1. ACGME’s Length of Training Pilot; Grassroots Disruptive Change & The Class of 2016 Joseph W. Gravel, Jr., MD Wendy Barr, MD Mary Kay Nordling, MD Jocelyn Hirschman, MD

2. Today’s Objectives 1. State the varied conditions and rationales that activated our program to apply for the ACGME 4 Year LoT Pilot rather than continue in the current 3 year training model. 2. Understand the early challenges, barriers, and creative solutions to 4 year curricular implementation including obtaining institutional support and anticipated additional needed resources for successful implementation.

3. Objectives (cont.) 3. Articulate early learnings of the pilot project including its effect on our program’s: 2012-2013 residency recruitment current resident reaction & plans faculty workload change management strategies

4. Strongly Agree(%) Agree (%)Neutral (%) Disagree (%) Strongly Disagree (%) The length of FM training should be 4 years. Increasing the LoT will significantly decrease medical student interest. Increasing the Length of training will improve the quality of medical care provided by graduates of FMRPs Without increased funding, increasing LoT would cause financial difficulties and ultimately cause FM residencies to close. GME and Primary Care Workforce. Carek P, Peterson L, Shokar N et al. Fam Med 2012; 44 (10): 712-5.

5. Strongly Agree(%) Agree (%)Neutral (%) Disagree (%) Strongly Disagree (%) The length of FM training should be 4 years. 11.028.625.320.116.9 Increasing the LoT will significantly decrease medical student interest. 17.527.324.7 5.8 Increasing the Length of training will improve the quality of medical care provided by graduates of FMRPs 15.639.018.819.57.1 Without increased funding, increasing LoT would cause financial difficulties and ultimately cause FM residencies to close. 55.837.06.500.7 GME and Primary Care Workforce. Carek P, Peterson L, Shokar N et al. Fam Med 2012; 44 (10): 712-5.

6. Law of Diffusion of Innovation

8. Timeline Willard Report 1966, FOFM Project 2004, P4 2007 FM Working Party 4 year LoT Summit 1/11 RPS Consultation 12/11 LFMR Starts Focus Groups/Internal Meetings 1/12 ACGME approved pilot 3/12 ACGME First Call for Proposals 3/12- 5/12 ACGME Selects 11 Original Programs 7/12 National Conference Recruitment Starts 8/12 ACGME Second Call for Proposals 9/12-12/12 Match- Lawrence FMR Class of 2017 3/13 LoT Pilot formally starts 7/13 Concludes July 2019 (1 st cohort) July 2020 (2 nd cohort)

9. Original ACGME 4 Year LoT Programs

10. Why 4 Years? (Lawrence)

11. Non-Factors Difficulty Recruiting Graduates Struggling With ABFM Exam Concerned about quality of our 3 year graduates’ practice Faculty and Residents Not Enough To Do Everyone Else Was Doing It More Funding Than We Know What To Do With No

12. Breadth and Depth

13. Conceptual Model of 4 Year Curriculum Existing 3 Years New Curricula 4 th Year of existing curricula AOC

14. Patient-centered | Physician-directed PCMH: The Family Medicine Model Family Medicine Foundation Health IT Patient Experience Health IT Great Outcomes Practice Organization Quality Measures Heath Information Technology Patient Experience

15. Year 1: “Foundations” Personal patient panel, Learning to practice in a team-based model Year 2: “Practice-Based Development” Developing clinical and team practice skills Early community integration Year 3: “Systems-Based Development” Leading the clinical teams in the PCMH (paired residents share leadership of a PCMH team) Leading other sites of clinical care (hospital, nursing home, etc) Taking on leadership roles in the community Year 4: “Capstone” Clinic/Community Leadership PCMH Medical Director for at least one month focusing on overall operations, systems, and community integration Complete practice-based research. 4 Year Curriculum Overview

17. Areas of Concentration Global Health High Risk Obstetrics Integrative Medicine HIV Academic/Faculty Development Women’s Health

18. Areas of Concentration Hospitalist Mental and Behavioral Health Geriatrics/Palliative Care Addiction/Pain Management Community Health Maternal Child Health/Breastfeeding Medicine Sports Medicine Personalized

19. Existing Curriculum- Augmentation of Depth/ Room to Increase Innovation

20. Lawrence Family Medicine Residency Four Year Residency Curriculum (an ACGME Length of Training Pilot Program) Wendy Brooks Barr MD, MPH, MSCE; Joseph Gravel MD; Keith Nokes, MD, MPH; Mary K. Nordling MD Lawrence Family Medicine Residency, Greater Lawrence Family Health Center, Lawrence, MA Year 1: “Foundations” Personal patient panel, Learning to practice in a team-based model Year 2: “Practice-Based Development” Developing clinical and team practice skills Early community integration Year 3: “Systems-Based Development” Leading the clinical teams in the PCMH (paired residents share leadership of a PCMH team) Leading other sites of clinical care (hospital, nursing home, etc) Taking on leadership roles in the community Year 4: “Capstone” Clinic/Community Leadership PCMH Medical Director for at least one month focusing on overall operations, systems, and community integration Complete practice-based research. 12345678910111213 Year 1 Adult Med Hospital Adult Med Hospital MedNFlt Hospital Adult Med Hospital Maternity Care Hospital MC/PD Night Float Hospital Peds Hospital Inpatient Surgey Hospital Geriatrics FMC/NH GYN FMC/Off Spanish Offsite Spanish Off Site vacation MC/PD NF Hospital FMC Ortho Private FM Intro FMCPCMH 12345678910111213 Year 2 ICU Med Hospital Adult Med Hospital Maternity care Hospital MCPD Nfloat Hospital Peds Hospital ED Hospital Outpt Surgey Private/ FMC Sub- Specialty private Derm private FMCPCMH Elective Off Site vacation FMC MedNFlt Hospital NEO Hospital Ortho/SM Private/Off Psych FMC/ private Geriatrics FMC/NH GYN FMC/priva te Comm Med Offsite 12345678910111213 Year 3 Adult Med Hospital Adult Med Hospital MedNFlt Hospital MCPD Nfloat Hospital Peds Hospital Adoles. Peds FMC/ private OP Peds FMC/ private ED Hospital Psych FMC/ private Elective Off-site AOC FMC AOC FMC vacation MedNFlt Hospital Maternity Care Hospital Develop Peds FMC/private Ortho/ SM Private/o ffPCMH FMC Year 4 12345678910111213 Adult Medi Hospital Adult Medi Hospital Maternity Care Hospital Peds ER HospitalAddiction FMC/priv ate/Hospi tal Integra- tive Medicine FMC Clinical Chief/ PCMH FMC Clinic Chief FMC AOC FMC AOC FMC AOC FMC vacation FM Night Float Hospital MCPD Nfloat Hospital OP Peds FMC/ private Ortho private/off Geriatrics FMC/NHHIV FMC Comm Med Off site Goals: 1.Provide residents with opportunities to develop advanced competency in an area of interest. 2.Develop resident skills in self-directed learning and promote the practice of life-long learning and skill development. Global Health Advoca cy/Lead ership Matern al Child Health Breastfeeding/Natural Childbirth High Risk Obstetrics Integrative Medicine HIV Academic/Faculty Development Pain/Palliative Care Addiction Medicine Planned Areas of Concentration 1.Development of competencies in all aspects of PCMH in our NCQA Level 3 Family Medicine Center through immersion in and graduated responsibility for management of the medical home. Including: a)team-based care, b)population medicine, c)community health, d)information mastery, e)chronic disease management, f)practice-based improvement, g)leadership 2.Increased depth of experience in core clinical aspects of Family Medicine, particularly essential in low resource clinical environments, with development of added competencies key to the care of underserved populations. 3.Increased opportunity for residents to develop additional competencies in areas of personal interest through the expansion of areas of concentration (AOC’s). 4.More meaningful and longitudinal community experiences which will serve as a foundation for substantive community involvement for residents throughout their careers. Outcomes that will be assessed include: 1.A high percentage of graduates reporting: a)Leadership roles in CHCs b)Leading QI projects in their practices c)Working in HPSA or international d)Practicing full-spectrum FM (maternity care, pediatrics, inpatient medicine, nursing home, home visits) e)Facilitating group medical visits in practice f)Caring for special populations g)Involvement with local community groups (outside of employer) h)Self-reported competence and confidence with population management, information mastery, integrative medicine, and clinical research methods 2. Graduates demonstrate: a)Completion of resident run QI project b)Improvement in patient panel key quality indicators c)Competency in facilitating and directing group visits with at least three group visit cohorts d)competency or expertise level in information mastery in residency – demonstrated in OSCE- like encounters and/or structured evaluation system Innovation Area Existing (Continuing)New (Additional) PCMH Longitudinal curriculum. QI project. Research projects. Annual PCMH block experience. Defined responsibility and progressive leadership within clinical teams. Development of FMC “Outpatient Service” with resident leadership. Group Visits Training in group visit model. Participant in prenatal group visit program. Progressive responsibility for leadership for at least 3 cycles of group visits within 2 distinct medical issues. HIV Longitudinal care within continuity panel. Required block experience with HIV care-management team. Addiction Medicine/Pain Management Longitudinal care within continuity panel. Standardized training in buprenorphine. Required block experience with addiction/chronic pain management team. Standardized training in OMT Mental Health Block, longitudinal and didactic experiences. Enhanced block and longitudinal experiences with a focus on team-based behavioral health management. Care of the Underserved Longitudinal care within continuity panel. Specialized longitudinal experiences (health literacy, use of interpreters, care for the homeless, health disparities, etc.). Community Medicine Didactic experiences. Experiential learning. Placement with community organization. Longitudinal involvement with a defined community within Lawrence as an expectation of training. Information Mastery (IM) Didactics. Journal Club. Enhanced didactic training through PCMH block. Info Mastery skill tasks in clinical experiences. Areas of Concentration (AOC) AOC time.Increased number of defined AOC’s. Increased curricular time available for AOC development and completion. Organizational Effectiveness/ Leadership Didactic experiences. Participation in advocacy activities. Increased attention to advocacy efforts. Progressive clinical leadership within health center. Increased focus on management skills through didactics in block PCMH. Practice- or Community- Based Research Required research project. Increased curricular time for development and completion of project. More intensive training in research methodology as part of block PCMH. Population Medicine Training in use of patient registries. Individual review of community and patient data with faculty support. Design, implementation, and evaluation of intervention based on population data. Integrative Medicine Depends upon level of interest. Core longitudinal experiences in proven integrative modalities. Lawrence Family Medicine Residency is one of twelve programs selected to begin implementation of a four-year curricular training program beginning in 2013 as part of the Family Medicine Length of Training Pilot (FM-LTP). The length of training pilot program has been developed by the ACGME Review Committee in Family Medicine (RC-FM), in conjunction with the American Board of Family Medicine (ABFM) and is looking to find innovative methods to prepare Family Physicians to “serve as highly effective personal physicians in a high performance health care system.” Selected programs will be matched and compared with a group of existing three-year programs in an evaluation process which will extend through 2019 (call for applications pending). Timeline: Selected residencies begin four year training pilot July 2013 Comparison with identified three year programs evaluated through 2019 Selected Residencies: University of Nevada-Truckee Meadows (Nevada) Mid Michigan Medical Center-Midland (Michigan) University of Tennessee-Knoxville (Tennessee) Bronx Lebanon Hospital Center (New York) John Peter Smith Hospital (Texas) Oregon Health and Science University Program (Oregon) Lawrence Family Medicine Residency (Massachusetts) US Navy Family Medicine Residency Program (US Naval Hospital Bremerton, WA) US Naval Hospital Camp LeJeune (North Carolina) US Naval Hospital Camp Pendleton (Florida) US Naval Hospital Jacksonville (Florida) US Naval Hospital Pensacola (Florida) Expanding to four years will allow for additional training opportunities in these areas as well as ensuring that new graduates are poised to function in a competent manner as they enter an ever changing health landscape. Expanded training opportunities: Population health management Team-based care Information mastery To evaluate the impact of the FM-LTP on Lawrence Family Medicine Residency graduates, a particular focus of our evaluation will be tracking improvements in three areas of competency: Practice-Based Learning and Improvement, Systems-Based Practice, and Managing the Health of Populations. Based on the results of the FM-LTP, a decision may be made to make four years the standard length of training in Family Medicine.

21. Early learnings- Lawrence Effect on involved programs‘: 2012-2013 residency recruitment current resident reaction faculty workload change management strategies

22. Residency Recruitment (Not Only Men!)

23. Lawrence FMR Match Year 2010 2011 2012 2013 Step 2 Avg 231 250 233 253

24. Current Residents- Reactions (Photos removed)

25. Faculty Workload 2 cartoons (removed)

26. Needed Program Resources Funding Faculty Patients Faculty & Resident Time

28. Change Management Process Review of Literature, Rationales in the Context of Needs of Lawrence FMR Graduates Focus Groups/ Multiple Survey Monkeys Faculty Meetings Resident- Faculty 4 year LoT Task Force Email communications Discussion with HC Administration- Approval Needed Discussion with Board of Directors- Approval Needed

29. Maybe Not in this Case, but…. “All important ideas pass through 3 stages. First, they are ridiculed. Second, they are violently opposed. Third, they are accepted as being self evident.” Arthur Schopenhauer (1788-1860)

30. Thanks!

31. Contact Us Joe Gravel jgravel@glfhc.orgjgravel@glfhc.org Wendy Barr wbarr@glfhc.orgwbarr@glfhc.org Kay Nordling mnordling@glfhc.orgmnordling@glfhc.org Jocelyn Hirschman jhirschman@glfhc.orgjhirschman@glfhc.org