From Crawling to Running: Helping Medical Students Understand and Implement Innovative Chronic Disease Management Techniques Christopher Scuderi D.O Medical Director UF New Berlin Family Medicine Center Assistant Professor of Community Health and Family Medicine Kenyatta Lee M.D. Medical Director UF Soutel Family Medicine Center

The Challenge (Crawling) In three weeks, take a third year medical student on a journey from learning about the abstract concepts of the PCMH and Chronic Disease Registries……

The Challenge (Walking) In three weeks take a third year medical student on a journey from learning about the abstract concepts of the PCMH and Chronic Disease Registries…… To developing a passion and a level of comfort in using these tools to improve chronic disease care…..

The Challenge (Running) In three weeks take a third year medical student on a journey from learning about the abstract concepts of the PCMH and Chronic Disease Registries…… To developing a passion and a level of comfort in using these tools to improve chronic disease care….. To becoming innovators and leaders in advancing these concepts in a clinical environment

Three Objectives Identify the challenge of teaching the PCMH concept and inspiring future physicians to implement it in practice Discuss the innovative methods we have used to address this problem Review how our students translate their experience into changing patient outcomes

Why This Challenge Only 56% of recommended care is being provided for patients with chronic illness in the United States*. The Chronic Care Model clearly shows that registries improve outcomes and quality. How can the next generation of family physicians learn to provide quality, evidence based care? Marriage of technology and commitment to quality care * Schmittdiel J, Bodenheimer T,2 Solomon A, BRIEF REPORT: The Prevalence and Use of Chronic Disease Registries in Physician Organizations J Gen Intern Med. 2005 September; 20(9): 855–858

Medical Student Awareness A recent study of medical students showed that only 40.9% of students were familiar with the concept of the patient centered medical home† Of these 40.9% almost 70% stated they learned about it during their primary care rotation Joo, P; Young,R; Medical Student Awareness of the Patient-centered Medical Home; Family Medicine 43: 10 Nov 2011

How Are We Currently Meeting This Challenge? A recent survey data revealed that 41% of departments had implemented a specific PCMH curriculum for medical students and 65% had developed a PCMH curriculum for residents David A, Baxley L. Education of Students and Residents in Patient Centered Medical Home (PCMH): Preparing the Way. Ann Fam Med 2011; 9:274-275. Alan David, MD; Libby Baxley, MD EDUCATION OF STUDENTS AND RESIDENTS IN PATIENT CENTERED MEDICAL HOME (PCMH): PREPARING THE WAY Ann Fam Med 2011;9:274-275. doi:10.1370/afm.1272

University of Florida Jacksonville Community Health and Family Medicine Active participation and utilization of Chronic Disease Registries is required of all rotating medical students UF New Berlin Family Medicine Center Florida Academy of Family Physicians Master Diabetes Clinician Program UF Soutel Family Medicine Center Unique multi-disease database

Orientation Three week rotation Third- and Fourth-year medical students Limited or no experience with PCMH Early assessment of student’s familiarity with the PCMH concept and individual professional goals

Week 1: Crawling Basic tenets of PCMH reviewed with an emphasis on chronic disease registries: 1. Discuss components of chronic disease registries 2. Introduce data demonstrating efficacy of registries 3. Review methods of data collection 4. Examine ways to target at-risk segments of our population 5. Stress why medical assistants are an integral part of the care team

Week 2: Walking -students choose an aspect of the registry UF New Berlin Family Medicine Center: -students choose an aspect of the registry -then design a project to improve clinical outcomes based on this component UF Soutel Family Medicine Center: -students choose a new chronic disease -create a new registry for a chronic disease working with the database coordinators

Week 3 Running Students execute their plans At the end of the week, their summary data is reviewed Students give a 15 minute presentation to the faculty and staff

Examples K.I., MSIII worked on improving the compliance of diabetic patients requiring the influenza vaccine in 2011

Improving Influenza Vaccination Rates in Diabetic Patients 2011 Phase 1: Crawling - Educational goals and personal assessment - Introduction to the PCMH - Discussion of the dangers of influenza in the diabetic patient - Taught about the efficacy of the influenza vaccine and common barriers to patients adherance to recommended immunization schedules

Improving Influenza Vaccination Rates in Diabetic Patients 2011 Phase 2: Walking Compiled a list of the patients who have not been immunized Contacted these patients to discuss their barriers to care and to offer them the opportunity to be vaccinated

Improving Influenza Vaccination Rates in Diabetic Patients 2011 Phase 3: Running Updated the database on the patients who have acted upon the students encouragement Educated the medical assistants and staff of the clinic on the dangers of influenza in diabetics and reviewed with them how to answer common reasons from patients on why they do not want to be immunized

Improving Influenza Vaccination Rates in Diabetic Patients 2011 K.I., MSIII was able in 10 days to increase our percentage of diabetics who received their yearly influenza vaccine from 44% to 56% More importantly he left a legacy of an empowered staff to educate the remaining 44% of diabetic patients of the dangers of influenza and the importance of immunization

Other Student Topics Transforming Our Diabetes Registry Improving rates of yearly diabetic retinopathy screening Addressing smoking cessation in diabetics Identification of patients with an A1C > 10 Targeting patients who have not had labs in > 1 year Recognizing the patients who have not been annually screened for microalbuminuria Addressing uncontrolled hypertension in our diabetic population

UF Soutel Family Medicine Center Hypothyroidism Project

Hypothyroidism Project Phase I: Crawling R.R., MSIII spent a 3 week rotation at UF Soutel Family Medicine Center Educational goals and personal assessment Introduction to the PCMH Student identified area of interest (hypothyroidism) Worked with database coordinators to interrogate data for 30 patients with hypothyroidism

Hypothyroidism Project Phase II: Walking Student reviewed data: Identified 5 out of 30 patients who were not managed properly Student identified 3 principles to target these patients: - Let’s put the system to work for us - Redundancy in the system will lead to improve quality of care - Patient centered medical homes are well-equipped to develop and maintain a protocol to track and treat patients with chronic diseases such as Hypothyroidism

Hypothyroidism Project Phase III: Running Student-designed registry with 5 key points Identify all the Hypothyroid patients within our practice based on TSH levels Euthyroid patients without symptoms are automatically scheduled to have their TSH checked every 6 months Uncontrolled patients will have repeat TSH levels every 6 weeks after a change in the medication dosage until euthyroid state is achieved The registry will be responsible to keep track of the patient’s numbers and to send reminders to the provider to make appropriate adjustment. Can also send reminders to the patients to get their labs drawn Ultimately the provider is still responsible for the overall management, but involving the registry creates redundancy which will lead to better care and outcome

Hypothyroidism Project Protocol TSH reference range: 0.27-4.2 TSH>4.2 Hypothyroid Send a reminder to provider to increase medication by 12.5 to 25 microgram increments and send letter to patient outlining need to change medication and get labs 6 weeks after TSH =0 .27-4.2 Schedule labs for every 6 months. Send a letter to patient to remind them to get labs drawn. TSH < 0.27 Over treated: Send a reminder to provider to decrease medication by 12.5 to 25 microgram increments and send letter to patient outlining need to change medication and get labs 6 weeks after

Hypothyroidism Project Phase III: Running Student finished rotation by educating staff on hypothyroidism and how to use his registry during his 15 minute lecture His registry is still in use helping providers track patients who are not optimally treated

Student Testimonial “While working at New Berlin Family Medicine Center, I witnessed the benefits in patient care not only in outcomes but in preventative medicine that successful use of the core principles of the patient centered medical home can have for a family practice.” Richard Moore MSIV

Lead Medical Assistants View “As a whole, we learn more about diabetes with every presentation. It helps us stay current on the newest findings in diabetic patients as well as the newest solutions. With that information we are more knowledgeable and feel empowered to help with the care of our patients.” - Latesha Harmon, Lead MA

UF New Berlin Family Medical Center Medical Student Wall of Fame

Questions