Integrating the Personal Medical Home into a Nursing Home Curriculum Huey Lin, MD Assistant Professor UC Davis Family and Community Medicine STFM Annual Spring Conference - 2009

Goals Establish a longitudinal nursing home rotation Assessments of needs and concerns / assets and barriers of all involved parties Create and grow a relationship between myself, the residents, and the skilled nursing facility that will facilitate excellent patient care and resident education Educational experience that consists of care of at least two patients over a minimum of two years.

Assets Enthusiasm by myself and Emerald Gardens Support from Program Director and Curriculum Director Current nursing home physician was considering retirement – relatively quickly build a patient panel SHARED VISION with Director of Nursing and the Administrator

Me /Me / Me / Me Myself Residents Emerald Gardens Faculty How do I have everyone meet eye-to-eye? Too busy; where is the time? Is this going to be more work for staff? Where can time be carved out for this? How do I not get overworked? It’s depressing; what’s the value? What is our financial incentive? Can this be done without other faculty involvement? Will patient care be affected? Will this be of any additional cost?

Goals -> GOAL Bring as many aspects of the patient-centered medical home to the nursing home curriculum

Patient-Centered Medical Home

Principles of Personal Medical Home already in place at Emerald Gardens Quality and Safety – patient safety focus, medication management, evidence-based outcome analysis, quality improvement, risk management, regulatory compliance Team Based Care – IDT meetings, physician leadership, collaborative staff, shared vision Information System – computers and high speed Internet access

PDSA: Phone Calls – 2005-2006 BEFORE AFTER All calls to me PMD to take calls during day Flowsheet

PDSA: Phone Calls – 2006-2007 BEFORE AFTER PMD to take calls during day Flowsheet AFTER Calls to PMD – day, night float - night Flowsheet

PDSA: Phone Calls – 2007-2008 AFTER BEFORE Flowsheet Resident education on phone triage Signout list Reminder notice to Emerald Gardens’ staff BEFORE Calls to PMD – day, night float – night Flowsheet

PDSA: Phone Calls – 2008-2009 BEFORE AFTER Calls to PMD – day, night float – night Flowsheet Resident education on phone triage Signout list Reminder notice to Emerald Gardens’ staff AFTER EHR Shared List Routine reminders with new staff

PCMH – Practice- Based Care via Communication Phone calls protocol established. Agreed upon by residents and Emerald Gardens staff. Mutual understanding that ongoing feedback is necessary.

PCMH – Continuity of Care / Access to Care Resident “buddies” work together to care for a pair of patients. Reinforce personal medical home when patients come to or are discharged from Emerald Gardens. Based on the resident buddy system that we have established in clinic for coverage when away on particularly hard rotations or vacation. Always a junior and senior resident. Learn from each other. Pair of nursing home patients – important to

PCMH – Continuity of Care Scheduled visits during weekly half-day resident didactics. Approved by Program Director and Curriculum Director. Changes to schedule need to be approved. Residents encouraged to attend important IDT meetings. Online and also posted in didactic conference room.

PCMH – Health Information Technology via ELECTRONIC HEALTH RECORD Visit documentation and billing Shared patient list Correspondence between night float and “buddies” Group decision making Resident education Referrals; continuity if hospitalized

PCMH – Practice-Based Care, Care Management, Quality and Safety Large and small group meetings on importance of nursing home care Quarterly meetings at Emerald Gardens Annual and “on-the-fly” feedback

PCMH – Place to Call “Home” FOOD! “Get togethers” at Emerald Gardens Desktop and laptop stations Constant support and thanks of each other

Summary Integrating the personal medical home into a nursing home curriculum is achievable, but does take time. Implementation of PDSA cycles to your nursing home curriculum can yield fruitful results. If possible, incorporate an EHR in your nursing home curriculum. Some of the results have exceeded our expectations. Keep the curriculum dynamic and strive for ongoing collaborations.

On the Horizon Improve wireless access for potential WOWs Moving our physician workplace to a central location accessible by patients and staff Patient and/or family be able to communicate with us electronically Expand on a culture of collaboration and collegiality