1. Join the conversation! Our Twitter hashtag is MSE12 Join the conversation. Our Twitter hashtag is #MSE12 From Motivational Interviewing to System-based Care A Third-Year Clerkship Chronic Care Model Curriculum and OSCE February 3, 2012 Caroline Wellbery, MD Vince WinklerPrins, MD Yumi Shitama Jarris, MD Ranit Mishori, MD, MPH

2. Join the conversation. Our Twitter hashtag is #MSE12 Do you teach systems-based care? If so, how?

3. At the end of the session, participants will: Identify strategies for teaching elements of the Chronic Care Model Describe how to incorporate motivational interviewing into a formative OSCE Explain how to incorporate EHR communications skills into an OSCE Objectives

4. Join the conversation. Our Twitter hashtag is #MSE12 Georgetown University Medical Education Structure 200 students/year Strong subspecialty focus – 6.8% students/year into Family Medicine Clerkship: 4 weeks, traditional structure – Didactics: every Friday with exception of first Monday – Work with community preceptor: 4 days/wk

5. Join the conversation. Our Twitter hashtag is #MSE12 Week 1 Orientation to clerkship and to the discipline of Family Medicine Behavioral Change and Motivational Interviewing workshop (60-90 minutes) Musculoskeletal workshop Case Discussions Week 2 Chronic care seminar (60 minutes) and EBM workshop Week 3 OSCE (3 groups of students, 60 minutes each) and case presentations Week 4 Case presentations and final exam Georgetown University Medical Education: Clerkship Didactic Structure

6. Join the conversation. Our Twitter hashtag is #MSE12 Behavioral change: Four common patient scenarios that highlight the challenges of changing behavior View video of physician doing this poorly Understanding and demystifying behavioral change—stages of change model—highlights where and how we can assist Introducing concepts of motivational interviewing and review of other core interviewing skills Review common patient scenarios introduced previously Break into four groups, assign a patient scenario, discuss and report out how each group would approach each patient View video of physician doing this well Behavioral Change and Motivational Interviewing Workshop

7. Join the conversation. Our Twitter hashtag is #MSE12 Chronic Care Seminar Required readings prior to session: The six elements of the chronic care model (http://www.improvingchroniccare.org/)http://www.improvingchroniccare.org/ 1.Health System 2.Delivery System Design 3.Decision Support 4.Clinical Information Systems 5.Self-Management Support 6.The Community

8. Join the conversation. Our Twitter hashtag is #MSE12 Chronic Care Seminar Required readings prior to session: 10 steps to a patient-centered medical home ( http://www.nxtbook.com/nxtbooks/aafp/fpm_20091112/index.php?startid=18) http://www.nxtbook.com/nxtbooks/aafp/fpm_20091112/index.php?startid=18 Required viewings prior to session: “Communicating with Patients While Using Electronic Health Records”—PowerPoint focused on: o Recognizing the benefits of using EHR in patient care o Identifying common mistakes that impede effective communication when using an EHR o Becoming familiar with positive behaviors that improve patient-physician communication using an EHR

9. Join the conversation. Our Twitter hashtag is #MSE12 Chronic Care Seminar “What is Chronic Disease? The Chronic Care Model” Interactive question based activity: What is chronic disease? Name chronic diseases (A to Z) Statistics Physician challenges Patient challenges System challenges

10. Join the conversation. Our Twitter hashtag is #MSE12 Chronic Care Seminar Discussing the Chronic Care Model as a structure to support chronic disease management :

11. Join the conversation. Our Twitter hashtag is #MSE12 Chronic Care Seminar Small group activity: Six small groups each of which is assigned a chronic care model element. Discuss amongst yourselves how these elements are manifest in the clinical practice you are working. Report out to the group

12. How would you assess elements of the CCM in an OSCE? Which elements and how?

13. 1.Practice motivational interviewing 2.Demonstrate EHR communication skills 3.Reflect on CCM elements OSCE: Objectives

14. OSCE: Prep On-line PPT review Motivational Interviewing & CCM sessions EHR Communication skills

15. Brief scenario and vital signs Instructions to student Review labs Conduct motivational interview Complete post-encounter on CCM 1-2 minutes OSCE: Door Chart

16. Student reviews labs with patient Static flow sheet of labs (2010-11) Now live EHR (2011-12) Student implements Motivational Interview Addresses worse DM control Addresses increased BMI 15 minutes OSCE: Patient encounter

17. Student answers 3 questions about the CCM 1.What elements of the CCM were you able to address in your encounter? 2.What features of an information system would you design to provide optimal care for your patient? 3.Thinking back on your clerkship experience, briefly describe a patient with a chronic condition who would have benefited from incorporation of one of these CCM elements? OSCE: Post-Encounter

18. Formative SP checklist Faculty debriefing & feedback session Self-observation on CD OSCE: Evaluation

19. Join the conversation. Our Twitter hashtag is #MSE12 Quantitative OSCE Evaluation

20. Join the conversation. Our Twitter hashtag is #MSE12 Skill Area/CaseFrances/Francis Taylor Chronic Care – DM with SP verbal feedback Skill Area Mean Skill Area StDev Skill Area High Skill Area Low EHR Communication Skills 68.7% (4/6) 24% (1/6) 100% (6/6) 0% (0/6) Motivational Interviewing 63.8% (8/12) 20% (2/12) 100% (12/12) 8.3% (1/12) Case High 100% (18/18) Case Low 16.7% (3/18) OSCE Scores AY 2010-2011 (n=176)

21. Join the conversation. Our Twitter hashtag is #MSE12 Mean Score 1.Student introduced self and greeted me BEFORE starting to use the computer. 97.7% 2.Student acknowledged/introduced the need to use the computer during the visit. 69.3% 3.Student asked me to join him/her so that I could visually share EHR information on the screen. 47.7% 4.Constructed a triangle between doctor/patient/computer.67% 5.Student alerted me verbally when turning attention from me to the computer. 33.5% 6.Student maintained eye contact with me during the encounter when not using the computer. 96.6% SP Checklist – EHR Communication Skills

22. Join the conversation. Our Twitter hashtag is #MSE12 Mean Score 7.Did the student review the normal labs and state something POSITIVE about them? 84.7% 8.Did the student express concern about how you’re doing after your LOSS? 84.1% 9.Did the student ask you what YOU wanted to work on?86.9% 10.Did the student ACCEPT your preference for diet and not exercise? 75.6% 11.Did the student elicit your READINESS in making a behavioral change? 58.5% 12.Did the student explore the PROs/benefits/motivating factors of changing? 64.8% SP Checklist – Motivational Interviewing

23. Join the conversation. Our Twitter hashtag is #MSE12 Mean Score 13.Did the student explore the CONs/barriers/inhibiting factors of changing? 59.7% 14.Did the student ask you what might help you move towards change? 60.2% 15.Did the student ASK what specific GOALS to set in achieving the chosen behavior change? 61.9% 16.Did the student offer other CLINIC resources, such as nutritionist?46.6% 17.Did the student ask about any COMMUNITY resources/support?13.6% 18.Did the student SUMMARIZE the plan?68.8% SP Checklist – Motivational Interviewing

24. Join the conversation. Our Twitter hashtag is #MSE12 Aside from greeting and eye contact, scores were generally low on EHR Communication Skills Conclusions: EHR Communication Skills 2.Student acknowledged/introduced the need to use the computer during the visit. 69.3% 3.Student asked me to join him/her so that I could visually share EHR information on the screen. 47.7% 4.Constructed a triangle between doctor/patient/computer.67% 5.Student alerted me verbally when turning attention from me to the computer. 33.5%

25. Join the conversation. Our Twitter hashtag is #MSE12 Scores were higher on interviewing skills requiring the student to be empathic and positive about progress Did the student review the normal labs and state something POSITIVE about them? 84.7% Did the student express concern about how you’re doing after your LOSS? 84.1% Did the student ask you what YOU wanted to work on? 86.9% Did the student ACCEPT your preference for diet and not exercise? 75.6% Conclusions: Motivational Interviewing

26. Join the conversation. Our Twitter hashtag is #MSE12 Scores were lower on interviewing skills regarding development of concrete techniques to change (finding resources, setting goals) Conclusions: Motivational Interviewing Did the student explore the CONs/barriers/inhibiting factors of changing? 59.7% Did the student ask you what might help you move towards change? 60.2% Did the student ASK what specific GOALS to set in achieving the chosen behavior change? 61.9% Did the student offer other CLINIC resources, such as nutritionist? 46.6% Did the student ask about any COMMUNITY resources/support? 13.6%

27. Join the conversation. Our Twitter hashtag is #MSE12 Highest scores Conclusions 1.Student introduced self and greeted me BEFORE starting to use the computer. 97.7% 6.Student maintained eye contact with me during the encounter when not using the computer. 96.6% Lowest scores 5.Student alerted me verbally when turning attention from me to the computer. 33.5% 17.Did the student ask about any COMMUNITY resources/support?13.6%

28. Join the conversation. Our Twitter hashtag is #MSE12 Random sample of 30 student surveys (total = 176) Chronic Care Model: Qualitative Analysis Study Design CCM Elements 1.Health System 2.Delivery System Design 3.Decision Support 4.Clinical Information Systems 5.Self-Management Support 6.The Community Post-Encounter Question What elements of the chronic care model were you able to address in your encounter?

29. Join the conversation. Our Twitter hashtag is #MSE12 Chronic Care Model: Qualitative Analysis Study Design ScenarioCCM Element CCM Definition 1Correctly identified CCM element AND Definition correctly matches element 2Correctly identified CCM element; Definition matches a different CCM element 3Different name/no name to CCM element; Definition correctly matches element 4Did not name a correct CCM element; No definition given or definition did not identify a CCM element Identification of CCM element and definition were used for evaluation of questions Split into four evaluation categories:

30. Join the conversation. Our Twitter hashtag is #MSE12 Chronic Care Model: Qualitative Analysis CCM Element Correctly Identified CCM Element Correctly Defined Number of Students Always YES 1 At least once YES 9 At least once NOYES 8 At least once YESNO 7 Never NO 12

31. Join the conversation. Our Twitter hashtag is #MSE12 ~60% had at least 1 correct answer (Q #1) ~40% had no correct answer (Q #1) Conclusion: Poor understanding of CCM Vague understanding of specific elements No sense of integration among elements “Health care system” least well understood Post-encounter evaluation: Qualitative

32. Join the conversation. Our Twitter hashtag is #MSE12 Most students were unable to list and define the CCM elements A major gap is knowing how organizational structures, leadership, and policy support patient care Conclusions

33. Join the conversation. Our Twitter hashtag is #MSE12 Well-received by students Excellent opportunity to practice Motivational Interviewing EHR facilitates communication skills practice Live EHR simulates clinical encounter Student Feedback (Debrief)

34. Join the conversation. Our Twitter hashtag is #MSE12 Improve didactics on CCM definitions and roles of CCM elements, especially health care system and community (the top tier of the CCM), possibly using cases Assign students CCM exercise to complete at their clinical sites Possible Solutions & Future Directions

35. Join the conversation. Our Twitter hashtag is #MSE12 Helena Manguerra Kristen Lewandowski Mary Donovan Acknowledgments

36. Join the conversation. Our Twitter hashtag is #MSE12 Caroline Wellbery, MD, PhD wellberc@georgetown.edu Vince WinklerPrins, MD vjw6@georgetown.edu Yumi Shitama Jarris, MD yj33@georgetown.edu Ranit Mishori, MD, MHS mishorir@georgetown.edu Contact Information