1. CIRCUS: Continuity In Resident Curriculum in University Settings Julie Monaco, MD Scott Klosterman, DO Megha Manek, MD Vishalakshi Sundaram, MD

2. Collaborative to Improve Resident Continuity in University Settings Megha Manek, MD Guthrie Medical Center Julie Monaco, MD UNC- Chapel Hill Scott Klosterman, DO Spartanburg Regional Vishalakshi Sundaram, MD NYMC Phelps FMR Jared Ellis, MD Tuscaloosa FMR Brent Messick, MD Cabarrus Family Medicine Jen Martini, MD VCU- Fairfax FMR

3. OBJECTIVES Understand importance, definition and measurement of continuity Become familiar with some QI methods for improving continuity Learn from our experience with interventions Successes, “opportunities for growth,” and results data

4. Intro Methods Results Lessons Wrap- up

5. Under the Big Top! Family Physicians + Residents value patient relationships Patients value seeing their usual provider Program requirements but curricular interference PCMH values as a key ingredient to health care reform More providers in a patient’s care = higher costs. (1,2)

6. In the Ring: At Our Home Shows Perceived importance to us and our patients Make practice more like graduates in private practice Access to us is safer, with better prevention, chronic disease outcomes and cost effective care compared to alternative sites (Urgent Care/ED/Hospitals)

7. Bringing the CIRCUS to Our Hometowns AIM statement –To improve usual provider continuity amongst the resident physicians at each training site Key measures –Primary Outcome To improve the % of all patient visits that were with their assigned PCP by 15% from July 2013-March 2014 –Secondary Outcome Measure the attendings’, residents’ and staff’s perception of continuity before and after the change packages implemented using an online survey

8. Defining Continuity ManagementInformational

9. Barriers to Continuity System Based Access (patient and provider) EMR informational cross walk Over empaneled providers Resident curricular block schedules Clinic staff Patient Based Patient perceived need for PCP (younger and healthier patients) Urgency of medical need Financial Insurance changes

10. Continuity & Healthcare Outcomes –Morbidity and mortality –Costs Referrals to specialists Hospitalizations ED utilization Staff satisfaction within a practice (less turnover=increased productivity and less cost for staff training) –Revenue for a practice Directly linked with patient satisfaction Perceived patient safety impacts patient retention

11. Outcomes, Quality Improvement, & Continuity Chronic Conditions COPD CHF Chest Pain CAD CVA Asthma Depression Mortality Settings Inpatient Outpatient Ancillary care??? International

12. Patient Satisfaction & Continuity Improved doctor-patient relationship Patient satisfaction Improved compliance with physician instructions

13. Utilization of Care & Continuity Well-executed communication among hospital providers, patients and receiving providers at time of d/c: –improved health outcomes –decreased overall cost –decrease in hospital admissions, readmissions and ED visits Increased number of providers involved in a patient’s care shown to drive up costs (8,9) With increased individual continuity with PCP, there was increased coordination of referrals to specialists (10

14. Patient Satisfaction Staff Satisfaction Utilization & Cost Practice Revenue Quality & Outcomes CONTINUITY

15. Intro Methods Results Lessons Wrap- up

16. Key Driver Diagrams AimSecondary DriversPrimary Drivers Aim & Drivers for Improvement – template

17. Change Concepts PCP Accuracy We decided to define patients’ PCPs using a “four-cut method” PDSA cycles to help improve PCP accuracy in the EMR were designed specific to individual sites

18. Improving PCP Accuracy & Continuity: example PDSA

19. Change Concepts cont’d Supply and Demand Balancing measures at the practice level First third available appointment No show rate Vacancy

20. Change Concepts cont’d Rightsizing Resident Panels Depending on the PGY year, number of clinics/week and number of patients/clinic, resident panel size was calculated Scheduling Improving linkages between scheduling program (IDX) and Electronic Medical Record (EPIC)

21. Change Concepts cont’d Future appointments Reassignment ‘Continuity carve-out’ Identify non- empanelled patients

22. Intro Methods Results Lessons Wrap- up

23. Measurement Patient-Centered Usual Provider Continuity Unadjusted vs. Adjusted UPC percentage. Variability of results between sites & over time.

24. Results Initial efforts across sites show trend to improvement.

25. Impact of full empanelment on data

26. Resident Continuity Satisfaction Survey Measure (Continuity is important in) Pre Intervention Post Intervention Change *Chronic Care76%75%-1% *Acute Care20%21%+1% *Hospital F/U61%60%-1% “Ideal” Chronic Care UPC 6%12%+6%

27. Intro Methods Results Lessons Wrap- up

28. Global Learning Points Obtaining appropriate sponsors Various IT technical difficulties Accurately paneled patients Determining active patient panels Multiple change cycles necessary Ongoing periodic panel re-evaluation Continued refining and enhancement

29. Individual Learning Points Obtaining RRC requirement for PGY3 numbers in clinic over continuity Certain rotations without continuity clinic Incorporation of a new EMR Opening of a new walk-in clinic Problems with measurement accuracy

30. Intro Methods Results Lessons Wrap- up

31. So you want to join the CIRCUS… A Five-Step Plan

32. Step One: set the right goals What objectives best fit your program? What does continuity mean to you?

33. Step 2: get psyched Buy-in is essential It takes a village (to finish a PDSA cycle)

34. Step Three: do something! Some interventions are high-yield. Others, not so much.

35. Step 4: measure, measure, measure Don’t forget to adjust based on what you find! QI is an infinite work- in-progress

36. Step 5: embrace the madness Change. Is. Hard. Expect & prepare for frustration

37. At the end of the day… remember the actual point

38. Thank You! Questions?

39. Disclosures none

40. Please evaluate this session at: stfm.org/sessionevaluation