1. A Longitudinal Coordinated Chronic Disease Curriculum at Swedish Family Medicine, First Hill Seattle, WA STFM Thursday, April 28 th, 2011 Carla Ainsworth MD MPH Elizabeth Hutchinson MD

2. Our residency 11 residents per year, across 3 clinics First Hill Family Med (6-6-6) Downtown Family Med (3-3-3) – partnership with Public Health Swedish Community Health (2-2-2) – founded as a residency PCMH 2 fellowships –advanced OB and geriatrics

3. Background Future of Family Medicine project Growing need for chronic disease education Low resident satisfaction in clinic

4. Our new outpatient clinic curriculum includes: 1.Longitudinal teaching of chronic disease management 2.Weekly clinic team meetings 3.Scheduled clinic “care coordination” time for residents

5. Developing the approach Future of Family Medicine Project core principles: 1. Focus on quality and outcomes 2. A patient-centered team approach –More functional offices 3. Train residents to be capable of adapting to varying patient needs and changing health care technologies Elimination of barriers to access Advanced information systems Enhanced practice finance www.transformed.com/ffm.cfm

6. Teach evidence-based, efficient chronic disease care Introduce national care standards and outcome measures Address changing preventive care guidelines Monthly didactic style lectures (“clinical rounds”) Journal club 1. Focus on quality and outcomes Monthly clinical case reports

7. Monthly didactic-style lectures “Clinical rounds” Outpatient management principles – q 4 months: Diabetes, Preventative care –q 6 months: HTN, Prenatal care –Once during 18 month cycle: CHF, asthma, depression, headaches, care of immigrant populations – Coordination with didactics

8. MonthTopicLecture title JulyDiabetesLifestyle interventions as they relate, resources, weight management, exercise prescriptions AugustHypertensionManagement of HTN in the outpatient setting, team-based management, home BP monitoring SeptemberCHFMonitoring parameters, lifestyle interventions OctoberPreventative medicine Informed discussions about offering screening tests NovemberDiabetesBenchmarks, pay for performance, interval between visits DecemberHTNBenchmarks, pay for performance, interval between visits JanuaryDepressionUse of PHQ, return visits, community resources FebruaryPreventionWell child visits, counseling on vaccinations MarchDiabetesCommon sequelae and complications, referral resources AprilAsthmaUse of diagnostic tests, patient education

9. MonthTopicLecture title MayCultural competency Use of resources in the community for immigrants, sexual minorities JunePreventionChildhood immunization statistics JulyDiabetesEvidence for use of statins, ARB, ASA

10. Support team work in the clinic setting - Define roles of the care team - Develop and effectively utilize clinic protocols - Incorporate social work, behavioral health and pharmacists into care plans - Intellectual collaboration among R1, R2, R3, faculty bimonthly team meetings -clinic flow protocols -“check list topics” Multidisciplinary team rounds the Team Room. (Environment) 2. A patient-centered team approach QI project requirement - collaboration on an intervention

11. First Hill Family Medicine Clinic 18 residents 2 geriatric fellows 10 faculty 1 full time physician assistant 9 nurses Master’s level social worker Clinical psychologist Pharmacist 2 resident teams –3-3-3 residents –3 or 4 faculty –2 nurses 1 fellowship team –2 fellows –3 faculty –2 nurses

12. Check list topics: □ Development of protocols for RN/MD/staff collaboration and communication □ Pre and post precepting □ Pre-clinic huddle □ Note writing □ Visit efficiency tricks and tools □ Patient-centered communication □ Use of interpreters □ Use of “My Chart” □ Point of care decision support tools □ Patient satisfaction measures □ Sharing of EPIC pearls/smart phrases Monthly team-based discussions Check list topics

13. Monthly meetings 45 min Complex patient presentation by resident in presence of the team of providers RN shares observations and her role in care Discussion run by the faculty facilitator Questions regarding case management and patient care identified Behavioral health, social work and pharmacy input Identification of resources available in the community Summary document produced Resident updates the chart and makes action plan for patient’s care Multidisciplinary team rounds, discussion of complex patients

14. 3. Practice care coordination Care coordination time set aside New clinic protocols to test alternative visit types (phone, secure messaging) 3. Train residents to be capable of adapting to varying patient needs and changing health care technologies Panel management - Monthly review of team panels

15. Care coordination time R2 & R3 - ½ day per 5 clinic half-days during most rotations R1 - sporadic ½ days given Expectation is that residents are physically in clinic To do: Phone visits Manage non-face to face communication with patients Communicate with specialists Help with nurse triage Panel management tasks InBasket clean up

16. What has been working well?  Didactic-style lectures have contributed to understanding of chronic disease and preventative care  Teamwork has improved  Use of care coordination time has been used efficiently by most residents  Residents better understand concept of panel management  Team rooms facilitate more spontaneous precepting & better intellectual collaboration  Residents are happier in clinic  About 1/3 rd of residents express desire to be leaders in their future patient-centered practices

17. Challenges  Consistency of across all three residency sites: lack of standard databases, inability to coordinate team meetings at the same time  Mismatch between amount of time spent on diabetes with perceived utility  Model of care coordination and non face-to-face interactions incompatible with the current payment structure

18. What’s next? 1.Longitudinal teaching of chronic disease management 2.Weekly clinic team meetings 3.Scheduled clinic “care coordination” time for residents 4.Increasing patient access to care – secure messaging, same-day access 5.Payment reform!

19. Outpatient curriculum schedule Wednesday 730-830 Journal club 845-920 Team meeting : review panel of patients corresponding to theme of the month 730-830 Clinical rounds 845-920 Team meeting: topical discussion of interventions based on clinical rounds topic. 730-830 Peds case conference 845-920 No meeting, care coordination as a team 730-830 Clinical case report 845-920 Team meeting, check list topics 730-830 prenatal cases 845-920 No meeting, care coordination as a team 1230-120p- multidisciplinary rounds, complex patient discussions Tuesday wk 1 2 3 4 5