Easing the Load of Precepting: Efficiently Integrating Students into Ambulatory Training Sites an Update on Tactic 3 of the STFM Preceptor Expansion Initiative A cross-disciplinary initiative Emily Walters Quinnette Jones, MSW, MHS, PA-C Vince WinklerPrins, MD, FAAFP

What are we going to talk about? Background and rationale—Vince Preceptor expansion initiative work to date— Emily Integrating students into ambulatory training sites: Tactic 3 deliverables—Quincy Questions

Collaborators and Conflicts of Interest Additional tactic team 3 collaborators: Adrian Billings MD, PhD, Chief Medical Officer, Presidio County Health Services, Associate Professor, Department of Family and Community Medicine, Texas Tech University Health Sciences Center Kathy Ellis DNP, RN, ANP-BC, FNP-BC, FAANP, Associate Professor of Professional Practice, Division Director, Graduate Nursing, Coordinator, Family Nurse Practitioner Program, Texas Christian University—Harris College of Nursing and Health Sciences Juleah Williams, Membership and Workforce Development Manager, Texas Academy of Family Physicians Conflicts of Interest: None

Background and Rationale Growth of number of training programs and class sizes More clinical education of healthcare learners being pushed into ambulatory training sites with intense competition for space—MAs/scribes/other learners The work of the clerkship director (or equivalent) increasingly concerns recruitment/retention of community faculty. It’s not just primary care. (If you own your own health system and primary care offices this may be easier—U of Michigan). Many health care training entities have weak systems to provide ambulatory clinical training and put the onus on students to find training sites Yesterday: “Sure we’ll take a student, send them on over!” Today: fewer private practice sites, more salaried positions and group practices=less control Education not in their business model—FQHCs, etc. We control some of the learning spaces but not others. Need to get past practice manager, compliance officer, or CFO to get in

Background and rationale (2) Additional pressures: Most training programs have not devoted enough resources to develop and nurture vital community and practice relationships Each training institution has their own processes, priorities and requirements for faculty appointments, grading, etc. Words matter: community faculty member—volunteer clinical faculty—clinical preceptor—other Electronic medical records—separate logins, concerns about student charting (compliance officer), contributions to clinician burnout leading to possible reduced willingness to teach Increased pressure on patient flow and payment (NC experience)

Background and rationale (3) Initiatives: Lots of work over the decades to address community faculty and their unique needs STFM Preceptor Education Project (PEP and PEP2) AHEC grants School specific Teaching physician teachingphysician.org

Preceptor Expansion Initiative Work to Date Summit—August, 2016 Emily

PA, NP, DO, MD initiative

Action Plan

Preceptor Expansion Initiative Work to Date Tactic 1: Work with CMS to revise student documentation guidelines Tactic 2: Integrate interprofessional interdisciplinary education into ambulatory primary care settings through integrated clinical clerkships Tactic 3: Develop standardized onboarding process for students and preceptors. Integrate students into the work of ambulatory primary care settings in useful and authentic ways Tactic 4: Develop educational collaboratives across departments, specialties, professions, and institutions to improve administrative efficiencies Tactic 5: Promote productivity incentive plans that include teaching and develop a culture of teaching in clinical settings Initiative status: https://stfm.org/about/keyinitiatives/preceptorexpansion/preceptorexpansioninitiative/

Tactic 1: Work with CMS to revise student documentation guidelines Success! After advocacy efforts, CMS released a transmittal that “allows the teaching physician to verify in the medical record any student documentation of components of E/M services, rather than redocumenting the work." The team continues to advocate for additional clarity for teaching hospitals and clear inclusivity of physician assistants and nurse practitioners. This team’s task was to explore ways to revise the student documentation guidelines to help relieve unnecessary administrative burdens on preceptors and increase the active learning of students. Status: On February 2, 2018, CMS released a revised transmittal, Pub 100-04 Medicare Claims Processing Manual (updated May 31), that “allows the teaching physician to verify in the medical record any student documentation of components of E/M services, rather than redocumenting the work." The team continues to advocate for making the guidelines more inclusive of physician assistants and nurse practitioners. Workshop 1: The Impact of 2018 CMS Guidelines on Medical Student Documentation; Friday, 2/1; Joel Heidelbaugh, MD; David Power, MD, MPH; Jacob Prunuske, MD, MSPH; Ranjani Natarajan, MEd; Ann Rutter, MD, MS; Scott Shipman, MD, MPH; Beat Steiner, MD, MPH

Tactic 2: Integrate interprofessional interdisciplinary education into ambulatory primary care settings through integrated clinical clerkships The Physician Assistant Education Association (PAEA) is creating a list of opportunities where students could be integrated in useful ways into clinical practice workflows Highlights areas and processes that could accommodate multiple and/or interprofessional students. The workflows will be vetted with preceptors and then translated into implementation tools. This tactic explores a means to increase the number of learners at a given site without putting more pressure on the clinician’s shoulders. This means transforming education, in conjunction with the practice, away from the 1:1 preceptor/student model. Status: The team has identified a comprehensive list of opportunities where students could be integrated in useful ways into clinical practice workflows. The list/workflows highlight areas and processes that could accommodate multiple and/or interprofessional students. The workflows will be vetted with preceptors and then translated into implementation tools. This project is being led by the Physician Assistant Education Association (PAEA).

Tactic 4: Develop educational collaboratives across departments, specialties, professions, and institutions to improve administrative efficiencies A multi-year pilot, funded by the ABFM, called Building Better Clinical Training Experiences: A Learning Collaborative. Pilot participants will choose one of three projects to standardize the onboarding of students and to engage community preceptors. Evaluate the onboarding materials developed by the Tactic 3 and Tactic 5 teams. Apply by February 22. Five family medicine departments will be selected for each of the three projects through a competitive application process. Preference will be given to departments collaborating with two or more other specialties/departments/professions. Over the next two years, departments and their collaborators will test the materials and processes being developed as part of Tactic 3, as well as recognition and incentive programs being developed as part of Tactic 5. The teams will participate in online and in-person learning communities to share/learn about intervention approaches; conduct standardized pre/post measurement; and disseminate their findings. Status: Funding has been secured, and the Graham Center has agreed to evaluate the projects. The tactic team is finalizing the application criteria, the project expectations, and the timeline. A call for applications for the pilot will open in January 2019.

Tactic 5: Promote productivity incentive plans that include teaching and developing a culture of teaching in clinical settings In 2018, STFM and the ABFM piloted a Precepting Performance Improvement program that offers PI credits to preceptors who teach med students or residents and participate in a teaching improvement activity. The program will be rolled out broadly in March 2019. Competencies and incentives for community faculty have been developed with the STFM Faculty Development Collaborative and will be piloted through the Tactic 4 project. The unifying theme of the tactics under this umbrella is creating the incentives and culture needed to expand the pool of preceptors. A key target audience for these efforts is the health systems that employ community preceptors. Status: On April 2, 2018 the Society of Teachers of Family Medicine and the American Board of Family Medicine kicked off a pilot program that offers Performance Improvement continuing certification credit (previously MOC Part IV) to ABFM diplomates who provide personal instruction, training, and supervision to a medical student or resident and who participate in a teaching improvement activity. The pilot ends on December 30, 2018. The program will be tweaked, based on lessons learned in the pilot, and rolled out broadly. Results of the pilot will be shared during several sessions at the 2019 Conference on Medical Student Education. Competencies and incentives for community faculty have been developed in collaboration with the STFM Faculty Development Collaborative, and will be piloted through the Tactic 4 project. Several articles/manuscripts have been published and information has been disseminated through presentations. This work is ongoing.

Tactic 3: Develop standardized onboarding process for students and preceptors. Integrate students into the work of ambulatory primary care settings in useful and authentic ways We’ve been developing student onboarding resources and processes to help students hit the ground running at their clinical rotation site. We are also developing preceptor onboarding resources that ease the administrative burden experienced by new community faculty who are onboarded with a school. The team is developing student onboarding resources and processes that will include: A student passport that captures a student's training, screenings, clerkship background, objectives for the current clerkship, and basic information about the student Education for students on how to hit the ground running at their clerkship site Three online training modules for students: "How to Create a High-Quality and Billable Note in the Medical Record," "How to Perform Medication Reconciliations," and "Motivational Interviewing.” Promotion of curriculum to meet goals and objectives outlined in the appendix of the AAMC’s Recommendations for Preclerkship Clinical Skills Education for Undergraduate Medical Education The team is developing preceptor onboarding and processes that will include: Use of the AAMC Uniform Clinical Training Affiliation Agreement with preceptors A faculty appointment onboarding process where administrative personnel at the institution assist new preceptors in developing and formatting CVs during a phone interview An online STFM course on Giving Feedback Status: These resources and processes will be piloted as part of Tactic 4. The pilot begins in early 2019.

Integrating students into ambulatory training sites—Tactic 3 deliverables Student Passport Learner Resources How to Be Awesome in an Ambulatory Clinic Rotation Online training modules Institution/Clinical Site Resources Promotion of AAMC Recommendations for Preclerkship Clinical Skills Education for Undergraduate Medical Education Promotion of AAMC Uniform Clinical Training Affiliation Agreement https://www.aamc.org/download/382530/data/clinicaltrainingagreementl cmeendorsed.pdf CV assistance in the faculty appointment process To be piloted as part of Tactic 4 Quincy These will be piloted as part of Tactic 4 (https://stfm.org/about/keyinitiatives/preceptorexpansion/buildin gbettercollaborativespilot/)

Tactic 3-Student Passport Aims to reduce administrative burden on clinical sites Web-based form to be completed by student/training program Includes student information demographic rotation details verification of completion of trainings & other clinical setting requirements can be downloaded in PDF/word- available April (passport not editable)-- includes important student information: demographics, previous experiences, procedures the student is comfortable with, rotation details, ensure the student has completed the recommended readings/modules, and includes verification from the educational program that the student has completed appropriate trainings such as: HIPAA, BBP, immunizations, background check, drug screening, etc.

Tactic 3-Student Resources How to Be Awesome in an Ambulatory Clinic Rotation Three online training modules Writing a High-Quality, Billable Note in the Medical Record Medication Reconciliation Motivational Interviewing Modules-- available April How to Be Awesome: written by Vince WinklerPrins highlights differences between working in inpatient settings and ambulatory care, describes core features of primary care practice, and outlines specific strategies for interacting in the clinical settings (presentations using SNAPPS model, describes wellcare and chronic care, utilizing USPSTF guidelines, and highlights a number of other ways the student can promote their own learning, be helpful to the preceptor, and contribute positively to patient care). Our tactic team has also developed 3 brief online training modules which are educational for students and also help integrate them in the clinic in a more meaningful. Each module is brief (~10 minutes) and focuses on topics - writing a high-quality billable note, med rec, MI. goal is for complete all 3 modules prior to starting clerkships/clinical rotations

Tactic 3 - Institutional/Clinical Site Resources Promotion of AAMC Recommendations for Preclerkship Clinical Skills Education for Undergraduate Medical Education Promotion of AAMC Uniform Clinical Training Affiliation Agreement https://www.aamc.org/download/382530/data/clinicaltrainingagr eementlcmeendorsed.pdf CV assistance in the faculty appointment process recommendation for separate requirements for appointment for community-based faculty revised CV formatting requirements administrative support AAMC Recommendations for Preclerkship Clinical Skills Education for UME-- to best prepare students for working in the ambulatory clinical environment. 2008, describes competency goals and skills objectives that learners should be able to demonstrate by the end of their preclerkship curriculum. AAMC Uniform Clinical Training AA: uniform agreement between schools/institutions and clinical training sites CV assistance in faculty appointment process:

Questions

References and other sources Latessa Robyn MD; Keen Susan MD; Byerley Julie MD; Foley Kathleen A. PhD; Payne Lauren E.; Conner Kirstie T.; Tarantino Heather MD; Peyser Bruce MD; Steiner Beat D. MD, MPH . The North Carolina Community Preceptor Experience: Third Study of Trends Over Twelve Years. Published online ahead of print. https://journals.lww.com/academicmedicine/Abstract/publishahead/The_North_Carolina_Community_Preceptor_Experience_.97743.aspx Association of American Medical Colleges et al. Recruiting and maintaining U.S. clinical training sites: joint report of the 2013 multi-discipline clerkship/clinical training site survey. https://members.aamc.org/eweb/upload/13-225%20wc%20report%202%20update.pdf. Updates about the Preceptor Expansion Initiative: https://stfm.org/preceptorexpansion “Building Better Clinical Training Experiences” call for pilot projects: https://stfm.org/bettertrainingexperiences Recommendations for Clinical Skills Curricula For Undergraduate Medical Education, AAMC 2008.https://www.aamc.org/download/130608/data/clinicalskills_oct09.pdf AAMC Uniform Clinical Training Affiliation Agreement: https://www.aamc.org/download/382530/data/clinicaltrainingagreementlcmeendorsed.pdf

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