Developing a PCMH Team Block Rotation: Practical Considerations for FM Residency Training Rabin Chandran, MD; Arnold Goldberg, MD; David Ashley, MD; Christopher Furey, MD; Kim Salloway Rickler, MSW; Judy Walker, BA; Gowri Anandarajah, MD

Introductions

Workshop Objectives Participants will be able to: – Articulate core competencies for a PCMH rotation in a family medicine residency program. – Develop didactic teaching strategies to address core content for a PCMH rotation. – Discuss experiential and clinical teaching strategies to address PCMH competencies. – Articulate ideas for adapting a PCMH rotation to their home institution

Presentation Overview Introductions and Overview (5 min) Large Group Brainstorming: Content for PCMH Rotation (5 min) The Brown FM PCMH Rotation (20 min) Small Group Breakout (20 min) Report Back From Groups (15 min) Large Group Discussion/problem solving (25 min)

Brainstorming: What elements of PCMH are important to prepare residents for practice? (There are no wrong answers in this storm.)

The Brown Family Medicine PCMH Rotation

Before the rotation Our residency: – 13 Residents per year (39 total) – Community hospital, with a Strong Medical School Affiliation – Yearly schedule broken into 13 four week blocks

Before the rotation Our Practice: – The Family Care Center – Residents divided into three teams – 12,500, primarily low income patients – 30,000 Annual Visits

PCMH at Brown Before the Rotation Some PCMH successes – NCQA Level 3 PCMH – On Site Behavioral Health Faculty – EMR – Nutritionist on-site – Open access scheduling

Before the rotation Our Previous PCMH Clinical Training – Third year rotation in outpatient family medicine, nursing home/home bound care, and transitions of care – R1 Practice Management Rotation with focus on outpatient ambulatory practices – Monthly Continuity Clinic Team Meetings

Before the rotation Our Previous PCMH Didactic Teaching – Annual ½ day workshops – Noon-conferences – PCMH champions as role- models

Before the Rotation 75% of 2011 graduates felt “prepared” to implement PCMH principles in their practice

The Brown PCMH Rotation So why change?

Needs Assessment Based on exit interviews of 2011 Grads – 50% Had never heard of NCQA – Almost half had never been involved in a PDSA Cycle and 75% felt unprepared to lead one. – 75% had never completed a chart audit – None had lead a GMV, only half felt prepared – Only half had analyzed a chronic disease registry (mostly only the report they received on their own patient panel)

Needs Assessment Experience breeds confidence – Residents who felt prepared to lead a GMV had participated in an average of 1.5 during residency, compared to an average of 0 for those who felt unprepared – Residents who felt prepared to lead a PDSA cycle had participated in an average of 1 during residency, compared to an average of 0 for those who felt unprepared

Building a PCMH Rotation Additional Resources – HRSA Grant – Pharm D Students – Nurse Care Managers – Behavioral Science Faculty (MSW and PhD)

The Brown PCMH Rotation Our solution: The PCMH Team Block Rotation – Create a month long team based rotation – Team composed of first year, second year and third year resident – Ultimately allow for senior residents to show leadership and proficiency in elements of PCMH to junior residents.

Combined Three Rotations The R1 outpatient Practice Management “Selective” The R3 Nursing home/homebound and ambulatory month A month we took back from the inpatient service.

Three Main Components PCMH Principles/Didactics/Practical skills Pre-existing Practice Management Curricular Elements Continuity of Care Clinical Components: – Review of overnight phone calls – Nursing home/Homebound acute visits – Transitions from the hospital to the NH – Acute Care visits and primary care sessions

The Structure Early am: hospital patient search Multidisciplinary teem meets for 30 min to review census, discharges, phone notes, plan acutes/day. Weekly didactics and projects – anchored by 2 hours blocks Monday and Friday afternoons. Patients most mornings, some blocks for projects Each afternoon R2/R3 either with acutes or NH/HB visits.

4 Themes 1. The PCMH Model (NCQA, Chronic Care Model,Dashboards, Registries…) 2. Patient Safety (MaPSF (Safety culture), Trigger Tools) 3. Group Medical Visits (motivational interviewing, working in teams, Chronic Disease management) 4. Chart Audits (quality, coding and billing)

The Brown PCMH Rotation So have the changes made a difference?

The Brown PCMH Rotation The (preliminary) Results – Data from exit interviews of 2011 grads – Compared to online survey asking same questions of 8 of 13 third year residents who have completed PCMH month

P Value: Using Mann-Whitney U Test

P Value: Using Mann-Whitney U Test

P Value: Using Mann-Whitney U Test

P Value: Using Mann-Whitney U Test

P Value: 1.0 Using Mann-Whitney U Test

The Brown PCMH Rotation After (almost) one year – Increased numbers of GMV’s, Chart Audits, PDSA Cycles – Improved residents confidence to lead GMV’s, Chart Audits, PDSA Cycles – Have not yet improved residents’ confidence to “implement PCMH principles” in their practice

The Future End of year assessment Continued assessment in future years Constant efforts to improve clinic as a PCMH

Small Group Breakout: Making a Better PCMH Rotation Group 1: Priorities for the PCMH Curriculum Group 2: Optimal experiential learning/clinical content Group 3: Adapting/modifying the structure of a PCMH rotation to different settings: rural, large academic, multi-site residencies, smaller residencies.

Presentation Overview Introductions and Overview Group Discussion: Content for PCMH Rotation The Brown FM PCMH Rotation Small Group Breakout Report Back From Groups Large Group Discussion

Presentation Overview Introductions and Overview Group Discussion: Content for PCMH Rotation The Brown FM PCMH Rotation Small Group Breakout Report Back From Groups Large Group Discussion

Wrap Up