Pioneering a Primary Care ANP Interprofessional Fellowship
Pioneering a Primary Care ANP Interprofessional Fellowship
The Department of Veterans Affairs Office of Academic Affiliations funded 5 Centers of Excellence in Primary Care Education. The West Haven site pioneered the first post-master's adult nurse practitioner (NP) interprofessional fellowship to address the gap in NP education. The experiences of the initial cohort were captured through semistructured interviews. Qualitative analysis revealed 4 common themes: (1) bridging into professional practice, (2) expanded appreciation of health professionals' roles, (3) commitment to interprofessional teamwork, and (4) the necessity of mentorship. The initial findings suggest that post-master's adult NP interprofessional fellowship programs are an essential "next step" for new NPs.
The United States Department of Veterans Affairs (VA) Connecticut Healthcare System (VACHS) Center of Excellence in Primary Care Education (CoEPCE), located within the VA New England region, is a training program that incorporates innovative structural and curricular approaches for transforming health professional education from individual health profession-centric "silo" models to team-based and interprofessional models of education and patient care. The CoEPCEs emerged from Patient Aligned Care Teams, which were implemented at VA hospitals across the nation in 2010 to improve access and enhance care management for more than 5 million primary care patients in the US. "Patient Aligned Care Teams build upon the foundations established in the 1990s when the VA undertook a major transformation from loosely organized hospitals that provided mainly inpatient and specialty care into a regionally integrated system focused on outpatient primary care." The CoEPCE initiative is more than role transition as evidenced by didactic, experiential, and clinical educational sessions that teach trainees how to provide longitudinal care to veterans in collegial, interprofessional teams.
The leadership of the VACHS CoEPCE designed the first post-master's adult nurse practitioner (NP) interprofessional fellowship not only to provide additional postgraduate clinical training but also to form interprofessional practice partnerships with physician trainees and establish a collaborative interprofessional team-based primary care model. Recent advanced practice nursing graduates from institutions around the state were recruited. Interested applicants were interviewed and selected to participate in a 1-year fellowship where they would actively cotrain and comanage patients with their medical colleagues. The NP fellowship component was instrumental to the initial design of the VACHS CoEPCE because of the current gap in postgraduate NP training.
In 2010, the Institute of Medicine (IOM) released a report stating that nursing and medical professions must learn to function interprofessionally if they intend to improve collaborations, affect change, and deliver high-quality patient care. Therefore, when VA implemented the Patient Aligned Care Team model and the VA Office of Academic Affiliations (OAA) released a call to develop CoEPCEs nationwide, 5 medical centers were selected as demonstration sites. Boise, Cleveland, San Francisco, Seattle, and West Haven responded to VA's and OAA's challenge to transform primary care education and develop a team-based, patient-centered health care workforce.
The CoEPCE program and NP fellowship launched in July 2011. The fellowship is a full-time postgraduate (40 hours per week) experience funded by the OAA. Table 1 provides the NP fellow functional statement, which summarizes all requirements and responsibilities of this position. Fellows are selected based on a variety of factors, including a competitive application package. Each NP fellow has a master of science in nursing, obtained an advanced practice license, and has or will have passed the "board" examination within 90 days of starting the fellowship. For the purposes of this program, a fellowship is defined as a period of NP training after graduate education is completed, allowing the fellow to develop a particular expertise. Three new NP graduates were selected to participate in the 2011–2012 academic year; 4 participated in the 2012–2013 academic year.
During the early months, NP fellows develop a collaborative skill set by working with physician (MD) and NP faculty members under a model of joint supervision. NP fellows subsequently transition to a full-time schedule of regular clinic activity, gradually building patient panels under the supervision of NP/MD faculty dyads. This allows them to strengthen their clinical acumen while continuing to receive supervision, mentorship, and support from assigned faculty. Additionally, NP fellows participate in subspecialty presentations and didactic portions of the program to sharpen their ability to practice autonomously in a primary care or specialty setting. NP fellows are assigned to a team that consists of 1 MD faculty/preceptor, 1 NP faculty/preceptor, 3 interns/residents, a registered nurse, and a health technician/medical assistant. The NP fellows rotate with their physician colleagues through the CoEPCE in four 4-week "immersion blocks," which include a total of 4 full-time months for physician trainees and a total of 6 full-time months for the NP fellows per year. An immersion block includes NP fellows, physician trainees, pharmacy residents, and health psychology postdoctorate fellows with 50% clinical time and 50% educational sessions.
The 4 core educational domains of the national program are as follows: (1) shared decision making, which aligns clinical care with the values and preferences of patients and families; (2) interprofessional collaboration, which is a team approach that underscores respect and understanding of each other's scope of practice, leading to improved efficiency, better quality of care, and cost-effectiveness; (3) performance improvement, which is a general requirement of all health profession education programs and contributes to high-quality safe patient care; and (4) sustained relationships, which emphasizes patient-centered, continuous, comprehensive, and coordinated care.
Because of the longitudinal immersion educational and clinical experiences of the fellows, they develop ownership of their patient panels, and continuous relationships with faculty members foster formative feedback and effective mentoring. Figure 1 shows a 1-week sample schedule of an immersion block month calendar, which is used by all faculty and physician trainees/NP fellows to plan their schedules. For example, the weekly primary care meeting allows time for performance improvement activities, and the weekly clinical education session provides an opportunity to review and discuss current evidence-based medicine. Both of these activities are offered through local VA primary care clinics. Clinic hours and learning sessions are also strategically placed in the calendar. Table 2 further highlights examples of CoEPCE curriculum by educational core domain. VA- and CoEPCE-specific courses include facilitation training and learner-driven journal club; all didactic sessions must reflect the core domains of the program and enhance team learning. The remainder of the year the NP fellows are on a "nonimmersion" block, and the physician trainees interact with the team during weekly half-day continuity clinics. Nonimmersion months consist of 4-week blocks in which the NP fellows act as practice partners to the physician trainees and are the bridge to continuity of care for the team patients. During the nonimmersion blocks, NP fellows also rotate through different subspecialty clinics, work on independent scholarly projects, and participate in home visits and other individualized educational activities. The initial panel size for the NP fellows is set at 50 patients, with a goal panel size of 300 by year's end. The primary focus is on the achievement of a high level of competency in the provision of primary care for both male and female patients.
(Enlarge Image)
Figure 1.
1-Week sample immersion block calendar.
Abstract and Introduction
Abstract
The Department of Veterans Affairs Office of Academic Affiliations funded 5 Centers of Excellence in Primary Care Education. The West Haven site pioneered the first post-master's adult nurse practitioner (NP) interprofessional fellowship to address the gap in NP education. The experiences of the initial cohort were captured through semistructured interviews. Qualitative analysis revealed 4 common themes: (1) bridging into professional practice, (2) expanded appreciation of health professionals' roles, (3) commitment to interprofessional teamwork, and (4) the necessity of mentorship. The initial findings suggest that post-master's adult NP interprofessional fellowship programs are an essential "next step" for new NPs.
Introduction
The United States Department of Veterans Affairs (VA) Connecticut Healthcare System (VACHS) Center of Excellence in Primary Care Education (CoEPCE), located within the VA New England region, is a training program that incorporates innovative structural and curricular approaches for transforming health professional education from individual health profession-centric "silo" models to team-based and interprofessional models of education and patient care. The CoEPCEs emerged from Patient Aligned Care Teams, which were implemented at VA hospitals across the nation in 2010 to improve access and enhance care management for more than 5 million primary care patients in the US. "Patient Aligned Care Teams build upon the foundations established in the 1990s when the VA undertook a major transformation from loosely organized hospitals that provided mainly inpatient and specialty care into a regionally integrated system focused on outpatient primary care." The CoEPCE initiative is more than role transition as evidenced by didactic, experiential, and clinical educational sessions that teach trainees how to provide longitudinal care to veterans in collegial, interprofessional teams.
The leadership of the VACHS CoEPCE designed the first post-master's adult nurse practitioner (NP) interprofessional fellowship not only to provide additional postgraduate clinical training but also to form interprofessional practice partnerships with physician trainees and establish a collaborative interprofessional team-based primary care model. Recent advanced practice nursing graduates from institutions around the state were recruited. Interested applicants were interviewed and selected to participate in a 1-year fellowship where they would actively cotrain and comanage patients with their medical colleagues. The NP fellowship component was instrumental to the initial design of the VACHS CoEPCE because of the current gap in postgraduate NP training.
In 2010, the Institute of Medicine (IOM) released a report stating that nursing and medical professions must learn to function interprofessionally if they intend to improve collaborations, affect change, and deliver high-quality patient care. Therefore, when VA implemented the Patient Aligned Care Team model and the VA Office of Academic Affiliations (OAA) released a call to develop CoEPCEs nationwide, 5 medical centers were selected as demonstration sites. Boise, Cleveland, San Francisco, Seattle, and West Haven responded to VA's and OAA's challenge to transform primary care education and develop a team-based, patient-centered health care workforce.
The CoEPCE program and NP fellowship launched in July 2011. The fellowship is a full-time postgraduate (40 hours per week) experience funded by the OAA. Table 1 provides the NP fellow functional statement, which summarizes all requirements and responsibilities of this position. Fellows are selected based on a variety of factors, including a competitive application package. Each NP fellow has a master of science in nursing, obtained an advanced practice license, and has or will have passed the "board" examination within 90 days of starting the fellowship. For the purposes of this program, a fellowship is defined as a period of NP training after graduate education is completed, allowing the fellow to develop a particular expertise. Three new NP graduates were selected to participate in the 2011–2012 academic year; 4 participated in the 2012–2013 academic year.
During the early months, NP fellows develop a collaborative skill set by working with physician (MD) and NP faculty members under a model of joint supervision. NP fellows subsequently transition to a full-time schedule of regular clinic activity, gradually building patient panels under the supervision of NP/MD faculty dyads. This allows them to strengthen their clinical acumen while continuing to receive supervision, mentorship, and support from assigned faculty. Additionally, NP fellows participate in subspecialty presentations and didactic portions of the program to sharpen their ability to practice autonomously in a primary care or specialty setting. NP fellows are assigned to a team that consists of 1 MD faculty/preceptor, 1 NP faculty/preceptor, 3 interns/residents, a registered nurse, and a health technician/medical assistant. The NP fellows rotate with their physician colleagues through the CoEPCE in four 4-week "immersion blocks," which include a total of 4 full-time months for physician trainees and a total of 6 full-time months for the NP fellows per year. An immersion block includes NP fellows, physician trainees, pharmacy residents, and health psychology postdoctorate fellows with 50% clinical time and 50% educational sessions.
The 4 core educational domains of the national program are as follows: (1) shared decision making, which aligns clinical care with the values and preferences of patients and families; (2) interprofessional collaboration, which is a team approach that underscores respect and understanding of each other's scope of practice, leading to improved efficiency, better quality of care, and cost-effectiveness; (3) performance improvement, which is a general requirement of all health profession education programs and contributes to high-quality safe patient care; and (4) sustained relationships, which emphasizes patient-centered, continuous, comprehensive, and coordinated care.
Because of the longitudinal immersion educational and clinical experiences of the fellows, they develop ownership of their patient panels, and continuous relationships with faculty members foster formative feedback and effective mentoring. Figure 1 shows a 1-week sample schedule of an immersion block month calendar, which is used by all faculty and physician trainees/NP fellows to plan their schedules. For example, the weekly primary care meeting allows time for performance improvement activities, and the weekly clinical education session provides an opportunity to review and discuss current evidence-based medicine. Both of these activities are offered through local VA primary care clinics. Clinic hours and learning sessions are also strategically placed in the calendar. Table 2 further highlights examples of CoEPCE curriculum by educational core domain. VA- and CoEPCE-specific courses include facilitation training and learner-driven journal club; all didactic sessions must reflect the core domains of the program and enhance team learning. The remainder of the year the NP fellows are on a "nonimmersion" block, and the physician trainees interact with the team during weekly half-day continuity clinics. Nonimmersion months consist of 4-week blocks in which the NP fellows act as practice partners to the physician trainees and are the bridge to continuity of care for the team patients. During the nonimmersion blocks, NP fellows also rotate through different subspecialty clinics, work on independent scholarly projects, and participate in home visits and other individualized educational activities. The initial panel size for the NP fellows is set at 50 patients, with a goal panel size of 300 by year's end. The primary focus is on the achievement of a high level of competency in the provision of primary care for both male and female patients.
(Enlarge Image)
Figure 1.
1-Week sample immersion block calendar.
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