The Personal Medical Home and Maternity Care Brooks Flood, DO, Brandy Deffenbacher, MD, Annamarie Meeuwsen, MD, Suzanne Gomez, MD, and Jay H. Lee, MD University of Colorado Family Medicine Residency (UCFMR)

Objectives Describe the Patient Centered Medical Home (PCMH) Describe the “current state” of maternity care at the UCFMR Discuss the PCMH curriculum Describe how residents use practice-based learning to assess change

PCMH Future of Family Medicine 2004 Evidence Based EMR’s Described “New Model” of Care Evidence Based EMR’s Asynchronous Communication Office design Advanced scheduling Group Visits Described Medical Home P4 2006 How do we put these concepts into residency training?

P4 Make a better doctor for today’s and tomorrow's needs Preparing the Personal Physician for Practice CU Goals: Make a better doctor for today’s and tomorrow's needs Revamp Curriculum “Intentionalize” Internship Create a PCMH

PCMH Prepare PGY2 residents to be effective participants in a practice that is a patient centered medical home by: More consistent presence in clinic More cohesive teams Group visits Community integration Health behavior change counseling New roles and relationships

Schedules Prior to PCMH Rotations dictated clinic days No clinic days during certain rotations Each month focused on specialty training “training to be surgeon, internist, ob/gyn”

Mon Tue Wed Thurs Fri AM PM Fixed Clinic Clinic Fixed Clinic Care Management Practice Improvement Fixed Clinic PM Fixed Clinic Elective Didactics Community Fixed Clinic

PCMH Research Question How does working in a PCMH residency affect our maternity care, especially in terms of continuity of care?

Methods Suzy Gomez

Study Method Retrospective chart review

Definition of Continuity and PCP Continuity Requirement for Residency Review Committee (RRC) Prenatal, natal, and postnatal Primary Care Provider Provider who saw the patient the most times

University of Colorado Family Medicine Residency University Track Academics and Research 6 Residents Denver Health Track Underserved 2 Residents

AF Williams Continuity clinic for the residents of the UH track Part of the University of Colorado Hospital system

Lowry Continuity clinic for residents of the DH track Part of the Denver Health and Hospitals system (eight community health centers)

Inclusion Criteria Receiving prenatal care from August 2008 to Feb 2009 Delivered before Feb 1, 2009 Prior to PCMH AFW included all OB patients Lowry data included OB patients seen by a resident

Exclusion Criteria Two or less prenatal visits Non-prenatal visits Ultrasounds Acute sick visits

Data Collection Lowry AF Williams Data gathered in central log from each OB patient seen by a resident AF Williams Obtained of all OB patients from medical records

Data Collection EMR search Age, Gravity, Parity LMP & EDC Insurance Number of providers Number of prenatal visits

Continuity Modified modified continuity index MMCI = (1 - P/V)/(1 - 1/V) P = # of providers who saw the patient V = # of visits J Fam Pract 1987; 24: 165-8.

Results Brandy Deffenbacher

Questions Is there a relationship between age and continuity? Do primigravidas or multigravidas have better continuity? Do non-resident providers have better continuity? Do insured patients have better continuity?

AFW (33) Lowry (35) Total (68) Mean #visits 9.27 8.71 8.99 Mean MMCI 0.77 0.65 0.71 Mean Age 28.1 27.8 27.9 Multips 22 27 49 Primips 11 8 19 Insured 23 1 24 Uninsured 10 34 44 Resident 17 41 Nonresident 9 18

AFW (33) Lowry (35) Total (68) Mean #visits 9.27 8.71 8.99 Mean MMCI 0.77 0.65 0.71 Mean Age 28.1 27.8 27.9 Multips 22 27 49 Primips 11 8 19 Insured 23 1 24 Uninsured 10 34 44 Resident 17 41 Nonresident 9 18

Is there a relationship between age and continuity?

AFW Lowry Overall Mean Age 28.1 27.8 27.9 Minimum age 16 42 Maximum age 15 41

Age and Continuity AFW Lowry Overall Spearman correlation=0.45 No correlation between age and continuity

Do multigravidas or primigravidas have better continuity? Multip vs Primip Do multigravidas or primigravidas have better continuity?

AFW (33) Lowry (35) Total (68) Mean #visits 9.27 8.71 8.99 Mean MMCI 0.77 0.65 0.71 Mean Age 28.1 27.8 27.9 Multips 22 27 49 Primips 11 8 19 Insured 23 1 24 Uninsured 10 34 44 Resident 17 41 Nonresident 9 18

Multip vs Primip AFW Lowry Multips median MMCI: 0.80 (IQ range 0.69-0.89) Primips median MMCI: 0.85 (IQ range 0.75-0.92) P*=0.31 Lowry Multips median MMCI: 0.67 (IQ range 0.55-0.83) Primips median MMCI: 0.71 (IQ range 0.67-0.74) P*= 0.62 *Wilcoxon Rank-Sum test (used for non-normally distributed data)

Multip vs Primip Overall Multips median MMCI: 0.75 (IQ range 0.60-0.83) Primips median MMCI: 0.75 (IQ range 0.70-0.89) P*=0.21 No difference in continuity * Wilcoxon Rank-Sum test

Nonresident vs Resident PCP Do non-resident providers have better continuity?

AFW (33) Lowry (35) Total (68) Mean #visits 9.27 8.71 8.99 Mean MMCI 0.77 0.65 0.71 Mean Age 28.1 27.8 27.9 Multips 22 27 49 Primips 11 8 19 Insured 23 1 24 Uninsured 10 34 44 Resident 17 41 Nonresident 9 18

Nonresident vs Resident PCP AFW NR PCP: MMCI 0.83 (IQ range 0.70-1.0) Res PCP: MMCI 0.80 (IQ range 0.74-0.89) P*=0.54 Lowry NR PCP: MMCI 0.71 (IQ range 0.60-0.83) Res PCP: MMCI 0.67 (IQ range 0.60-0.75) P*=0.34 *Wilcoxon Rank-Sum test

Nonresident vs Resident PCP Overall NR PCP: MMCI 0.71 (IQ range 0.60-0.85) Res PCP: MMCI 0.75 (IQ range 0.67-0.86) P*=0.88 No difference *Wilcoxon rank-sum test

Level of Resident Training Is there a difference in continuity between residents in different years of postgraduate training?

Level of Training n AFW Lowry Overall PGY1 PGY2 10 11 21 PGY3 14 6 20

Level of Training Overall: No difference No data for PGY1 PGY2 median MMCI: 0.67 (0.67-0.80) PGY3 median MMCI: 0.78 (0.71-0.89) P*= 0.08 No difference *Wilcoxon rank-sum test

Do insured patients have better continuity? Insured vs Uninsured Do insured patients have better continuity?

AFW (33) Lowry (35) Total (68) Mean #visits 9.27 8.71 8.99 Mean MMCI 0.77 0.65 0.71 Mean Age 28.1 27.8 27.9 Multips 22 27 49 Primips 11 8 19 Insured 23 1 24 Uninsured 10 34 44 Resident 17 41 Nonresident 9 18

Insured vs Uninsured AFW Lowry Insured MMCI: 0.80 (IQ range 0.72-0.89) Uninsured MMCI: 0.82 (IQ range 0.67-0.93) P*=0.92 Lowry Insured MMCI: 0.83 Uninsured MMCI: 0.67 (IQ range 0.60-0.78) P*=0.30 *Wilcoxon rank-sum test

Insured vs Uninsured Overall Insured MMCI: 0.82 (IQ range 0.74-0.89) Uninsured MMCI: 0.70 (IQ range 0.60-0.83) P*= 0.001 *Wilcoxon rank-sum test

DISCUSSION Brooks Flood

Outline How this evolved Flaws What we learned Future plans for continued study

How this idea started The original idea for this project presented as we pondered “What are the challenges and barriers for family medicine residents to reach the 10 continuity deliveries required by the RCC

The minimum requirements for a continuity patient (program requirements IV.A.5.b.3.c) at a minimum residents must provide antenatal, natal and post natal care for a delivery to be counted as a continuity delivery (program requirements IV.A.5.b.3.c)

What the idea evolved into: How to provide better continuity in the care of our patients

Our new goal focused on how our new PCMH curriculum changes our OB continuity So far we have gathered data for the ‘old’ curriculum only. Over the next (6) months we will gather data under our new curriculum design and compare our data sets.

Upon doing the study we came upon difficulties and realized flaws in our design

Definitions of continuity differed RRC definition of continuity was more lenient MMCI more strictly defined The RCC definition of continuity is more open and lenient than the MMCI definition

Other variables that affected our data Lowry and AFW collected data differently Patients were excluded if not seen more than twice during the antenatal period (Lowry used only OB pts seen by residents and we used a sticker method to track patients. At AFW Brandy and Anna collected data on all OB patients using their EMR) this changed our overall ‘continuity’

The MMCI numbers we came up with are actually better than we anticipated

Why our results may be different than what we expected: Retrospective study design Artificial designation of PCP Inconsistent methods of collection Poor handwriting on some charts Providers having the same initials The MMCI numbers we came up with are actually quite better than we anticipated, we think this may be influenced by many factors, including inconsistent methods of collection, poor handwriting on some charts making it difficult to assess who had seen the patient, and also some providers having the same initials

What we’ve learned This preliminary look at data has been informative for us. As we collect data, we learn how to improve our data collection methods for our future project

Poor communication = Poor continuity One important thing we learned about the barriers to establishing continuity patients is that communication with clinic staff and non resident providers has been poor in the past. Improved communication regarding the goals for continuity care has been an integral part of even the first phase of this study.

Future Directions

In the future Focus on improved clinic communication Predictable presence in clinic Collect nine more months of data while in PCMH

Thank you!

Acknowledgements Rachel Everhart Jay Lee