Teaching PCMH Concepts A Plan Do Study (Act) Adventure Please note that more information about our project and the practice registry can easily be downloaded from our website Kelly Bossenbroek Fedoriw MD kbossen@med.unc.edu Beat Steiner MD MPH University of North Carolina SOM Chapel Hill www.med.unc.edu/fmclerk

Goals of Session Get you excited about teaching PCMH Give you specific tools to use Report initial results from our curriculum Get input from you on how to improve

CARE Assignment Integrate sometimes conflicting guidelines into the lives of patients with multiple chronic illnesses. See individual patients as part of a larger population that can be cared for with system level interventions.

CARE assignment Learn about MI and goal setting (TBL) Work closely with one patient Review relevant guidelines Make recommendations Introduction to registries (TBL) Study population of patients

Individual Readiness Assessment Test (iRAT) Team Based Learning Individual Readiness Assessment Test (iRAT) Group Readiness Assessment Test (gRAT) Application Questions 1st TBL session during orientation that focuses on motivational interviewing and the social determinants of health 2nd TBL session – PCMH concepts and moving from the idea of treating an individual patient to the population. This includes an overview of registries.

Teaching Registry A disease based registry is essential for teaching the concepts of PCMH but practice registries are not readily available. About one year ago we developed a curriculum using team based learning and a practice registry to teach these concepts.

Access the Registry Google: url: UNC family medicine clerkship teaching registry url: http://www.med.unc.edu/fmclerk/files/teaching-registry-1

Access Via email

10 minutes to work on questions #1 and #2 Registry 10 minutes to work on questions #1 and #2 Then 10 min debrief – Benefit of TBL format is the discussion and active learning Was there discussion? Did they feel like the answers were accessible within the registry? Students tend to understand the workings of the registry much more quickly than faculty. Preceptors office’s may not have a registry and that’s ok. Students are still exposed and are beginning to understand the benefits of a registry and it’s limitations. Ask for show of hands for answers A group of high risk patients have been embedded in the registry. About 25 patients have very high blood pressures and also high HgbA1c values. This group has a disproportionate % of co-existing mental health conditions and do not show up as regularly for routine care. This group is also concentrated in census tract 201. Steiner sees more patients in that census tract. Students may hypothesize that Steiner is providing substandard care but the more likely explanation based on the information in the registry is that social determinants in census tract 201 are responsible for pattern.

Learn about MI and goal setting (TBL) Work closely with one patient CARE assignment Learn about MI and goal setting (TBL) Work closely with one patient Review relevant guidelines Make recommendations Introduction to registries (TBL) Study population of patients Going back to the CARE assignment. Now that the students have had exposure to PCMH concepts and registries, we ask the students to identify 8-10 patients with similar characteristics to their individual patient and do a chart review. The final product of the assignment is a detailed document with reflective writing as well as specific recommendations for the care of their individual patient as well as the population of patients they studied. This goes back to the preceptor – examples in the handout.

Preceptor Survey 36% of preceptors felt that students offered useful suggestions for the care of a population Change in Practice? Pool therapy suggestion for pt with OA Looking for polypharmacy Monitor medication compliance more carefully Referral for home health services I would love to see more specific recommendations elicited by the students.

48/63 students responded = 76% response rate Student Survey 48/63 students responded = 76% response rate 75% of students spent 5-15 hours on assignment 76% of students felt the assignment was effective or very effective (worth the time invested) Time spent – 75% spent 5-15 hours, 20% spent over 15 hours 76% response rate – 48 students

Most important lesson learned? Individual Population Community Resources Impact of comorbidities Benefits of registries Individualize guidelines Systems Based Change Social Determinants PDSA cycles Motivational Interviewing

“I began to think like a responsible health care provider and member of society. My goal is not just to improve the health of an individual but the health of the community.”

Discussion Questions Would assignment generalize to your setting? Is assignment appropriate for 3rd year students? How could the practice registry be improved?