Montgomery & Graham 5-3-2008 Creating PCMH Leaders by Reconfiguring Traditional Residency Structure and Content Dan Burke, MD University of CO Family Medicine Residency Brandy Deffenbacher, MD University of CO Family Medicine Residency Bonnie Jortberg, MS, RD, CDE Colorado Family Medicine Residency PCMH Projectg Barb Kelly, MD Linda Montgomery, MD STFM: S58 Personal Care Plans 1

Lecture Objectives By the end you should be able to… Montgomery & Graham 5-3-2008 Lecture Objectives By the end you should be able to… explain how rotations can be resequenced and longitudinal elements added to create PCMH teaching capacity outline the major content that should be taught in a PCMH curriculum articulate the importance of integrating the practice and the residency for true PMCH creation and teaching Intro – Structure, Content, Integration STFM: S58 Personal Care Plans 2

Who We Are… 8-8-8 Residency Urban Denver Opened 1995 Montgomery & Graham 5-3-2008 Who We Are… 8-8-8 Residency Urban Denver Opened 1995 STFM: S58 Personal Care Plans 3

Of course…P4 UCFMR P4 Project 2006 - present Montgomery & Graham 5-3-2008 Of course…P4 UCFMR P4 Project 2006 - present Comprehensive Care Leadership Community Integration Health Behavior Change Curriculum UCFMR major threads Comprehensive Care Model Health Behavior Change Community Integration Important to understand what we said in our P4 proposal --- that any new curricular changes to the residency would emphasize three major threads 4 STFM: S58 Personal Care Plans 4 4

Where we teach the PCMH R-1Learning Intensives July Chautuaqua -1: Adult inpatient October C -2: OB et al May C-3: ICU et al R-2 Year -March-May 6 week PCMH Block Rotation 1 session/week each -CM -QI R-3 CM/QI session 2x/mo. PCMH seminar 1x/mo.

UCFMR PGYI Schedule Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Chautauqua Medicine Surgery Obstetrics Out Patient Pediatrics Jan Feb Mar Apr May Jun Newborn Care Family Medicine Service Adult Family Medicine Service Emergency Medicine Chautauqua PGY2 Level Rotation (ICU, IP Peds) This structure gave us opportunities for longitudinal learning that our old block schedule did not

Chautauqua learning blocks R-1Jul. , Oct Chautauqua learning blocks R-1Jul., Oct. May Chautauqua Park in Boulder

R-2s work week PCMH Block March - May Mon Tues Wed Thurs Fri AM Clinic Fixed Clinic Care Management Practice Improvement PM Area Of Clinical Concentration Didactics Community Project Fixed clinic Created time for creation of care plans

Longitudinal R-3 PCMH Mon Tues Wed Thurs Fri AM Fixed Clinic PM Rotation Fixed Clinic Care Team -QI PM Didactics Com- munity Project Fixed clinic My Shot at making Care Plan a Verb

By the Numbers R-1 C-1 1. Health Behavior and Community (Talk & assignment) 2 2. P4 Project Overview (Talk) 1 3. Health Behavior Change (Interactive Discussion) 2 4. Resident Health & Community Presentations 8 (Case based research and PowerPoint presentation) ____________ C-1 Total 13 C-2 1. PCMH Collaborative Orientation (Talk) 1 2. PCMH Collaborative Meeting (State wide meeting) 12 _____________ C-2 Total 13 C-3 1. The CCM and PCMH (Talk and assignment) 2 2. Community Resources (Talk) 1 3. SMS / Health Behavior Change (Talk) 1 4. Resident Presentations on PCMH elements 8 5. PCMH Collaborative Meeting 12 6. Intro to PCMH Block Rotation 1 C-3 Total 25 R-1 Total 51 Hours

By the Numbers R-2 PCMH Block 1. CM – 4Hr/wk x 6 wks 24 2. QI – 4 Hr/wk x 6 wks 24 3.PCMH Seminar 2 ___________________ Total 50

By the Numbers R-3 About 7 months of the R-3 year allow for attendance twice per month at on going CM/QI activities and once monthly PCMH seminar. 1. CM/QI 14 x 4 hours 56 2. PCMH Seminar 7 x 2hours 14 3. Capstone Month 38 _____________ R-3 Total 108

By the Numbers R-1 13 R-2 50 R-3 108 ______________ Total 171

By the Numbers 6 Rotations R-1 Chautauqua x 3 Montgomery & Graham 5-3-2008 By the Numbers 6 Rotations R-1 Chautauqua x 3 R-2 PCMH x 2 (actually 6 weeks) R-3 “Capstone” STFM: S58 Personal Care Plans

What did we Lose? Community Medicine (became longitudinal) Behavioral Medicine (became longitudinal Electives (some became longitudinal) Geriatrics (sort of) FMS

How do we translate Structure into a Curriculum? Montgomery & Graham 5-3-2008 How do we translate Structure into a Curriculum? STFM: S58 Personal Care Plans

Resources for Curriculum Building 2009 Montgomery & Graham 5-3-2008 Resources for Curriculum Building 2009 “7 Principles” John Rogers “Assembling the Medical Home” series “Care Principles” “Infrastructure Principles” Kathy Miller “Competency Based Goals and Objectives for PCMH Block” STFM: S58 Personal Care Plans

R-2s work week PCMH Block Mon Tues Wed Thurs Fri AM Clinic Fixed Clinic PCMH: Care Management Practice Improve- ment PM Didactics Community Project Fixed clinic

Goals of Care Management Morning Montgomery & Graham 5-3-2008 Goals of Care Management Morning Introduce team-based care to residents and clinic Improve patient outcomes and satisfaction through more coordinated care Explore how to create and use Personal Care Plans STFM: S58 Personal Care Plans

Care Management Morning Structure Montgomery & Graham 5-3-2008 Care Management Morning Structure Care Management Team Meeting Working on complex patient care Care Plan Creation Work on “care beyond the exam room” (behavioral health/social work co-consults, home visits, self management support follow-up, care plan creation) STFM: S58 Personal Care Plans

The Care Management Team Montgomery & Graham 5-3-2008 The Care Management Team Family medicine attending and resident(s) Psychology attending Pharmacology attending and residents Social Worker Charge Nurse STFM: S58 Personal Care Plans

Montgomery & Graham 5-3-2008 Care Plans STFM: S58 Personal Care Plans

R-2s work week PCMH Block Mon Tues Wed Thurs Fri AM Clinic Fixed Clinic PCMH: Care Management Practice Improve- ment PM Didactics Community Project Fixed clinic Created time for creation of care plans

Practice Improvement Mornings Montgomery & Graham 5-3-2008 Practice Improvement Mornings Time to work on PDSA Cycles Work on population management: registries, patient panels, guideline use Attendance at PCMH Improvement Team STFM: S58 Personal Care Plans

Montgomery & Graham 5-3-2008 PCMH Improvement Team Clinic Manager, Charge Nurse, administrative support, Residents, Faculty Mostly work on NCQA PCMH recognition STFM: S58 Personal Care Plans

Lessons Learned After Year One Montgomery & Graham 5-3-2008 Lessons Learned After Year One More structured learning Better communication Increased connection of efforts to the clinic Very labor intensive for faculty STFM: S58 Personal Care Plans

Colorado FM Residency PCMH Project Montgomery & Graham 5-3-2008 Colorado FM Residency PCMH Project Colorado Clinical Guidelines Collaborative (CCGC),  Univ. of CO DFM, Colorado Association of Family Medicine Residencies (CAFMR) and the Colorado Institute of Family Medicine (CIFM) Providing curricular support with competencies, coaching, assessments, Collaboratives STFM: S58 Personal Care Plans

Learning Modules Basics (PCMH concepts, financing models) Montgomery & Graham 5-3-2008 Learning Modules Basics (PCMH concepts, financing models) QI and Population Management Leadership (meetings, change management, teamwork) Care Coordination Self Management Support STFM: S58 Personal Care Plans

Montgomery & Graham 5-3-2008 Blog STFM: S58 Personal Care Plans

Blog Pages AFW Gold AFW Green AFW Red Lowry Diamond Lowry Gold Montgomery & Graham 5-3-2008 Blog Pages AFW Gold AFW Green AFW Red Lowry Diamond Lowry Gold PCMH Schedule Basics of the PCMH Quality Improvement Basics Leadership Care Coordination Self-management support/health behavior change Community Medicine STFM: S58 Personal Care Plans

Montgomery & Graham 5-3-2008 Team AFW STFM: S58 Personal Care Plans

Next steps for the curriculum… Montgomery & Graham 5-3-2008 Next steps for the curriculum… More work on how to finance the PCMH More on critical appraisal of the PCMH (Starfield, Rogers, TransforMed objective data) More deliverables by residents Care management R2/R3 pod leaders Care management integration with inpatient team 5-3-2008 S58: Personal Care Plans STFM: S58 Personal Care Plans

PCMH/P4 The birth of a new PCMH What is that new medical director up to? Intro Purpose wedding practice and residency New medical director

Preconception P4 January 2007 to current Two years of residency work, faculty development and culture change Not integrated into the clinic Listen and understand I would “forget” that the staff and clinic had not been discussing this for years as the residency faculty had. I had to understand their frustrations and figure out where they were in their day to day lives. It was my job to figure out how to integrate these ideas about PCMH and training doctors for the future into our actual day to day lives working in the clinic.

Conception: A new paradigm May 2008 Retreat All inclusive Reintroduce P4 Introduce NCQA and PCMH Listen Survey results Propose change Common vision and language So we used a retreat to get us all at least on the same page. Mandatory. feel good about who we were already with the right people and the right structure ( beta site for EMR, University and Hospital support, training future doctors). As I looked back at what to tell you today I realized that this retreat may have been one of the keys to our success. It allowed us to become a different place to work, a new paradigm, using a common vision and a common language to create something now.

Expectant Waiting No traction on 3 projects No nurses Coaches to start soon PCMH Curriculum soon We kept talking about our vision and planning for our future We started with 3 projects that really did not work due to lack of support both time and money to get them done. Reality was we had no nurses, life was difficult working in the clinic, and it was easy keep talking about our vision, to wait until the residency curriculum with resident support started in February. Over the fall the stars aligned . . .

Birth: Baby PCMH January 2009 CCGC: Coaching and $$$ PCMH Curriculum February 2009 Resident workforce/RRC curriculum Fixed and variable clinics PI meetings QI meetings PCMH meetings weekly Practice mgt RRC Fixed and variable allowed staff and patients and residents to change their vision and function day to day

Parenting 101 First time parents: learning to lead but also to let others learn EMR fiasco Vision progresses to doing ( Ages and Stages PDSA) Project managers identified

Playing with Others Colorado Clinical Guidelines Collaborative All 9 CO FM residencies supported in NCQA PCMH transformation. very supportive process and key to our success.

Baby Steps Project managers take charge (and get paid) Pods and Teams: Staff empowerment (culture change) QI projects with coaching PDSA Aim statements Process mapping Clinic issues first Leadership development and time Podcasts/Survey Monkey/Fun Agenda driven meetings with FOOD!

Lessons learned Prioritize—multiple directions at once is difficult Get “buy in” Start at where you are Change is slow “Life happens” --keep the vision alive If we can fix their daily work frustrations they have the time and energy to tackle more and create new things. We prioritized the staff needs first, and as a result change is slow.

Success Infrastructure Time Meetings, food, coaching support Talent: The RIGHT project managers Staff development and support Treasure Again FOOD Financial support of time for project managers and pod leaders Success needs infrastructure.

WHERE ARE WE HEADED? PCMH TIME Begin training for Pod Leaders Coaching Program 3 Year CCGC Completed February 2012 PCMH TIME Pod PDSA Project #2 March 2010 Pod PDSA Project #1 November 2009 Clinically Important Conditions PDSA Cycles surrounding June 2010 And finally here is an example of our Podman, and a timeline of where we are headed. We are not done. Finally we have a resident here, Brandy Deffenbacher, to tell you about her experience as a resident during this process. Begin training for Pod Leaders January 2010 Current 2nd years PCMH Blocks March 2010-May 2010 Start Registry Setting NCQA Application Final Deadline February 2012 Next TEAM AFW Dec. 10th Noon – Conference Room There will be food!

Montgomery & Graham 5-3-2008 Interactive Session How are you currently tying together PCMH elements in your residency? What are the opportunities/barriers to change? STFM: S58 Personal Care Plans