Marcus D. Ruopp, MD

The Federal Bureau of Labor Statistics projects 37% job growth for physician assistants (PAs) from 2016 to 2026, much greater than the average for all other occupations as well as for other medical professions.¹ This growth has been accompanied by increased enrollment in medical (doctor of medicine [MD], doctor of osteopathic medicine) and nurse practitioner (NP) schools.² Clinical teaching sites serve a crucial function in the training of all clinical disciplines. These sites provide hands-on and experiential learning in medical settings, necessary components for learners practicing to become clinicians. Significant PA program expansion has led to increased demand for clinical training, creating competition for sites and a shortage of willing and well-trained preceptors.³

This challenge has been recognized by PA program directors. In the Joint Report of the 2013 Multi-Discipline Clerkship/Clinical Training Site Survey, PA program directors expressed concern about the adequacy of clinical opportunities for students, increased difficulty developing new core sites, and preserving existing core sites. In addition, they noted that a shortage of clinical sites was one of the greatest barriers to the PA programs’ sustained growth and success.⁴

Program directors also indicated difficulty securing clinical training sites in internal medicine (IM) and high rates of attrition of medicine clinical preceptors for their students.⁵ The reasons are multifold: increasing clinical demands, time, teaching competence, lack of experience, academic affiliation, lack of reimbursement, or compensation. Moreover, there is a declining number of PAs who work in primary care compared with specialty and subspecialty care, limiting the availability of clinical training preceptors in medicine and primary care.^6-8 According to the American Academy of PAs (AAPA) census and salary survey data, the percentage of PAs working in the primary care specialties (ie, family medicine, IM, and general pediatrics) has decreased from > 47% in 1995 to 24% in 2017.⁹ As such, there is a need to broaden the educational landscape to provide more high-quality training sites in IM.

The postacute health care setting may address this training need. It offers a unique clinical opportunity to expose learners to a broad range of disease complexity and clinical acuity, as the percentage of patients discharged from hospitals to postacute care (PAC) has increased and care shifts from the hospital to the PAC setting.^10,11 The longer PAC length of stay also enables learners to follow patients longitudinally over several weeks and experience interprofessional team-based care. In addition, the PAC setting offers learners the ability to acquire the necessary skills for smooth and effective transitions of care. This setting has been extensively used for trainees of nursing, pharmacy, physical therapy (PT) and occupational therapy (OT), speech-language pathology, psychology, and social work (SW), but few programs have used the PAC setting as clerkship sites for IM rotations for PA students. To address this need for IM sites, the VA Boston Healthcare System (VABHS), in conjunction with the Boston University School of Medicine Physician Assistant Program, developed a novel medicine clinical clerkship site for physician assistants in the PAC unit of the community living center (CLC) at VABHS. This report describes the program structure, curriculum, and participant evaluation results.

Clinical Clerkship Program

VABHS CLC is a 110-bed facility comprising 3 units: a 65-bed PAC unit, a 15-bed closed hospice/palliative care unit, and a 30-bed long-term care unit. The service is staffed continuously with physicians, PAs, and NPs. A majority of patients are admitted from the acute care hospital of VABHS (West Roxbury campus) and other regional VA facilities. The CLC offers dynamic services, including phlebotomy, general radiology, IV diuretics and antibiotics, wound care, and subacute PT, OT, and speech-language pathology rehabilitation. The CLC serves as a venue for transitioning patients from acute inpatient care to home. The patient population is often elderly, with multiple active comorbidities and variable medical literacy, adherence, and follow-up.

The CLC provides a diverse interprofessional learning environment, offering core IM rotations for first-year psychiatry residents, oral and maxillofacial surgery residents, and PA students. The CLC also has expanded as a clinical site both for transitions-in-care IM resident curricula and electives as well as a geriatrics fellowship. In addition, the site offers rotations for NPs, nursing, pharmacy, physical and occupational therapies, speech-language pathology, psychology, and SW.

The Boston University School of Medicine Physician Assistant Program was founded in 2015 as a master’s degree program completed over 28 months. The first 12 months are didactic, and the following 16 months are clinical training with 14 months of rotations (2 IM, family medicine, pediatrics, emergency medicine, general surgery, obstetrics and gynecology, psychiatry, neurology, and 5 elective rotations), and 2 months for a thesis. The program has about 30 students per year and 4 clerkship sites for IM.

Program Description

The VABHS medicine clerkship hosts 1 to 2 PA students for 4-week blocks in the PAC unit of the CLC. Each student rotates on both PA and MD teams. Students follow 3 to 4 patients and participate fully in their care from admission to discharge; they prepare daily presentations and participate in medical management, family meetings, chart documentation, and care coordination with the interprofessional team. Students are provided a physical examination checklist and feedback form, and they are expected to track findings and record feedback and goals with their supervising preceptor weekly. They also make formal case presentations and participate in monthly medicine didactic rounds available to all VABHS IM students and trainees via videoconference.

In addition, beginning in July 2017, all PA students in the CLC began to participate in a 4-week Interprofessional Curriculum in Transitional Care. The curriculum includes 14 didactic lectures taught by 16 interprofessional faculty, including medicine, geriatric, and palliative care physicians; PAs; social workers; physical and occupational therapists; pharmacists; and a geriatric psychologist. The didactics include topics on the interprofessional team, the care continuum, teams and teamwork, interdisciplinary coordination of care, components of effective transitions in care, medication reconciliation, approaching difficult conversations, advance care planning, and quality improvement. The goal of the curriculum is to provide learners the knowledge, skills, and dispositions necessary for high-quality transitional care and interprofessional practice as well as specific training for effective and safe transfers of care between clinical settings. Although PA students are the main participants in this curriculum, all other learners in the PAC unit are also invited to attend the lectures.

The unique attributes of this training site include direct interaction with supervising PAs and physicians, rather than experiencing the traditional teaching hierarchy (with interns, residents, fellows); observation of the natural progression of disease of both acute care and primary care issues due to the longer length of stay (2 to 6 weeks, where the typical student will see the same patient 7 to 10 times during their rotation); exposure to a host of medically complex patients offering a multitude of clinical scenarios and abnormal physical exam findings; exposure to a hospice/palliative care ward and end-of-life care; and interaction within an interprofessional training environment of nursing, pharmacy, PT, OT, speech-language pathology, psychology, and SW trainees.

Program Evaluation

At the end of rotations continuously through the year, PA students electronically complete a site evaluation from the Boston University School of Medicine Physician Assistant Program. The evaluation consists of 14 questions: 6 about site quality and 8 about instruction quality. The questions are answered on a 5-point Likert scale. Also included are 2 open-ended response questions that ask what they liked about the rotation and what they felt could be improved. Results are anonymous, de-identified and blinded both to the program as well as the clerkship site. Results are aggregated and provided to program sites annually. Responses are converted to a dichotomous variable, where any good or excellent response (4 or 5) is considered positive and any neutral or below (3, 2, 1) is considered a nonpositive response.

Results

The clerkship site has been operational since June 22, 2015. There have been 59 students who participated in the rotation. A different scale in these evaluations was used between June 22, 2015, and September 13, 2015. Therefore, 7 responses were excluded from the analysis, leaving 52 usable evaluations. The responses were analyzed both in total (for the CLC as well as other IM rotation sites) and by individual clerkship year to look for any trends over time: September 14, 2015, through April 24, 2016; April 25, 2016, through April 28, 2017; and May 1, 2017, through March 1, 2018 (Table).

Site evaluations showed high satisfaction regarding the quality of the physical environment as well as the learning environment. Students endorsed the PAC unit having resources and physical space for them, such as a desk and computer, opportunity for participation in patient care, and parking (100%; n = 52). Site evaluations revealed high satisfaction with the quality of teaching and faculty encouragement and support of their learning (100%; n = 52). The evaluations revealed that bedside teaching was strong (94%; n = 49). The students reported high satisfaction with the volume of patients provided (92%; n = 48) as well as the diversity of diagnoses (92%; n = 48).

There were fewer positive responses in the first 2 years of the rotation with regard to formal lectures (50% and 67%; 7/14 and 16/24, respectively). In the third year of the rotation, students had a much higher satisfaction rate (93%; 13/14). This increased satisfaction was associated with the development and incorporation of the Interprofessional Curriculum in Transitional Care in 2017.

Discussion

Access to high-quality PA student clerkship sites has become a pressing issue in recent years because of increased competition for sites and a shortage of willing and well-trained preceptors. There has been marked growth in schools and enrollment across all medical professions. The Accreditation Review Commission on Education for the PA (ARC-PA) reported that the total number of accredited entry-level PA programs in 2018 was 246, with 58 new accredited programs projected by 2022.¹² The Joint Report of the 2013 Multi-Discipline Clerkship/Clinical Training Site Survey reported a 66% increase in first-year enrollment in PA programs from 2002 to 2012.⁵ Programs must implement alternative strategies to attract clinical sites (eg, academic appointments, increased clinical resources to training sites) or face continued challenges with recruiting training sites for their students. Postacute care may be a natural extension to expand the footprint for clinical sites for these programs, augmenting acute inpatient and outpatient rotations. This implementation would increase the pool of clinical training sites and preceptors.

The experience with this novel training site, based on PA student feedback and evaluations, has been positive, and the postacute setting can provide students with high-quality IM clinical experiences. Students report adequate patient volume and diversity. In addition, evaluations are comparable with that of other IM site rotations the students experience. Qualitative feedback has emphasized the value of following patients over longer periods; eg, weeks vs days (as in acute care) enabling students to build relationships with patients as well as observe a richer clinical spectrum of disease over a less compressed period. “Patients have complex issues, so from a medical standpoint it challenges you to think of new ways to manage their care,” commented a representative student. “It is really beneficial that you can follow them over time.”

Furthermore, in response to student feedback on didactics, an interprofessional curriculum was developed to add formal structure as well as to create a curriculum in care transitions. This curriculum provided a unique opportunity for PA students to receive formal instruction on areas of particular relevance for transitional care (eg, care continuum, end of life issues, and care transitions). The curriculum also allows the interprofessional faculty a unique and enjoyable opportunity for interprofessional collaboration.

The 1 month PAC rotation is augmented with inpatient IM and outpatient family medicine rotations, consequently giving exposure to the full continuum of care. The PAC setting provides learners multifaceted benefits: the opportunity to strengthen and develop the knowledge, attitudes, and skills necessary for IM; increased understanding of other professions by observing and interacting as a team caring for a patient over a longer period as opposed to the acute care setting; the ability to perform effective, efficient, and safe transfer between clinical settings; and broad exposure to transitional care. As a result, the PAC rotation enhances but does not replace the necessary and essential rotations of inpatient and outpatient medicine.

Moreover, this rotation provides unique and core IM training for PA students. Our site focuses on interprofessional collaboration, emphasizing the importance of team-based care, an essential concept in modern day medicine. Formal exposure to other care specialties, such as PT and OT, SW, and mental health, is essential for students to appreciate clinical medicine and a patient’s physical and mental experience over the course of a disease and clinical state. In addition, the physical exam checklist ensures that students are exposed to the full spectrum of IM examination findings during their rotation. Finally, weekly feedback forms require students to ask and receive concrete feedback from their supervising providers.

Limitations

The generalizability of this model requires careful consideration. VABHS is a tertiary care integrated health care system, enabling students to learn from patients moving through multiple care transitions in a single health care system. In addition, other settings may not have the staffing or clinical volume to sustain such a model. All PAC clinical faculty teach voluntarily, and local leadership has set expectations for all clinicians to participate in teaching of trainees and PA students. Evaluations also note less diversity in the patient population, a challenge that some VA facilities face. This issue could be addressed by ensuring that students also have IM rotations at other inpatient medical facilities. A more balanced experience, where students reap the positive benefits of PAC but do not lose exposure to a diverse patient pool, could result. Furthermore, some of the perceived positive impacts also may be related to professional and personal attributes of the teaching clinicians rather than to the PAC setting.

Conclusion

PAC settings can be effective training sites for medicine clerkships for PA students and can provide high-quality training in IM as PA programs continue to expand. This setting offers students exposure to interprofessional, team-based care and the opportunity to care for patients with a broad range of disease complexity. Learning is further enhanced by the ability to follow patients longitudinally over their disease course as well as to work directly with teaching faculty and other interprofessional health care professionals. Evaluations of this novel clerkship experience have shown high levels of student satisfaction in knowledge growth, clinical skills, bedside teaching, and mentorship.

Acknowledgments
We thank Juman Hijab for her critical role in establishing and maintaining the clerkship. We thank Steven Simon, Matt Russell, and Thomas Parrino for their leadership and guidance in establishing and maintaining the clerkship. We thank the Boston University School of Medicine Physician Assistant Program Director Mary Warner for her support and guidance in creating and supporting the clerkship. In addition, we thank the interprofessional education faculty for their dedicated involvement in teaching, including Stephanie Saunders, Lindsay Lefers, Jessica Rawlins, Lindsay Brennan, Angela Viani, Eric Charette, Nicole O’Neil, Susan Nathan, Jordana Meyerson, Shivani Jindal, Wei Shen, Amy Hanson, Gilda Cain, and Kate Hinrichs.

The Federal Bureau of Labor Statistics projects 37% job growth for physician assistants (PAs) from 2016 to 2026, much greater than the average for all other occupations as well as for other medical professions.¹ This growth has been accompanied by increased enrollment in medical (doctor of medicine [MD], doctor of osteopathic medicine) and nurse practitioner (NP) schools.² Clinical teaching sites serve a crucial function in the training of all clinical disciplines. These sites provide hands-on and experiential learning in medical settings, necessary components for learners practicing to become clinicians. Significant PA program expansion has led to increased demand for clinical training, creating competition for sites and a shortage of willing and well-trained preceptors.³

This challenge has been recognized by PA program directors. In the Joint Report of the 2013 Multi-Discipline Clerkship/Clinical Training Site Survey, PA program directors expressed concern about the adequacy of clinical opportunities for students, increased difficulty developing new core sites, and preserving existing core sites. In addition, they noted that a shortage of clinical sites was one of the greatest barriers to the PA programs’ sustained growth and success.⁴

Program directors also indicated difficulty securing clinical training sites in internal medicine (IM) and high rates of attrition of medicine clinical preceptors for their students.⁵ The reasons are multifold: increasing clinical demands, time, teaching competence, lack of experience, academic affiliation, lack of reimbursement, or compensation. Moreover, there is a declining number of PAs who work in primary care compared with specialty and subspecialty care, limiting the availability of clinical training preceptors in medicine and primary care.^6-8 According to the American Academy of PAs (AAPA) census and salary survey data, the percentage of PAs working in the primary care specialties (ie, family medicine, IM, and general pediatrics) has decreased from > 47% in 1995 to 24% in 2017.⁹ As such, there is a need to broaden the educational landscape to provide more high-quality training sites in IM.

The postacute health care setting may address this training need. It offers a unique clinical opportunity to expose learners to a broad range of disease complexity and clinical acuity, as the percentage of patients discharged from hospitals to postacute care (PAC) has increased and care shifts from the hospital to the PAC setting.^10,11 The longer PAC length of stay also enables learners to follow patients longitudinally over several weeks and experience interprofessional team-based care. In addition, the PAC setting offers learners the ability to acquire the necessary skills for smooth and effective transitions of care. This setting has been extensively used for trainees of nursing, pharmacy, physical therapy (PT) and occupational therapy (OT), speech-language pathology, psychology, and social work (SW), but few programs have used the PAC setting as clerkship sites for IM rotations for PA students. To address this need for IM sites, the VA Boston Healthcare System (VABHS), in conjunction with the Boston University School of Medicine Physician Assistant Program, developed a novel medicine clinical clerkship site for physician assistants in the PAC unit of the community living center (CLC) at VABHS. This report describes the program structure, curriculum, and participant evaluation results.

Clinical Clerkship Program

VABHS CLC is a 110-bed facility comprising 3 units: a 65-bed PAC unit, a 15-bed closed hospice/palliative care unit, and a 30-bed long-term care unit. The service is staffed continuously with physicians, PAs, and NPs. A majority of patients are admitted from the acute care hospital of VABHS (West Roxbury campus) and other regional VA facilities. The CLC offers dynamic services, including phlebotomy, general radiology, IV diuretics and antibiotics, wound care, and subacute PT, OT, and speech-language pathology rehabilitation. The CLC serves as a venue for transitioning patients from acute inpatient care to home. The patient population is often elderly, with multiple active comorbidities and variable medical literacy, adherence, and follow-up.

The CLC provides a diverse interprofessional learning environment, offering core IM rotations for first-year psychiatry residents, oral and maxillofacial surgery residents, and PA students. The CLC also has expanded as a clinical site both for transitions-in-care IM resident curricula and electives as well as a geriatrics fellowship. In addition, the site offers rotations for NPs, nursing, pharmacy, physical and occupational therapies, speech-language pathology, psychology, and SW.

The Boston University School of Medicine Physician Assistant Program was founded in 2015 as a master’s degree program completed over 28 months. The first 12 months are didactic, and the following 16 months are clinical training with 14 months of rotations (2 IM, family medicine, pediatrics, emergency medicine, general surgery, obstetrics and gynecology, psychiatry, neurology, and 5 elective rotations), and 2 months for a thesis. The program has about 30 students per year and 4 clerkship sites for IM.

Program Description

The VABHS medicine clerkship hosts 1 to 2 PA students for 4-week blocks in the PAC unit of the CLC. Each student rotates on both PA and MD teams. Students follow 3 to 4 patients and participate fully in their care from admission to discharge; they prepare daily presentations and participate in medical management, family meetings, chart documentation, and care coordination with the interprofessional team. Students are provided a physical examination checklist and feedback form, and they are expected to track findings and record feedback and goals with their supervising preceptor weekly. They also make formal case presentations and participate in monthly medicine didactic rounds available to all VABHS IM students and trainees via videoconference.

In addition, beginning in July 2017, all PA students in the CLC began to participate in a 4-week Interprofessional Curriculum in Transitional Care. The curriculum includes 14 didactic lectures taught by 16 interprofessional faculty, including medicine, geriatric, and palliative care physicians; PAs; social workers; physical and occupational therapists; pharmacists; and a geriatric psychologist. The didactics include topics on the interprofessional team, the care continuum, teams and teamwork, interdisciplinary coordination of care, components of effective transitions in care, medication reconciliation, approaching difficult conversations, advance care planning, and quality improvement. The goal of the curriculum is to provide learners the knowledge, skills, and dispositions necessary for high-quality transitional care and interprofessional practice as well as specific training for effective and safe transfers of care between clinical settings. Although PA students are the main participants in this curriculum, all other learners in the PAC unit are also invited to attend the lectures.

The unique attributes of this training site include direct interaction with supervising PAs and physicians, rather than experiencing the traditional teaching hierarchy (with interns, residents, fellows); observation of the natural progression of disease of both acute care and primary care issues due to the longer length of stay (2 to 6 weeks, where the typical student will see the same patient 7 to 10 times during their rotation); exposure to a host of medically complex patients offering a multitude of clinical scenarios and abnormal physical exam findings; exposure to a hospice/palliative care ward and end-of-life care; and interaction within an interprofessional training environment of nursing, pharmacy, PT, OT, speech-language pathology, psychology, and SW trainees.

Program Evaluation

At the end of rotations continuously through the year, PA students electronically complete a site evaluation from the Boston University School of Medicine Physician Assistant Program. The evaluation consists of 14 questions: 6 about site quality and 8 about instruction quality. The questions are answered on a 5-point Likert scale. Also included are 2 open-ended response questions that ask what they liked about the rotation and what they felt could be improved. Results are anonymous, de-identified and blinded both to the program as well as the clerkship site. Results are aggregated and provided to program sites annually. Responses are converted to a dichotomous variable, where any good or excellent response (4 or 5) is considered positive and any neutral or below (3, 2, 1) is considered a nonpositive response.

Results

The clerkship site has been operational since June 22, 2015. There have been 59 students who participated in the rotation. A different scale in these evaluations was used between June 22, 2015, and September 13, 2015. Therefore, 7 responses were excluded from the analysis, leaving 52 usable evaluations. The responses were analyzed both in total (for the CLC as well as other IM rotation sites) and by individual clerkship year to look for any trends over time: September 14, 2015, through April 24, 2016; April 25, 2016, through April 28, 2017; and May 1, 2017, through March 1, 2018 (Table).

Site evaluations showed high satisfaction regarding the quality of the physical environment as well as the learning environment. Students endorsed the PAC unit having resources and physical space for them, such as a desk and computer, opportunity for participation in patient care, and parking (100%; n = 52). Site evaluations revealed high satisfaction with the quality of teaching and faculty encouragement and support of their learning (100%; n = 52). The evaluations revealed that bedside teaching was strong (94%; n = 49). The students reported high satisfaction with the volume of patients provided (92%; n = 48) as well as the diversity of diagnoses (92%; n = 48).

There were fewer positive responses in the first 2 years of the rotation with regard to formal lectures (50% and 67%; 7/14 and 16/24, respectively). In the third year of the rotation, students had a much higher satisfaction rate (93%; 13/14). This increased satisfaction was associated with the development and incorporation of the Interprofessional Curriculum in Transitional Care in 2017.

Discussion

Access to high-quality PA student clerkship sites has become a pressing issue in recent years because of increased competition for sites and a shortage of willing and well-trained preceptors. There has been marked growth in schools and enrollment across all medical professions. The Accreditation Review Commission on Education for the PA (ARC-PA) reported that the total number of accredited entry-level PA programs in 2018 was 246, with 58 new accredited programs projected by 2022.¹² The Joint Report of the 2013 Multi-Discipline Clerkship/Clinical Training Site Survey reported a 66% increase in first-year enrollment in PA programs from 2002 to 2012.⁵ Programs must implement alternative strategies to attract clinical sites (eg, academic appointments, increased clinical resources to training sites) or face continued challenges with recruiting training sites for their students. Postacute care may be a natural extension to expand the footprint for clinical sites for these programs, augmenting acute inpatient and outpatient rotations. This implementation would increase the pool of clinical training sites and preceptors.

The experience with this novel training site, based on PA student feedback and evaluations, has been positive, and the postacute setting can provide students with high-quality IM clinical experiences. Students report adequate patient volume and diversity. In addition, evaluations are comparable with that of other IM site rotations the students experience. Qualitative feedback has emphasized the value of following patients over longer periods; eg, weeks vs days (as in acute care) enabling students to build relationships with patients as well as observe a richer clinical spectrum of disease over a less compressed period. “Patients have complex issues, so from a medical standpoint it challenges you to think of new ways to manage their care,” commented a representative student. “It is really beneficial that you can follow them over time.”

Furthermore, in response to student feedback on didactics, an interprofessional curriculum was developed to add formal structure as well as to create a curriculum in care transitions. This curriculum provided a unique opportunity for PA students to receive formal instruction on areas of particular relevance for transitional care (eg, care continuum, end of life issues, and care transitions). The curriculum also allows the interprofessional faculty a unique and enjoyable opportunity for interprofessional collaboration.

The 1 month PAC rotation is augmented with inpatient IM and outpatient family medicine rotations, consequently giving exposure to the full continuum of care. The PAC setting provides learners multifaceted benefits: the opportunity to strengthen and develop the knowledge, attitudes, and skills necessary for IM; increased understanding of other professions by observing and interacting as a team caring for a patient over a longer period as opposed to the acute care setting; the ability to perform effective, efficient, and safe transfer between clinical settings; and broad exposure to transitional care. As a result, the PAC rotation enhances but does not replace the necessary and essential rotations of inpatient and outpatient medicine.

Moreover, this rotation provides unique and core IM training for PA students. Our site focuses on interprofessional collaboration, emphasizing the importance of team-based care, an essential concept in modern day medicine. Formal exposure to other care specialties, such as PT and OT, SW, and mental health, is essential for students to appreciate clinical medicine and a patient’s physical and mental experience over the course of a disease and clinical state. In addition, the physical exam checklist ensures that students are exposed to the full spectrum of IM examination findings during their rotation. Finally, weekly feedback forms require students to ask and receive concrete feedback from their supervising providers.

Limitations

The generalizability of this model requires careful consideration. VABHS is a tertiary care integrated health care system, enabling students to learn from patients moving through multiple care transitions in a single health care system. In addition, other settings may not have the staffing or clinical volume to sustain such a model. All PAC clinical faculty teach voluntarily, and local leadership has set expectations for all clinicians to participate in teaching of trainees and PA students. Evaluations also note less diversity in the patient population, a challenge that some VA facilities face. This issue could be addressed by ensuring that students also have IM rotations at other inpatient medical facilities. A more balanced experience, where students reap the positive benefits of PAC but do not lose exposure to a diverse patient pool, could result. Furthermore, some of the perceived positive impacts also may be related to professional and personal attributes of the teaching clinicians rather than to the PAC setting.

Conclusion

PAC settings can be effective training sites for medicine clerkships for PA students and can provide high-quality training in IM as PA programs continue to expand. This setting offers students exposure to interprofessional, team-based care and the opportunity to care for patients with a broad range of disease complexity. Learning is further enhanced by the ability to follow patients longitudinally over their disease course as well as to work directly with teaching faculty and other interprofessional health care professionals. Evaluations of this novel clerkship experience have shown high levels of student satisfaction in knowledge growth, clinical skills, bedside teaching, and mentorship.

Acknowledgments
We thank Juman Hijab for her critical role in establishing and maintaining the clerkship. We thank Steven Simon, Matt Russell, and Thomas Parrino for their leadership and guidance in establishing and maintaining the clerkship. We thank the Boston University School of Medicine Physician Assistant Program Director Mary Warner for her support and guidance in creating and supporting the clerkship. In addition, we thank the interprofessional education faculty for their dedicated involvement in teaching, including Stephanie Saunders, Lindsay Lefers, Jessica Rawlins, Lindsay Brennan, Angela Viani, Eric Charette, Nicole O’Neil, Susan Nathan, Jordana Meyerson, Shivani Jindal, Wei Shen, Amy Hanson, Gilda Cain, and Kate Hinrichs.

The Federal Bureau of Labor Statistics projects 37% job growth for physician assistants (PAs) from 2016 to 2026, much greater than the average for all other occupations as well as for other medical professions.¹ This growth has been accompanied by increased enrollment in medical (doctor of medicine [MD], doctor of osteopathic medicine) and nurse practitioner (NP) schools.² Clinical teaching sites serve a crucial function in the training of all clinical disciplines. These sites provide hands-on and experiential learning in medical settings, necessary components for learners practicing to become clinicians. Significant PA program expansion has led to increased demand for clinical training, creating competition for sites and a shortage of willing and well-trained preceptors.³

This challenge has been recognized by PA program directors. In the Joint Report of the 2013 Multi-Discipline Clerkship/Clinical Training Site Survey, PA program directors expressed concern about the adequacy of clinical opportunities for students, increased difficulty developing new core sites, and preserving existing core sites. In addition, they noted that a shortage of clinical sites was one of the greatest barriers to the PA programs’ sustained growth and success.⁴

Program directors also indicated difficulty securing clinical training sites in internal medicine (IM) and high rates of attrition of medicine clinical preceptors for their students.⁵ The reasons are multifold: increasing clinical demands, time, teaching competence, lack of experience, academic affiliation, lack of reimbursement, or compensation. Moreover, there is a declining number of PAs who work in primary care compared with specialty and subspecialty care, limiting the availability of clinical training preceptors in medicine and primary care.^6-8 According to the American Academy of PAs (AAPA) census and salary survey data, the percentage of PAs working in the primary care specialties (ie, family medicine, IM, and general pediatrics) has decreased from > 47% in 1995 to 24% in 2017.⁹ As such, there is a need to broaden the educational landscape to provide more high-quality training sites in IM.

The postacute health care setting may address this training need. It offers a unique clinical opportunity to expose learners to a broad range of disease complexity and clinical acuity, as the percentage of patients discharged from hospitals to postacute care (PAC) has increased and care shifts from the hospital to the PAC setting.^10,11 The longer PAC length of stay also enables learners to follow patients longitudinally over several weeks and experience interprofessional team-based care. In addition, the PAC setting offers learners the ability to acquire the necessary skills for smooth and effective transitions of care. This setting has been extensively used for trainees of nursing, pharmacy, physical therapy (PT) and occupational therapy (OT), speech-language pathology, psychology, and social work (SW), but few programs have used the PAC setting as clerkship sites for IM rotations for PA students. To address this need for IM sites, the VA Boston Healthcare System (VABHS), in conjunction with the Boston University School of Medicine Physician Assistant Program, developed a novel medicine clinical clerkship site for physician assistants in the PAC unit of the community living center (CLC) at VABHS. This report describes the program structure, curriculum, and participant evaluation results.

Clinical Clerkship Program

VABHS CLC is a 110-bed facility comprising 3 units: a 65-bed PAC unit, a 15-bed closed hospice/palliative care unit, and a 30-bed long-term care unit. The service is staffed continuously with physicians, PAs, and NPs. A majority of patients are admitted from the acute care hospital of VABHS (West Roxbury campus) and other regional VA facilities. The CLC offers dynamic services, including phlebotomy, general radiology, IV diuretics and antibiotics, wound care, and subacute PT, OT, and speech-language pathology rehabilitation. The CLC serves as a venue for transitioning patients from acute inpatient care to home. The patient population is often elderly, with multiple active comorbidities and variable medical literacy, adherence, and follow-up.

The CLC provides a diverse interprofessional learning environment, offering core IM rotations for first-year psychiatry residents, oral and maxillofacial surgery residents, and PA students. The CLC also has expanded as a clinical site both for transitions-in-care IM resident curricula and electives as well as a geriatrics fellowship. In addition, the site offers rotations for NPs, nursing, pharmacy, physical and occupational therapies, speech-language pathology, psychology, and SW.

The Boston University School of Medicine Physician Assistant Program was founded in 2015 as a master’s degree program completed over 28 months. The first 12 months are didactic, and the following 16 months are clinical training with 14 months of rotations (2 IM, family medicine, pediatrics, emergency medicine, general surgery, obstetrics and gynecology, psychiatry, neurology, and 5 elective rotations), and 2 months for a thesis. The program has about 30 students per year and 4 clerkship sites for IM.

Program Description

The VABHS medicine clerkship hosts 1 to 2 PA students for 4-week blocks in the PAC unit of the CLC. Each student rotates on both PA and MD teams. Students follow 3 to 4 patients and participate fully in their care from admission to discharge; they prepare daily presentations and participate in medical management, family meetings, chart documentation, and care coordination with the interprofessional team. Students are provided a physical examination checklist and feedback form, and they are expected to track findings and record feedback and goals with their supervising preceptor weekly. They also make formal case presentations and participate in monthly medicine didactic rounds available to all VABHS IM students and trainees via videoconference.

In addition, beginning in July 2017, all PA students in the CLC began to participate in a 4-week Interprofessional Curriculum in Transitional Care. The curriculum includes 14 didactic lectures taught by 16 interprofessional faculty, including medicine, geriatric, and palliative care physicians; PAs; social workers; physical and occupational therapists; pharmacists; and a geriatric psychologist. The didactics include topics on the interprofessional team, the care continuum, teams and teamwork, interdisciplinary coordination of care, components of effective transitions in care, medication reconciliation, approaching difficult conversations, advance care planning, and quality improvement. The goal of the curriculum is to provide learners the knowledge, skills, and dispositions necessary for high-quality transitional care and interprofessional practice as well as specific training for effective and safe transfers of care between clinical settings. Although PA students are the main participants in this curriculum, all other learners in the PAC unit are also invited to attend the lectures.

The unique attributes of this training site include direct interaction with supervising PAs and physicians, rather than experiencing the traditional teaching hierarchy (with interns, residents, fellows); observation of the natural progression of disease of both acute care and primary care issues due to the longer length of stay (2 to 6 weeks, where the typical student will see the same patient 7 to 10 times during their rotation); exposure to a host of medically complex patients offering a multitude of clinical scenarios and abnormal physical exam findings; exposure to a hospice/palliative care ward and end-of-life care; and interaction within an interprofessional training environment of nursing, pharmacy, PT, OT, speech-language pathology, psychology, and SW trainees.

Program Evaluation

At the end of rotations continuously through the year, PA students electronically complete a site evaluation from the Boston University School of Medicine Physician Assistant Program. The evaluation consists of 14 questions: 6 about site quality and 8 about instruction quality. The questions are answered on a 5-point Likert scale. Also included are 2 open-ended response questions that ask what they liked about the rotation and what they felt could be improved. Results are anonymous, de-identified and blinded both to the program as well as the clerkship site. Results are aggregated and provided to program sites annually. Responses are converted to a dichotomous variable, where any good or excellent response (4 or 5) is considered positive and any neutral or below (3, 2, 1) is considered a nonpositive response.

Results

The clerkship site has been operational since June 22, 2015. There have been 59 students who participated in the rotation. A different scale in these evaluations was used between June 22, 2015, and September 13, 2015. Therefore, 7 responses were excluded from the analysis, leaving 52 usable evaluations. The responses were analyzed both in total (for the CLC as well as other IM rotation sites) and by individual clerkship year to look for any trends over time: September 14, 2015, through April 24, 2016; April 25, 2016, through April 28, 2017; and May 1, 2017, through March 1, 2018 (Table).

Site evaluations showed high satisfaction regarding the quality of the physical environment as well as the learning environment. Students endorsed the PAC unit having resources and physical space for them, such as a desk and computer, opportunity for participation in patient care, and parking (100%; n = 52). Site evaluations revealed high satisfaction with the quality of teaching and faculty encouragement and support of their learning (100%; n = 52). The evaluations revealed that bedside teaching was strong (94%; n = 49). The students reported high satisfaction with the volume of patients provided (92%; n = 48) as well as the diversity of diagnoses (92%; n = 48).

There were fewer positive responses in the first 2 years of the rotation with regard to formal lectures (50% and 67%; 7/14 and 16/24, respectively). In the third year of the rotation, students had a much higher satisfaction rate (93%; 13/14). This increased satisfaction was associated with the development and incorporation of the Interprofessional Curriculum in Transitional Care in 2017.

Discussion

Access to high-quality PA student clerkship sites has become a pressing issue in recent years because of increased competition for sites and a shortage of willing and well-trained preceptors. There has been marked growth in schools and enrollment across all medical professions. The Accreditation Review Commission on Education for the PA (ARC-PA) reported that the total number of accredited entry-level PA programs in 2018 was 246, with 58 new accredited programs projected by 2022.¹² The Joint Report of the 2013 Multi-Discipline Clerkship/Clinical Training Site Survey reported a 66% increase in first-year enrollment in PA programs from 2002 to 2012.⁵ Programs must implement alternative strategies to attract clinical sites (eg, academic appointments, increased clinical resources to training sites) or face continued challenges with recruiting training sites for their students. Postacute care may be a natural extension to expand the footprint for clinical sites for these programs, augmenting acute inpatient and outpatient rotations. This implementation would increase the pool of clinical training sites and preceptors.

The experience with this novel training site, based on PA student feedback and evaluations, has been positive, and the postacute setting can provide students with high-quality IM clinical experiences. Students report adequate patient volume and diversity. In addition, evaluations are comparable with that of other IM site rotations the students experience. Qualitative feedback has emphasized the value of following patients over longer periods; eg, weeks vs days (as in acute care) enabling students to build relationships with patients as well as observe a richer clinical spectrum of disease over a less compressed period. “Patients have complex issues, so from a medical standpoint it challenges you to think of new ways to manage their care,” commented a representative student. “It is really beneficial that you can follow them over time.”

Furthermore, in response to student feedback on didactics, an interprofessional curriculum was developed to add formal structure as well as to create a curriculum in care transitions. This curriculum provided a unique opportunity for PA students to receive formal instruction on areas of particular relevance for transitional care (eg, care continuum, end of life issues, and care transitions). The curriculum also allows the interprofessional faculty a unique and enjoyable opportunity for interprofessional collaboration.

The 1 month PAC rotation is augmented with inpatient IM and outpatient family medicine rotations, consequently giving exposure to the full continuum of care. The PAC setting provides learners multifaceted benefits: the opportunity to strengthen and develop the knowledge, attitudes, and skills necessary for IM; increased understanding of other professions by observing and interacting as a team caring for a patient over a longer period as opposed to the acute care setting; the ability to perform effective, efficient, and safe transfer between clinical settings; and broad exposure to transitional care. As a result, the PAC rotation enhances but does not replace the necessary and essential rotations of inpatient and outpatient medicine.

Moreover, this rotation provides unique and core IM training for PA students. Our site focuses on interprofessional collaboration, emphasizing the importance of team-based care, an essential concept in modern day medicine. Formal exposure to other care specialties, such as PT and OT, SW, and mental health, is essential for students to appreciate clinical medicine and a patient’s physical and mental experience over the course of a disease and clinical state. In addition, the physical exam checklist ensures that students are exposed to the full spectrum of IM examination findings during their rotation. Finally, weekly feedback forms require students to ask and receive concrete feedback from their supervising providers.

Limitations

The generalizability of this model requires careful consideration. VABHS is a tertiary care integrated health care system, enabling students to learn from patients moving through multiple care transitions in a single health care system. In addition, other settings may not have the staffing or clinical volume to sustain such a model. All PAC clinical faculty teach voluntarily, and local leadership has set expectations for all clinicians to participate in teaching of trainees and PA students. Evaluations also note less diversity in the patient population, a challenge that some VA facilities face. This issue could be addressed by ensuring that students also have IM rotations at other inpatient medical facilities. A more balanced experience, where students reap the positive benefits of PAC but do not lose exposure to a diverse patient pool, could result. Furthermore, some of the perceived positive impacts also may be related to professional and personal attributes of the teaching clinicians rather than to the PAC setting.

Conclusion

PAC settings can be effective training sites for medicine clerkships for PA students and can provide high-quality training in IM as PA programs continue to expand. This setting offers students exposure to interprofessional, team-based care and the opportunity to care for patients with a broad range of disease complexity. Learning is further enhanced by the ability to follow patients longitudinally over their disease course as well as to work directly with teaching faculty and other interprofessional health care professionals. Evaluations of this novel clerkship experience have shown high levels of student satisfaction in knowledge growth, clinical skills, bedside teaching, and mentorship.

Acknowledgments
We thank Juman Hijab for her critical role in establishing and maintaining the clerkship. We thank Steven Simon, Matt Russell, and Thomas Parrino for their leadership and guidance in establishing and maintaining the clerkship. We thank the Boston University School of Medicine Physician Assistant Program Director Mary Warner for her support and guidance in creating and supporting the clerkship. In addition, we thank the interprofessional education faculty for their dedicated involvement in teaching, including Stephanie Saunders, Lindsay Lefers, Jessica Rawlins, Lindsay Brennan, Angela Viani, Eric Charette, Nicole O’Neil, Susan Nathan, Jordana Meyerson, Shivani Jindal, Wei Shen, Amy Hanson, Gilda Cain, and Kate Hinrichs.

Care transitions between hospitals and skilled nursing facilities (SNFs) are a vulnerable time for patients. The current health care climate of decreasing hospital length of stay, readmission penalties, and increasing patient complexity has made hospital care transitions an important safety concern. Suboptimal transitions across clinical settings can result in adverse events, inadequately controlled comorbidities, deficient patient and caregiver preparation for discharge, medication errors, relocation stress, and overall increased morbidity and mortality.^1,2 Such care transitions also may generate unnecessary spending, including avoidable readmissions, emergency department utilization, and duplicative laboratory and imaging studies. Approximately 23% of patients admitted to SNFs are readmitted to acute care hospitals within 30 days, and these patients have increased mortality rates in risk-adjusted analyses. ^3,4

Compounding the magnitude of this risk and vulnerability is the significant growth in the number of patients discharged to SNFs over the past 30 years. In 2013, more than 20% of Medicare patients discharged from acute care hospitals were destined for SNFs.^5,6 Paradoxically, despite the increasing need for SNF providers, there is a shortage of clinicians with training in geriatrics or nursing home care.⁷ The result is a growing need to identify organizational systems to optimize physician practice in these settings, enhance quality of care, especially around transitions, and increase educational training opportunities in SNFs for future practitioners.

Many SNFs today are staffed by physicians and other licensed clinicians whose exclusive practice location is the nursing facility or possibly several such facilities. This prevailing model of care can isolate the physicians, depriving them of interaction with clinicians in other specialties, and can contribute to burnout.⁸ This model does not lend itself to academic scholarship, quality improvement (QI), and student or resident training, as each of these endeavors depends on interprofessional collaboration as well as access to an academic medical center with additional resources.⁹

Few studies have described innovative hospitalist rotation models from acute to subacute care. The Cleveland Clinic implemented the Connected Care model where hospital-employed physicians and advanced practice professionals integrated into postacute care and reduced the 30-day hospital readmission rate from SNFs from 28% to 22%.¹⁰ Goth and colleagues performed a comparative effectiveness trial between a postacute care hospitalist (PACH) model and a community-based physician model of nursing home care. They found that the institution of a PACH model in a nursing home was associated with a significant increase in laboratory costs, nonsignificant reduction in medication errors and pharmacy costs, and no improvement in fall rates.¹¹ The conclusion was that the PACH model may lead to greater clinician involvement and that the potential decrease in pharmacy costs and medications errors may offset the costs associated with additional laboratory testing. Overall, there has been a lack of studies on the impact of these hospitalist rotation models from acute to subacute care on educational programs, QI activities, and the interprofessional environment.

To achieve a system in which physicians in a SNF can excel in these areas, Veterans Affairs Boston Healthcare System (VABHS) adopted a staffing model in which academic hospitalist physicians rotate between the inpatient hospital and subacute settings. This report describes the model structure, the varying roles of the physicians, and early indicators of its positive effects on educational programs, QI activities, and the interprofessional environment.

Methods

The VABHS consists of a 159-bed acute care hospital in West Roxbury, Massachusetts; and a 110-bed SNF in Brockton, Massachusetts, with 3 units: a 65-bed transitional care unit (TCU), a 30-bed long-term care unit, and a 15-bed palliative care/hospice unit. The majority of patients admitted to the SNF are transferred from the acute care hospital in West Roxbury and other regional hospitals. Prior to 2015, the TCU was staffed with full-time clinicians who exclusively practiced in the SNF.

In the new staffing model, 6 hospitalist physicians divide their clinical time between the acute care hospital’s inpatient medical service and the TCU. The hospitalists come from varied backgrounds in terms of years in practice and advanced training (Table 1). 

The amount of nonclinical (protected) time and clinical time on the acute inpatient service and the TCU varies for each physician. For example, a physician serves as principal investigator for several major research grants and has a hospital-wide administrative leadership role; as a result, the principal investigator has fewer months of clinical responsibility. Physicians are expected to use the protected time for scholarship, educational program development and teaching, QI, and administrative responsibilities. The VABHS leadership determines the amount of protected time based on individualized benchmarks for research, education, and administrative responsibilities that follow VA national and local institutional guidelines. These metrics and time allocations are negotiated at the time of recruitment and then are reviewed annually.

The TCU also is staffed with 4 full-time clinicians (2 physicians and 2 physician assistants) who provide additional continuity of care. The new hospitalist staffing model only required an approximate 10% increase in TCU clinical staffing full-time equivalents. Patients and admissions are divided equally among clinicians on service (census per clinician 12-15 patients), with redistribution of patients at times of transition from clinical to nonclinical time. Blocks of clinical time are scheduled for greater than 2 weeks at a time to preserve continuity. In addition, the new staffing model allocates assignment of clinical responsibilities that allows for clinicians to take leave without resultant shortages in clinical coverage.

To facilitate communication among physicians serving in the acute inpatient facility and the TCU, leaders of both of these programs meet monthly and ad hoc to review the transitions of care between the 2 settings. The description of this model and its assessment have been reviewed and deemed exempt from oversight by the VA Boston Healthcare System Research and Development Committee.

Results

Since the implementation of this staffing model in 2015, the system has grown considerably in the breadth and depth of educational programming, QI, and systems redesign in the TCU and, more broadly, in the SNF. The TCU, which previously had limited training opportunities, has experienced marked expansion of educational offerings. It is now a site for core general medicine rotations for first-year psychiatry residents and physician assistant students. The TCU also has expanded as a clinical site for transitions-in-care internal medicine resident curricula and electives, as well as a clinical site for a geriatrics fellowship.

A hospitalist developed and implemented a 4-week interprofessional curriculum for all clinical trainees and students, which occurs continuously. The curriculum includes a monthly academic conference and 12 didactic lectures and is taught by 16 interprofessional faculty from the TCU and the Palliative Care/Hospice Unit, including medicine, geriatric and palliative care physicians, physician assistants, social workers, physical and occupational therapists, pharmacists, and a geriatric psychologist. The goal of the curriculum is to provide learners the knowledge, attitudes, and skills necessary to perform effective, efficient, and safe transfers between clinical settings as well as education in transitional care. In addition, using a team of interprofessional faculty, the curriculum develops the interprofessional competencies of teamwork and communication. The curriculum also has provided a significant opportunity for interprofessional collaboration among faculty who have volunteered their teaching time in the development and teaching of the curriculum, with potential for improved clinical staff knowledge of other disciplines.

Quality improvement and system redesign projects in care transitions also have expanded (Table 2). 

Early assessment indicates that the new staffing model is having positive effects on the clinical environment of the TCU. A survey was conducted of a convenience sample of all physicians, nurse managers, social workers, and other members of the clinical team in the TCU (N=24)(Table 3), with response categories ranging on a Likert scale from 1 (very negative) to 5 (very positive). 

Although not rigorously analyzed using qualitative research methods, comments from respondents have consistently indicated that this staffing model increases the transfer of clinical and logistical knowledge among staff members working in the acute inpatient facility and the TCU. 

Discussion

With greater numbers of increasingly complex patients transitioning from the hospital to SNF, health care systems need to expand the capacity of their skilled nursing systems, not only to provide clinical care, but also to support QI and medical education. The VABHS developed a physician staffing model with the goal of enriching physician practice and enhancing QI and educational opportunities in its SNF. The model offers an opportunity to improve transitions in care as physicians gain a greater knowledge of both the hospital and subacute clinical settings. This hospitalist rotation model may improve the knowledge necessary for caring for patients moving across care settings, as well as improve communication between settings. It also has served as a foundation for systematic innovation in QI and education at this institution. Clinical staff in the transitional care setting have reported positive effects of this model on clinical skills and patient care, educational opportunities, as well as a desire for replication in other health care systems.

The potential generalizability of this model requires careful consideration. The VABHS is a tertiary care integrated health care system, enabling physicians to work in multiple clinical settings. Other settings may not have the staffing or clinical volume to sustain such a model. In addition, this model may increase discontinuity in patient care as hospitalists move between acute and subacute settings and nonclinical roles. This loss of continuity may be a greater concern in the SNF setting, as the inpatient hospitalist model generally involves high provider turnover as shift work. Our survey included nurse managers, and not floor nurses due to survey administration limitations, and feedback may not have captured a comprehensive view from CLC staff. Moreover, some of the perceived positive impacts also may be related to professional and personal attributes of the physicians rather than the actual model of care. In addition, the survey response rate was 86%. However, the nature of the improvement work (focused on care transitions) and educational opportunities (interprofessional care) would likely not occur had the physicians been based in one clinical setting.

Other new physician staffing models have been designed to improve the continuity between the hospital, subacute, and outpatient settings. For example, the University of Chicago Comprehensive Care model pairs patients with trained hospitalists who provide both inpatient and outpatient care, thereby optimizing continuity between these settings.¹⁴ At CareMore Health System, high-risk patients also are paired with hospitalists, referred to as “extensivists,” who lead care teams that follow patients between settings and provide acute, postacute, and outpatient care.¹⁵ In these models, a single physician takes responsibility for the patient throughout transitions of care and through various care settings. Both models have shown reduction in hospital readmissions. One concern with such models is that the treatment teams need to coexist in the various settings of care, and the ability to impact and create systematic change within each environment is limited. This may limit QI, educational opportunities, and system level impact within each environment of care.

In comparison, the “transitionalist” model proposed here features hospitalist physicians rotating between the acute inpatient hospital and subacute care with dedicated time in each environment. This innovative organizational structure may enhance physician practice and enrich QI and educational opportunities in SNFs. Further evaluation will include the impact on quality metrics of patient care and patient satisfaction, as this model has the potential to influence quality, cost, and overall health outcomes.

Acknowledgments
We would like to thank Shivani Jindal, Matthew Russell, Matthew Ronan, Juman Hijab, Wei Shen, Sandra Vilbrun-Bruno, and Jack Earnshaw for their significant contributions to this staffing model. We would also like to thank Paul Conlin, Jay Orlander, and the leadership team of Veterans Affairs Boston Healthcare System for supporting this staffing model.

Care transitions between hospitals and skilled nursing facilities (SNFs) are a vulnerable time for patients. The current health care climate of decreasing hospital length of stay, readmission penalties, and increasing patient complexity has made hospital care transitions an important safety concern. Suboptimal transitions across clinical settings can result in adverse events, inadequately controlled comorbidities, deficient patient and caregiver preparation for discharge, medication errors, relocation stress, and overall increased morbidity and mortality.^1,2 Such care transitions also may generate unnecessary spending, including avoidable readmissions, emergency department utilization, and duplicative laboratory and imaging studies. Approximately 23% of patients admitted to SNFs are readmitted to acute care hospitals within 30 days, and these patients have increased mortality rates in risk-adjusted analyses. ^3,4

Compounding the magnitude of this risk and vulnerability is the significant growth in the number of patients discharged to SNFs over the past 30 years. In 2013, more than 20% of Medicare patients discharged from acute care hospitals were destined for SNFs.^5,6 Paradoxically, despite the increasing need for SNF providers, there is a shortage of clinicians with training in geriatrics or nursing home care.⁷ The result is a growing need to identify organizational systems to optimize physician practice in these settings, enhance quality of care, especially around transitions, and increase educational training opportunities in SNFs for future practitioners.

Many SNFs today are staffed by physicians and other licensed clinicians whose exclusive practice location is the nursing facility or possibly several such facilities. This prevailing model of care can isolate the physicians, depriving them of interaction with clinicians in other specialties, and can contribute to burnout.⁸ This model does not lend itself to academic scholarship, quality improvement (QI), and student or resident training, as each of these endeavors depends on interprofessional collaboration as well as access to an academic medical center with additional resources.⁹

Few studies have described innovative hospitalist rotation models from acute to subacute care. The Cleveland Clinic implemented the Connected Care model where hospital-employed physicians and advanced practice professionals integrated into postacute care and reduced the 30-day hospital readmission rate from SNFs from 28% to 22%.¹⁰ Goth and colleagues performed a comparative effectiveness trial between a postacute care hospitalist (PACH) model and a community-based physician model of nursing home care. They found that the institution of a PACH model in a nursing home was associated with a significant increase in laboratory costs, nonsignificant reduction in medication errors and pharmacy costs, and no improvement in fall rates.¹¹ The conclusion was that the PACH model may lead to greater clinician involvement and that the potential decrease in pharmacy costs and medications errors may offset the costs associated with additional laboratory testing. Overall, there has been a lack of studies on the impact of these hospitalist rotation models from acute to subacute care on educational programs, QI activities, and the interprofessional environment.

To achieve a system in which physicians in a SNF can excel in these areas, Veterans Affairs Boston Healthcare System (VABHS) adopted a staffing model in which academic hospitalist physicians rotate between the inpatient hospital and subacute settings. This report describes the model structure, the varying roles of the physicians, and early indicators of its positive effects on educational programs, QI activities, and the interprofessional environment.

Methods

The VABHS consists of a 159-bed acute care hospital in West Roxbury, Massachusetts; and a 110-bed SNF in Brockton, Massachusetts, with 3 units: a 65-bed transitional care unit (TCU), a 30-bed long-term care unit, and a 15-bed palliative care/hospice unit. The majority of patients admitted to the SNF are transferred from the acute care hospital in West Roxbury and other regional hospitals. Prior to 2015, the TCU was staffed with full-time clinicians who exclusively practiced in the SNF.

In the new staffing model, 6 hospitalist physicians divide their clinical time between the acute care hospital’s inpatient medical service and the TCU. The hospitalists come from varied backgrounds in terms of years in practice and advanced training (Table 1). 

The amount of nonclinical (protected) time and clinical time on the acute inpatient service and the TCU varies for each physician. For example, a physician serves as principal investigator for several major research grants and has a hospital-wide administrative leadership role; as a result, the principal investigator has fewer months of clinical responsibility. Physicians are expected to use the protected time for scholarship, educational program development and teaching, QI, and administrative responsibilities. The VABHS leadership determines the amount of protected time based on individualized benchmarks for research, education, and administrative responsibilities that follow VA national and local institutional guidelines. These metrics and time allocations are negotiated at the time of recruitment and then are reviewed annually.

The TCU also is staffed with 4 full-time clinicians (2 physicians and 2 physician assistants) who provide additional continuity of care. The new hospitalist staffing model only required an approximate 10% increase in TCU clinical staffing full-time equivalents. Patients and admissions are divided equally among clinicians on service (census per clinician 12-15 patients), with redistribution of patients at times of transition from clinical to nonclinical time. Blocks of clinical time are scheduled for greater than 2 weeks at a time to preserve continuity. In addition, the new staffing model allocates assignment of clinical responsibilities that allows for clinicians to take leave without resultant shortages in clinical coverage.

To facilitate communication among physicians serving in the acute inpatient facility and the TCU, leaders of both of these programs meet monthly and ad hoc to review the transitions of care between the 2 settings. The description of this model and its assessment have been reviewed and deemed exempt from oversight by the VA Boston Healthcare System Research and Development Committee.

Results

Since the implementation of this staffing model in 2015, the system has grown considerably in the breadth and depth of educational programming, QI, and systems redesign in the TCU and, more broadly, in the SNF. The TCU, which previously had limited training opportunities, has experienced marked expansion of educational offerings. It is now a site for core general medicine rotations for first-year psychiatry residents and physician assistant students. The TCU also has expanded as a clinical site for transitions-in-care internal medicine resident curricula and electives, as well as a clinical site for a geriatrics fellowship.

A hospitalist developed and implemented a 4-week interprofessional curriculum for all clinical trainees and students, which occurs continuously. The curriculum includes a monthly academic conference and 12 didactic lectures and is taught by 16 interprofessional faculty from the TCU and the Palliative Care/Hospice Unit, including medicine, geriatric and palliative care physicians, physician assistants, social workers, physical and occupational therapists, pharmacists, and a geriatric psychologist. The goal of the curriculum is to provide learners the knowledge, attitudes, and skills necessary to perform effective, efficient, and safe transfers between clinical settings as well as education in transitional care. In addition, using a team of interprofessional faculty, the curriculum develops the interprofessional competencies of teamwork and communication. The curriculum also has provided a significant opportunity for interprofessional collaboration among faculty who have volunteered their teaching time in the development and teaching of the curriculum, with potential for improved clinical staff knowledge of other disciplines.

Quality improvement and system redesign projects in care transitions also have expanded (Table 2). 

Early assessment indicates that the new staffing model is having positive effects on the clinical environment of the TCU. A survey was conducted of a convenience sample of all physicians, nurse managers, social workers, and other members of the clinical team in the TCU (N=24)(Table 3), with response categories ranging on a Likert scale from 1 (very negative) to 5 (very positive). 

Although not rigorously analyzed using qualitative research methods, comments from respondents have consistently indicated that this staffing model increases the transfer of clinical and logistical knowledge among staff members working in the acute inpatient facility and the TCU. 

Discussion

With greater numbers of increasingly complex patients transitioning from the hospital to SNF, health care systems need to expand the capacity of their skilled nursing systems, not only to provide clinical care, but also to support QI and medical education. The VABHS developed a physician staffing model with the goal of enriching physician practice and enhancing QI and educational opportunities in its SNF. The model offers an opportunity to improve transitions in care as physicians gain a greater knowledge of both the hospital and subacute clinical settings. This hospitalist rotation model may improve the knowledge necessary for caring for patients moving across care settings, as well as improve communication between settings. It also has served as a foundation for systematic innovation in QI and education at this institution. Clinical staff in the transitional care setting have reported positive effects of this model on clinical skills and patient care, educational opportunities, as well as a desire for replication in other health care systems.

The potential generalizability of this model requires careful consideration. The VABHS is a tertiary care integrated health care system, enabling physicians to work in multiple clinical settings. Other settings may not have the staffing or clinical volume to sustain such a model. In addition, this model may increase discontinuity in patient care as hospitalists move between acute and subacute settings and nonclinical roles. This loss of continuity may be a greater concern in the SNF setting, as the inpatient hospitalist model generally involves high provider turnover as shift work. Our survey included nurse managers, and not floor nurses due to survey administration limitations, and feedback may not have captured a comprehensive view from CLC staff. Moreover, some of the perceived positive impacts also may be related to professional and personal attributes of the physicians rather than the actual model of care. In addition, the survey response rate was 86%. However, the nature of the improvement work (focused on care transitions) and educational opportunities (interprofessional care) would likely not occur had the physicians been based in one clinical setting.

Other new physician staffing models have been designed to improve the continuity between the hospital, subacute, and outpatient settings. For example, the University of Chicago Comprehensive Care model pairs patients with trained hospitalists who provide both inpatient and outpatient care, thereby optimizing continuity between these settings.¹⁴ At CareMore Health System, high-risk patients also are paired with hospitalists, referred to as “extensivists,” who lead care teams that follow patients between settings and provide acute, postacute, and outpatient care.¹⁵ In these models, a single physician takes responsibility for the patient throughout transitions of care and through various care settings. Both models have shown reduction in hospital readmissions. One concern with such models is that the treatment teams need to coexist in the various settings of care, and the ability to impact and create systematic change within each environment is limited. This may limit QI, educational opportunities, and system level impact within each environment of care.

In comparison, the “transitionalist” model proposed here features hospitalist physicians rotating between the acute inpatient hospital and subacute care with dedicated time in each environment. This innovative organizational structure may enhance physician practice and enrich QI and educational opportunities in SNFs. Further evaluation will include the impact on quality metrics of patient care and patient satisfaction, as this model has the potential to influence quality, cost, and overall health outcomes.

Acknowledgments
We would like to thank Shivani Jindal, Matthew Russell, Matthew Ronan, Juman Hijab, Wei Shen, Sandra Vilbrun-Bruno, and Jack Earnshaw for their significant contributions to this staffing model. We would also like to thank Paul Conlin, Jay Orlander, and the leadership team of Veterans Affairs Boston Healthcare System for supporting this staffing model.

Care transitions between hospitals and skilled nursing facilities (SNFs) are a vulnerable time for patients. The current health care climate of decreasing hospital length of stay, readmission penalties, and increasing patient complexity has made hospital care transitions an important safety concern. Suboptimal transitions across clinical settings can result in adverse events, inadequately controlled comorbidities, deficient patient and caregiver preparation for discharge, medication errors, relocation stress, and overall increased morbidity and mortality.^1,2 Such care transitions also may generate unnecessary spending, including avoidable readmissions, emergency department utilization, and duplicative laboratory and imaging studies. Approximately 23% of patients admitted to SNFs are readmitted to acute care hospitals within 30 days, and these patients have increased mortality rates in risk-adjusted analyses. ^3,4

Compounding the magnitude of this risk and vulnerability is the significant growth in the number of patients discharged to SNFs over the past 30 years. In 2013, more than 20% of Medicare patients discharged from acute care hospitals were destined for SNFs.^5,6 Paradoxically, despite the increasing need for SNF providers, there is a shortage of clinicians with training in geriatrics or nursing home care.⁷ The result is a growing need to identify organizational systems to optimize physician practice in these settings, enhance quality of care, especially around transitions, and increase educational training opportunities in SNFs for future practitioners.

Many SNFs today are staffed by physicians and other licensed clinicians whose exclusive practice location is the nursing facility or possibly several such facilities. This prevailing model of care can isolate the physicians, depriving them of interaction with clinicians in other specialties, and can contribute to burnout.⁸ This model does not lend itself to academic scholarship, quality improvement (QI), and student or resident training, as each of these endeavors depends on interprofessional collaboration as well as access to an academic medical center with additional resources.⁹

Few studies have described innovative hospitalist rotation models from acute to subacute care. The Cleveland Clinic implemented the Connected Care model where hospital-employed physicians and advanced practice professionals integrated into postacute care and reduced the 30-day hospital readmission rate from SNFs from 28% to 22%.¹⁰ Goth and colleagues performed a comparative effectiveness trial between a postacute care hospitalist (PACH) model and a community-based physician model of nursing home care. They found that the institution of a PACH model in a nursing home was associated with a significant increase in laboratory costs, nonsignificant reduction in medication errors and pharmacy costs, and no improvement in fall rates.¹¹ The conclusion was that the PACH model may lead to greater clinician involvement and that the potential decrease in pharmacy costs and medications errors may offset the costs associated with additional laboratory testing. Overall, there has been a lack of studies on the impact of these hospitalist rotation models from acute to subacute care on educational programs, QI activities, and the interprofessional environment.

To achieve a system in which physicians in a SNF can excel in these areas, Veterans Affairs Boston Healthcare System (VABHS) adopted a staffing model in which academic hospitalist physicians rotate between the inpatient hospital and subacute settings. This report describes the model structure, the varying roles of the physicians, and early indicators of its positive effects on educational programs, QI activities, and the interprofessional environment.

Methods

The VABHS consists of a 159-bed acute care hospital in West Roxbury, Massachusetts; and a 110-bed SNF in Brockton, Massachusetts, with 3 units: a 65-bed transitional care unit (TCU), a 30-bed long-term care unit, and a 15-bed palliative care/hospice unit. The majority of patients admitted to the SNF are transferred from the acute care hospital in West Roxbury and other regional hospitals. Prior to 2015, the TCU was staffed with full-time clinicians who exclusively practiced in the SNF.

In the new staffing model, 6 hospitalist physicians divide their clinical time between the acute care hospital’s inpatient medical service and the TCU. The hospitalists come from varied backgrounds in terms of years in practice and advanced training (Table 1). 

The amount of nonclinical (protected) time and clinical time on the acute inpatient service and the TCU varies for each physician. For example, a physician serves as principal investigator for several major research grants and has a hospital-wide administrative leadership role; as a result, the principal investigator has fewer months of clinical responsibility. Physicians are expected to use the protected time for scholarship, educational program development and teaching, QI, and administrative responsibilities. The VABHS leadership determines the amount of protected time based on individualized benchmarks for research, education, and administrative responsibilities that follow VA national and local institutional guidelines. These metrics and time allocations are negotiated at the time of recruitment and then are reviewed annually.

The TCU also is staffed with 4 full-time clinicians (2 physicians and 2 physician assistants) who provide additional continuity of care. The new hospitalist staffing model only required an approximate 10% increase in TCU clinical staffing full-time equivalents. Patients and admissions are divided equally among clinicians on service (census per clinician 12-15 patients), with redistribution of patients at times of transition from clinical to nonclinical time. Blocks of clinical time are scheduled for greater than 2 weeks at a time to preserve continuity. In addition, the new staffing model allocates assignment of clinical responsibilities that allows for clinicians to take leave without resultant shortages in clinical coverage.

To facilitate communication among physicians serving in the acute inpatient facility and the TCU, leaders of both of these programs meet monthly and ad hoc to review the transitions of care between the 2 settings. The description of this model and its assessment have been reviewed and deemed exempt from oversight by the VA Boston Healthcare System Research and Development Committee.

Results

Since the implementation of this staffing model in 2015, the system has grown considerably in the breadth and depth of educational programming, QI, and systems redesign in the TCU and, more broadly, in the SNF. The TCU, which previously had limited training opportunities, has experienced marked expansion of educational offerings. It is now a site for core general medicine rotations for first-year psychiatry residents and physician assistant students. The TCU also has expanded as a clinical site for transitions-in-care internal medicine resident curricula and electives, as well as a clinical site for a geriatrics fellowship.

A hospitalist developed and implemented a 4-week interprofessional curriculum for all clinical trainees and students, which occurs continuously. The curriculum includes a monthly academic conference and 12 didactic lectures and is taught by 16 interprofessional faculty from the TCU and the Palliative Care/Hospice Unit, including medicine, geriatric and palliative care physicians, physician assistants, social workers, physical and occupational therapists, pharmacists, and a geriatric psychologist. The goal of the curriculum is to provide learners the knowledge, attitudes, and skills necessary to perform effective, efficient, and safe transfers between clinical settings as well as education in transitional care. In addition, using a team of interprofessional faculty, the curriculum develops the interprofessional competencies of teamwork and communication. The curriculum also has provided a significant opportunity for interprofessional collaboration among faculty who have volunteered their teaching time in the development and teaching of the curriculum, with potential for improved clinical staff knowledge of other disciplines.

Quality improvement and system redesign projects in care transitions also have expanded (Table 2). 

Early assessment indicates that the new staffing model is having positive effects on the clinical environment of the TCU. A survey was conducted of a convenience sample of all physicians, nurse managers, social workers, and other members of the clinical team in the TCU (N=24)(Table 3), with response categories ranging on a Likert scale from 1 (very negative) to 5 (very positive). 

Although not rigorously analyzed using qualitative research methods, comments from respondents have consistently indicated that this staffing model increases the transfer of clinical and logistical knowledge among staff members working in the acute inpatient facility and the TCU. 

Discussion

With greater numbers of increasingly complex patients transitioning from the hospital to SNF, health care systems need to expand the capacity of their skilled nursing systems, not only to provide clinical care, but also to support QI and medical education. The VABHS developed a physician staffing model with the goal of enriching physician practice and enhancing QI and educational opportunities in its SNF. The model offers an opportunity to improve transitions in care as physicians gain a greater knowledge of both the hospital and subacute clinical settings. This hospitalist rotation model may improve the knowledge necessary for caring for patients moving across care settings, as well as improve communication between settings. It also has served as a foundation for systematic innovation in QI and education at this institution. Clinical staff in the transitional care setting have reported positive effects of this model on clinical skills and patient care, educational opportunities, as well as a desire for replication in other health care systems.

The potential generalizability of this model requires careful consideration. The VABHS is a tertiary care integrated health care system, enabling physicians to work in multiple clinical settings. Other settings may not have the staffing or clinical volume to sustain such a model. In addition, this model may increase discontinuity in patient care as hospitalists move between acute and subacute settings and nonclinical roles. This loss of continuity may be a greater concern in the SNF setting, as the inpatient hospitalist model generally involves high provider turnover as shift work. Our survey included nurse managers, and not floor nurses due to survey administration limitations, and feedback may not have captured a comprehensive view from CLC staff. Moreover, some of the perceived positive impacts also may be related to professional and personal attributes of the physicians rather than the actual model of care. In addition, the survey response rate was 86%. However, the nature of the improvement work (focused on care transitions) and educational opportunities (interprofessional care) would likely not occur had the physicians been based in one clinical setting.

Other new physician staffing models have been designed to improve the continuity between the hospital, subacute, and outpatient settings. For example, the University of Chicago Comprehensive Care model pairs patients with trained hospitalists who provide both inpatient and outpatient care, thereby optimizing continuity between these settings.¹⁴ At CareMore Health System, high-risk patients also are paired with hospitalists, referred to as “extensivists,” who lead care teams that follow patients between settings and provide acute, postacute, and outpatient care.¹⁵ In these models, a single physician takes responsibility for the patient throughout transitions of care and through various care settings. Both models have shown reduction in hospital readmissions. One concern with such models is that the treatment teams need to coexist in the various settings of care, and the ability to impact and create systematic change within each environment is limited. This may limit QI, educational opportunities, and system level impact within each environment of care.

In comparison, the “transitionalist” model proposed here features hospitalist physicians rotating between the acute inpatient hospital and subacute care with dedicated time in each environment. This innovative organizational structure may enhance physician practice and enrich QI and educational opportunities in SNFs. Further evaluation will include the impact on quality metrics of patient care and patient satisfaction, as this model has the potential to influence quality, cost, and overall health outcomes.

Acknowledgments
We would like to thank Shivani Jindal, Matthew Russell, Matthew Ronan, Juman Hijab, Wei Shen, Sandra Vilbrun-Bruno, and Jack Earnshaw for their significant contributions to this staffing model. We would also like to thank Paul Conlin, Jay Orlander, and the leadership team of Veterans Affairs Boston Healthcare System for supporting this staffing model.