From the Nexus vision to the NexusIPE™ learning model.

The Nexus vision of simultaneously transforming health professions education and healthcare delivery to achieve Triple (now Quadruple) Aim outcomes was first articulated in the 2012 proposal and funding of the National Center for Interprofessional Practice and Education (National Center). Over the past decade, the National Center has worked with over 70 sites implementing large scale and practice-based interprofessional practice and education (IPE) programs. Because what is needed to implement the Nexus to achieve Quadruple Aim outcomes was not well understood in 2012, the National Center took a social innovations and developmental evaluation approach. This iterative method led to the development of the National Center NexusIPE™ Learning Model that adapts the 3-P high-level stages (Presage, Process, and Product), proposed as a framework for IPE by Barr and colleagues. National Center collaborators' lessons learned about the Nexus vision are highlighted in this issue and provide real-world examples of elements of the NexusIPETM Learning Model. Reflecting on ten years of experience, the National Center leaders recognize the need for Nexus transformation and the relevance of the NexusIPETM Learning Model today as education and health systems grapple with mounting workforce challenges. The model provides opportunities to address growing workforce shortages, provide equitable care that leads to health, and support the well-being of practice teams in the face of challenges such as the COVID-19 pandemic.

National Center for Interprofessional Practice and Education 2023: reflecting back, looking forward.

The United States (US) National Center for Interprofessional Practice and Education was funded at the University of Minnesota to serve as the National Coordinating Center for Interprofessional Education and Collaborative Practice (IPECP) in the US In 2012, the funders had specific expectations for operationalizing their vision that included scholarship, programs and leadership as an unbiased, neutral convener to align education with health system redesign. While US specific, the National Center benefited from and contributed to the international maturity of the field over the past decade. Through its various services and technology platforms, the National Center has a wide reach nationally and internationally. This perspective provides a unique view of the field in the US with observations and implications for the future.

Burnout and Commitment to Primary Care: Lessons From the Early Impacts of COVID-19 on the Workplace Stress of Primary Care Practice Teams.

PURPOSE: The COVID-19 pandemic has dramatically affected all areas of health care. Primary care practices are on the front lines for patients seeking health care during this period. Understanding clinical and administrative staff members' strategies for managing the broad-ranging changes to primary care service delivery is important for the support of workforce well-being, burnout, and commitment to primary care. METHODS: Thirty-three staff members from 8 practices within a single health care system completed short, semistructured interviews from May 11, 2020 to July 20, 2020. Interviews were coded using a combination of conventional and directed content analysis. RESULTS: Themes emerged from the data that mapped onto the Job Demands-Control-Social Support model. Participants reported that every aspect of primary care service delivery needed to be adapted for COVID-19, which increased their job demands significantly. Several also described pride in their development of new skills, and in most interviews, they expressed that the experience brought staff together. Staff engaged in active cognitive reframing of events during the interviews as they coped with increased workplace stress. However, as the pandemic changed from an acute stress event to a chronic stressor, staff were more likely to indicate signs of burnout. CONCLUSIONS: Primary care teams absorbed tremendous burdens during COVID-19 but also found that some stress was offset by increased support from management and colleagues, belief in their own necessity, and new development opportunities. Considering high prepandemic strain levels, the ability of primary care teams to persist under these conditions might erode as the crisis becomes an enduring challenge.

The Jefferson Scale of Attitudes Toward Interprofessional Collaboration (JeffSATIC): development and multi-institution psychometric data.

This study was designed to develop a psychometrically sound instrument to measure attitudes toward interprofessional collaboration in health profession students and practitioners regardless of their professions and areas of practice. Based on a review of the literature a list of 27 items was generated, 12 faculty judged the face validity of the items, and 124 health profession faculty examined the content validity of the items. The preliminary version of the instrument was administered to 1976 health profession students in three universities (Thomas Jefferson University, n = 510; Midwestern University, n = 392; and Monash University, n = 1074). Twenty items that survived the psychometric scrutiny were included in the Jefferson Scale of Attitudes Toward Interprofessional Collaboration (JeffSATIC). Two constructs of "working relationships" and "accountability" emerged from factor analysis of the JeffSATIC. Cronbach's α coefficients for the JeffSATIC ranged from 0.84 to 0.90 in the three samples. Women obtained significantly higher JeffSATIC mean scores than men. Medical students obtained lower mean score on the JeffSATIC than most other health profession students at the same university. Psychometric support from a relatively large sample size of students in a variety of health profession programs in this multi-institutional study is encouraging which adds to the credibility of the JeffSATIC.

The health mentors program: three years experience with longitudinal, patient-centered interprofessional education.

Increased emphasis on team care has accelerated interprofessional education (IPE) of health professionals. The health mentors program (HMP) is a required, longitudinal, interprofessional curriculum for all matriculating students from medicine, nursing, occupational therapy, physical therapy, pharmacy, and couple and family therapy. Volunteer lay health mentors serve as educators. Student teams complete four modules over 2 years. A mixed-methods approach has been employed since program inception, evaluating 2911 students enrolled in HMP from 2007 to 2013. Program impact on 577 students enrolled from 2009-2011 is reported. Two interprofessional scales were employed to measure attitudes toward IPE and attitudes toward interprofessional practice. Focus groups and reflection papers provide qualitative data. Students enter professional training with very positive attitudes toward IPE, which are maintained over 2 years. Students demonstrated significantly improved attitudes toward team care, which were not different across programs. Qualitative data suggested limited tolerance for logistic challenges posed by IPE, but strongly support that students achieved the major program goals of understanding the roles of colleagues and understanding the perspective of patients. Ongoing longitudinal evaluation will further elucidate the impact on future practice and patient outcomes.

The (stalled) progress of interprofessional collaboration: the role of gender.

Researchers have demonstrated that team-based, collaborative care improves patient outcomes and fosters safer, more effective health care. Despite such positive findings, interprofessional collaboration (IPC) has been somewhat stunted in its adoption. Utilizing a socio-historical lens and employing expectation states theory, we explore potential reasons behind IPC's slow integration. More specifically, we argue that a primary mechanism hindering the achievement of the full promise of IPC stems not only from the rigid occupational status hierarchy nested within health care delivery, but also from the broader status differences between men and women--and how these societal-level disparities are exercised and perpetuated within health care delivery. For instance, we examine not only the historical differences in occupational status of the more "gendered" professions within health care delivery teams (e.g. medicine and nursing), but also the persistent under-representation of women in the physician workforce, especially in leadership positions. Doing so reveals how gender representation, or lack thereof, could potentially lead to ineffective, mismanaged and segmented interprofessional care. Implications and potential solutions are discussed.

Burnout and Commitment After 18 Months of the COVID-19 Pandemic: A Follow-Up Qualitative Study with Primary Care Teams.

BACKGROUND: Primary care practice teams continue to grapple with the demands of the COVID-19 pandemic. Early in the pandemic, despite the increased demands and low levels of control, in practices where protective equipment were available and practice-level support was high, few team members reported burnout, and many described a greater sense of purpose. However, since those early days, burnout levels have increased and high rates of turnover have been reported across the health care system, and further qualitative studies are needed. OBJECTIVE: The present study is a follow-up to a qualitative study on the workplace stress during the pandemic. DESIGN, PARTICIPANTS, APPROACH: Fourteen primary care providers and staff completed 1-year follow-up semistructured interviews (approximately 1.5 years into the pandemic) about their workplace demands, control, social support, burnout, and commitment to primary care. PRIMARY RESULTS: Primary care practice was characterized as high demand before the pandemic but the additional demands of the pandemic were leading participants to consider early retirement, quitting primary care or health care, and expressing a profound need for health care redesign. Short staffing extended medical leaves for COVID-19 and non-COVID-19 needs, increased management of patient mental health and aggressive behaviors, and frustration that practices were being held to prepandemic metrics all contributed to ever higher rates of burnout. Troublingly, while many described high-quality relationships at the practice level, the majority of participants described their organization-level support as largely unresponsive to their input and as offering little support or resources, though a few acknowledged that this could reflect that leadership is also under immense strain. Despite challenges, a number of participants expressed continued commitment to primary care. CONCLUSION: Fundamental redesign of primary care is required to prevent further loss of health care personnel and to provide opportunities for these staff to recover during the grueling, ongoing crisis.

Racial differences in the recognition of cognitive dysfunction in older persons.

We assessed the influence of race and education on informants' reports of cognitive decline in 252 community-residing older persons who were receiving services from senior health agencies. An expert consensus panel made diagnoses of normal cognition, cognitive impairment no dementia (CIND), and dementia based on clinical evaluations and standardized neuropsychological testing (using both population and race-adjusted norms). Informants were interviewed using the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE). Informants of black participants with CIND reported less cognitive decline (lower IQCODE scores) than informants of white CIND participants [3.03 (0.61) vs. 3.23 (0.41); t (117)=2.12, P≤0.036] even though there were no significant differences in the participants' functional and neuropsychological impairments. An analysis of covariance which controlled for informant education indicated that this difference in IQCODE scores was attributable to the fact that black informants had fewer years of education than white informants. There was no statistically significant difference in IQCODE scores for black and white participants with dementia [4.0 (0.7) vs. 4.3 (0.7); t (67)=1.37, P=0.177]. We conclude that racially determined differences in perceptions of early cognitive decline and education may influence informant ratings of older persons. These differences may contribute to disparities in the detection and treatment of cognitive disorders in older black persons.

Implementing and Evaluating a Fellowship for Community-Based Physicians and Physician Assistants: Leadership, Practice Transformation, and Precepting.

INTRODUCTION: Formal training in practice transformation, leadership, clinical education, and/or the time to gain these skills are limited postresidency for primary care physicians and physician assistants. Therefore, we created a novel Primary Care Champions fellowship program that provides practical experiences in education, practice transformation, and leadership for primary care physicians and physician assistants in community practice. The purpose of this study is to describe the fellowship and evaluate feedback from the first cohort. METHODS: In the Jefferson Primary Care Champions Fellowship, fellows are provided protected time from clinical obligations to engage in didactic, informal, and experiential learning. They meet monthly and participate in student precepting training and receive mentorship from senior clinician administrators, scientists, educators, and population health researchers to hone skills for leadership and practice transformation endeavors. Cohort one began in September 2018. All fellows were family physicians from community-based practices in Philadelphia, PA (N = 4) and selected in collaboration with their practice leadership. Mixed-methods postprogram evaluations included Organizational Readiness Assessment and qualitative feedback. RESULTS: Fellows denoted individual time, small-group mentorship, protected project time, and open-robust discussions about primary care most useful. Three fellows reported that they plan to continue their practice-improvement projects postfellowship and one published her initial project findings and reflections. DISCUSSION: Overall feedback from the first cohort was positive. Fellows greatly appreciated structured time to explore primary care interests, contemplated long-term career prospects, and considered leadership opportunities. Cohort two is currently underway and cohort three is in recruitment.

The Importance of Interprofessional Practice in Family Medicine Residency Education.

The practice of family medicine is undergoing rapid transformation, with increasing recognition that family physicians can most effectively meet the needs of individual patients and populations within the context of highly effective interprofessional teams. A substantive evidence base exists to support effective workplace learning by practicing health care teams and learners, much of which has been developed in primary care teaching practices. A strong national consensus now emphasizes the importance of the interprofessional clinical learning environment, including in graduate medical education. Evidence for the impact of improved team function on quadruple aim outcomes is increasingly robust. The World Health Organization, Interprofessional Education Consortium, National Collaborative for Improving the Clinical Learning Environment, and National Center for Interprofessional Practice and Education have developed evidence-based approaches and tools for improving interprofessional collaboration to improve important health outcomes in the clinical learning environment. Embracing the practice as the curriculum and preparing our residency graduates to work within high-functioning interprofessional collaborative practice teams, family medicine has the opportunity to lead the way in demonstrating the value of effective interprofessional practice across health care settings, including virtual teaming, to improve the health of the communities we serve, and across the nation.

Evaluation of a Quality Improvement Experience for Family Medicine Clerkship Students.

BACKGROUND AND OBJECTIVES: There is emphasis on systems-based practice competencies and quality improvement (QI) training in postgraduate medical education. However, we lack effective approaches to provide experiences in these areas during undergraduate medical education. To address this, we developed a novel approach to providing didactic and experiential learning experiences in QI during a third-year family medicine clerkship. METHODS: We implemented and evaluated a QI curriculum combining self-directed learning with real-world experience to increase knowledge and confidence in the plan-do-study-act (PDSA) process for family medicine clerkship students. Students collaborated and presented their change ideas in a "Shark Tank" format for practice leaders at the end of their rotation. We used pre- and postcurriculum surveys to assess knowledge of and comfort with completing QI projects. RESULTS: Three hundred eighty-nine students completed precurriculum surveys and 242 completed postcurriculum surveys. Pre- and postlearning evaluations revealed an increase in agreement or strong agreement with self-reported understanding of specific QI topic areas of 50%. Almost all (91.3%) reported feeling confident or reasonably confident in their ability to create change in health care after exposure to the curriculum, compared with 66.3% in the precurriculum survey. One-third of students (34%) reported intent to complete the Institute for Healthcare Improvement Open School curriculum in QI. CONCLUSIONS: Self-directed learning about QI, combined with practice observation, small-group discussion and presentation in a Shark Tank format was effective and engaging for learners. Students had limited preexisting knowledge of QI principles, suggesting a need for preclinical exposure to this topic. The family medicine clerkship provides an ideal environment for teaching QI.

Critical Race Theory as a Lens for Examining Primary Care Provider Responses to Persistently-Elevated HbA1c.

INTRODUCTION: Clinical inertia remains a persistent problem in the treatment of diabetes in clinical care. Primary care provider behavior is thought to be a significant contributor to diabetes clinical inertia. This study used the lens of Critical Race Theory to examine whether provider's diabetes management activities differ by patient race and frame implications for future research. METHODS: Chart abstractors retrospectively reviewed a random sample of charts from primary care patients with persistently-elevated HbA1c to assess providers' diabetes management activities in the subsequent year. Provider activities aligned with the American Diabetes Association's standards of medical care and included HbA1c test ordering, documentation of patient medication adherence, counseling on lifestyle modification, lifestyle modification referral, endocrinologist participation in care, and medication titration. Differences in provider actions by patient race (Black, white, or other) were examined using chi-square tests. RESULTS: A total of 188 patient charts were reviewed. For all provider actions, there were statistically-significant differences by patient race. Black patients were least likely to be counseled on dietary changes (72.0%) or physical activity (57.7%) by their primary care provider, but most likely to be referred to an outside specialist for this counseling (46.2%). Black patients were also least likely to have medication adjustments made (72%). DISCUSSION: Study findings showed an association between provider diabetes management behaviors and patient race, Future studies showed explore providers' racial beliefs, attitudes and clinical decision-making, and patients' experiences with historical exclusion from medical care and racism in healthcare encounters In addition, more research is needed to explore the role of structural racism in clinical inertia.

Organizational Readiness to Change: Quality Improvement in Family Medicine Residency.

INTRODUCTION: Primary care is evolving to meet greater demands for the inclusion of collaborative health care quality improvement (QI) processes at the practice level. Yet, data on organizational preparedness for change are limited. We assessed the feasibility of incorporating an organizational-level readiness-to-change tool that identifies factors relevant to QI implementation at the practice level impacting new family medicine physicians. METHODS: We assessed organizational readiness to change at the practice level among residents participating in a team-based QI training curriculum from April 2016 to April 2019. Seventy-six current and former residents annually completed the modified Organizational Readiness to Change Assessment (ORCA) survey. We evaluated QI and leadership readiness among five subscales: empowerment, management, QI, QI leadership (skills), and QI leadership (ability). We calculated mean survey scores and compared across all 3 years. Resident interviews captured unique perspectives and experiences with team-based activities. Qualitative analysis identified emergent themes. RESULTS: Residents completed 73 modified ORCA surveys (96% response rate). Compared to years 2016-2019, 2018 results were highest in mean negative responses for the QI subscale (24.62, SD 6.70). Four volunteers completed postsurvey interviews. Qualitative analysis identified issues concerning communication, team collaboration, practice site functioning, and survey relevance. CONCLUSIONS: Our study determined that miscommunication and practice site disruptions undermine organizational-level readiness to change, as measured by the ORCA tool which was part of a multimethod assessment included within a team-based QI training curriculum. Training programs undergoing curricula transformations may feasibly incorporate ORCA as a tool to identify impediments to collaborative practice and inform resource allocation important for enhancing physician training in QI leadership.

Evaluation of the Chronic Disease Self-Management Program with low-income, urban, African American older adults.

A 1-group pretest-posttest design to assess for changes in outcomes at 10 weeks and 6 months was the method used to evaluate the standardized 6-session Chronic Disease Self Management Program (CDSMP) with low income, urban African American older adults. Participants included 153 older adults (primarily African American) with 1 or more chronic health conditions. Classes were provided in the community at senior citizen centers, senior housing, and churches. Significant improvements were noted in selected areas at 10 weeks and 6 months after the program completion. The CDSMP was feasible and well-received with the older adults who participated in the study.

Health Professions Students' Perceptions of Their IPE Program: Potential Barriers to Student Engagement with IPE Goals.

BACKGROUND: Extensive evaluative efforts are underway to explore nuances of interprofessional education (IPE). Few studies, however, have utilized methodology that includes multiple interviews with students of various health disciplines, thereby potentially concealing factors that may be impacting students' attitudes and perceptions of IPE. By focusing on the students' perspectives, this case study explores potential barriers and facilitators to students' engagement with their IPE program. METHODS: In-depth, semi-structured interviews were conducted with 20 students from six health disciplines at the ends of years 1 and 2 of their IPE program. Data were analyzed utilizing multi-step coding processes to identify patterns of students' perceptions and attitudes. FINDINGS: Elements that were internal and external to the IPE program (e.g., assignments, time constraints, lack of accountability, anticipatory socialization, and insufficient professional identity formation) were found to impact students' perceptions of the program and possibly their engagement with IPE goals. CONCLUSIONS: This case study sheds new light on how factors related to an IPE program's structure and implementation, as well as factors outside the program, may affect students' perceptions of IPE and perhaps even their willingness and ability to engage in interprofessionalism.

Potentially inappropriate prescribing for elderly patients in 2 outpatient settings.

Research has shown a high prevalence of potentially inappropriate medication prescribing (PIP) for elderly patients in outpatient settings, but little is known about whether a physician's practice setting influences prescribing attitudes. This study examines the prevalence of PIP among elderly patients in 2 out-patient practices, 1 located in a senior citizens center and 1 in a general family medicine clinic. The authors conducted a retrospective chart review of a random sample of 50 individuals aged 65 years or older from each practice. The 2003 version of the Beers criteria was used to identify PIP. Results show that some one fourth of the elderly sampled in both practices had 1 or more incidents of PIP. The most common potentially inappropriate drug classes prescribed were psychotropic agents and anti-inflammatory drugs. Demographic patient variables were not significantly associated with PIP. This study suggests that PIP may be prevalent across physician groups.

A national survey of family medicine residency education in geriatric medicine: comparing findings in 2004 to 2001.

BACKGROUND AND OBJECTIVES: We compared findings from this 2004 survey with our 2001 survey to determine progress in family medicine residency programs' efforts to better train residents to care for America's aging population. METHODS: A survey was mailed and made available on-line to all 470 family medicine residency directors in the United States. RESULTS: The response rate was 71%. Ninety-six percent of family medicine residencies have a required geriatrics curriculum, compared to 92% in 2001. There was a significant increase in the number of required lecture hours in geriatrics in 2004 as compared to 2001. Since 2001, the median number of MD geriatrics faculty per program has nearly doubled from .5 full-time equivalent (FTE) to .9 FTE. Conflicting time demands with other curricula was ranked as the most significant barrier to geriatrics education in both 2004 and 2001. However, in 2001, the attitude of residents was listed as a significant barrier by 32.1% of the program directors as compared to just 3.6% in 2004. CONCLUSIONS: Family medicine educators are continuing to improve the training of residents to provide state-of-the-art care for the aging population. Faculty must take advantage of this period of experimentation in residency education to identify best practices for geriatrics education.