1. 1 Transforming Our Practices Transformed Our Teaching: Meeting ACGME Competencies with New Models of Care Katherine Miller, M.D. John Nagle, MPA U. Of Colorado Family Medicine Residency

2. 2 Our program University residency – 19 residents University residency – 19 residents Two practice sites – Urban practice and a federally qualified community health center Two practice sites – Urban practice and a federally qualified community health center Selected as a Preparing the Personal Physician for Practice (P4) project site Selected as a Preparing the Personal Physician for Practice (P4) project site –Health Behavior Change Counseling –Community advocacy, leadership, resource utilization –Use of the Chronic/Comprehensive Care Model

3. 3 ICIC Chronic Care Model Resources and Policies Community Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Health Care Organization Informed, Activated Patient Prepared, Proactive Practice Team Productive Interactions Improved Outcomes CC

4. 4 Components of the Chronic Care Model Community Linkages, Resources, Policies Community Linkages, Resources, Policies Organization of the Healthcare Delivery System Organization of the Healthcare Delivery System Self Management Support Self Management Support Decision Support Decision Support Delivery System Design Delivery System Design Clinical Information Systems Clinical Information Systems

5. 5 Participation in national efforts to improve care of chronic diseases Lowry – IHI and Bureau of Primary Health Care Collaboratives past 7 years Lowry – IHI and Bureau of Primary Health Care Collaboratives past 7 years A.F. Williams – Two years participating in the Academic Chronic Care Collaborative– AAMC A.F. Williams – Two years participating in the Academic Chronic Care Collaborative– AAMC Implementing components of the Chronic Care model into operations of both practices Implementing components of the Chronic Care model into operations of both practices

6. 6 ACGME Competencies Patient Care Patient Care Medical Knowledge Medical Knowledge Professionalism Professionalism Interpersonal and communication skills Interpersonal and communication skills Practice based Learning Practice based Learning Systems Based Practice Systems Based Practice

7. 7 Our observation By implementing the practice changes necessary to provide care using the chronic care model we are able to provide training in both systems-based practice and practice- based learning. These had been the most elusive general competencies to teach effectively before the practice changes were made. This includes evidence-based practice and participation in performance improvement activities which are now expected of residents.

8. 8 Colorado Comprehensive Care Curriculum Grid (C4G). Takes the six ACGME Competencies and the six components of the Chronic Care Model and creates a matrix that suggests educational methods and behavioral competencies at the intersections. Takes the six ACGME Competencies and the six components of the Chronic Care Model and creates a matrix that suggests educational methods and behavioral competencies at the intersections. Developed by Dan Burke, M.D. and David Graham, M.D. UCFM Residency Developed by Dan Burke, M.D. and David Graham, M.D. UCFM Residency

9. * Dan Burke, M.D.; David Graham, M.D. UCFM Residency9 Colorado Comprehensive Care Curriculum Grid (C4G)* CommunityLinkages Healthcare System Self- management support Decision Support Delivery System Design Clinical Information Systems Patient Care Medical Knowledge Practice-based Learning Systems-based practice Professionalism Interpersonal and Communication

10. 10 Practice Based Learning Residents must be able to improve their patient care practices by investigating and evaluating their investigating and evaluating their practices practices using best scientific evidence using best scientific evidence

11. * Dan Burke, M.D.; David Graham, M.D. UCFM Residency11 Colorado Comprehensive Care Curriculum Grid (C4G)* Community Linkages Healthcare System Self- management support Decision Support Delivery System Design Clinical Information Systems Patient Care Medical Knowledge Practice- based Learning Systems-based practice Professionalism Interpersonal and Communication

12. 12 Clinical Information Systems Individual patient reports at the point of care Individual patient reports at the point of care Provider panel reports on patients with specific disease conditions Provider panel reports on patients with specific disease conditions Reports on the practice’s compliance with disease management recommendations Reports on the practice’s compliance with disease management recommendations Residents learn to deal with information, rather than just collect it. Clinic meetings become lively discussions about resident’s care and the practice’s care of patients. Residents learn to deal with information, rather than just collect it. Clinic meetings become lively discussions about resident’s care and the practice’s care of patients.

13. 13 Decision Support Use of evidence based clinical guidelines Use of evidence based clinical guidelines Embedded in daily practice Embedded in daily practice Shared with clinic team and patients Shared with clinic team and patients Residents really question the evidence that determines care; are willing to look at practice change, and develop the ability to think of care for a group. Residents really question the evidence that determines care; are willing to look at practice change, and develop the ability to think of care for a group.

14. 14 Delivery System Design Group Visits Group Visits Planned Visits Planned Visits Institutionalizing performance improvement efforts Institutionalizing performance improvement efforts Point of care testing Point of care testing Care by a team Care by a team Residents are able to be part of practice change by doing planned visits, organizing group visits, and looking to other team members for care of the patient. Residents are able to be part of practice change by doing planned visits, organizing group visits, and looking to other team members for care of the patient.

15. 15 Systems Based Practice Residents must demonstrate An awareness of and responsiveness to the larger context and system of health care An awareness of and responsiveness to the larger context and system of health care An ability to call on system resources to provide optimal care An ability to call on system resources to provide optimal care

16. * Dan Burke, M.D.; David Graham, M.D. UCFM Residency16 Colorado Comprehensive Care Curriculum Grid (C4G)* Community Linkages Healthcare System Self- management support Decision Support Delivery Systems Design Clinical Information Systems Patient Care Medical Knowledge Practice-based Learning Systems- based practice Professionalism Interpersonal and Communication

17. 17 Community Resources and Policies Linking practice to community resources that facilitate patient’s self-care management Linking practice to community resources that facilitate patient’s self-care management Linking patients to organizations Linking patients to organizations Teaching skills in effectively advocating for needed resources Teaching skills in effectively advocating for needed resources By doing a health behavior analysis, residents explore resources for individual patients. They also explore resources for the practice. By doing a health behavior analysis, residents explore resources for individual patients. They also explore resources for the practice.

18. 18 Health Care Organization Linking to institutional system-wide efforts to improve the care of patients with particular health problems Linking to institutional system-wide efforts to improve the care of patients with particular health problems Participating in the formulation of clinical guidelines Participating in the formulation of clinical guidelines Residents begin to examine and to incorporate institutional changes in the context of improving patient care. Residents begin to examine and to incorporate institutional changes in the context of improving patient care.

19. 19 Trapping yourself so you do the right thing Our residents no longer want to hear about the Chronic Care Model. They want to do it. Our residents no longer want to hear about the Chronic Care Model. They want to do it. Teaching needed to shift from the classroom to practice meetings and precepting encounters Teaching needed to shift from the classroom to practice meetings and precepting encounters Required formalization of the longitudinal teaching of the CCM as a curricular area with Competency-based goals and objectives Required formalization of the longitudinal teaching of the CCM as a curricular area with Competency-based goals and objectives