Continuity Patient Panel Reassignment in Primary Care Residencies: A Report from the I 3 Collaborative Chuck Carter, MD, FAAFP Mark Robinson, MD Michele Stanek, MS I 3 Collaborative

Disclosures We have no conflicts of interest to disclose.

Background Continuity of care, personal doctoring foundational to Family Medicine Continuity improves patient outcomes ACGME program requirements for FM, IM, Pediatrics: designated panel of patients No prior published studies describing processes used by residencies

Multi-state residency education collaborative In its third iteration – I 3 POP –focused on the IHI “Triple Aim” 27 residencies –Family Medicine (23) –Internal Medicine (2) –Pediatrics (2)

Methods Descriptive, cross sectional study Survey of I 3 Program Directors using SurveyMonkey® web survey tool 38-items, mix of closed and open-ended questions. Questions included items measuring program characteristics, continuity of care measurement, panel size by training year and faculty status, reassignment practices, utilization of EMR for panel management and patient notification. Approved under master IRB for I 3 Collaborative participation, UNC-CH IRB

Results – Program Characteristics Self-identified program category% Community-based10.34% (n-3) Community-based, university affiliated62.07% (n-18) Community-based, university administered6.90% (n-2) University-based20.69% (n-6) 29 responding programs Family Medicine86.21% (n-25) Internal Medicine6.90% (n-2) Pediatrics6.90% (n-2) Faculty and residents see patients at same location/Tax ID - 90% (n-26/29)

Residents per class Median class size 8.5 X

Panel Size (Median)Panel Size (Mean)Range PGY PGY PGY Faculty % (N-16) manage lists on a regular basis Continuously: N=4Bi-annually: N=4Annually: N=8 Do you? Yes Assign a primary care clinician to all patients96% Assigns patients to care teams65% Routinely measure continuity of care72% Assign a designated patient panel to residents86%

Does EMR allow continuity physician assignment? 96% Yes

Reassignment processes and EMR Hand count/Manual, with panel lists separately maintained outside of EMR 20.00% (n-5) Automated/Electronic, with panel lists separately maintained outside of EMR 8.00% (n-2) Hand count/Manual, with manual input into the EMR28.00% (n-7) Hand count/Manual, with electronic input into the EMR (ex. database import) 8.00% (n-2) Electronic reassignment, manual input into EMR20.00% (n-5) Electronic reassignment, electronic input into EMR8.00% (n-2) Fully electronic, embedded in the EMR8.00% (n-2)

Programs devote approx. 2 staff to process Takes a median of 4-5 weeks (range 1-2 up to 3 months), mostly in June and July Notification –81% notify patients (majority are form letters –46% allow patient input

Rate your impression reassignment has on patient satisfaction with your practice

Conclusions Variation in program approach, panel size, EMR support Large numbers of patient reassignments I 3 Collaborative: ≈3289 patients (387 x 8.5) per program each year, i.e. > 1 FTE physician Resource intense – hidden cost for programs Staff Hand counting, databases, manual input Overall negative perceived impact on patient satisfaction

Next steps and implications Next steps –Submit for publication –Refine survey for CERA Implications –Are we delivering on the PCMH and/or model practice ideal? –Conflict between personal doctoring and transient nature of residency –What is the best balance of interests? –Investigate patients’ perceptions of reassignment

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