Elsevier

Healthcare

Volume 1, Issues 3–4, December 2013, Pages 63-68
Healthcare

The Leading Edge
The EFECT framework for interprofessional education in the patient centered medical home

https://doi.org/10.1016/j.hjdsi.2013.08.003Get rights and content

Abstract

The very nature of the Patient-Centered Medical Home (PCMH) necessitates new instructional models that prepare learners for the roles they will have to assume in these transformed primary care practices. In this manuscript we describe a new instructional framework that seeks to blend the goals of patient-centered care and inter-professional education, and can be implemented in existing training environments while practice transformation continues to proceed. We propose a 5-step process, the EFECT framework, which is simultaneously a sequence of tasks for effective patient care and a guide for the learners and faculty in teaching and evaluating that care delivery. These steps include: (1) Eliciting a patient-centered narrative, (2) Facilitating an inter-professional team discussion, (3) Evaluating clinical evidence, (4) Creating a shared care plan, and (5) Tracking outcomes. We then report preliminary descriptive outcomes from the first EFECT pilot. Our proposed framework supports learners' abilities to construct a patient-centered narrative from multiple professional perspectives as the basis for developing an evidence-based, integrated care plan between the patient and the inter-professional care team and deliberately following up on outcomes. We present this framework to stimulate a process for creating new curricula and evaluative tools to measure and promote learner functioning in medical home environments.

Introduction

The Patient-Centered Medical Home (PCMH) is gaining momentum among an array of stakeholders as a way to improve the structure and function of primary care practice.1 Though career interest in primary care remains low,2 this patient-centered, team-based model of care delivery may increase interest in primary care as a sustainable career choice.3 The nature of the PCMH model as an interprofessional team-based collaboration necessitates new educational approaches. In order to prepare primary care learners for practice in a PCMH, learners will need to engage in educational experiences that prepare them for their roles, building sufficient skills in team-based care, population management, quality improvement, and behavioral health.

Simultaneous transformation of the academic practice and the educational program is a daunting task. Dysfunctional academic ambulatory practice settings have been well described.4 Ignoring the importance of the workplace as the context for learning has deleterious effects.5 Yet, waiting to change the educational programs until after PCMH implementation in existing environments simply delays preparing learners for practice.

As a part of an Education Summit sponsored by the Society of General Internal Medicine in 2011,6 we developed and pilot tested a new educational framework that blends the goals of patient-centered care and interprofessional learning competencies7 within existing training environments, supporting educational innovation while academic practice transformation proceeds. We propose a 5-step process that is simultaneously a sequence of tasks for effective patient care and a guide for faculty and learners in teaching and evaluating that care delivery.

Section snippets

The EFECT framework

Our proposed EFECT framework (Fig. 1) centers on the development and assessment of a learner's ability to construct a patient-centered narrative that uses the patient's values and experience as the basis for developing an integrated shared care plan with the patient and the care team. The framework further develops and assesses the learner's ability to partner with the patient and care team to improve clinical outcomes.

This model is based in part on Kolb's theory of experiential learning:

EFECT framework Step 1: elicit a patient-centered narrative from multiple professional perspectives

Rationale: For the PCMH model to work, the patient must be at the center. A critical way to promote learners' patient-centeredness is to evaluate their skills in eliciting and reporting the patient's narrative. Patient satisfaction and outcomes may be improved when narrative and storytelling are central to patient-provider communication.10, 11 An ability to develop a patient-centered narrative distinguishes a care team with the capacity to fully partner with the patient and to understand the

EFECT framework Step 2: Facilitate a reflective team discussion

Rationale: Teams form the backbone of the PCMH structure. The ability to facilitate an interprofessional team meeting is predicated on the capacity to communicate with other professionals. Key attributes include demonstrating respect, building trust, and acknowledging team members' varied expertise in delivering patient-centered care12 (Box 1).

EFECT framework Step 3: Evaluate clinical evidence

Rationale: This step requires the learners to incorporate physical examination findings and clinical data with the shared patient narrative, and identify gaps in evidence-based quality of care to inform the development of a care plan. It continues to be, by necessity, a team-based activity.

EFECT framework Step 4: Create a shared care plan

Rationale: This step requires learners to develop an actionable plan, articulate its limitations with feedback from others, and then to partner with the patient in its implementation. Until now, the health care team has been engaged in data gathering and discussion. The team now turns its attention to the patient to engage in shared decision-making (SDM) to consider the complex trade-offs often present in the care of chronic health conditions. SDM places the patient's preferences and values at

EFECT framework Step 5: Track outcomes identified in the shared care plan

Rationale: Each learner capable of functioning well in a robust PCMH setting must be able to track clinical outcomes, interpret outcomes in the context of patients' goals, communicate results in a timely and appropriate manner, and continuously re-negotiate the care plan in partnership with the patient. Exposure to this process, which may mirror the real-time feedback necessary for continuous quality improvement, is an important additional educational goal. This tracking function can also be

EFECT implementation pilot

The Boise Veterans Affairs (VA) Center of Excellence in Primary Care Education began a pilot of the EFECT model with learners in January 2013. As part of the Center's educational redesign within the primary care teaching practice, a new weekly clinical care conference was developed (the Patient-Aligned Care Team Interprofessional Care Update, PACT-ICU) to improve care for veterans with complex health needs while simultaneously addressing the learning goals outlined for the EFECT model above.

Discussion

Across the primary care disciplines, efforts are underway to envision and design training models to prepare current learners to practice in PCMHs (P4 residency training program15). Although a growing number of academic ambulatory care practices are qualifying as PCMH sites or have adopted some core PCMH tenets,16 many clinician educators practice and teach in environments that fall far short of a functioning PCMH. The challenge is to prepare learners across the health professions for a future

Declaration of interest

The authors all declare no conflicts of interest.

Acknowledgments

We thank Eric Holmboe and Lorna Lynn for their helpful feedback on previous drafts of the manuscript, as well as Lydia Flier and Sara Carlini for their editorial assistance. We acknowledge the Josiah Macy Jr. Foundation for financial support of the 2011 Society of General Internal Medicine PCMH Education Summit. We also thank other financial and in-kind supporters including the United Health Foundation, American College of Physicians, Primary Care Progress, and the Veterans Health

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