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Multiple Chronic Conditions Healthcare Workforce Education and Training: An Annotated Bibliography

The following annotated bibliography lists selected publications relevant to multiple chronic conditions (MCC) curricula, education, and training modules. Specific domains and competencies central to education and care delivery for MCC populations are also addressed. Key curricula and domains were derived from examination of the literature (years 2003–2014) and interviews with technical experts. Articles were selected if they related to MCC, interprofessional education, and/or constructs and competencies related to MCC (e.g., team-based care, self-management, care coordination).


Adam, P., Brandenburg, D. L., Bremer, K., & Nordstrom, D. L. (2010). Effects of team care of frequent attenders on patients and physicians.  Families, Systems, & Health, 28(3), 247-257.

This article describes primary care team member’s perceptions of team care using quantitative and qualitative methods. Medically complex patients with eight or more clinic visits throughout one year were non-randomly assigned to usual care or team care. Changes in patient health care use, well-being, and satisfaction from baseline to 6 months were compared between team care and usual care patients. Overall, the authors found that team care is feasible within a family medicine residency practice and may improve quality of care.

Advisory Committee on Interdisciplinary, Community-Based Linkages. (2013). Redesigning health professions education and practice to prepare the interprofessional team to care for populations: Twelfth annual report to the Secretary of the United States Department of Health and Human Services and to the Congress of the United States. Washington, DC: Health Resources and Services Administration.

This report outlines the importance of approaching health professional education and policy making through interprofessional collaboration. Framing curricula and policy decisions using a population-based approach and optimizing use of available technologies are also emphasized. The rationale of each and step-by-step instructions for how to achieve these recommendations are included.

Alford, C. L., Lawler, W. R., Talamantes, M. A., & Espino, D. V. (2003). A geriatrics curriculum for first year medical students: Community volunteers become “senior professors.”  Gerontology & Geriatrics Education, 23(1), 13-29.

This article outlines the design, implementation, evaluation, and subsequent revisions made to a geriatric continuity of care curriculum for first-year medical students. The program addressed student’s beliefs about physical decline, comfort with older patients, attitudes about career opportunities, and interest in geriatric research. Outcomes of the course included an increase in student interest in the physician’s role in treating the geriatric patient population.

American College of Clinical Pharmacy, Hume, A. L., Kirwin, J., Bieber, H. L., Couchenour, R. L., Hall, D. L., ... Wiggins, B. (2012). Improving care transitions: Current practice and future opportunities for pharmacists.  Pharmacotherapy, 32(11), e326-327.

This article describes the roles and responsibilities of pharmacists in ensuring optimal outcomes from drug therapy during care transitions. Barriers to effective care transitions, including inadequate communication, poor care coordination, and the lack of one clinician ultimately responsible for these transitions, are discussed. The article also identifies specific patient populations at high risk of adverse drug events during care transitions. Several national initiatives and newer care transition models are discussed, including multi- and interdisciplinary programs with pharmacists as key members. The article concludes with a discussion about the importance of recognizing and addressing health literacy issues to promote patient empowerment during and after care transitions.

American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. (2012). Patient-centered care for older adults with multiple chronic conditions: A stepwise approach from the American Geriatrics Society.  Journal of the American Geriatrics Society, 60(10), 1957–1968.

This article outlines guiding principles for the clinical management of care for older adults with multiple chronic conditions. Experts on the American Geriatric Society panel concluded that the five domains upon which clinicians should focus are patient preferences, interpreting the evidence, prognosis, clinical feasibility, and optimizing therapies and care plans. Barriers to the implementation of each area are also discussed.

Bajcar, J., Kennie, N., & Iglar, K. (2008). Teaching pharmacotherapeutics to family medicine residents — A curriculum. Canadian Family Physician, 54(4), 549-549.

This article presents a curriculum to support the development of rational prescribing skills among family medicine residents. Ensuring that rational prescription techniques are used when caring for individuals with multiple chronic conditions is an overarching theme. The four main components of the curricula are 1) a medication prescribing framework based on the main tasks and key decisions related to the prescribing of medications, 2) 12 pharmacotherapeutic topics identified by a needs assessment, 3) a 5-step process for session design used by a curriculum development team, and 4) a description of specific roles of facilitators involved in delivering the curriculum.

Bazaldua, O., Ables, A. Z., Dickerson, L. M., Hansen, L., Harris, I., Hoehns, J., ... Society of Teachers of Family Medicine Group on Pharmacotherapy. (2005). Suggested guidelines for pharmacotherapy curricula in family medicine residency training: recommendations from the Society of Teachers of Family Medicine Group on Pharmacotherapy. Family Medicine, 37(2), 99-104.

This article makes the case for pharmacotherapy training as an integral component of residency curricula. The authors suggest that pharmacotherapy training may lower the risk of incorrect medication management by health professionals. The resulting rational drug use would lower health care costs nationwide.

Beaulieu, M. D., Samson, L., Rocher, G., Rioux, M., Boucher, L., & Del Grande, C. (2009). Investigating the barriers to teaching family physicians’ and specialists’ collaboration in the training environment: A qualitative study.  BMC Medical Education, 9(1), 31.

This article analyzes how collaboration between family physicians and specialists is conceptualized in residency training curricula in Canada. A multiple-case study based on Abbott’s theory of professions was used. Collaboration with the following specialties was analyzed: general psychiatry, radiology, and internal medicine. The authors concluded that increased awareness and action should be pursued in order to observe true collaboration between these fields.

Bennett, C., Kennedy, S. & Donato, A. S., (2011). Preparing NPs for primary care: Unraveling complexity with unfolding cases.  Journal of Nursing Education, 50(6), 328-331.

This article summarizes an online Behavioral Health Therapeutics course developed for a Doctor of Nursing Practice program. Components of the curricula reflect changes called for in the 2010 Carnegie report, “Summary of Educating Physicians: A Call for Reform of Medical School and Residency.” Special highlights of the course include an unfolding case study using Backward Design, Zull’s model for engaging the brain, and grading criteria based on Dr. Christine Tanner’s “Case for Cases: A Pedagogy for Developing Habits of Thought.”

Banerjee, S. (2015). Multimorbidity—older adults need health care that can count past one. The Lancet, 385(9968), 587-589.

This article emphasizes the need to develop a healthcare system that works for multimorbidity, and to create policies, as well as commission services, research and education to deliver high quality of care to patients with more than one chronic condition. Health systems are not providing adequate care for this population because of the recent focus in developing technical treatments for individual disorders. The education of healthcare staff from all professional backgrounds does not prepare them well for the challenges of multimorbidity or long-term conditions. In particular, older adults with Dementia are more prone to multiple chronic conditions which are often ignored or managed by many specialist referrals. One example of what might be done to improve education is The Time for Dementia program; a longitudinal clerkship that helps students develop an understanding of the emerging challenges presented by older adults, multimorbidity, and long term conditions.

Boult, C., Green, A. F., Boult, L. B., Pacala, J. T., Snyder, C., & Leff, B. (2009). Successful models of comprehensive care for older adults with chronic conditions: Evidence for the Institute of Medicine’s “Retooling for an Aging America” report.  Journal of the American Geriatrics Society, 57(12), 2328–2337.

This article identified models of comprehensive health care that have shown the potential to improve the quality, efficiency, or health-related outcomes of care for chronically ill older persons (ages 65 or older) between the years 1987 and 2008. Fifteen models showed significant positive effects in at least one outcome. The areas of improvement include primary care supplements, transitional care, acute care in patients’ homes, nurse-physician teams for residents of nursing homes, and models of comprehensive care in hospitals.

Boult, C., Reider, L., Leff, B., Frick, K. D., Boyd, C. M., Wolff, J. L., ... Scharfstein, D. O. (2011). The effect of guided care teams on the use of health services: Results from a cluster-randomized controlled trial. Archives of Internal Medicine, 171(5), 460-466.

This article evaluated the effect of guided care teams on the use of health services by older patients with multiple chronic conditions. The study included 850 older patients at high risk for using health care heavily in the future. Researchers concluded that guided care reduces the use of home health care, but has little effect on the use of other health services when implemented over a brief period of time.

Boyd, C. M., Weiss, C. O., Halter, J., Han, K. C., Ershler, W. B., & Fried, L. P. (2007). Framework for evaluating disease severity measures in older adults with comorbidity. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 62(3), 286-295.

This article presents a framework for evaluating severity classification systems for common chronic diseases. The framework evaluates the 1) goal or purpose of the classification system; 2) physiological and/or functional criteria for severity graduation; and 3) potential reliability and validity of the system balanced against burden and costs associated with classification. Researchers concluded that most approaches to severity classification do not adequately address multiple chronic conditions.

Buring, S. M., Kirby, J., & Conrad, W. F. (2007). A structured approach for teaching students to counsel self-care patients. American Journal of Pharmaceutical Education, 71(1), Article 08.

This article analyses whether the use of a structured interviewing framework improved students’ ability to treat self-care patients. To achieve this, pharmacy students were taught self-care through a series of 4 modules. In each module, students’ content knowledge and application were assessed using quizzes and role-play scenarios, respectively. During the second module, a structured interview model (QuEST process) was presented by the instructor and students were tested on the same content and role-play used in module 1. Researchers concluded that QuEST process is an effective tool to teach students how to counsel patients with self-care issues.

Casey, D., & Mackreth, P. (2007). Developing education for long-term conditions management. British Journal of Community Nursing, 12(1), 19-22.

This article discusses the experience of one university in the development, implementation, and evaluation of a modular program of study for nurses working with people with long-term conditions. It addresses the complexity of developing a curriculum in response to Department of Health initiatives and highlights the importance of interprofessional collaboration. The article includes the assessment used as well as a description of the learning and teaching strategies implemented.

Cheffins, T. E., Twomey, J. A., Grant, J. A., & Larkins, S. L. (2012). An evaluation of the self-management support capacity of providers of chronic condition primary care. Australian Journal of Primary Health, 18(2), 112-115.

This study aimed to ascertain whether self-management support (SMS) is being used in the primary care setting and to identify barriers and enablers for SMS in practice. Health professionals who underwent SMS training were invited to participate in a semi-structured interview. Respondents reported being most likely to use SMART goals and decision balance. Core skills used included problem solving, reflective listening, open-ended questions, identifying readiness to change, and goal setting. Barriers to use of SMS and recommendations for increased use of these strategies are discussed.

Col, N., Bozzuto, L., Kirkegaard, P., Koelewijn-van Loon, M., Majeed, H., Jen Ng, C., & Pacheco-Huergo, V. (2011). Interprofessional education about shared decision making for patients in primary care settings. Journal of Interprofessional Care, 25(6), 409-415.

This article proposes a framework for interprofessional education about shared decision making (SDM) targeted to primary care settings. Five areas of knowledge and skills in interprofessional education and SDM were agreed to be essential for all relevant stakeholders to be successful: understanding the concept of SDM; acquiring relevant communication skills to facilitate SDM; understanding interprofessional sensitivities; understanding the roles of different professions within the relevant primary care group; and acquiring relevant skills to implement SDM. Recommendations around a series of teaching methods for the aforementioned areas, using principles from adult learning, are addressed.

Corbridge, S. J., Corbridge, T., Tiffen, J., & Carlucci, M. (2013). Implementing team-based learning in a nurse practitioner curriculum. Nurse Educator, 38(5), 202-205.

This article provides an overview of team-based learning (TBL). TBL is an innovative, learner-centered teaching strategy that promotes active learning. The authors describe their experience with implementing TBL in an adult-gerontology acute and primary care course for nurse practitioners as well as their evaluation of student outcomes.

Darer, J. D., Hwang, W., Pham, H. H., Bass, E. B., & Anderson, G. (2004). More training needed in chronic care: A survey of U.S. physicians.  Academic Medicine, 79(6), 541-548.

The authors evaluated physicians’ perceptions of the adequacy of their chronic illness care training and the effects of this on their attitudes toward care of persons with chronic conditions. The interview instrument examined demographics, career satisfaction, practice characteristics, and perceived adequacy of chronic illness care training in ten competencies (geriatric syndromes, chronic pain, nutrition, developmental milestones, end-of-life care, psychosocial issues, patient education, assessment of caregiver needs, coordination of services, and interdisciplinary teamwork), and effect of training on attitudes toward chronic illness care. The authors concluded that physicians perceived their medical training for chronic illness care as inadequate.

Department of Vermont Health Access. (2011). Vermont Blueprint for Health 2010 annual report. Williston, VT.

This report outlines the development of Vermont Blueprint for Health, Vermont’s cutting edge health reform program and public-private partnership. Vermont’s participation in the Centers for Medicare & Medicaid Services’ Multi-Payer Advanced Primary Care Practice Demonstration Project is highlighted, along with milestones achieved in expanding access to Blueprint Integrated Health Services (IHS). IHS is a model that includes Advanced Primary Care Practices with recognition as patient-centered medical homes and community health teams supported by multi-insurer payment reforms. Evaluation and early program impact data are also discussed.

Deutschlander, S., & Sute, E. (2011). Interprofessional mentoring guide for supervisors, staff and students. Calgary, Alberta, Canada: Alberta Health Services.

This guide serves as a tool for health care professionals and students to support interprofessional practice education for students in the workplace setting. Topics covered include interprofessional mentoring; an overview of the Canadian National Interprofessional (IP) Competency Framework; facilitation methods; best practices for supervisors; evaluation techniques; and recommendations for further reading material. Modules for use in a professional setting are included for each topic area.

Dorr, D. A., Wilcox, A., Burns, L., Brunker, C. P., Narus, S. P., & Clayton, P. D. (2006). Implementing a multidisease chronic care model in primary care using people and technology.  Disease Management, 9(1), 1-15.

This article outlines a generalist model, the Intermountain Healthcare (Intermountain) approach, of chronic disease management to overcome the limitations associated with specialization. In the Intermountain approach, which reflects elements of the Chronic Care Model, care managers located in multipayer primary care clinics collaborate with physicians, patients, and other members of a primary care team to improve patient outcomes for a variety of conditions. An important part of the intervention is widespread use of an electronic health record. Early results from the application of this model show improved patient outcomes and improved physician productivity. Success factors, challenges, and obstacles in implementing the model are discussed.

Douglass, M. A., Casale, J. P., Skirvin, J.A ., & DiVall, M. V. (2013). A virtual patient software program to improve pharmacy student learning in a comprehensive disease management course. American Journal of Pharmaceutical Education, 77(8).

This article assesses the impact of a virtual patient pilot program on pharmacy students’ clinical competence skills. Pharmacy students completed interactive software-based patient case scenarios embedded with drug-therapy problems as part of a course requirement at the end of their third year. Assessments included drug-therapy problem competency achievement, performance on a pretest and posttest, and a pilot evaluation survey instrument. The program summarized the course series, and significant improvements in students’ posttest scores demonstrated advancement of clinical skills involving drug-therapy problem solving. Students agreed that completing the pilot program improved their chronic disease management skills.

Dounis, G., Ditmyer, M., VanBeuge, S., Schuerman, S., McClain, M., ... Mobley, C. (2014). Interprofessional faculty development: Integration of oral health into the geriatric diabetes curriculum, from theory to practice. Journal of Multidisciplinary Healthcare, 7, 1–9.

This article analyzes the effectiveness of an interprofessional health care faculty training program. A statewide comprehensive type 2 diabetes training program was developed and offered to multidisciplinary health care faculty using innovative educational methods. Video-recorded clinically simulated patient encounters concentrated on the oral–systemic interactions between type 2 diabetes and multiple chronic conditions. Post-encounter, instructors facilitated debriefing focused on preconceptions, self-assessment, and peer discussions to develop a joint interprofessional care plan. Overall, attitude, knowledge, and perceptions of health care faculty regarding interprofessional team building and the team approach to management of the oral–systemic manifestations of chronic disease in older adults improved.

Durso, S. C. (2005). Interaction with other health team members in caring for elderly patients. Dental Clinics of North America, 49(2), 377-388.

This article discusses detailed methods for interprofessional collaboration in caring for elderly patients. Topics highlighted include the importance of communication and consultation as appropriate to ensure safe and effective care. The article is useful for health care practitioners working with older patients, especially those with multiple chronic conditions.

Dyer, C. B., Hyer, K., Feldt, K. S., Lindemann, D. A., Busby-Whitehead, J., Greenberg, S., … Flaherty, E. (2003). Frail older patient care by interdisciplinary teams: A primer for generalists. Gerontology & Geriatrics Education, 24(2), 51-62.

This article describes the roles of participating team members in the context of interdisciplinary care for older adults. Examples from existing Geriatric Interdisciplinary Teams are outlined. Interprofessional collaboration and special approaches to older adults with multiple chronic conditions are also discussed, along with challenges to working in these teams.

Eldercare Workforce Alliance. (2011). Education & training: Meeting the needs of older adults. Washington, DC.

This Brief outlines education and training needs for health care professionals caring for older adults. Challenges around expanding geriatric education for health care professionals, training needs for direct-care workers, and policy recommendations are outlined. A call to action and an emphasis on findings by the Institute of Medicine are included.

Friedman, A., Hahn, K. A., Etz, R., Rehwinkel-Morfe, A. M., Miller, W. L., Nutting, P. A., … Crabtree, B. F. (2014). A typology of primary care workforce innovations in the United States since 2000. Medical Care, 52(2), 101-111.

This report analyzes existing workforce models used by primary care practices to develop a typology to be modeled. Researchers found that many workforce innovations added personnel to existing practices, whereas others sought to retrain existing personnel or even develop roles outside the traditional practice. The analysis identified 5 key workforce innovation concepts through the literature: team care, population focus, additional resource support, creating workforce connections, and role change.

Gray-Miceli, D., Mezey, M. (2007). Critical thinking related to complex care of older adults. Lexington, KY: National Gerontological Nursing Association.

This article outlines five recommendations for nursing care of older adults with multiple chronic conditions. These recommendations suggest that the use of advanced health planning, an increased vigilance around drug interactions, an increased surveillance of functional and cognitive status, and the use of hospital system-based models of care, among other factors, should be used in planning nursing care. Encouragement toward a shift in the nursing process and plans of care which earmark interventions directed at the primary and secondary prevention of frailty, functional decline, and geriatric syndromes is the overarching theme of the article. The researchers emphasized the importance of reducing the burden of these health care problems through individualized and team assessments of older adults.

Gunderson, E. W., Coffin, P. O., Chang, N., Polydorou, S., & Levin, F. R. (2009). The interface between substance abuse and chronic pain management in primary care: A curriculum for medical residents. Substance Abuse, 30(3), 253-260.

This article describes a curriculum designed to instruct second-year medical residents to recognize prescription opioid and other substance abuse among patients with chronic noncancer pain (CNCP). The two-hour, case-based curriculum delivered to small groups of medical residents sought to improve assessment and management of opioid-treated CNCP patients, including those with a substance use disorder. A two-page pre–post survey was administered to assess self-efficacy change. The brief curriculum was well received and appears effective.

Haas, S., Swan, B. A., & Haynes, T. (2013). Developing ambulatory care registered nurse competencies for care coordination and transition management. Nurse Economics, 31(1), 44-9, 43.

This article outlines a care coordination competencies action plan with three phases to delineate registered nurse (RN) competencies and develop an education program for care coordination and transition management in ambulatory settings. Activities linked to each competency and a table of dimensions, activities, and competencies (including knowledge, skills, and attitudes) for ambulatory care, care coordination and transition management are included.

Heflin, M. T., Bragg, E. J., Fernandez, H., Christmas, C., Osterweil, D., Sauvigné, K., … Durso, S. C. (2012). The Donald W. Reynolds Consortium for Faculty Development to Advance Geriatrics Education (FD~AGE): A model for dissemination of subspecialty educational expertise. Academic Medicine, 87(5), 618-626.

This article measures the impact of the varying educational components of the Donald W. Reynolds Foundation Faculty Development to Advance Geriatrics Education (FD~AGE) program. Measurements evaluated the impact of the three instructional activities of the program: advanced fellowships in clinical education for geriatricians who have completed clinical training; mini-fellowships and intensive courses for faculty in geriatrics, teaching skills, and curriculum development; and on-site consultations to assist institutions with reviewing and redesigning geriatrics education programs. The authors concluded that the FD~AGE program represents a unique model for extending concentrated expertise in geriatrics education to a broad group of faculty and institutions to accelerate progress in training future physicians.

Institute of Medicine. (2014). Assessing health professional education — workshop summary. Washington, DC: National Academies Press.

This report summarizes the Institute of Medicine Global Forum on Innovation in Health Professional Education workshop to explore the challenges, opportunities, and innovations in assessment across the education-to-practice continuum. The workshop was held on October 9–10, 2013. Issues such as assessment of learners and educators of interprofessional education and team-based care are outlined.

Ives-Kennedy, B., Kennedy, W. C., & Southard, D. R. (2008). A medical education model for collaborative chronic disease management. Journal of Physician Assistant Education, 19(2), 18-29.

This article analyzes the impact of a curriculum enhancement project on physician assistant (PA) students’ abilities, attitudes, and preparedness to provide collaborative disease management. The authors identified competencies needed for collaborative chronic disease management and developed curriculum interventions. Researchers found that while curriculum enhancement may not significantly improve attitudes, the study suggests that interventions may be supportive of already favorable attitudes.

Just, J. M., Schulz, C., Bongartz, M., & Schnell, M. W. (2010). Palliative care for the elderly — Developing a curriculum for nursing and medical students. BMC Geriatrics, 10, 66.

This article describes an interdisciplinary curriculum focusing on the palliative care needs of the elderly. The curriculum uses four deduction domains: Geriatrics, Palliative Care, Communication and Patient Autonomy, and Organization and Social Networks. The curriculum was successfully implemented following the steps outlined in the book, Curriculum Development for Medical Education: A Six-Step Approach, by Dr. David E. Kern, MD, MPH.

Klitzner, T. S., Rabbitt, L. A., & Chang, R. K. (2010). Benefits of care coordination for children with complex disease: A pilot medical home project in a resident teaching clinic. The Journal of Pediatrics, 156(6), 1006-1010.

This article summarizes the integration of comprehensive care coordination for children with complex diseases in a resident education clinic by analyzing alterations in medical resource use. The project was designed to include four basic elements: 1) 60-minute intake appointment; 2) follow-up appointments twice the length of a standard visit; 3) access to a “family liaison”; and 4) a family notebook (“All about Me” binder). Researchers found that incorporating a program of care coordination according to the principles of the medical home into an outpatient pediatric residency teaching clinic may not only serve as a training vehicle for pediatric residents but also create favorable alterations in medical resource use.

Körner, M., Ehrhardt, H., & Steger, A. K. (2013). Designing an interprofessional training program for shared decision making. Journal of Interprofessional Care, 27(2), 146-154.

This article identifies the preferences of patients and health care professionals concerning internal and external participation in rehabilitation clinics, in order to develop an interprofessional shared decision-making (SDM) training program for health care professionals to enhance both types of participation. The study consists of two parts: focus groups with patients and a survey of experts (senior health care professionals from medicine, psychotherapy, physical therapy, and nursing). The results of these assessments have been used to develop an interprofessional SDM training program for implementing internal and external participation in interprofessional teams in medical rehabilitation.

Kullgren, J., Radhakrishnan, R., Unni, E., & Hanson, E. (2013). An integrated course in pain management and palliative care bridging the basic sciences and pharmacy practice.  American Journal of Pharmaceutical Education, 77(6), Article 121.

This article describes the development of an integrated pain and palliative care course and investigates the long-term effectiveness of the course during doctor of pharmacy (PharmD) students’ advanced pharmacy practice experiences and in their practice after graduation. The course is a three-week elective course in pain and palliative care developed by integrating relevant clinical and pharmaceutical sciences. Instructional strategies included lectures, team and individual activities, case studies, and student presentations. Researchers found that integrating basic and clinical sciences in therapeutic courses is an effective learning strategy.

Lipson, D., Rich, E., Libersky, J., & Parchman, M. (2011). Ensuring that patient-centered medical homes effectively serve patients with complex health needs. (Prepared by Mathematica Policy Research under Contract No. HHSA290200900019I TO 2.) AHRQ Publication No. 11-0109. Rockville, MD: Agency for Healthcare Research and Quality.

This brief answers the question, “How can decision makers help smaller primary care practices become effective patient-centered medical homes (PCMHs) for patients with complex health care needs, such as the frail elderly and people with disabilities?” A detailed description of PCMHs is outlined. Recommendations around payment reform, coordinating care, and supporting additional research are also included.

Lown, B. A., Kryworuchko, J., Bieber, C., Lillie, D. M., Kelly, C., Berger, B., & Loh, A. (2011). Continuing professional development for interprofessional teams supporting patients in healthcare decision making. Journal of Interprofessional Care, 25(6), 401-408.

This article describes a model that can be used to design, implement, and evaluate continuing education curricula in interprofessional shared decision making and decision support. This model aligns curricular goals, objectives, educational strategies, and evaluation instruments and strategies with desired learning and organizational outcomes. Educational leaders and researchers can institutionalize such curricula by linking them with quality improvement and patient safety initiatives.

Lynn, L. A., Hess, B. J., Conforti, L. N., Lipner, R. S., & Holmboe, E. S. (2009). Clinic systems and the quality of care for older adults in residency clinics and in physician practices. Academic Medicine, 84(12), 1732-40.

This article examines the quality of care for older adults in residency clinics and physician practices. Characteristics of the practice systems in the clinics and offices and the relationship between specific elements of practice systems and the quality of care were studied. Researchers concluded that practice system elements designed to support care for older adults perform differently in residency clinics than in practicing physicians’ offices. Significant gaps in the quality of care for older adults exist and are much more pronounced in the residency clinic setting.

Marsteller, J. A., Hsu, Y. J., Reider, L., Frey, K., Wolff, J., Boyd, C., ... Boult, C. (2010). Physician satisfaction with chronic care processes: A cluster-randomized trial of guided care. The Annals of Family Medicine, 8(4), 308-315.

This article evaluates the effect of the Guided Care model on primary care physicians’ impressions of processes of care for chronically ill older patients. Physicians’ satisfaction with chronic care processes, time spent on chronic care, knowledge of their chronically ill older patients, and care coordination provided by physicians and office staff was measured. Researchers found that, based on physician report, Guided Care provides important benefits to physicians by improving communication with chronically ill older patients and their families and in physicians’ knowledge of their patients’ clinical conditions.

McSpadden, C., Therrien, M., & McEwen, I. R. (2012). Care coordination for children with special health care needs and roles for physical therapists. Pediatric Physical Therapy, 24(1), 70-77.

This article summarizes the research on the possible benefits of care coordination for children with special health care needs and explores potential roles for physical therapists in care coordination, including roles as primary care coordinators, members of interprofessional teams, advocates, and researchers. The article also outlines the medical home model and its benefits. The barriers to care coordination are reviewed and recommendations to reduce barriers and better prepare therapists for care coordination are offered.

Mitchell, P., Wynia, M., Golden, R., McNellis, B., Okun, S., Webb, C. E., Rohrbach, V., & Von Kohorn, I. (2012). Core principles & values of effective team-based health care. Discussion Paper, Institute of Medicine, Washington, DC.

This paper describes a set of core principles, the purpose of which is to help enable health professionals, researchers, policy makers, administrators, and patients to achieve appropriate, high-value team-based health care. Core principles of effective team-based health care and examples of best practices are highlighted. The paper concludes with a recommended research agenda to advance the state of effective team-based health care.

Morrow, C. E., Reed, V. A., Eliassen, M. S., & Imset, I. (2011). Skill acquisition for year III medical students. Family Medicine, 43(10), 721-5.

This article outlines an integrated curriculum on shared decision-making (SDM) in the third-year Family Medicine Clerkship at Dartmouth Medical School. The curriculum consisted of a mix of experiential, classroom, and online experiences designed to provide students with opportunities to learn content, practice skills, and share observations from their preceptorships. Researchers concluded that there exist many benefits and challenges in attempting to teach sophisticated communication and decision-making precepts to medical students who are working to master fundamentals of clinical work and who may or may not see such precepts reinforced in practice.

Nasca, T. J., Weiss, K. B., & Bagian, J. P. (2014). Improving clinical learning environments for tomorrow’s physicians.  New England Journal of Medicine, (370), 991-993.

This article describes the rationale and development of the Clinical Learning Environment Review (CLER) program. An overview of the CLER Pathways to Excellence document is also given. This document serves as a guide to graduate medical education (GME) teaching institutions, providing ways to improve training in the six areas evaluated by the CLER program and help to create environments that support the development of competence. The Pathways document will be the basis of the CLER formative assessment process, and it will serve as the framework for providing periodic reports on national performance in GME programs on patient safety and quality improvement.

National Council on Patient Information and Education. (2013). Accelerating progress in prescription medicine adherence: The Adherence Action Agenda, a national action plan to address America’s “other drug problem”. Rockville, MD.

This report outlines the findings of the National Council on Patient Information and Education’s Adherence Action Agenda, or A3 Project. This project brought together 22 professional societies and voluntary health organizations, government agencies, and industry leaders to review the state of prescription adherence today and to identify the major challenges for the future. The report provides a detailed look at multiple chronic conditions as they relate to prescription adherence, along with guidance for improving adherence in the future.

Nieman, L. Z., & Cheng, L. (2011). Chronic illness needs educated doctors: An innovative primary care training program for chronic illness education. Medical Teacher, 33(6), e340-348.

This article evaluates the effectiveness of a chronic illness training program, Chronic Illness Needs Educated Doctors (CINED). Four instructional components were administered and assessed using an objective standardized clinical exercise : 1) measurements of the health-related quality of life of patients with chronic illnesses; 2) didactic sessions in which they described chronically ill patients and their care; 3) written narratives describing the trainees’ reactions to these patients; and 4) portfolios offering evidence of chronic illness learning. Researchers concluded that CINED is an effective curriculum for promoting chronic illness learning among trainees.

Oeseburg, B., Hilberts, R., Luten, T. A., van Etten, A. V., Slaets, J. P., & Roodbol, P. F. (2013). Interprofessional education in primary care for the elderly: A pilot study.  BMC Medical Education, 13, 161.

This article analyses an interprofessional education (IPE) program for general practitioners (GPs) and practice nurses and evaluates the feasibility of an IPE program for professionals with different educational backgrounds and its effect on the division of professionals’ tasks and responsibilities. During the program, tasks and responsibilities, in particular those related to the care plan, shifted from GP to practice nurse. Researchers found that an IPE program for professionals with different educational backgrounds (GPs and practice nurses) is feasible and has an added value to the redefining of tasks and responsibilities among GPs and practice nurses.

Osterkamp, E.M., Costanzo, A. J., Ehrhardt, B. S., & Gormley, D. K. (2013). Transition of care for adolescent patients with chronic illness: education for nurses. The Journal of Continuing Education in Nursing, 44(1), 38-42.

This article describes the development of an educational program for nurses who care for chronically ill young adult patients who are transitioning to adult care.

Paget, L., Han, P., Nedza, S., Kurtz, P., Racine, E., Russell, S., ... Von Kohorn, I. (2011). Patient-clinician communication: Basic principles and expectations. Discussion Paper, Institute of Medicine, Washington, DC.

This paper outlines a detailed approach to patient-clinician communication. The components were developed by the Best Practices and Evidence Communication Innovation Collaboratives of the Institute of Medicine Roundtable on Value & Science-Driven Health Care. Collaborative participants intended these principles and expectations to serve as common touchstone reference points for both patients and clinicians, as they and their related organizations seek to foster the partnership and patient engagement necessary to improve health outcomes and value from care delivered.

Pols, R. G., Battersby, M. W., Regan-Smith, M., Markwick, M. J., Lawrence, J., Auret, K., ... Nguyen, H. (2009). Chronic condition self-management support: proposed competencies for medical students. Chronic Illness, 5(1), 7-14.

This article outlines curriculum content in chronic condition management (CCM) and chronic condition self-management (CCSM). Components of the curriculum include consideration to the changing nature of medical practice; as part of this change, doctors will need skills in team participation, continuity of care, self-management support, and patient-centered collaborative care planning. Additional considerations are recommended for skills needed to assist patients to better adhere to medical management, lifestyle behavior change, and risk factor reduction, if optimal health outcomes are to be achieved and costs are to be contained.

Poncelet, A., Bokser, S., Calton, B., Hauer, K. E., Kirsch, H., Jones, T., … Robertson, P. (2011). Development of a longitudinal integrated clerkship at an academic medical center. Medical Education Online, 16.

This article highlights the components of an effective longitudinal integrated clerkship developed and implemented by a tertiary care academic medical center. Principles of the clerkship include continuity with faculty preceptors, patients and peers; a developmentally progressive curriculum with emphasis on interdisciplinary teaching; and exposure to undiagnosed illness in acute and chronic care settings. Graduates of the clerkship performed slightly higher than traditional peers on standardized patient examinations.

Ramaswamy, R. (2013). How to teach medication management: A review of novel educational materials in geriatrics. Journal of the American Geriatrics Society, 61(9), 1598-1601.

This article outlines 26 minimum geriatrics competencies in eight domains for graduating medical students put forth by the Association of American Medical Colleges. The Portal of Geriatric Online education (www.POGOe.org) is an online public repository of geriatrics educational materials and modules developed by geriatrics educators and academicians in the United States, freely available for use by educators and learners in the field. The three POGOe materials presented in this review feature key components of medication management for medical and other professional students in novel learning formats that can be administered without major preparation. The review compares and contrasts the three materials in descriptive and tabular formats to enable its use by educators in promoting self-learning or group learning.

Rich, E., Lipson, D., Libersky, J., & Parchman, M. (2012). Coordinating care for adults with complex care needs in the patient-centered medical home: Challenges and solutions. White Paper (Prepared by Mathematica Policy Research under Contract No. HHSA290200900019I/HHSA29032005T). AHRQ Publication No. 12-0010-EF. Rockville, MD: Agency for Healthcare Research and Quality.

This paper explores the current landscape of patient-centered medical home services for patients with complex needs, details five programs that have addressed the challenges of caring for these patients, and offers programmatic and policy changes that can help smaller practices better deliver services to all patients, including those with the most complex health needs.

Ritchie, L. (2012). Integration of chronic illness care into a primary healthcare focused nursing curriculum. Nurse Educator, 37(1), 23-24.

This article highlights one nursing program’s third-year baccalaureate chronic illness courses that were developed within a primary health care framework.

Rowan, N. L., Gillette, P. D., Faul, A. C., Yankeelov, P. A., Borders, K. W., Deck, S., ... Wiegand, M. (2009). Innovative interdisciplinary training in and delivery of evidence-based geriatric services: Creating a bridge with social work and physical therapy. Gerontology & Geriatrics Education, 30(3), 187-204.

This article outlines an evidence-based geriatric assessment and brief intervention research, training, and service project for community-dwelling older adults with a focus on interdisciplinary education models, social work, and physical therapy. This article describes the process of implementing this innovative multipartner project, the obstacles faced, and lessons learned. Adult learning theory and social cognitive theory served to underpin the project. The objectives were achieved, and an evaluation noted many positive experiences in training and service delivery.

Sampalli, T., Fox, R. A., Dickson, R., & Fox, J. (2012). Proposed model of integrated care to improve health outcomes for individuals with multimorbidities. Journal of Patient Preference and Adherence, 6, 757-64.

This article outlines the components of an integrated model of care that routinely treats individuals with multiple chronic conditions. This care model is designed to address the specific needs of this complex patient population, with integrated and coordinated care modules that meet the needs of the person versus the disease. The results of a pilot evaluation of this care model are also discussed.

Schlaudecker, J. D., Lewis, T. J., Moore, I., Pallerla, H., Stecher, A. M., Wiebracht, N. D., & Warshaw, G. A. (2013). Teaching resident physicians chronic disease management: Simulating a 10-year longitudinal clinical experience with a standardized dementia patient and caregiver.  Journal of Graduate Medical Education, 5(3), 468-475. Available at http://www.jgme.org/doi/abs/10.4300/JGME-D-12-00247.1

This article describes the development, implementation, and evaluation of a chronic disease/geriatric medicine curriculum designed to teach Accreditation Council for Graduate Medical Education core competencies and geriatric medicine competencies to residents by using longitudinal encounters with a standardized dementia patient and her caregiver daughter. Residents found this standardized patient–based curriculum realistic and valuable. Residents improved in both self-perceived knowledge of dementia and the use of patient-centered language and professionalism.

Shea, J., Grossman, S., Wallace, M., & Lange, J. (2010). Assessment of advanced practice palliative care nursing competencies in nurse practitioner students: Implications for the integration of ELNEC curricular modules. Journal of Nursing Education, 49(4), 183-189.

This article describes a mixed-method formative assessment of 36 graduate nursing students’ knowledge about and attitudes toward palliative care preliminary to curricular integration of the End-of-Life Nursing Education Consortium (ELNEC) graduate core modules. Students’ knowledge about palliative care was assessed using the 106-item ELNEC examination. In addition, qualitative data were gathered regarding students’ definitions of palliative care, the role of the advanced practice nurse in palliative care, and their definitions of a “good” and “bad” death. Results revealed students’ limited knowledge about palliative care. Implications for curriculum design, advanced practice role development, and collaboration with community health partners are discussed.

Shrader, S., & Griggs, C. (2014). Multiple interprofessional education activities delivered longitudinally within a required clinical assessment course.  American Journal of Pharmaceutical Education, 78(1), Article 14.

This article outlines the implementation and assessment of the effects of delivering multiple interprofessional educational (IPE) activities as a longitudinal curriculum within a required clinical assessment on pharmacy students’ perceptions regarding interprofessional collaboration. Nine separate IPE activities were embedded into the course longitudinally over the semester using various active-learning strategies and simulated patients. The IPE activities required student participation from medical, nursing, and physician assistant students. Students were assessed using the Interdisciplinary Education Perception Scale. Researchers found that incorporating multiple IPE activities longitudinally into a required clinical assessment course significantly changed pharmacy students’ perceptions of interprofessional collaboration.

Silver, I. L., & Leslie, K. (2009). Faculty development for continuing interprofessional education and collaborative practice.  The Journal of Continuing Education in the Health Professions, 29(3), 172-177.

This article proposes a framework for faculty development in continuing interprofessional education (CIPE) and collaborative practice. The framework was built on best practices in faculty development and CIPE. It was informed by local experience in the development, delivery, and evaluation of a faculty development program to promote capacity for dissemination of concepts relating to interprofessional education (IPE) and interprofessional collaboration in health care environments. Researchers found that strategic planning, including the application of a systems approach, attention to the principles of effective learning, and an outcomes-based curriculum design are recommended for the development of continuing IPE faculty development programs that enhance interprofessional collaboration.

Slonim, A., Wheeler, F. C., Quinlan, K. M., & Smith, S. M. (2010). Designing competencies for chronic disease practice. Preventing Chronic Disease, 7(2), A44.

This article discusses the findings of a group of stakeholders engaged by the National Association of Chronic Disease Directors in developing competencies for chronic disease practice.

The final product presents an integrated graphic that highlights interrelationships among the specific skills and knowledge required for leading and managing state chronic disease programs. Those competencies fall into 7 clusters: 1) lead strategically, 2) manage people, 3) manage programs and resources, 4) design and evaluate programs, 5) use public health science, 6) influence policies and systems change, and 7) build support. Researchers suggest the use of these competencies by those caring for individuals with chronic disease issues.

Social Work Leadership Institute. (2013). Interprofessional care coordination: Looking to the future. New York, NY: The New York Academy of Medicine.

This Brief describes twelve recommendations around developing a blueprint for interprofessional care coordination practice and clinical education within emerging health care delivery systems. The Brief outlines the two phases of the New York Academy of Medicine Initiative on Interprofessional Care Coordination. This Brief is their final product, a detailed description of the twelve recommended critical elements of a blueprint for policy makers and educators to implement evidence-based, interprofessional care coordination models and to integrate interprofessional care coordination principles and training experiences into health professions education.

The Annapolis Coalition on the Behavioral Health Workforce on behalf of the Center for Integrated Health Solutions. (n.d.). Primary and behavioral healthcare integration — Guiding principles for workforce development. Washington, DC: SAMHSA-HRSA Center for Integrated Health Solutions.

This report discusses existing barriers to the promotion of integrated delivery of behavioral health services with other forms of health care. Recommendations for overcoming these barriers are discussed as part of a larger set of goals listed to meet the seven core strategic goals identified in the Action Plan on Behavioral Health Workforce Development sponsored by the Substance Abuse and Mental Health Services Administration.

Towle, A., & Godolphin, W. (2011). The neglect of chronic disease self-management in medical education: Involving patients as educators. Academic Medicine, 86(11), 1350.

This article emphasizes the importance of patient chronic disease self-management (CDSM) and self-management support by clinicians. A call for more training in the core competencies required for quality CDSM support is highlighted. Special attention is given to the inclusion of patients and their families as partners in education as a means of addressing chronic disease management.

Walters, J. A., Courtney-Pratt, H., Cameron-Tucker, H., Nelson, M., Robinson, A., Scott, J., ... Wood-Baker, R. (2012). Engaging general practice nurses in chronic disease self-management support in Australia: Insights from a controlled trial in chronic obstructive pulmonary disease. Australian Journal of Primary Health, 18(1), 74-79.

This article analyzes the potential for general practice nurses to adopt the role of self-management and health behavior change. Researchers found that for those nurses whose roles had previously included some chronic disease management, the training enhanced their understanding and skills of self-management approaches and increased the focus on patient partnership, prioritizing patients’ choices, and achievability. Researchers found the training effective, but acknowledged significant system barriers that need to be addressed through funding models and organizational change.

Wamsley, M., Staves, J., Kroon, L., Topp, K., Hossaini, M., Newlin, B., … O’Brien, B. (2012). The impact of an interprofessional standardized patient exercise on attitudes toward working in interprofessional teams. Journal of Interprofessional Care, 26(1), 28–35.

This article describes an interprofessional standardized patient exercise (ISPE) and evaluates its impact on students’ attitudes toward working in interprofessional teams. Students were assessed using the Attitudes Toward Health Care Teams (ATHCT) survey. Researchers found there were significant differences in attitudes toward team-based care by profession and that faculty and student satisfaction with the ISPE was high. These findings contribute to the growing body of literature on efforts to generate positive attitudes toward interprofessional collaboration early in training, which may influence students’ ability to be effective members of health care teams.

Yank, V., Laurent, D., Plant, K., & Lorig, K. (2012). Web-based self-management support training for health professionals: A pilot study. Patient Education and Counseling, 90(1), 29-37.

This article evaluates web-based self-management training for health professionals. Researchers found that the training for health professionals was feasible and changed beliefs and confidence. The program may maximize patient self-management by increasing provider self-efficacy and skill for self-management support.

Content created by Assistant Secretary for Health (ASH)
Content last reviewed on July 1, 2015