily applied to a range of medication-related aims, such as reducing medications, managing medications and adherence, and addressing adverse effects (AEs). These goals are 2-fold: (1) implement a trainee-led performance improvement project that reduces polypharmacy in elderly veterans; and (2) develop a hands-on, experiential geriatrics training program that enhances trainee skills and knowledge related to safe prescribing.

Related: Pharmacist Interventions to Reduce Modifiable Bleeding Risk Factors Using HAS-BLED in Patients Taking Warfarin (FULL)

Planning and Implementation

IMPROVE has its origins in a scholarly project developed by a West Haven CoE physician resident trainee. Development of the IMPROVE program involved VA health psychology, internal medicine faculty, geriatric medicine faculty, NP faculty, and geriatric pharmacy residents and faculty. Planning started in 2013 with a series of pilot clinics and became an official project of the West Haven CoE in September 2014. The intervention required no change in West Haven VAMC policy. However, the initiative required buy-in from West Haven CoE leadership and the director of the West Haven primary care clinic.

Curriculum

IMPROVE is an educational, workplace learning, and clinical activity that combines a 1-hour trainee teaching session, a 45-minute group visit, and a 60-minute individual clinic visit to address the complex problem of polypharmacy. It emphasizes the sharing of trainee and faculty backgrounds by serving as a venue for interprofessional trainees and providers to discuss pharmacologic and nonpharmacologic treatment in the elderly and brainstorm strategies to optimize treatment regimens, minimize risk, and execute medication plans with patients.

All CoEPCE trainees in West Haven are required to participate in IMPROVE and on average, each trainee presents and sees one of their patients at least 3 times per year in the program. Up to 5 trainees participate in each IMPROVE session. Trainees are responsible for reviewing their panels to identify patients who might benefit from participation, followed by inviting the patient to participate. Patients are instructed to bring their pill bottles to the visit. To prepare for the polypharmacy clinic, the trainees, the geriatrician, and the geriatric pharmacist perform an extensive medication chart review, using the medication review worksheet developed by West Haven VAMC providers.⁴ They also work with a protocol for medication discontinuation, which was compiled by West Haven VAMC clinicians. The teams use a variety of tools that guide appropriate prescribing in older adult populations.^5,6 During a preclinic conference, trainees present their patients to the interprofessional team for discussion and participate in a short discussion led by a pharmacist, geriatrician, or health psychologist on a topic related to prescribing safety in older adults or nonpharmacologic treatments.

IMPROVE emphasizes a patient-centered approach to develop, execute, and monitor medication plans. Patients and their family members are invited by their trainee clinician to participate in a group visit. Typically, trainees invite patients aged ≥ 65 years who have ≥ 10 medications and are considered appropriate for a group visit. 

The group visit process is based on health psychology strategies, which often incorporate group-based engagement with patients. The health psychologist can give advice to facilitate the visit and optimize participant involvement. There is a discussion facilitator guide that lists the education points to be covered by a designated trainee facilitator and sample questions to guide the discussion.⁷ A health psychology resident and other rotating trainees cofacilitate the group visit with a goal to reach out to each group member, including family members, and have them discuss perceptions and share concerns and treatment goals. There is shared responsibility among the trainees to address the educational material as well as involve their respective patients during the sessions.

Immediately following the group visit, trainees conduct a 1-hour clinic session that includes medication reconciliation, a review of an IMPROVE questionnaire, orthostatic vital signs, and the St. Louis University Mental Status (SLUMS) exam to assess changes in cognition.^7,8 Discussion involved the patient’s medication list as well as possible changes that could be made to the list. Using shared decision-making techniques, this conversation considers the patients’ treatment goals, feelings about the medications, which medications they would like to stop, and AEs they may be experiencing. After the individual visit is completed, the trainee participates in a 10-minute interprofessional precepting session, which may include a geriatrician, a pharmacist, and a health psychologist. In the session they may discuss adjustments to medications and a safe follow-up plan, including appropriate referrals. Trainees discuss the plan with the patient and send a letter describing the plan shortly after the visit.

IMPROVE combines didactic teaching with experiential education. It embodies the 4 core domains that shape the CoEPCE curriculum. First, trainees learn interprofessional collaboration concepts, including highlighting the roles of each profession and working with an interprofessional team to solve problems. Second, CoEPCE trainees learn performance improvement under the supervision of faculty. Third, IMPROVE allows trainees to develop sustained relationships with other team members while improving the quality of the clinic experience as well as with patients through increased continuity of care. Trainees see patients on their panel and are responsible for outreach before and after the visit. Finally, with a focus on personalized patient goals, trainees have the opportunity to further develop skills in shared decision making (SDM).

Related: Reducing Benzodiazepine Prescribing in Older Veterans: A Direct-to-Consumer Educational Brochure

The IMPROVE model continues to evolve. The original curriculum involved an hour-long preclinic preparation session before the group visit in which trainees and faculty discussed the medication review for each patient scheduled that day. This preparation session was later shortened to 40 minutes, and a 20-minute didactic component was added to create the current preclinic session. The didactic component focused on a specific topic in appropriate prescribing for older patients. For example, one didactic lesson is on a particular class of medications, its common AEs, and practical prescribing and “deprescribing” strategies for that class. Initially, the oldest patients or patients who could be grouped thematically, such as those taking both narcotics and benzodiazepines, were invited to participate, but that limited the number of appropriate patients within the CoEPCE. Currently, trainees identify patients from their panels who might benefit, based on age, number of medications, or potential medication-related concerns, such as falls, cognitive impairment, or other concerns for adverse drug effects. These trainees have the unique opportunity to apply learned strategies to their patients to continue to optimize the medication regimen even after the IMPROVE visit. Another significant change was the inclusion of veterans who are comanaged with PCPs outside the VA, because we found that patients with multiple providers could benefit from improved coordination of care.

Faculty Role

CoE faculty and non-CoE VA faculty participate in supervisory, consulting, teaching and precepting roles. Some faculty members such as the health psychologists are already located in or near the VA primary care clinic, so they can assist in curriculum development and execution during their regular clinic duties. The geriatrician reviews the patients’ health records before the patients come into the clinic, participates in the group visit, and coprecepts during the 1:1 patient visits. Collaboration is inherent in IMPROVE. For example, the geriatrician works with the geriatric pharmacist to identify and teach an educational topic. IMPROVE is characterized by a strong faculty/trainee partnership, with trainees playing roles as both teacher and facilitator in addition to learning how to take a team approach to polypharmacy.

Resources

IMPROVE requires administrative and academic support, especially faculty and trainee preparation of education sessions. The CoEPCE internal medicine resident and the internal medicine chief resident work with the health technicians for each patient aligned care team (PACT) to enter the information into the VA medical scheduling system. Trainee clinic time is blocked for their group visits in advance. Patients are scheduled 1 to 3 weeks in advance. Trainees and faculty are expected to review the medication review worksheet and resources prior to the visit. One CoEPCE faculty member reviews patients prior to the preclinic session (about an hour of preparation per session). Sufficient space also is required: a room large enough to accommodate up to 10 people for both didactic lessons and preclinic sessions, a facility patient education conference room for the group visit, and up to 5 clinic exam rooms. CoEPCE staff developed a templated note in the VA Computerized Patient Record System (CPRS), the VA electronic health record system to guide trainees step-by-step through the clinic visit and allow them to directly enter information into the system.⁷

Monitoring and Assessment

CoEPCE staff are evaluating IMPROVE by building a database for patient-level and trainee-level outcomes, including changes in trainee knowledge and attitudes over time. The CoEPCE also validated the polypharmacy knowledge assessment tool for medicine and NP trainees.

Partnerships

IMPROVE has greatly benefited from partnerships with facility department leadership, particularly involvement of pharmacy staff. In addition, we have partnered with both the health psychology and pharmacy faculty and trainees to participate in the program. Geriatrics faculty and trainees also have contributed extensively to IMPROVE. Future goals include offering the program to non-COEPCE patients throughout primary care.

The Yale Primary Care Internal Medicine Residency program and the Yale Categorical Internal Medicine Residency Program are integral partners to the CoEPCE. IMPROVE supports their mandate to encourage interprofessional teamwork in primary care, meet the Accreditation Council for Graduate Medical Education interprofessional milestones, and promote individual trainee scholarship and performance improvement in areas of broad applicability. IMPROVE also is an opportunity to share ideas across institutions and stimulate new collaborations and dissemination of the model to other primary care settings outside the VA.

Challenges and Solutions

The demand for increased direct patient care pressures programs like IMPROVE, which is a time-intensive process with high impact on a few complex patients. The assumption is that managing medications will save money in the long run, but in the short-term, a strong case has to be made for securing resources, particularly blocking provider time and securing an education room for group visits and clinic exam rooms for individual visits. First, decision makers need to be convinced that polypharmacy is important and should be a training priority. The CoEPCE has tried different configurations to increase the number of patients being seen, such as having ≥ 1 IMPROVE session in an afternoon, but trainees found this to be labor intensive and stressful.

Second, patients with medications prescribed by providers outside the VA require additional communication and coordination to reduce medications. The CoEPCE initially excluded these patients, but after realizing that some of these patients needed the most help, it developed a process for reaching out to non-VA providers and coordinating care. Additionally, there is significant diversity in patient polypharmacy needs. These can range from adherence problems to the challenge of complex psychosocial needs that are more easily (but less effectively) addressed with medications. The issue of polypharmacy is further complicated by evolving understanding of medications’ relative risks and benefits in older adults with multiple chronic conditions. IMPROVE is an effective vehicle for synthesizing current science in medications and their management, especially in complex older patients with multiple chronic conditions.

Other challenges include developing a templated CPRS electronic note that interfaces with the VA information technology system. The process of creating a template, obtaining approval from the forms committee, and working with information technology personnel to implement the template was more time intensive than anticipated and required multiple iterations of proofreading and editing.

Related: Effect of High-Dose Ergocalciferol on Rate of Falls in a Community-Dwelling, Home-Based Primary Care Veteran Population: A Case-Crossover Study

Factors for Success

The commitment to support new models of trainee education by West Haven CoEPCE faculty and leadership, and West Haven VAMC and primary care clinic leadership facilitated the implementation of IMPROVE. Additionally, there is strong CoEPCE collaboration at all levels—codirectors, faculty, and trainees—for the program. High interprofessional trainee interest, organizational insight, and an academic orientation were critical for developing and launching IMPROVE.

Additionally, there is synergy with other team-based professions. Geriatrics has a tradition of working in multidisciplinary teams as well as working with SDM concepts as part of care discussions. High interest and collaboration by a geriatrician and an experienced geriatric pharmacist has been key. The 2 specialties complement each other and address the complex health needs of participating veterans. Health psychologists transition patients to nonpharmacologic treatments, such as sleep hygiene education and cognitive behavioral therapy, in addition to exploring barriers to behavior change.

Another factor for success has been the CoEPCE framework and expertise in interprofessional education. While refining the model, program planners tapped into existing expertise in polypharmacy within the VA from the geriatrics, pharmacy, and clinical health psychology departments. The success of the individual components—the preparation session, the group visit, and the 1:1 patient visit—is in large part the result of a collective effort by CoEPCE staff and the integration of CoEPCE staff through coordination, communications, logistics, quality improvement, and faculty involvement from multiple professions.

The IMPROVE model is flexible and can accommodate diverse patient interests and issues. Model components are based on sound practices that have demonstrated success in other arenas, such as diabetes mellitus group visits. The model can also accommodate diverse trainee levels. Senior trainees can be more independent in developing their care plans, teaching the didactic topic, or precepting during the 1:1 patient exam.

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.

A structured forum for discussing patients and their care options supports professionals’ utilization of the full scope of their practice. Trainees learn and apply team skills, such as communication and the warm handoff, which can be used in other clinic settings. A warm handoff is often described as an intervention in which “a clinician directly introduces a patient to another clinician at the time of the patient’s visit and often a brief encounter between the patient and the health care professional occurs.”⁹ An interprofessional care plan supports trainee clinical performance, providing a more robust approach to patient care than individual providers might on their own.

Patient Outcomes

IMPROVE is an enriched care plan informed by multiple professions with the potential to improve medication use and provide better care. Veterans also are receiving better medication education as well as access to a health psychologist who can help them with goal setting and effective behavioral interventions. On average, 5 patients participate each month. As of December 2015, 68 patients have participated in IMPROVE.

The group visit and the 1:1 patient visits focus exclusively on medication issues and solutions, which would be less common in a typical primary care visit with a complex patient who brings a list of agenda items. In addition to taking a thorough look at their medications and related problems, it also educates patients on related issues such as sleep hygiene. Participating veterans also are encouraged to share their concerns, experiences, and solutions with the group, which may increase the saliency of the message beyond what is offered in counseling from a provider.

To date, preliminary data suggest that in some patients, cognition (as measured with SLUMS after 6 months) has modestly improved after decreasing their medications. Other outcomes being monitored in follow-up are utilization of care, reported history of falls, number of medications, and vital signs at initial and follow-up visits.

Patients experience increased continuity of care because the patient now has a team focusing on his or her care. Team members have a shared understanding of the patient’s situation and are better able to establish therapeutic rapport with patients during the group visit. Moreover, CoEPCE trainees and faculty try to ensure that everyone knows about and concurs with medication changes, including outside providers and family members.

Satisfaction Questionnaire

Patients that are presented at IMPROVE can be particularly challenging, and there may be a psychological benefit to working with a team to develop a new care plan. Providers are able to get input and look at the patient in a new light.

Results of postvisit patient satisfaction questionnaires are encouraging and result in a high level of patient satisfaction and perception of clinical benefit. Patients identify an improvement in the understanding of their medications, feel they are able to safely decrease their medications, and are interested in participating again.

CoEPCE Benefits

IMPROVE expands the prevention and treatment options for populations at risk of hospitalization and adverse outcomes from medication complications, such as AEs and drug-drug or drug-disease interactions. Embedding the polypharmacy clinic within the primary care setting rather than in a separate specialty clinic results in an increased likelihood of implementation of pharmacist and geriatrician recommendations for polypharmacy and allows for direct interprofessional education and collaboration.

IMPROVE also combines key components of interprofessional education—an enriched clinical training model and knowledge of medications in an elderly population—into a training activity that complements other CoEPCE activities. The model not only has strengthened CoEPCE partnerships with other VA departments and specialties, but also revealed opportunities for collaboration with academic affiliates as a means to break down traditional silos among medicine, nursing, pharmacy, geriatrics, and psychology.

IMPROVE combines key components of interprofessional education, including all 4 CoEPCE core domains, to provide hands-on experience with knowledge learned in other aspects of the CoEPCE training program (eg, shared decision-making strategies for eliciting patient goals, weighing risks and benefits in complex clinical situations). Physician and NP trainees work together with trainees in pharmacy and health psychology in the complex approach to polypharmacy. IMPROVE provides the framework for an interprofessional clinic that could be used in the treatment of other complex or high-risk chronic conditions.

The Future

An opportunity for improvement and expansion includes increased patient involvement (as patients continue to learn they have a team working on their behalf). Opportunities exist to connect with patients who have several clinicians prescribing medications outside the CoEPCE to provide comprehensive care and decrease medication complexity.

The CoEPCE has been proactive in increasing the visibility of IMPROVE through multiple presentations at local and national meetings, facilitating collaborations and greater adoption in primary care. Individual and collective IMPROVE components can be adapted to other contexts. For example, the 20-minute geriatrics education session and the forms completed prior and during the patient visit can be readily applied to other complex patients that trainees meet in clinic. Under stage 2 of the CoEPCE program, the CoEPCE is developing an implementation kit that describes the training process and includes the medication worksheet, assessment tools, and directions for conducting the group visit.

It is hoped that working collaboratively with the West Haven COEPCE polypharmacy faculty, a similar model of education and training will be implemented at other health professional training sites at Yale University in New Haven, Connecticut. Additionally, the West Haven CoEPCE is planning to partner with the other original CoEPCE program sites to implement similar interprofessional polypharmacy clinics.

In 2011, 5 VA medical centers (VAMCs) were selected by the Office of Academic Affiliations (OAA) to establish CoEPCE. Part of the VA New Models of Care initiative, the 5 Centers of Excellence (CoE) in Boise, Idaho; Cleveland, Ohio; San Francisco, California; Seattle, Washington; and West Haven, Connecticut, are utilizing VA primary care settings to develop and test innovative approaches to prepare physician residents and students, advanced practice nurse residents and undergraduate nursing students, and other professions of health trainees (eg, pharmacy, social work, psychology, physician assistants [PAs], physical therapists) for primary care practice in the 21st century. The CoEs are developing, implementing, and evaluating curricula designed to prepare learners from relevant professions to practice in patient-centered, interprofessional team-based primary care settings. The curricula at all CoEs must address 4 core domains (Table).

Health care professional education programs do not have many opportunities for workplace learning where trainees from different professions can learn and work together to provide care to patients in real time. 

The VA Connecticut Healthcare System CoEPCE developed and implemented an education and practice-based immersion learning model with physician residents, nurse practitioner (NP) residents and NP students, pharmacy residents, postdoctorate psychology learners, and PA and physical therapy learners and faculty. This interprofessional, collaborative team model breaks from the traditional independent model of siloed primary care providers (PCPs) caring for a panel of patients.

Methods

In 2015, OAA evaluators reviewed background documents and conducted open-ended interviews with 12 West Haven CoEPCE staff, participating trainees, VA faculty, VA facility leadership, and affiliate faculty. Informants described their involvement, challenges encountered, and benefits of the Initiative to Minimize Pharmaceutical Risk in Older Veterans (IMPROVE) program to trainees, veterans, and the VA.

Lack of Clinical Approaches to Interprofessional Education and Care

Polypharmacy is a common problem among older adults with multiple chronic conditions, which places patients at higher risk for multiple negative health outcomes.^2,3 The typical primary care visit rarely allows for a thorough review of a patient’s medications, much less the identification of strategies to reduce polypharmacy and improve medication management. Rather, the complexity inherent to polypharmacy makes it an ideal challenge for a team-based approach.

Team Approach to Medication Needs

A key CoEPCE program aim is to expand workplace learning instruction strategies and to create more clinical opportunities for CoEPCE trainees to work together as a team to anticipate and address the health care needs of veterans. To address this training need, the West Haven CoEPCE developed IMPROVE to focus on high-need patients and provides a venue in which trainees and supervisors from different professions can collaborate on a specific patient case, using a patient-centered framework. IMPROVE can be easily applied to a range of medication-related aims, such as reducing medications, managing medications and adherence, and addressing adverse effects (AEs). These goals are 2-fold: (1) implement a trainee-led performance improvement project that reduces polypharmacy in elderly veterans; and (2) develop a hands-on, experiential geriatrics training program that enhances trainee skills and knowledge related to safe prescribing.

Related: Pharmacist Interventions to Reduce Modifiable Bleeding Risk Factors Using HAS-BLED in Patients Taking Warfarin (FULL)

Planning and Implementation

IMPROVE has its origins in a scholarly project developed by a West Haven CoE physician resident trainee. Development of the IMPROVE program involved VA health psychology, internal medicine faculty, geriatric medicine faculty, NP faculty, and geriatric pharmacy residents and faculty. Planning started in 2013 with a series of pilot clinics and became an official project of the West Haven CoE in September 2014. The intervention required no change in West Haven VAMC policy. However, the initiative required buy-in from West Haven CoE leadership and the director of the West Haven primary care clinic.

Curriculum

IMPROVE is an educational, workplace learning, and clinical activity that combines a 1-hour trainee teaching session, a 45-minute group visit, and a 60-minute individual clinic visit to address the complex problem of polypharmacy. It emphasizes the sharing of trainee and faculty backgrounds by serving as a venue for interprofessional trainees and providers to discuss pharmacologic and nonpharmacologic treatment in the elderly and brainstorm strategies to optimize treatment regimens, minimize risk, and execute medication plans with patients.

All CoEPCE trainees in West Haven are required to participate in IMPROVE and on average, each trainee presents and sees one of their patients at least 3 times per year in the program. Up to 5 trainees participate in each IMPROVE session. Trainees are responsible for reviewing their panels to identify patients who might benefit from participation, followed by inviting the patient to participate. Patients are instructed to bring their pill bottles to the visit. To prepare for the polypharmacy clinic, the trainees, the geriatrician, and the geriatric pharmacist perform an extensive medication chart review, using the medication review worksheet developed by West Haven VAMC providers.⁴ They also work with a protocol for medication discontinuation, which was compiled by West Haven VAMC clinicians. The teams use a variety of tools that guide appropriate prescribing in older adult populations.^5,6 During a preclinic conference, trainees present their patients to the interprofessional team for discussion and participate in a short discussion led by a pharmacist, geriatrician, or health psychologist on a topic related to prescribing safety in older adults or nonpharmacologic treatments.

IMPROVE emphasizes a patient-centered approach to develop, execute, and monitor medication plans. Patients and their family members are invited by their trainee clinician to participate in a group visit. Typically, trainees invite patients aged ≥ 65 years who have ≥ 10 medications and are considered appropriate for a group visit. 

The group visit process is based on health psychology strategies, which often incorporate group-based engagement with patients. The health psychologist can give advice to facilitate the visit and optimize participant involvement. There is a discussion facilitator guide that lists the education points to be covered by a designated trainee facilitator and sample questions to guide the discussion.⁷ A health psychology resident and other rotating trainees cofacilitate the group visit with a goal to reach out to each group member, including family members, and have them discuss perceptions and share concerns and treatment goals. There is shared responsibility among the trainees to address the educational material as well as involve their respective patients during the sessions.

Immediately following the group visit, trainees conduct a 1-hour clinic session that includes medication reconciliation, a review of an IMPROVE questionnaire, orthostatic vital signs, and the St. Louis University Mental Status (SLUMS) exam to assess changes in cognition.^7,8 Discussion involved the patient’s medication list as well as possible changes that could be made to the list. Using shared decision-making techniques, this conversation considers the patients’ treatment goals, feelings about the medications, which medications they would like to stop, and AEs they may be experiencing. After the individual visit is completed, the trainee participates in a 10-minute interprofessional precepting session, which may include a geriatrician, a pharmacist, and a health psychologist. In the session they may discuss adjustments to medications and a safe follow-up plan, including appropriate referrals. Trainees discuss the plan with the patient and send a letter describing the plan shortly after the visit.

IMPROVE combines didactic teaching with experiential education. It embodies the 4 core domains that shape the CoEPCE curriculum. First, trainees learn interprofessional collaboration concepts, including highlighting the roles of each profession and working with an interprofessional team to solve problems. Second, CoEPCE trainees learn performance improvement under the supervision of faculty. Third, IMPROVE allows trainees to develop sustained relationships with other team members while improving the quality of the clinic experience as well as with patients through increased continuity of care. Trainees see patients on their panel and are responsible for outreach before and after the visit. Finally, with a focus on personalized patient goals, trainees have the opportunity to further develop skills in shared decision making (SDM).

Related: Reducing Benzodiazepine Prescribing in Older Veterans: A Direct-to-Consumer Educational Brochure

The IMPROVE model continues to evolve. The original curriculum involved an hour-long preclinic preparation session before the group visit in which trainees and faculty discussed the medication review for each patient scheduled that day. This preparation session was later shortened to 40 minutes, and a 20-minute didactic component was added to create the current preclinic session. The didactic component focused on a specific topic in appropriate prescribing for older patients. For example, one didactic lesson is on a particular class of medications, its common AEs, and practical prescribing and “deprescribing” strategies for that class. Initially, the oldest patients or patients who could be grouped thematically, such as those taking both narcotics and benzodiazepines, were invited to participate, but that limited the number of appropriate patients within the CoEPCE. Currently, trainees identify patients from their panels who might benefit, based on age, number of medications, or potential medication-related concerns, such as falls, cognitive impairment, or other concerns for adverse drug effects. These trainees have the unique opportunity to apply learned strategies to their patients to continue to optimize the medication regimen even after the IMPROVE visit. Another significant change was the inclusion of veterans who are comanaged with PCPs outside the VA, because we found that patients with multiple providers could benefit from improved coordination of care.

Faculty Role

CoE faculty and non-CoE VA faculty participate in supervisory, consulting, teaching and precepting roles. Some faculty members such as the health psychologists are already located in or near the VA primary care clinic, so they can assist in curriculum development and execution during their regular clinic duties. The geriatrician reviews the patients’ health records before the patients come into the clinic, participates in the group visit, and coprecepts during the 1:1 patient visits. Collaboration is inherent in IMPROVE. For example, the geriatrician works with the geriatric pharmacist to identify and teach an educational topic. IMPROVE is characterized by a strong faculty/trainee partnership, with trainees playing roles as both teacher and facilitator in addition to learning how to take a team approach to polypharmacy.

Resources

IMPROVE requires administrative and academic support, especially faculty and trainee preparation of education sessions. The CoEPCE internal medicine resident and the internal medicine chief resident work with the health technicians for each patient aligned care team (PACT) to enter the information into the VA medical scheduling system. Trainee clinic time is blocked for their group visits in advance. Patients are scheduled 1 to 3 weeks in advance. Trainees and faculty are expected to review the medication review worksheet and resources prior to the visit. One CoEPCE faculty member reviews patients prior to the preclinic session (about an hour of preparation per session). Sufficient space also is required: a room large enough to accommodate up to 10 people for both didactic lessons and preclinic sessions, a facility patient education conference room for the group visit, and up to 5 clinic exam rooms. CoEPCE staff developed a templated note in the VA Computerized Patient Record System (CPRS), the VA electronic health record system to guide trainees step-by-step through the clinic visit and allow them to directly enter information into the system.⁷

Monitoring and Assessment

CoEPCE staff are evaluating IMPROVE by building a database for patient-level and trainee-level outcomes, including changes in trainee knowledge and attitudes over time. The CoEPCE also validated the polypharmacy knowledge assessment tool for medicine and NP trainees.

Partnerships

IMPROVE has greatly benefited from partnerships with facility department leadership, particularly involvement of pharmacy staff. In addition, we have partnered with both the health psychology and pharmacy faculty and trainees to participate in the program. Geriatrics faculty and trainees also have contributed extensively to IMPROVE. Future goals include offering the program to non-COEPCE patients throughout primary care.

The Yale Primary Care Internal Medicine Residency program and the Yale Categorical Internal Medicine Residency Program are integral partners to the CoEPCE. IMPROVE supports their mandate to encourage interprofessional teamwork in primary care, meet the Accreditation Council for Graduate Medical Education interprofessional milestones, and promote individual trainee scholarship and performance improvement in areas of broad applicability. IMPROVE also is an opportunity to share ideas across institutions and stimulate new collaborations and dissemination of the model to other primary care settings outside the VA.

Challenges and Solutions

The demand for increased direct patient care pressures programs like IMPROVE, which is a time-intensive process with high impact on a few complex patients. The assumption is that managing medications will save money in the long run, but in the short-term, a strong case has to be made for securing resources, particularly blocking provider time and securing an education room for group visits and clinic exam rooms for individual visits. First, decision makers need to be convinced that polypharmacy is important and should be a training priority. The CoEPCE has tried different configurations to increase the number of patients being seen, such as having ≥ 1 IMPROVE session in an afternoon, but trainees found this to be labor intensive and stressful.

Second, patients with medications prescribed by providers outside the VA require additional communication and coordination to reduce medications. The CoEPCE initially excluded these patients, but after realizing that some of these patients needed the most help, it developed a process for reaching out to non-VA providers and coordinating care. Additionally, there is significant diversity in patient polypharmacy needs. These can range from adherence problems to the challenge of complex psychosocial needs that are more easily (but less effectively) addressed with medications. The issue of polypharmacy is further complicated by evolving understanding of medications’ relative risks and benefits in older adults with multiple chronic conditions. IMPROVE is an effective vehicle for synthesizing current science in medications and their management, especially in complex older patients with multiple chronic conditions.

Other challenges include developing a templated CPRS electronic note that interfaces with the VA information technology system. The process of creating a template, obtaining approval from the forms committee, and working with information technology personnel to implement the template was more time intensive than anticipated and required multiple iterations of proofreading and editing.

Related: Effect of High-Dose Ergocalciferol on Rate of Falls in a Community-Dwelling, Home-Based Primary Care Veteran Population: A Case-Crossover Study

Factors for Success

The commitment to support new models of trainee education by West Haven CoEPCE faculty and leadership, and West Haven VAMC and primary care clinic leadership facilitated the implementation of IMPROVE. Additionally, there is strong CoEPCE collaboration at all levels—codirectors, faculty, and trainees—for the program. High interprofessional trainee interest, organizational insight, and an academic orientation were critical for developing and launching IMPROVE.

Additionally, there is synergy with other team-based professions. Geriatrics has a tradition of working in multidisciplinary teams as well as working with SDM concepts as part of care discussions. High interest and collaboration by a geriatrician and an experienced geriatric pharmacist has been key. The 2 specialties complement each other and address the complex health needs of participating veterans. Health psychologists transition patients to nonpharmacologic treatments, such as sleep hygiene education and cognitive behavioral therapy, in addition to exploring barriers to behavior change.

Another factor for success has been the CoEPCE framework and expertise in interprofessional education. While refining the model, program planners tapped into existing expertise in polypharmacy within the VA from the geriatrics, pharmacy, and clinical health psychology departments. The success of the individual components—the preparation session, the group visit, and the 1:1 patient visit—is in large part the result of a collective effort by CoEPCE staff and the integration of CoEPCE staff through coordination, communications, logistics, quality improvement, and faculty involvement from multiple professions.

The IMPROVE model is flexible and can accommodate diverse patient interests and issues. Model components are based on sound practices that have demonstrated success in other arenas, such as diabetes mellitus group visits. The model can also accommodate diverse trainee levels. Senior trainees can be more independent in developing their care plans, teaching the didactic topic, or precepting during the 1:1 patient exam.

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.

A structured forum for discussing patients and their care options supports professionals’ utilization of the full scope of their practice. Trainees learn and apply team skills, such as communication and the warm handoff, which can be used in other clinic settings. A warm handoff is often described as an intervention in which “a clinician directly introduces a patient to another clinician at the time of the patient’s visit and often a brief encounter between the patient and the health care professional occurs.”⁹ An interprofessional care plan supports trainee clinical performance, providing a more robust approach to patient care than individual providers might on their own.

Patient Outcomes

IMPROVE is an enriched care plan informed by multiple professions with the potential to improve medication use and provide better care. Veterans also are receiving better medication education as well as access to a health psychologist who can help them with goal setting and effective behavioral interventions. On average, 5 patients participate each month. As of December 2015, 68 patients have participated in IMPROVE.

The group visit and the 1:1 patient visits focus exclusively on medication issues and solutions, which would be less common in a typical primary care visit with a complex patient who brings a list of agenda items. In addition to taking a thorough look at their medications and related problems, it also educates patients on related issues such as sleep hygiene. Participating veterans also are encouraged to share their concerns, experiences, and solutions with the group, which may increase the saliency of the message beyond what is offered in counseling from a provider.

To date, preliminary data suggest that in some patients, cognition (as measured with SLUMS after 6 months) has modestly improved after decreasing their medications. Other outcomes being monitored in follow-up are utilization of care, reported history of falls, number of medications, and vital signs at initial and follow-up visits.

Patients experience increased continuity of care because the patient now has a team focusing on his or her care. Team members have a shared understanding of the patient’s situation and are better able to establish therapeutic rapport with patients during the group visit. Moreover, CoEPCE trainees and faculty try to ensure that everyone knows about and concurs with medication changes, including outside providers and family members.

Satisfaction Questionnaire

Patients that are presented at IMPROVE can be particularly challenging, and there may be a psychological benefit to working with a team to develop a new care plan. Providers are able to get input and look at the patient in a new light.

Results of postvisit patient satisfaction questionnaires are encouraging and result in a high level of patient satisfaction and perception of clinical benefit. Patients identify an improvement in the understanding of their medications, feel they are able to safely decrease their medications, and are interested in participating again.

CoEPCE Benefits

IMPROVE expands the prevention and treatment options for populations at risk of hospitalization and adverse outcomes from medication complications, such as AEs and drug-drug or drug-disease interactions. Embedding the polypharmacy clinic within the primary care setting rather than in a separate specialty clinic results in an increased likelihood of implementation of pharmacist and geriatrician recommendations for polypharmacy and allows for direct interprofessional education and collaboration.

IMPROVE also combines key components of interprofessional education—an enriched clinical training model and knowledge of medications in an elderly population—into a training activity that complements other CoEPCE activities. The model not only has strengthened CoEPCE partnerships with other VA departments and specialties, but also revealed opportunities for collaboration with academic affiliates as a means to break down traditional silos among medicine, nursing, pharmacy, geriatrics, and psychology.

IMPROVE combines key components of interprofessional education, including all 4 CoEPCE core domains, to provide hands-on experience with knowledge learned in other aspects of the CoEPCE training program (eg, shared decision-making strategies for eliciting patient goals, weighing risks and benefits in complex clinical situations). Physician and NP trainees work together with trainees in pharmacy and health psychology in the complex approach to polypharmacy. IMPROVE provides the framework for an interprofessional clinic that could be used in the treatment of other complex or high-risk chronic conditions.

The Future

An opportunity for improvement and expansion includes increased patient involvement (as patients continue to learn they have a team working on their behalf). Opportunities exist to connect with patients who have several clinicians prescribing medications outside the CoEPCE to provide comprehensive care and decrease medication complexity.

The CoEPCE has been proactive in increasing the visibility of IMPROVE through multiple presentations at local and national meetings, facilitating collaborations and greater adoption in primary care. Individual and collective IMPROVE components can be adapted to other contexts. For example, the 20-minute geriatrics education session and the forms completed prior and during the patient visit can be readily applied to other complex patients that trainees meet in clinic. Under stage 2 of the CoEPCE program, the CoEPCE is developing an implementation kit that describes the training process and includes the medication worksheet, assessment tools, and directions for conducting the group visit.

It is hoped that working collaboratively with the West Haven COEPCE polypharmacy faculty, a similar model of education and training will be implemented at other health professional training sites at Yale University in New Haven, Connecticut. Additionally, the West Haven CoEPCE is planning to partner with the other original CoEPCE program sites to implement similar interprofessional polypharmacy clinics.

The weather grows colder, the leaves are changing colors then falling, and it is time to gather close all we hold dear and to remember those who have gone before and those who have given for us—it is November. Across the world nations set aside a day to honor fallen heroes and wounded warriors. In Canada and Australia, it is Remembrance Day, in the US, it is Veterans Day, November 11.

War is older than recorded history, and every culture has experiences of violent conflict. Thus, every society has those men and women who have been harmed in body and mind and soul in mortal combat and yet survived and those who have perished on the battlefield or in its aftermath or wished they had.

The bloody, brutal human toll of organized strife has led many a society to recognize a moral obligation to develop a dedicated means of delivering medical care and social support to not just those who are serving actively but to those whose days in action are past. The utilitarian rationale for military medicine is clearly stated in the United States Army Medical Command mission, “Army Medicine provides sustained health services and research in support of the Total Force to enable readiness and conserve the fighting strength while caring for our Soldiers for Life and Families.”¹ It is a measure of the self-sacrifice of those who have sworn to defend their homeland and their healing brothers and sisters in arms that they deliberately make this commitment to each other and their fellow citizens. Yet we cannot easily extend this logic to the care of veterans. Why have diverse countries across millennia seen fit to carve out a special space for veteran health care? In this column, we will seek an answer in culture and history.

Related: Why VA Health Care Is Different

The Roman Empire, which relied heavily on its soldiers for the peace and prosperity of the empire was among the first political entities to recognize the need for military health care and to dedicate human and financial capital to subsidize care for veterans. Among the first hospitals in the world were built to care for Roman legions and the ancient medics like their modern counterparts advanced medical and especially surgical progress that benefited the public.²Today it is not only the US that has special systems of health care for veterans. The Australia Department of Veterans’ Affairs provides many of the same health and social service benefits as those of the US Department of Veterans Affairs (VA). Likewise, Veterans Affairs Canada (VAC) offers those who served and are eligible a variety of resources, including health care. Why does VAC provide health care for veterans?

Veterans Affairs Canada deeply values the contribution that Veterans have made to the development of our nation and we honour the sacrifices they have made.... In expressing Canada’s gratitude to them, we strive to exemplify many of the same principles which they represent–integrity, respect, service and commitment, accountability, and teamwork. ³

Many of these same motifs are repeated in the legislation that officially changed the November 11th commemoration from Armistice Day to Veterans Day. The holiday originated to mark the ending of the terrible First World War in which so many young men’s futures ended in the stench and mud of European trenches. Where Armistice Day celebrated the peace of the Treaty of Versailles and Memorial Day commemorates those in uniform who made the ultimate sacrifice; Veterans Day honors all veterans those still with us and those who have gone before. At the urging of veterans service organizations, as President, the great Army general Dwight D. Eisenhower declared in 1954 November 11 to be Veterans Day with these words:

On that day let us solemnly remember the sacrifices of all those who fought so valiantly, on the seas, in the air, and on foreign shores, to preserve our heritage of freedom, and let us reconsecrate ourselves to the task of promoting an enduring peace so that their efforts shall not have been in vain. ⁴

From these and other political proclamations, we can discern 4 ethical purposes that have motivated so many eras and states to maintain institutions to protect the health and promote the well-being of veterans. The first is gratitude, for those who lost something precious—be it health, function, soundness of mind, wholeness of limb, even life itself. The soldiers, airmen, sailors, marines, and others deserve not only our thanks, but also giving of our substance through taxes and the discharge of our democratic duties to support them through health care and housing, benefits, and burial.

Related: Am I My Brother’s/Sister’s Keeper?

The second purpose is that we owe all veterans a debt, a debt we can never fully repay, because no price can be placed on mental health, on freedom from pain and suffering, from being without a husband or a mother, and yet that is the price that many veterans paid. The least we can do is ensure that they have a health care system that understands the nature of their narratives and invests in the development of expertise particularity in psychophysical sequelae of war like traumatic brain injuries, amputations, posttraumatic stress disorder, and substance use.

The third purpose is that those who carried weapons, who were shot at, and who suffered so many other assaults outside the range of expected human experience fought to secure for all generations the 2 most precious qualities of civilization: freedom and peace. Once their work was done and the uniform hung in the closet and the medals put in a drawer, service men and women passed on to all of us—especially those who are committed to provide their medical care—that cause.

The fourth purpose is the simplest yet perhaps the most morally compelling—to remember the history of sacrifice. In my VA and in many others, unlike any private hospital on the planet, the walls are filled with military memorabilia. There is a memorial statute of a Medal of Honor winner for whom the facility is named in front of the main hospital with a giant American flag waiving proudly. All these symbols tell the veteran walking through the halls that this he or she is the primary ethical justification for this health care organization.

Related: The VA Cannot Be Privatized

These are the most powerful arguments to refute the many recent articles that question the very existence of the VA. Many of those authors, including one of my mentors, have ethical grounds for their calls for an end to a separate health care system for veterans.⁵ Believe me, after nearly 2 decades in the VA, I know firsthand we have much to improve in efficiency, responsiveness, and accountability. But is it really an ethical or even a scientific truth that veteran health care can be delivered more successfully by the private sector? That depends on the terms in which success is defined. Many of those who so blithely and at times irresponsibly proclaim that “we do not need a VA” display in the words of my own admired commander, “the reckless courage of noncombatants.” Solid health care research from independent sources suggests that the VA offers most community health care organizations a run for their money in terms of economies of scale and quality of outcomes in many areas.⁶ Yet this column contends that the measure of success for veteran health care is that the majority of VA and US Department of Defense health care professionals and administrators remain dedicated to these 4 core purposes. Success for these institutions is to seek and to strive through research, teaching, and clinical care to discover and deliver those therapies and medicaments with the most potential to preserve and enhance freedom of body and peace of mind that veterans deserve every day, not only on November 11.

The weather grows colder, the leaves are changing colors then falling, and it is time to gather close all we hold dear and to remember those who have gone before and those who have given for us—it is November. Across the world nations set aside a day to honor fallen heroes and wounded warriors. In Canada and Australia, it is Remembrance Day, in the US, it is Veterans Day, November 11.

War is older than recorded history, and every culture has experiences of violent conflict. Thus, every society has those men and women who have been harmed in body and mind and soul in mortal combat and yet survived and those who have perished on the battlefield or in its aftermath or wished they had.

The bloody, brutal human toll of organized strife has led many a society to recognize a moral obligation to develop a dedicated means of delivering medical care and social support to not just those who are serving actively but to those whose days in action are past. The utilitarian rationale for military medicine is clearly stated in the United States Army Medical Command mission, “Army Medicine provides sustained health services and research in support of the Total Force to enable readiness and conserve the fighting strength while caring for our Soldiers for Life and Families.”¹ It is a measure of the self-sacrifice of those who have sworn to defend their homeland and their healing brothers and sisters in arms that they deliberately make this commitment to each other and their fellow citizens. Yet we cannot easily extend this logic to the care of veterans. Why have diverse countries across millennia seen fit to carve out a special space for veteran health care? In this column, we will seek an answer in culture and history.

Related: Why VA Health Care Is Different

The Roman Empire, which relied heavily on its soldiers for the peace and prosperity of the empire was among the first political entities to recognize the need for military health care and to dedicate human and financial capital to subsidize care for veterans. Among the first hospitals in the world were built to care for Roman legions and the ancient medics like their modern counterparts advanced medical and especially surgical progress that benefited the public.²Today it is not only the US that has special systems of health care for veterans. The Australia Department of Veterans’ Affairs provides many of the same health and social service benefits as those of the US Department of Veterans Affairs (VA). Likewise, Veterans Affairs Canada (VAC) offers those who served and are eligible a variety of resources, including health care. Why does VAC provide health care for veterans?

Veterans Affairs Canada deeply values the contribution that Veterans have made to the development of our nation and we honour the sacrifices they have made.... In expressing Canada’s gratitude to them, we strive to exemplify many of the same principles which they represent–integrity, respect, service and commitment, accountability, and teamwork. ³

Many of these same motifs are repeated in the legislation that officially changed the November 11th commemoration from Armistice Day to Veterans Day. The holiday originated to mark the ending of the terrible First World War in which so many young men’s futures ended in the stench and mud of European trenches. Where Armistice Day celebrated the peace of the Treaty of Versailles and Memorial Day commemorates those in uniform who made the ultimate sacrifice; Veterans Day honors all veterans those still with us and those who have gone before. At the urging of veterans service organizations, as President, the great Army general Dwight D. Eisenhower declared in 1954 November 11 to be Veterans Day with these words:

On that day let us solemnly remember the sacrifices of all those who fought so valiantly, on the seas, in the air, and on foreign shores, to preserve our heritage of freedom, and let us reconsecrate ourselves to the task of promoting an enduring peace so that their efforts shall not have been in vain. ⁴

From these and other political proclamations, we can discern 4 ethical purposes that have motivated so many eras and states to maintain institutions to protect the health and promote the well-being of veterans. The first is gratitude, for those who lost something precious—be it health, function, soundness of mind, wholeness of limb, even life itself. The soldiers, airmen, sailors, marines, and others deserve not only our thanks, but also giving of our substance through taxes and the discharge of our democratic duties to support them through health care and housing, benefits, and burial.

Related: Am I My Brother’s/Sister’s Keeper?

The second purpose is that we owe all veterans a debt, a debt we can never fully repay, because no price can be placed on mental health, on freedom from pain and suffering, from being without a husband or a mother, and yet that is the price that many veterans paid. The least we can do is ensure that they have a health care system that understands the nature of their narratives and invests in the development of expertise particularity in psychophysical sequelae of war like traumatic brain injuries, amputations, posttraumatic stress disorder, and substance use.

The third purpose is that those who carried weapons, who were shot at, and who suffered so many other assaults outside the range of expected human experience fought to secure for all generations the 2 most precious qualities of civilization: freedom and peace. Once their work was done and the uniform hung in the closet and the medals put in a drawer, service men and women passed on to all of us—especially those who are committed to provide their medical care—that cause.

The fourth purpose is the simplest yet perhaps the most morally compelling—to remember the history of sacrifice. In my VA and in many others, unlike any private hospital on the planet, the walls are filled with military memorabilia. There is a memorial statute of a Medal of Honor winner for whom the facility is named in front of the main hospital with a giant American flag waiving proudly. All these symbols tell the veteran walking through the halls that this he or she is the primary ethical justification for this health care organization.

Related: The VA Cannot Be Privatized

These are the most powerful arguments to refute the many recent articles that question the very existence of the VA. Many of those authors, including one of my mentors, have ethical grounds for their calls for an end to a separate health care system for veterans.⁵ Believe me, after nearly 2 decades in the VA, I know firsthand we have much to improve in efficiency, responsiveness, and accountability. But is it really an ethical or even a scientific truth that veteran health care can be delivered more successfully by the private sector? That depends on the terms in which success is defined. Many of those who so blithely and at times irresponsibly proclaim that “we do not need a VA” display in the words of my own admired commander, “the reckless courage of noncombatants.” Solid health care research from independent sources suggests that the VA offers most community health care organizations a run for their money in terms of economies of scale and quality of outcomes in many areas.⁶ Yet this column contends that the measure of success for veteran health care is that the majority of VA and US Department of Defense health care professionals and administrators remain dedicated to these 4 core purposes. Success for these institutions is to seek and to strive through research, teaching, and clinical care to discover and deliver those therapies and medicaments with the most potential to preserve and enhance freedom of body and peace of mind that veterans deserve every day, not only on November 11.

The weather grows colder, the leaves are changing colors then falling, and it is time to gather close all we hold dear and to remember those who have gone before and those who have given for us—it is November. Across the world nations set aside a day to honor fallen heroes and wounded warriors. In Canada and Australia, it is Remembrance Day, in the US, it is Veterans Day, November 11.

War is older than recorded history, and every culture has experiences of violent conflict. Thus, every society has those men and women who have been harmed in body and mind and soul in mortal combat and yet survived and those who have perished on the battlefield or in its aftermath or wished they had.

The bloody, brutal human toll of organized strife has led many a society to recognize a moral obligation to develop a dedicated means of delivering medical care and social support to not just those who are serving actively but to those whose days in action are past. The utilitarian rationale for military medicine is clearly stated in the United States Army Medical Command mission, “Army Medicine provides sustained health services and research in support of the Total Force to enable readiness and conserve the fighting strength while caring for our Soldiers for Life and Families.”¹ It is a measure of the self-sacrifice of those who have sworn to defend their homeland and their healing brothers and sisters in arms that they deliberately make this commitment to each other and their fellow citizens. Yet we cannot easily extend this logic to the care of veterans. Why have diverse countries across millennia seen fit to carve out a special space for veteran health care? In this column, we will seek an answer in culture and history.

Related: Why VA Health Care Is Different

The Roman Empire, which relied heavily on its soldiers for the peace and prosperity of the empire was among the first political entities to recognize the need for military health care and to dedicate human and financial capital to subsidize care for veterans. Among the first hospitals in the world were built to care for Roman legions and the ancient medics like their modern counterparts advanced medical and especially surgical progress that benefited the public.²Today it is not only the US that has special systems of health care for veterans. The Australia Department of Veterans’ Affairs provides many of the same health and social service benefits as those of the US Department of Veterans Affairs (VA). Likewise, Veterans Affairs Canada (VAC) offers those who served and are eligible a variety of resources, including health care. Why does VAC provide health care for veterans?

Veterans Affairs Canada deeply values the contribution that Veterans have made to the development of our nation and we honour the sacrifices they have made.... In expressing Canada’s gratitude to them, we strive to exemplify many of the same principles which they represent–integrity, respect, service and commitment, accountability, and teamwork. ³

Many of these same motifs are repeated in the legislation that officially changed the November 11th commemoration from Armistice Day to Veterans Day. The holiday originated to mark the ending of the terrible First World War in which so many young men’s futures ended in the stench and mud of European trenches. Where Armistice Day celebrated the peace of the Treaty of Versailles and Memorial Day commemorates those in uniform who made the ultimate sacrifice; Veterans Day honors all veterans those still with us and those who have gone before. At the urging of veterans service organizations, as President, the great Army general Dwight D. Eisenhower declared in 1954 November 11 to be Veterans Day with these words:

On that day let us solemnly remember the sacrifices of all those who fought so valiantly, on the seas, in the air, and on foreign shores, to preserve our heritage of freedom, and let us reconsecrate ourselves to the task of promoting an enduring peace so that their efforts shall not have been in vain. ⁴

From these and other political proclamations, we can discern 4 ethical purposes that have motivated so many eras and states to maintain institutions to protect the health and promote the well-being of veterans. The first is gratitude, for those who lost something precious—be it health, function, soundness of mind, wholeness of limb, even life itself. The soldiers, airmen, sailors, marines, and others deserve not only our thanks, but also giving of our substance through taxes and the discharge of our democratic duties to support them through health care and housing, benefits, and burial.

Related: Am I My Brother’s/Sister’s Keeper?

The second purpose is that we owe all veterans a debt, a debt we can never fully repay, because no price can be placed on mental health, on freedom from pain and suffering, from being without a husband or a mother, and yet that is the price that many veterans paid. The least we can do is ensure that they have a health care system that understands the nature of their narratives and invests in the development of expertise particularity in psychophysical sequelae of war like traumatic brain injuries, amputations, posttraumatic stress disorder, and substance use.

The third purpose is that those who carried weapons, who were shot at, and who suffered so many other assaults outside the range of expected human experience fought to secure for all generations the 2 most precious qualities of civilization: freedom and peace. Once their work was done and the uniform hung in the closet and the medals put in a drawer, service men and women passed on to all of us—especially those who are committed to provide their medical care—that cause.

The fourth purpose is the simplest yet perhaps the most morally compelling—to remember the history of sacrifice. In my VA and in many others, unlike any private hospital on the planet, the walls are filled with military memorabilia. There is a memorial statute of a Medal of Honor winner for whom the facility is named in front of the main hospital with a giant American flag waiving proudly. All these symbols tell the veteran walking through the halls that this he or she is the primary ethical justification for this health care organization.

Related: The VA Cannot Be Privatized

These are the most powerful arguments to refute the many recent articles that question the very existence of the VA. Many of those authors, including one of my mentors, have ethical grounds for their calls for an end to a separate health care system for veterans.⁵ Believe me, after nearly 2 decades in the VA, I know firsthand we have much to improve in efficiency, responsiveness, and accountability. But is it really an ethical or even a scientific truth that veteran health care can be delivered more successfully by the private sector? That depends on the terms in which success is defined. Many of those who so blithely and at times irresponsibly proclaim that “we do not need a VA” display in the words of my own admired commander, “the reckless courage of noncombatants.” Solid health care research from independent sources suggests that the VA offers most community health care organizations a run for their money in terms of economies of scale and quality of outcomes in many areas.⁶ Yet this column contends that the measure of success for veteran health care is that the majority of VA and US Department of Defense health care professionals and administrators remain dedicated to these 4 core purposes. Success for these institutions is to seek and to strive through research, teaching, and clinical care to discover and deliver those therapies and medicaments with the most potential to preserve and enhance freedom of body and peace of mind that veterans deserve every day, not only on November 11.

The FDA approves sufentanil for managing pain in patients who are in certified medical health care settings. Also today, Crohn’s disease is tied to anal canal high-risk HPV vaccination. Also today, ultrasound denervation tops radiofrequecy ablation for resistant hypertension, and primary care needs pile up for patients with sickle cell disease.

Amazon Alexa
Apple Podcasts
Spotify

The FDA approves sufentanil for managing pain in patients who are in certified medical health care settings. Also today, Crohn’s disease is tied to anal canal high-risk HPV vaccination. Also today, ultrasound denervation tops radiofrequecy ablation for resistant hypertension, and primary care needs pile up for patients with sickle cell disease.

Amazon Alexa
Apple Podcasts
Spotify

The FDA approves sufentanil for managing pain in patients who are in certified medical health care settings. Also today, Crohn’s disease is tied to anal canal high-risk HPV vaccination. Also today, ultrasound denervation tops radiofrequecy ablation for resistant hypertension, and primary care needs pile up for patients with sickle cell disease.

Amazon Alexa
Apple Podcasts
Spotify

Doctor Stephen Bergman now goes by Samuel Shem and lives outside Boston, but in the 1970s, he published arguably one of the most impactful books on medicine in recent memory -- the cult classic, the House of God.  Newsweek named the House of God the second best satirical piece of fiction of all time behind Don Quixote. In this conversation, Shem tells me about his motivation for the House of God and reveals that there will be a sequel in 2019 on the current state of medicine.
 

Doctor Stephen Bergman now goes by Samuel Shem and lives outside Boston, but in the 1970s, he published arguably one of the most impactful books on medicine in recent memory -- the cult classic, the House of God.  Newsweek named the House of God the second best satirical piece of fiction of all time behind Don Quixote. In this conversation, Shem tells me about his motivation for the House of God and reveals that there will be a sequel in 2019 on the current state of medicine.
 

Doctor Stephen Bergman now goes by Samuel Shem and lives outside Boston, but in the 1970s, he published arguably one of the most impactful books on medicine in recent memory -- the cult classic, the House of God.  Newsweek named the House of God the second best satirical piece of fiction of all time behind Don Quixote. In this conversation, Shem tells me about his motivation for the House of God and reveals that there will be a sequel in 2019 on the current state of medicine.
 

Researchers suggest that revising the threshold for high CV risk from 7.5% at 10 years to 10% at 10 years. Also today, psoriasis adds to risk of CV procedures and surgery in hypertension, sickle cell disease gene therapy seen advancing, and early appendectomy is linked with a reduction in risk for developing Parkinson’s later in life.

Amazon Alexa
Apple Podcasts
Spotify

Researchers suggest that revising the threshold for high CV risk from 7.5% at 10 years to 10% at 10 years. Also today, psoriasis adds to risk of CV procedures and surgery in hypertension, sickle cell disease gene therapy seen advancing, and early appendectomy is linked with a reduction in risk for developing Parkinson’s later in life.

Amazon Alexa
Apple Podcasts
Spotify

Researchers suggest that revising the threshold for high CV risk from 7.5% at 10 years to 10% at 10 years. Also today, psoriasis adds to risk of CV procedures and surgery in hypertension, sickle cell disease gene therapy seen advancing, and early appendectomy is linked with a reduction in risk for developing Parkinson’s later in life.

Amazon Alexa
Apple Podcasts
Spotify

Over the next 6 months she developed progressive liver failure (Model for End-stage Liver Disease score 34), and required several hospitalizations for worsening abdominal pain and debility. Despite the high risk of complications, she agreed to pursue a liver transplant. During the course of surgery, there was significant hemorrhage from tearing of the portal vein (PV) anastomosis and surrounding areas; despite all resuscitative efforts, she went into cardiac arrest and died. The sections of explanted liver revealed soft, spongy parenchyma with blood-filled cyst-like cavities measuring 1-6 mm in diameter (Figure F). The entire liver was affected by vascular malformations (VMs) and there was no evidence of malignancy. On elastin stain, the elastic lamina of the vascular wall appeared thin and disrupted; D2-40 and GLUT1 antibody stains were negative. The hilar PV wall thickness was variable with areas of intramural loose connective tissue separating smooth muscle bundles. This made the PV very friable, which, along with coagulopathy, was the likely cause of uncontrollable intraoperative bleeding. These findings indicate that the vascular spaces were derived from malformation of PV branches.

AGA Institute

VMs are rare liver lesions that can be idiopathic or associated with cirrhosis, traumatic injuries, and syndromes such as hereditary hemorrhagic telangiectasia. Although not always apparent, VMs are present at birth and grow proportionally with the patient’s age.¹ They are usually solitary or multifocal, but rare cases of diffuse hepatic involvement have been reported.² To our knowledge, this is the first reported case of diffuse hepatic VM in an adult with no evidence of extrahepatic involvement. Diffuse hepatic VM may be confused with diffuse hepatic hemangiomatosis, another rare condition in adults characterized by replacement of the hepatic parenchyma with hemangiomatous lesions, but differs in that it is a vascular tumor and not VM. While vascular tumors, such as hemangioma, are characterized by abnormal endothelial proliferation, VMs develop from abnormal vascular morphogenesis, and are named after the vascular element they closely resemble, namely, capillary, venous, or arterial malformations. Although these are 2 distinct entities, the terms hemangioma and VM have been used indiscriminately and interchangeably in the literature to describe vascular anomalies.¹ Most hepatic VMs are asymptomatic, but depending on the extent of involvement, patients may develop high-output heart failure, portal hypertension, and biliary disease.³ Despite extensive liver involvement, our patient did not manifest shunt physiology. The radiographic findings were nonspecific but indicative of diffuse vascular lesions in the liver. Histologic characteristics include dilated, irregular vascular channels, lined by a flat endothelium, separated by liver parenchyma and fibrovascular tissue.² Histochemical stains for collagen, elastin, and smooth muscle are often used to further characterize VMs. Therapeutic options in focal VMs include sclerotherapy, embolization, and surgical resection. In severe cases with progressive hepatic failure, liver transplantation may be the only feasible option. A case of successful living donor liver transplant in a 14-year-old with VMs involving liver and colon has been described in literature.³ Unfortunately, our patient did not survive the surgery. More reports using accurate terminology to describe hepatic vascular anomalies are needed for further understanding of this rare yet fatal disease.

References
1. George A., Mani V., Noufal A. Update on the classification of hemangioma. J Oral Maxillofac Pathol. 2014;18:S117-20.
2. Sato K., Amanuma M., Fukusato T., et al. Diffuse hepatic vascular malformations with right aortic arch. J Hepatol. 2005;43:1094-5.
3. Hatanaka M., Nakazawa A., Nakano N., et al. Successful living donor liver transplantation for giant extensive venous malformation. Pediatr Transplant. 2014;18:E152-6.

[email protected]
 

Over the next 6 months she developed progressive liver failure (Model for End-stage Liver Disease score 34), and required several hospitalizations for worsening abdominal pain and debility. Despite the high risk of complications, she agreed to pursue a liver transplant. During the course of surgery, there was significant hemorrhage from tearing of the portal vein (PV) anastomosis and surrounding areas; despite all resuscitative efforts, she went into cardiac arrest and died. The sections of explanted liver revealed soft, spongy parenchyma with blood-filled cyst-like cavities measuring 1-6 mm in diameter (Figure F). The entire liver was affected by vascular malformations (VMs) and there was no evidence of malignancy. On elastin stain, the elastic lamina of the vascular wall appeared thin and disrupted; D2-40 and GLUT1 antibody stains were negative. The hilar PV wall thickness was variable with areas of intramural loose connective tissue separating smooth muscle bundles. This made the PV very friable, which, along with coagulopathy, was the likely cause of uncontrollable intraoperative bleeding. These findings indicate that the vascular spaces were derived from malformation of PV branches.

AGA Institute

VMs are rare liver lesions that can be idiopathic or associated with cirrhosis, traumatic injuries, and syndromes such as hereditary hemorrhagic telangiectasia. Although not always apparent, VMs are present at birth and grow proportionally with the patient’s age.¹ They are usually solitary or multifocal, but rare cases of diffuse hepatic involvement have been reported.² To our knowledge, this is the first reported case of diffuse hepatic VM in an adult with no evidence of extrahepatic involvement. Diffuse hepatic VM may be confused with diffuse hepatic hemangiomatosis, another rare condition in adults characterized by replacement of the hepatic parenchyma with hemangiomatous lesions, but differs in that it is a vascular tumor and not VM. While vascular tumors, such as hemangioma, are characterized by abnormal endothelial proliferation, VMs develop from abnormal vascular morphogenesis, and are named after the vascular element they closely resemble, namely, capillary, venous, or arterial malformations. Although these are 2 distinct entities, the terms hemangioma and VM have been used indiscriminately and interchangeably in the literature to describe vascular anomalies.¹ Most hepatic VMs are asymptomatic, but depending on the extent of involvement, patients may develop high-output heart failure, portal hypertension, and biliary disease.³ Despite extensive liver involvement, our patient did not manifest shunt physiology. The radiographic findings were nonspecific but indicative of diffuse vascular lesions in the liver. Histologic characteristics include dilated, irregular vascular channels, lined by a flat endothelium, separated by liver parenchyma and fibrovascular tissue.² Histochemical stains for collagen, elastin, and smooth muscle are often used to further characterize VMs. Therapeutic options in focal VMs include sclerotherapy, embolization, and surgical resection. In severe cases with progressive hepatic failure, liver transplantation may be the only feasible option. A case of successful living donor liver transplant in a 14-year-old with VMs involving liver and colon has been described in literature.³ Unfortunately, our patient did not survive the surgery. More reports using accurate terminology to describe hepatic vascular anomalies are needed for further understanding of this rare yet fatal disease.

References
1. George A., Mani V., Noufal A. Update on the classification of hemangioma. J Oral Maxillofac Pathol. 2014;18:S117-20.
2. Sato K., Amanuma M., Fukusato T., et al. Diffuse hepatic vascular malformations with right aortic arch. J Hepatol. 2005;43:1094-5.
3. Hatanaka M., Nakazawa A., Nakano N., et al. Successful living donor liver transplantation for giant extensive venous malformation. Pediatr Transplant. 2014;18:E152-6.

[email protected]
 

Over the next 6 months she developed progressive liver failure (Model for End-stage Liver Disease score 34), and required several hospitalizations for worsening abdominal pain and debility. Despite the high risk of complications, she agreed to pursue a liver transplant. During the course of surgery, there was significant hemorrhage from tearing of the portal vein (PV) anastomosis and surrounding areas; despite all resuscitative efforts, she went into cardiac arrest and died. The sections of explanted liver revealed soft, spongy parenchyma with blood-filled cyst-like cavities measuring 1-6 mm in diameter (Figure F). The entire liver was affected by vascular malformations (VMs) and there was no evidence of malignancy. On elastin stain, the elastic lamina of the vascular wall appeared thin and disrupted; D2-40 and GLUT1 antibody stains were negative. The hilar PV wall thickness was variable with areas of intramural loose connective tissue separating smooth muscle bundles. This made the PV very friable, which, along with coagulopathy, was the likely cause of uncontrollable intraoperative bleeding. These findings indicate that the vascular spaces were derived from malformation of PV branches.

AGA Institute

VMs are rare liver lesions that can be idiopathic or associated with cirrhosis, traumatic injuries, and syndromes such as hereditary hemorrhagic telangiectasia. Although not always apparent, VMs are present at birth and grow proportionally with the patient’s age.¹ They are usually solitary or multifocal, but rare cases of diffuse hepatic involvement have been reported.² To our knowledge, this is the first reported case of diffuse hepatic VM in an adult with no evidence of extrahepatic involvement. Diffuse hepatic VM may be confused with diffuse hepatic hemangiomatosis, another rare condition in adults characterized by replacement of the hepatic parenchyma with hemangiomatous lesions, but differs in that it is a vascular tumor and not VM. While vascular tumors, such as hemangioma, are characterized by abnormal endothelial proliferation, VMs develop from abnormal vascular morphogenesis, and are named after the vascular element they closely resemble, namely, capillary, venous, or arterial malformations. Although these are 2 distinct entities, the terms hemangioma and VM have been used indiscriminately and interchangeably in the literature to describe vascular anomalies.¹ Most hepatic VMs are asymptomatic, but depending on the extent of involvement, patients may develop high-output heart failure, portal hypertension, and biliary disease.³ Despite extensive liver involvement, our patient did not manifest shunt physiology. The radiographic findings were nonspecific but indicative of diffuse vascular lesions in the liver. Histologic characteristics include dilated, irregular vascular channels, lined by a flat endothelium, separated by liver parenchyma and fibrovascular tissue.² Histochemical stains for collagen, elastin, and smooth muscle are often used to further characterize VMs. Therapeutic options in focal VMs include sclerotherapy, embolization, and surgical resection. In severe cases with progressive hepatic failure, liver transplantation may be the only feasible option. A case of successful living donor liver transplant in a 14-year-old with VMs involving liver and colon has been described in literature.³ Unfortunately, our patient did not survive the surgery. More reports using accurate terminology to describe hepatic vascular anomalies are needed for further understanding of this rare yet fatal disease.

References
1. George A., Mani V., Noufal A. Update on the classification of hemangioma. J Oral Maxillofac Pathol. 2014;18:S117-20.
2. Sato K., Amanuma M., Fukusato T., et al. Diffuse hepatic vascular malformations with right aortic arch. J Hepatol. 2005;43:1094-5.
3. Hatanaka M., Nakazawa A., Nakano N., et al. Successful living donor liver transplantation for giant extensive venous malformation. Pediatr Transplant. 2014;18:E152-6.

[email protected]
 

Today, an analysis that may challenge ASCVD guidelines, a new formula may predict adverse events from NSAIDs, a potentially important myocardial infarction risk factor is identified, and a diabetes drug gets a new cardiovascular indication.

Subscribe to Cardiocast wherever you get your podcasts.
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Apple Podcasts

Today, an analysis that may challenge ASCVD guidelines, a new formula may predict adverse events from NSAIDs, a potentially important myocardial infarction risk factor is identified, and a diabetes drug gets a new cardiovascular indication.

Subscribe to Cardiocast wherever you get your podcasts.
Amazon Alexa
Apple Podcasts

Today, an analysis that may challenge ASCVD guidelines, a new formula may predict adverse events from NSAIDs, a potentially important myocardial infarction risk factor is identified, and a diabetes drug gets a new cardiovascular indication.

Subscribe to Cardiocast wherever you get your podcasts.
Amazon Alexa
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Rationale

The patient clinically has rumination syndrome or an adaptation to the belch reflex, with effortless regurgitation, with voluntary re-swallowing of the regurgitated material. Recurrent small bowel obstruction is less likely as the pattern of regurgitation is with almost every meal, within minutes and does not follow the typical pattern of a bowel obstruction. Idiopathic gastroparesis is less likely as the pattern of regurgitation is not consistent with gastroparesis, in addition she is not diabetic.

She has no psychiatric history and there are no findings suggestive of bulimia.
 

Reference

1. Marrero F.J., Shay S.S. Regurgitation and rumination. In: Richter, J.E. Castell, D.O., eds. The Esophagus, 5th ed. West Sussex, England: Wiley-Blackwell; 2012.

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Rationale

The patient clinically has rumination syndrome or an adaptation to the belch reflex, with effortless regurgitation, with voluntary re-swallowing of the regurgitated material. Recurrent small bowel obstruction is less likely as the pattern of regurgitation is with almost every meal, within minutes and does not follow the typical pattern of a bowel obstruction. Idiopathic gastroparesis is less likely as the pattern of regurgitation is not consistent with gastroparesis, in addition she is not diabetic.

She has no psychiatric history and there are no findings suggestive of bulimia.
 

Reference

1. Marrero F.J., Shay S.S. Regurgitation and rumination. In: Richter, J.E. Castell, D.O., eds. The Esophagus, 5th ed. West Sussex, England: Wiley-Blackwell; 2012.

[email protected]

Rationale

The patient clinically has rumination syndrome or an adaptation to the belch reflex, with effortless regurgitation, with voluntary re-swallowing of the regurgitated material. Recurrent small bowel obstruction is less likely as the pattern of regurgitation is with almost every meal, within minutes and does not follow the typical pattern of a bowel obstruction. Idiopathic gastroparesis is less likely as the pattern of regurgitation is not consistent with gastroparesis, in addition she is not diabetic.

She has no psychiatric history and there are no findings suggestive of bulimia.
 

Reference

1. Marrero F.J., Shay S.S. Regurgitation and rumination. In: Richter, J.E. Castell, D.O., eds. The Esophagus, 5th ed. West Sussex, England: Wiley-Blackwell; 2012.

[email protected]

Rationale

This patient’s symptoms are most concerning for Whipple’s disease in light of the diarrhea, weight loss, arthralgias, and CNS symptoms. This diagnosis requires identification of periodic acid-Schiff staining macrophages in the duodenal lamina propria. Further PCR analysis can also be used to identify RNA of the causative pathogen, Tropheryma whipplei. Congo Red staining is indicated if amyloidosis is suspected. Sudan staining is used to test stool for fat. Birefringence is used to detect crystals, most typically in synovial fluid. Immunohistochemistry has many applications and is commonly employed to evaluate for Helicobacter pylori.

Reference

1. Moos V., Schneider T. Changing paradigms in Whipple’s disease and infection with Tropheryma whipplei. Eur J Clin Microbiol Infect Dis. 2011;30(10):1151-8.

[email protected]

Rationale

This patient’s symptoms are most concerning for Whipple’s disease in light of the diarrhea, weight loss, arthralgias, and CNS symptoms. This diagnosis requires identification of periodic acid-Schiff staining macrophages in the duodenal lamina propria. Further PCR analysis can also be used to identify RNA of the causative pathogen, Tropheryma whipplei. Congo Red staining is indicated if amyloidosis is suspected. Sudan staining is used to test stool for fat. Birefringence is used to detect crystals, most typically in synovial fluid. Immunohistochemistry has many applications and is commonly employed to evaluate for Helicobacter pylori.

Reference

1. Moos V., Schneider T. Changing paradigms in Whipple’s disease and infection with Tropheryma whipplei. Eur J Clin Microbiol Infect Dis. 2011;30(10):1151-8.

[email protected]

Rationale

This patient’s symptoms are most concerning for Whipple’s disease in light of the diarrhea, weight loss, arthralgias, and CNS symptoms. This diagnosis requires identification of periodic acid-Schiff staining macrophages in the duodenal lamina propria. Further PCR analysis can also be used to identify RNA of the causative pathogen, Tropheryma whipplei. Congo Red staining is indicated if amyloidosis is suspected. Sudan staining is used to test stool for fat. Birefringence is used to detect crystals, most typically in synovial fluid. Immunohistochemistry has many applications and is commonly employed to evaluate for Helicobacter pylori.

Reference

1. Moos V., Schneider T. Changing paradigms in Whipple’s disease and infection with Tropheryma whipplei. Eur J Clin Microbiol Infect Dis. 2011;30(10):1151-8.

[email protected]

Treatment with transcutaneous electrical nerve stimulation led to a significant cut in pain during movement in women with fibromyalgia. Also today, brisk walking may decrease total knee replacement, smoking is neglected in the treatment of some patients with peripheral arterial disease, and the ACP beefs up its firearms policy in the wake of the shooting in Pittsburgh.
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Treatment with transcutaneous electrical nerve stimulation led to a significant cut in pain during movement in women with fibromyalgia. Also today, brisk walking may decrease total knee replacement, smoking is neglected in the treatment of some patients with peripheral arterial disease, and the ACP beefs up its firearms policy in the wake of the shooting in Pittsburgh.
Amazon Alexa
Apple Podcasts
Spotify

Treatment with transcutaneous electrical nerve stimulation led to a significant cut in pain during movement in women with fibromyalgia. Also today, brisk walking may decrease total knee replacement, smoking is neglected in the treatment of some patients with peripheral arterial disease, and the ACP beefs up its firearms policy in the wake of the shooting in Pittsburgh.
Amazon Alexa
Apple Podcasts
Spotify