1. An affiliate of the Duke University Medical Center and in association with The North Carolina Area Health Education Centers Program Duke/SRAHEC Family Medicine Residency Program Fayetteville, NC Eron Manusov, MD & Dan Marlowe, PhD, LMFT

2. An affiliate of the Duke University Medical Center and in association with The North Carolina Area Health Education Centers Program During this session, participants will be able to: 1.Review ACGME and PCMH requirements and apply a gap analysis 2.Understand and apply how PCMH and ACGME requirements are used to change a family medicine residency program and associated clinic. 3.Describe the process of change that is required to achieve PCMH accreditation at a FM residency training program: Using simulation and simulation 4.Discuss the benefits and issues of the PCMH in family medicine education

3. An affiliate of the Duke University Medical Center and in association with The North Carolina Area Health Education Centers Program The Accreditation Council for Graduate Medical Education (ACGME) is responsible for the Accreditation of post-MD medical training programs within the United States. Accreditation is accomplished through a peer review process and is based upon established standards and guidelines Accreditation NCQA’s Patient-Centered Medical Home (PCMH) 2011 is an innovative program for improving primary care. In a set of standards that describe clear and specific criteria, the program gives practices information about organizing care around patients, working in teams and coordinating and tracking care over time.

4. An affiliate of the Duke University Medical Center and in association with The North Carolina Area Health Education Centers Program Patient-centered medical homes “can be constructed out of three fundamental building blocks— continuity of care, prompt access to care, and care provided by teams—”

5. An affiliate of the Duke University Medical Center and in association with The North Carolina Area Health Education Centers Program Patient Care Medical Knowledge Practice Based learning and improvement Inter-personal communication skills Professionalism Systems based practice

6. An affiliate of the Duke University Medical Center and in association with The North Carolina Area Health Education Centers Program ACGME Requirements Practice Based learning and improvement Inter-personal communication skills Professionalism Systems based practice PCMH six standards align with the core components of primary care. Enhance Access and Continuity Identify and Manage Patient Populations Plan and Manage Care Provide Self-Care Support and Community Resources Track and Coordinate Care Measure and Improve Performance

7. An affiliate of the Duke University Medical Center and in association with The North Carolina Area Health Education Centers Program Robust patient-centeredness is an important program goal: There is a stronger focus on integrating behavioral healthcare and care management Patient survey results help drive quality improvement Patients and their families are involved in quality improvement.

8. An affiliate of the Duke University Medical Center and in association with The North Carolina Area Health Education Centers Program Element A --Access During Office Hours: i.Advice by telephone during the day. ii.Providing clinical advice via secure electronic messaging during office hours iii.Document phone and electronic message advice in medical record Element B—After-hours Access Element C—Electronic Access i.Electronic clinical summary—MU stipulates that it is provided to >50% of office visits within 3 days. ii.Secure 2-way electronic messaging between patients and the practice.

9. An affiliate of the Duke University Medical Center and in association with The North Carolina Area Health Education Centers Program Element D: Continuity need to monitor % age of patient visits with a PCP or team Element F: Culturally and Linguistically Appropriate Services Element G: The Practice Team— i.Defined roles for the clinical and non-clinical team members. ii.Identify and Manage Patient Populations. iii.Clinical Data—Do we collect data on smoking status and tobacco use. iv.Comprehensive Health Assessment. v.Element D: Use Data for Population Management

10. An affiliate of the Duke University Medical Center and in association with The North Carolina Area Health Education Centers Program PCMH3: Plan and Manage Care—Element A: Implement Evidence based Guidelines Element B: Identify High-Risk Patients—we need to set criteria for high risk patients Element C: Care Management—MUST-PASS element. Element D: Medication management. Element E: Use Electronic Prescribing PCMH 4: Provide Self-Care Support and Community Resources. Element B: Provide referrals to Community Resources PCMH 5: Track and Coordinate Care.

11. An affiliate of the Duke University Medical Center and in association with The North Carolina Area Health Education Centers Program PCMH 6: Measure and Improve Performance A.Measure Patient/Family Experience. B.Implement Continuous Quality Improvement. C.Demonstrate Continuous Quality Improvement D.Report Performance.

12. An affiliate of the Duke University Medical Center and in association with The North Carolina Area Health Education Centers Program

13. An affiliate of the Duke University Medical Center and in association with The North Carolina Area Health Education Centers Program FMR and Organizational analysis ACGME requirements PCMH recognition Team Building Exercises 1.Ice breaker 2.Sculpting exercise 3.Group dynamics: Pillars 4.Walk in your shoes 5.Individual meetings Inefficiency. Disgruntled physicians, nurses, and staff. Physician centered Physician over-utilized Working below level of license. Service vs. Learning issues Need to meet ACGME

14. An affiliate of the Duke University Medical Center and in association with The North Carolina Area Health Education Centers Program High functioning team of APPs Teams with faculty, residents, nurses, lab, front desk, referrals, records, scheduling, MH, PharmD, and library Emphasize ACGME, PCMH, but most importantly: – Work satisfaction and well-being – Patient satisfaction and well-being

15. An affiliate of the Duke University Medical Center and in association with The North Carolina Area Health Education Centers Program Standardized patients 1.Non-English Speaking 2.Depression 3.Diabetic /HTN 4.Child 5.Walk-in with rash 6.STI Tool Kit Standardized orders EHR function Screening PHQ9, eye Immunizations and lab orders Back to work note

16. An affiliate of the Duke University Medical Center and in association with The North Carolina Area Health Education Centers Program MH referral Health Literacy Referral Use of language interpreter EHR tricks Residents worked with nurses and admin

17. An affiliate of the Duke University Medical Center and in association with The North Carolina Area Health Education Centers Program BeforeAfter MDRNADMINMDRNADMIN Use of an electronic “tool kit” with physician designated tasks described in standing orders Opening of electronic chart and nurse completing information. Writing excuses, school notes, etc.. Completing screenings (PHQ9, growth charts, eye screening, patient education) Input medications, update past medical history, and social history

18. An affiliate of the Duke University Medical Center and in association with The North Carolina Area Health Education Centers Program Ice Breaker resulted in more bonding Pillars: Respect, Defined roles Increased satisfaction: more efficient, equitable, improved learning More involvement in PCMH/ACGME requirements – QI committee – QI projects – Research projects – Leadership