- Email: [email protected]
needs in adults attending primary care visits in a patient-centered medical home located in Appalachia
Abstracts / Journal of Interprofessional Education & Practice 1 (2015) 48e77 improvements implemented or urgencies for improvements needed to maximize clinical and financial outcomes. Local programmability enabled EMR/EHR alteration to match all best practices to local population, setting realities, and innovations agreed upon (i.e. governance).
73
baccalaureate honors nursing student's community clinical rotation in fall 2014 by providing a faculty supervised STCT. Students provide home care to NYHA Class II and III CHF patients recently discharged from the hospital. Methods
Results/Findings Examples of gains within 3 months (all p<0.001): Falls: 83.6% reduction: 140+ fewer patients, $1.5 million initial annualized savings. Pressure Ulcers: 69.0% reduction (3s, 4s), 14 quarters w/zero acquired 4s, £1.46 million initial annualized savings. Medication Ordering Errors: Wrong drug (illegibility) reduced 100%, wrong dose reduced 86.3%, wrong route reduced 91.8%, compliance to best practice recommendations increased 81.1%. Medication Administration Errors: 71.8% reduction, 51.9% PICU, 76.9% NICU, 86.2% Med/Surg. Stroke: +9.4% discharged to home vs. skilled-nursingfacilities or rehab, -35.7% 31-day readmits, -7.5% LOS, -12.7% cost-pre-case: initial annualized savings estimated between $125,000 and $565,000. Blood-sugar: -16.6% blood-glucose day-1 post-op, -14.4% further day 2. 100% compliance to goals. Sepsis: -62.5% Sepsis cases, with $14.2 million initial annualized savings. 185% improved survey ratings for clinicians, leaders, IT professionals. Reflected “Shared priorities”, “Collaborative approach to best/better future.”
The STCT provides weekly contact with CHF patients by phone and/or home visits to reinforce hospital discharge instructions, medication reconciliation and compliance, nutritional education, functional status evaluation and social support to help patients maximize their self-care abilities and improve their self-care confidence. Any emergent patient concerns and issues are channeled by phone directly to the CHF's Advanced Practice Nurse. Weekly transitional care team meetings are held to review each patient and discuss appropriate plans of care.
Findings Formative and summative evaluations from students demonstrated a high degree of satisfaction. Moreover, the project was deemed successful by the hospital, CHF clinic and school of nursing in terms of student learning and patient outcomes.
Conclusion/Lessons Learned Lessons Learned Compliance is not sufficient for ensuring best care locally due to facility, population and clinician considerations. Compliance must be balanced with innovation and local relevance, including Analytics to see needs and manage change, and EMR/EHR programmability/adaptability to ensure ownership and governed evolution. Reliance on any EMR/EHR vendor as the sole source of best practice for compliance purposes negates the foundations of healthcare progress and professionalism.
Student educational needs can be met using this unique transitional care model and with positive patient outcomes. This model is being expanded to include interdisciplinary honors students and faculty from social work, food science, exercise physiology and psychology to expand services offered to CHF patients while providing a rich academic environment.
A UNIQUE EDUCATIONAL MODEL IN CONGESTIVE HEART FAILURE PATIENTS
INTEGRATING PAPER AND ELECTRONIC HEALTH RECORD (EHR DATA) TO IDENTIFY HEALTH RISKS/NEEDS IN ADULTS ATTENDING PRIMARY CARE VISITS IN A PATIENT-CENTERED MEDICAL HOME LOCATED IN APPALACHIA
TRANSITIONAL
CARE
OF
Nan Smith-Blair PhD, RN, Audrey Weymiller RN, CNP.
Background Health-related quality of life (HRQOL) in individuals with congestive heart failure (CHF) is frequently compromised and associated with increased readmissions to the hospital and use of healthcare resources. Evidence supports the use of transitional care programs to effectively reduce hospital readmission rates. This project's unique approach to providing transitional care is comprised of senior nursing honors students bridging the gap between hospital, home and clinic. The IOMs Future of Nursing: Leading Change, Advancing Health (2011) identified that changes needed to occur in nursing education if we are to prepare competent and skilled nurses required to practice in the future healthcare system. Through designing a new model of clinical education, the student transitional care team (STCT) demonstrates improved utilization of resources for patients and learning opportunities for students. This model demonstrates innovative academic and practice collaboration providing students with learning experiences in a patient-centered environment spanning the care continuum. The National League for Nursing identified national research priorities for nursing education (2012) to reform nursing education needed to prepare nurses to meet emerging health care needs. Integration of the transitional care program could potentially improve management of medical illnesses that fuel nearly 50% of re-hospitalizations and emergency department visits. Leveraging nursing students with the expertise and resources in academic and practice settings allows the team to focus on overcoming individual, environmental and structural barriers to help the CHF patient achieve effective self-care management.
Purpose The purpose of this project was to establish an undergraduate honors STCT that could provide care to NYHA class II and III CHF patients. This project is a collaboration between an urban hospital, clinic based CHF clinic, school of nursing and the CHF patient and family. It was initiated as part of the
Laurie Theeke PhD, FNP-BC, Jennifer Mallow PhD, FNP-BC, Emily Barnes DNP, FNP-BC, Elizabeth Minchau MSN, FNP-BC, Elliott Theeke, Holli Neiman-Hart MD, Treah Haggerty MD, Karen Fitzpatrick MD.
Background/Introduction Quality standards mandate that practices document comprehensive health assessments that may not be incorporated into existing EHRs. This study reports the results of a paper screening initiative that aimed to meet this standard in adults with chronic conditions in West Virginia.
Purpose The purpose of this study is to describe the health behaviors of adults in West Virginia who are attending a wellness visit at a primary care center and patient-centered medical home. Methods/Design The cross-sectional descriptive study reports the analyses of existing data from an adapted version of the HowsYourHealth Medicare Wellness Checkup questionnaire, which included the PHQ-4 depression and anxiety screen, and EHR data. Additional questions asked about illicit drug use, familial behavioral health problems, communication needs, and exposure to secondhand smoke and diet. The existing data retrieved from the EHR included sociodemographics, biomarkers of chronic illness, and chronic illness diagnoses were collected from 144 medical records. Results/Findings The sample had a mean age of 44.37 years (SD 16.32), was distributed equally on gender, and suffered multiple chronic conditions (mode ¼ 2) including: hypertension (34.7%), hyperlipidemia (32.6%), depression (22.9%), arthritis (18.8%), chronic headaches (18.1%), arthritis (12.5%), diabetes (8.3%), and lung disease (11.6%). The mean Body Mass Index (BMI) was 30.07 (SD 8.23) and mean systolic blood pressure was 126.28 (SD 18.91). There was an average of 5.14 medications (SD 4.69) listed as currently being taken. PHQ-4 results for depression were mean of 1.11 (SD ¼ 1.79)
74
Abstracts / Journal of Interprofessional Education & Practice 1 (2015) 48e77
and for anxiety, mean of 1.44 (SD 1.85), indicating minimal depressive or anxiety symptoms. Mean alcohol consumption was mean of 2 drinks per week. Total number of chronic illnesses positively correlated with depressive symptoms (p < 001), anxiety symptoms (p <.05), and BMI (p < .05). Poverty and lack of confidence to manage multiple chronic conditions were not identified as barriers. Over 82% still rated their health as good to excellent. Health rating did not differ based on total number of chronic illnesses.
Conclusion The IPE Summit is an important next step in ASCO's commitment to supporting optometry's role in IPE, team-based collaborative patient centered care and ultimately improved patient outcomes. CONNECTING THE DOTS IMPROVEMENT EDUCATION
Conclusions Effecting change in a population with a positive health rating in the context of multiple chronic conditions is challenging. Implementing a quality standard screening is not enough. Including patient input and understanding patient expectations for health is integral for the development of patient-centered interventions. THE ASSOCIATION OF SCHOOLS AND COLLEGES OF OPTOMETRY TO CONVENE AN INTERPROFESSIONAL EDUCATION SUMMIT IN FEBRUARY 2016 Melissa Vitek OD, John Baker OD, MSEd, Jennifer Coyle OD, MS, Elizabeth Hoppe OD, MPH, DrPH, David Troilo PhD.
Background In 2013, The Association of Schools and Colleges of Optometry (ASCO) created an interprofessional education (IPE) task force. The task force, under the leadership of Dr. Jennifer Smythe Coyle, was given a charge that included examining and supporting the educational strategies of other health care professions. In addition, the task force was to identify best practices of IPE to prepare graduates for team-based practice. The IPE task force has recently become a standing IPE Committee within ASCO.
IN
INTERPROFESSIONAL
QUALITY
Laura Silversteyn NP, Tina Vonhaz NP, Bridgette Christopher MD, PhD, Jason Tuckerman MD, PhD, Pete Spanos BA, Mary Dolansky RN, PhD, Mamta Singh MD, MS, Anne Rusterholtz NP, Alli Heilman NP.
Background The Center of Excellence in Primary Care Education (CoEPCE) at the Louis Stokes Cleveland VA, Transforming Out-Patient Care (TOPC COE) is an interprofessional program that trains Physician residents, Nurse Practitioner residents and students, and Health Psychology residents in an immersive Patient-Centered Medical Home model emphasizing teamwork, shared decision making, sustained relationships and performance improvement. A longitudinal quality improvement curriculum was developed to take advantage of this interprofessional trainee structure. QI is currently mandated in many health professions graduate programs, but limited interprofessional models have been the mainstay.
Purpose To describe an interprofessional QI curriculum that connects teamwork, systems, and the impact on both learner outcomes and clinical improvements. Methods
Purpose In alignment with the original ASCO IPE task force charge, a survey of all schools and colleges of optometry in the United States was conducted in August of 2013. The purpose of the survey was to identify current IPE practices, identify barriers to IPE at member institutions and to ask how ASCO can best support the implementation, sustainability, and further development of IPE and collaborative care at their institutions.
Methods The results of the survey were analyzed by members of the ASCO IPE task force. In addition to noting that an equal number of schools and colleges of optometry reported participation in and barriers to IPE, a number of requests were put forth to support IPE activities. One of these requests was for ASCO to convene a national IPE conference aimed at strengthening optometry's role in the patient care team.
Results ASCO plans to convene a national IPE Summit in February of 2016 at Southern California College of Optometry at Marshall B. Ketchum University. Three main goals of the IPE Summit with corresponding objectives have been defined. The first goal is to assemble representatives from ASCO member institutions and other champions of interprofessional collaboration. The objectives for this goal are to create opportunities among attendees for networking and collaboration, raise the role optometry plays in interprofessional healthcare teams and to identify synergies in obtaining grant funding for developing and sustaining IPE and (interprofessional practice) IPP. The second goal is to share current best practices in IPE and IPP. The objectives for this goal are to communicate techniques, strategies, and considerations for IPE and IPP including engagement of optometry in team based patient care and to identify outcome measures and tools to assess the impact of IPE and IPP on student learning. The third goal is to share ideas on future development of IPE and IPP. The objectives for this goal are to explore future options for enhanced engagement in IPE and IPP and to develop strategies to assess the impact of IPE and IPP on patient outcomes.
The interprofessional team approach combines didactic and experiential learning of QI content that is applied to a project aiming to improve care. In promoting a program structured to support transdisciplinary relationships, current curriculum offers educational opportunities and QI projects that incorporate best evidence and proficient methodology into clinical decisions thereby promoting a QI culture. Throughout the curriculum numerous learning sessions in multiple formats are presented to increase knowledge of quality and improvement science. Learners are exposed to topics such as policy development and developing trends in health industry. The curriculum provides skills and tools applicable to patient care, working within interprofessional teams that involve primary care providers, nurses, social workers, psychologists, and pharmacists. Learners are required to rotate through a number of specialties such as pulmonary, cardiology, neurology, rheumatology, woman's clinic, as well as getting certified in Lean Six Sigma Yellow Belt training. Results In the last four years, the interprofessional approach and the opportunity to observe, learn and improve the processes and procedures in patient care resulted in 20 QI projects. Prior projects that have been sustained include reduction in low-acuity ED visits, HIV screening, and shared medical appointments for pain management. Current projects aim to improve appropriate vaccination of HCV patients, screening for colorectal cancer, serum folate testing, aspirin for primary prevention, and the appropriate use of statins. The improvements have resulted in meeting evidencebased outcome targets and efficiency of delivering primary care. A project to improve aspirin prescribing will be presented. Trainees complete short Minute Paper evaluations as part of the QI curriculum that provide ratings on usefulness and confidence-building. These sessions have received an average rating of 4.56 out of 5 (1-5; 5¼high; n¼503; mode¼5) for usefulness and average rating of 4.35 out of 5 (n¼500; mode¼5) for increased confidence.
Conclusions While the TOPC COE at the Louis Stokes Cleveland VA is still in its early years, the impact on learners to connect the dots among teamwork, local policy, and systems has made an impact on the learners' perspective of their work. Application of this QI interprofessional education model to
73
baccalaureate honors nursing student's community clinical rotation in fall 2014 by providing a faculty supervised STCT. Students provide home care to NYHA Class II and III CHF patients recently discharged from the hospital. Methods
Results/Findings Examples of gains within 3 months (all p<0.001): Falls: 83.6% reduction: 140+ fewer patients, $1.5 million initial annualized savings. Pressure Ulcers: 69.0% reduction (3s, 4s), 14 quarters w/zero acquired 4s, £1.46 million initial annualized savings. Medication Ordering Errors: Wrong drug (illegibility) reduced 100%, wrong dose reduced 86.3%, wrong route reduced 91.8%, compliance to best practice recommendations increased 81.1%. Medication Administration Errors: 71.8% reduction, 51.9% PICU, 76.9% NICU, 86.2% Med/Surg. Stroke: +9.4% discharged to home vs. skilled-nursingfacilities or rehab, -35.7% 31-day readmits, -7.5% LOS, -12.7% cost-pre-case: initial annualized savings estimated between $125,000 and $565,000. Blood-sugar: -16.6% blood-glucose day-1 post-op, -14.4% further day 2. 100% compliance to goals. Sepsis: -62.5% Sepsis cases, with $14.2 million initial annualized savings. 185% improved survey ratings for clinicians, leaders, IT professionals. Reflected “Shared priorities”, “Collaborative approach to best/better future.”
The STCT provides weekly contact with CHF patients by phone and/or home visits to reinforce hospital discharge instructions, medication reconciliation and compliance, nutritional education, functional status evaluation and social support to help patients maximize their self-care abilities and improve their self-care confidence. Any emergent patient concerns and issues are channeled by phone directly to the CHF's Advanced Practice Nurse. Weekly transitional care team meetings are held to review each patient and discuss appropriate plans of care.
Findings Formative and summative evaluations from students demonstrated a high degree of satisfaction. Moreover, the project was deemed successful by the hospital, CHF clinic and school of nursing in terms of student learning and patient outcomes.
Conclusion/Lessons Learned Lessons Learned Compliance is not sufficient for ensuring best care locally due to facility, population and clinician considerations. Compliance must be balanced with innovation and local relevance, including Analytics to see needs and manage change, and EMR/EHR programmability/adaptability to ensure ownership and governed evolution. Reliance on any EMR/EHR vendor as the sole source of best practice for compliance purposes negates the foundations of healthcare progress and professionalism.
Student educational needs can be met using this unique transitional care model and with positive patient outcomes. This model is being expanded to include interdisciplinary honors students and faculty from social work, food science, exercise physiology and psychology to expand services offered to CHF patients while providing a rich academic environment.
A UNIQUE EDUCATIONAL MODEL IN CONGESTIVE HEART FAILURE PATIENTS
INTEGRATING PAPER AND ELECTRONIC HEALTH RECORD (EHR DATA) TO IDENTIFY HEALTH RISKS/NEEDS IN ADULTS ATTENDING PRIMARY CARE VISITS IN A PATIENT-CENTERED MEDICAL HOME LOCATED IN APPALACHIA
TRANSITIONAL
CARE
OF
Nan Smith-Blair PhD, RN, Audrey Weymiller RN, CNP.
Background Health-related quality of life (HRQOL) in individuals with congestive heart failure (CHF) is frequently compromised and associated with increased readmissions to the hospital and use of healthcare resources. Evidence supports the use of transitional care programs to effectively reduce hospital readmission rates. This project's unique approach to providing transitional care is comprised of senior nursing honors students bridging the gap between hospital, home and clinic. The IOMs Future of Nursing: Leading Change, Advancing Health (2011) identified that changes needed to occur in nursing education if we are to prepare competent and skilled nurses required to practice in the future healthcare system. Through designing a new model of clinical education, the student transitional care team (STCT) demonstrates improved utilization of resources for patients and learning opportunities for students. This model demonstrates innovative academic and practice collaboration providing students with learning experiences in a patient-centered environment spanning the care continuum. The National League for Nursing identified national research priorities for nursing education (2012) to reform nursing education needed to prepare nurses to meet emerging health care needs. Integration of the transitional care program could potentially improve management of medical illnesses that fuel nearly 50% of re-hospitalizations and emergency department visits. Leveraging nursing students with the expertise and resources in academic and practice settings allows the team to focus on overcoming individual, environmental and structural barriers to help the CHF patient achieve effective self-care management.
Purpose The purpose of this project was to establish an undergraduate honors STCT that could provide care to NYHA class II and III CHF patients. This project is a collaboration between an urban hospital, clinic based CHF clinic, school of nursing and the CHF patient and family. It was initiated as part of the
Laurie Theeke PhD, FNP-BC, Jennifer Mallow PhD, FNP-BC, Emily Barnes DNP, FNP-BC, Elizabeth Minchau MSN, FNP-BC, Elliott Theeke, Holli Neiman-Hart MD, Treah Haggerty MD, Karen Fitzpatrick MD.
Background/Introduction Quality standards mandate that practices document comprehensive health assessments that may not be incorporated into existing EHRs. This study reports the results of a paper screening initiative that aimed to meet this standard in adults with chronic conditions in West Virginia.
Purpose The purpose of this study is to describe the health behaviors of adults in West Virginia who are attending a wellness visit at a primary care center and patient-centered medical home. Methods/Design The cross-sectional descriptive study reports the analyses of existing data from an adapted version of the HowsYourHealth Medicare Wellness Checkup questionnaire, which included the PHQ-4 depression and anxiety screen, and EHR data. Additional questions asked about illicit drug use, familial behavioral health problems, communication needs, and exposure to secondhand smoke and diet. The existing data retrieved from the EHR included sociodemographics, biomarkers of chronic illness, and chronic illness diagnoses were collected from 144 medical records. Results/Findings The sample had a mean age of 44.37 years (SD 16.32), was distributed equally on gender, and suffered multiple chronic conditions (mode ¼ 2) including: hypertension (34.7%), hyperlipidemia (32.6%), depression (22.9%), arthritis (18.8%), chronic headaches (18.1%), arthritis (12.5%), diabetes (8.3%), and lung disease (11.6%). The mean Body Mass Index (BMI) was 30.07 (SD 8.23) and mean systolic blood pressure was 126.28 (SD 18.91). There was an average of 5.14 medications (SD 4.69) listed as currently being taken. PHQ-4 results for depression were mean of 1.11 (SD ¼ 1.79)
74
Abstracts / Journal of Interprofessional Education & Practice 1 (2015) 48e77
and for anxiety, mean of 1.44 (SD 1.85), indicating minimal depressive or anxiety symptoms. Mean alcohol consumption was mean of 2 drinks per week. Total number of chronic illnesses positively correlated with depressive symptoms (p < 001), anxiety symptoms (p <.05), and BMI (p < .05). Poverty and lack of confidence to manage multiple chronic conditions were not identified as barriers. Over 82% still rated their health as good to excellent. Health rating did not differ based on total number of chronic illnesses.
Conclusion The IPE Summit is an important next step in ASCO's commitment to supporting optometry's role in IPE, team-based collaborative patient centered care and ultimately improved patient outcomes. CONNECTING THE DOTS IMPROVEMENT EDUCATION
Conclusions Effecting change in a population with a positive health rating in the context of multiple chronic conditions is challenging. Implementing a quality standard screening is not enough. Including patient input and understanding patient expectations for health is integral for the development of patient-centered interventions. THE ASSOCIATION OF SCHOOLS AND COLLEGES OF OPTOMETRY TO CONVENE AN INTERPROFESSIONAL EDUCATION SUMMIT IN FEBRUARY 2016 Melissa Vitek OD, John Baker OD, MSEd, Jennifer Coyle OD, MS, Elizabeth Hoppe OD, MPH, DrPH, David Troilo PhD.
Background In 2013, The Association of Schools and Colleges of Optometry (ASCO) created an interprofessional education (IPE) task force. The task force, under the leadership of Dr. Jennifer Smythe Coyle, was given a charge that included examining and supporting the educational strategies of other health care professions. In addition, the task force was to identify best practices of IPE to prepare graduates for team-based practice. The IPE task force has recently become a standing IPE Committee within ASCO.
IN
INTERPROFESSIONAL
QUALITY
Laura Silversteyn NP, Tina Vonhaz NP, Bridgette Christopher MD, PhD, Jason Tuckerman MD, PhD, Pete Spanos BA, Mary Dolansky RN, PhD, Mamta Singh MD, MS, Anne Rusterholtz NP, Alli Heilman NP.
Background The Center of Excellence in Primary Care Education (CoEPCE) at the Louis Stokes Cleveland VA, Transforming Out-Patient Care (TOPC COE) is an interprofessional program that trains Physician residents, Nurse Practitioner residents and students, and Health Psychology residents in an immersive Patient-Centered Medical Home model emphasizing teamwork, shared decision making, sustained relationships and performance improvement. A longitudinal quality improvement curriculum was developed to take advantage of this interprofessional trainee structure. QI is currently mandated in many health professions graduate programs, but limited interprofessional models have been the mainstay.
Purpose To describe an interprofessional QI curriculum that connects teamwork, systems, and the impact on both learner outcomes and clinical improvements. Methods
Purpose In alignment with the original ASCO IPE task force charge, a survey of all schools and colleges of optometry in the United States was conducted in August of 2013. The purpose of the survey was to identify current IPE practices, identify barriers to IPE at member institutions and to ask how ASCO can best support the implementation, sustainability, and further development of IPE and collaborative care at their institutions.
Methods The results of the survey were analyzed by members of the ASCO IPE task force. In addition to noting that an equal number of schools and colleges of optometry reported participation in and barriers to IPE, a number of requests were put forth to support IPE activities. One of these requests was for ASCO to convene a national IPE conference aimed at strengthening optometry's role in the patient care team.
Results ASCO plans to convene a national IPE Summit in February of 2016 at Southern California College of Optometry at Marshall B. Ketchum University. Three main goals of the IPE Summit with corresponding objectives have been defined. The first goal is to assemble representatives from ASCO member institutions and other champions of interprofessional collaboration. The objectives for this goal are to create opportunities among attendees for networking and collaboration, raise the role optometry plays in interprofessional healthcare teams and to identify synergies in obtaining grant funding for developing and sustaining IPE and (interprofessional practice) IPP. The second goal is to share current best practices in IPE and IPP. The objectives for this goal are to communicate techniques, strategies, and considerations for IPE and IPP including engagement of optometry in team based patient care and to identify outcome measures and tools to assess the impact of IPE and IPP on student learning. The third goal is to share ideas on future development of IPE and IPP. The objectives for this goal are to explore future options for enhanced engagement in IPE and IPP and to develop strategies to assess the impact of IPE and IPP on patient outcomes.
The interprofessional team approach combines didactic and experiential learning of QI content that is applied to a project aiming to improve care. In promoting a program structured to support transdisciplinary relationships, current curriculum offers educational opportunities and QI projects that incorporate best evidence and proficient methodology into clinical decisions thereby promoting a QI culture. Throughout the curriculum numerous learning sessions in multiple formats are presented to increase knowledge of quality and improvement science. Learners are exposed to topics such as policy development and developing trends in health industry. The curriculum provides skills and tools applicable to patient care, working within interprofessional teams that involve primary care providers, nurses, social workers, psychologists, and pharmacists. Learners are required to rotate through a number of specialties such as pulmonary, cardiology, neurology, rheumatology, woman's clinic, as well as getting certified in Lean Six Sigma Yellow Belt training. Results In the last four years, the interprofessional approach and the opportunity to observe, learn and improve the processes and procedures in patient care resulted in 20 QI projects. Prior projects that have been sustained include reduction in low-acuity ED visits, HIV screening, and shared medical appointments for pain management. Current projects aim to improve appropriate vaccination of HCV patients, screening for colorectal cancer, serum folate testing, aspirin for primary prevention, and the appropriate use of statins. The improvements have resulted in meeting evidencebased outcome targets and efficiency of delivering primary care. A project to improve aspirin prescribing will be presented. Trainees complete short Minute Paper evaluations as part of the QI curriculum that provide ratings on usefulness and confidence-building. These sessions have received an average rating of 4.56 out of 5 (1-5; 5¼high; n¼503; mode¼5) for usefulness and average rating of 4.35 out of 5 (n¼500; mode¼5) for increased confidence.
Conclusions While the TOPC COE at the Louis Stokes Cleveland VA is still in its early years, the impact on learners to connect the dots among teamwork, local policy, and systems has made an impact on the learners' perspective of their work. Application of this QI interprofessional education model to