1. Population Health: A Curriculum to Teach the Next Generation of Residents Brian Halstater, MD Mina Silberberg, PhD Viviana Martinez-Bianchi, MD, FAAFP

2. Workshop Outline Introductions Requirements for Population Health Training – FM-RC – Milestones Illustrative Curriculum Demonstration/ Workshop Lessons Learned Q and A

3. Population Health Why Important? Potential to impact the ‘social determinants of health’ Financial incentives to providers – ‘quality over volume’ Skill set we all need to develop FM aim per World Organization of Family Doctors  provide personal, comprehensive and continuing care in the context of the family and the community

4. FM-RC Requirements: Prior (July 1, 2007) Found under Community Medicine curriculum requirements (IV.A.5.b).(9) -population epidemiology, interpretation of public health statistical information -community-based disease screening, prevention, health promotion -factors associated with differential health status among sub-populations, the role of family physicians in reducing such gaps -structured interaction with the public health system -experience in community health assessment -experience in developing programs to address community health priorities -community-based health education of children and adults Mentioned elsewhere Management of Health Systems Leadership roles in communities QI project with FMC population “Population Health”

5. FM-RC Requirements: New (July 1, 2014) “Population Health” – mentioned one time, under Curriculum Organization and Resident Experiences IV.A.6.p) There must be a structured curriculum in which residents address population health, including the evaluation of health problems of the community. (Detail)

6. Milestones – Population Health Found in a myriad of different Milestones for all six of the ACGME Core Competencies. Specifically: PC-2 Cares for patients with chronic conditions PC-3 Partners with the patient, family, and community to improve health through disease prevention and health promotion

7. Milestones – Population Health Smattering of other Milestones, including: MK-2 SBP-1, 2 and 3 PBLI-1 and 3 PROF-3 C-2

8. One Illustrative Curriculum Since 2004, iterative process: Research Curriculum  Community Engaged Population Health Research  Population Health Improvement and Leadership Curriculum (PHIL)

9. PHIL: Goals To train Family Physicians to: Serve as leaders Develop sustainable approaches to population health improvement Utilize skills that integrate, and enhance both primary care and public health Engage with communities

10. PHIL – 3 year curriculum PGY I – Introduction to Population Health PGY II – Classroom and project PGY III – Project continuance, continued learning, teaching, and “final exam” Strongly influenced by ‘Competency Map’ article published in Academic Medicine

11. DomainPHIL Year 1 (PGY1)PHIL Year 2 (PGY2)PHIL Year 3 (PGY3) Population Health- General, i.e., All 4 Domains Introduction to Population Health. Population Health Workshop Project. (Participate in Pickens Clinic priority- setting. Work as team member.) Population Health Core Course. Project (Participate in Pickens Clinic priority-setting. Serve as project manager in team). Project (Participate in Pickens Clinic priority-setting. Complete existing project as project manager. Participate in team’s new project. Advanced Population Health (6 session). Facilitation of one core course discussion session. Population Health Domain I: Public Health Attending Partnership for Healthy Durham meetings. Public Health Essential Function web-based modules with one follow-up discussion. Serving as instructors in interprofessional prevention course. Population Health Domain II: Community Engagement Two week community health rotation (including IT for population health). Site visits (e.g., CAARE, Lincoln, Public Health Dept.). Community health assessment and presentation. Leading a community health education session. Attending a PAC meeting. Precepting in community clinic. Sometime over the three years: 1 session: Professionalism and cross-cultural communications.

12. DomainPHIL Year 1 (PGY1)PHIL Year 2 (PGY2)PHIL Year 3 (PGY3) Population Health Domain III: Critical Thinking Journal club. Lead: Ostbye Population Health Domain IV: Leadership/Team Skills) Resident as Clinic Director (including assessment of remaining leadership training needs and corresponding plan). Lead: Ragsdale Assessment of leadership skills in year 1, tailored leadership training plan, assessments every 6 months. Sometime over the three years: 1 session: Communication at work; challenging conversations with patients and co-workers, setting limits, and asking for what you want. 1 session: How to negotiate; how to receive criticism/feedback from colleagues and supervisors. 1 session: Supervising personnel. 1 session: Cognitive fallacies and decision-making.

13. PGY I – First year General/All Domains Introduction to population health, population health workshop Assist with current PGY 2 Project 13

14. PGY 1 - PH Web-based modules with follow-up discussion (GME Innovations Grant) Learning to use other sites to look at local, state and national data 14

16. PGY 1 - CE Orientation to local community upon joining program Site visits Community health rotation Professionalism and cross-cultural communications 16

17. PGY 1 - CT Journal club 17 I am so glad we are learning how to critically appraise literature! Prostate Cancer Screening Recommendations

18. PGY 1 – Team Skills* Participation in clinical teams – Team training and leadership development Communication skills development, including – challenging conversations, limit setting and agenda setting, negotiation skills, feedback (giving and receiving) 18

19. PGY 2 – All Domains Core Course – Population Health Readings, Modules and Discussion Project Practical Playbook - recently released, will be used for future readings/ activities www.practicalplaybook.org 19

20. PGY 2 - Core Course Group discussions, following readings and modules Faculty and resident-facilitated Demonstrate understanding of – Theoretical Concepts – Practical implications of the concepts – Role in projects Includes faculty, residents, students and others

21. PGY 2 – Prior Projects Mentored population health improvement projects – Faculty-resident pair – Two-year project* where skills and concepts covered are needed to complete, including Community engagement Leadership Team-building Critical thinking Data analysis Strategic development Evaluation

22. PGY 2 – Finishing Projects (5) Transitions of care IP-> OP [1 R, 2 F] Chronic narcotics in FMC [1R, 1F] Expectations at physical visits [1R, 1F] Diabetes educational tool [1R, 1F] Patient satisfaction [1 R, 3 F] – Part of multi-state collaborative N = 5 Residents (R) and 6 Faculty (F) One resident off cycle Two faculty on two projects

23. PGY 2 – New Projects Clinical-team based, Continuous Quality Improvement with PDSA cycles Clinic as starting point, but community- engaged Progress discussed with entire cohort on regular basis – Input provided by other teams All projects this year are part of a multi-state collaborative for population health improvement and are on obesity

24. PGY 2 – Public Health (PH) Public Health Department - Partnership for a Healthy Durham meetings Prevention Course instructors for interdisciplinary health professions 24

25. PGY 2 – Community Engagement (CE) CAARE Facility Tour Lincoln Community Health Center Durham County Health Department Attending a PAC meeting. Provide care in community clinic. Professionalism and cross-cultural communications. 25 Community health assessment and presentation Leading a community health education session Seeing patients in a community clinic site

26. PGY 2 – Critical Thinking (CT) Journal club* Data analysis – Own patient population – Compared with Durham community data and other clinicians data. 26 This population health stuff is very interesting, I can’t wait to learn more!

27. PGY 2 – Team Skills (TS) Participation in clinical teams – Team training and leadership development Communication skills development, including – challenging conversations, limit setting and agenda setting, negotiation skills, feedback (giving and receiving) – Advocacy (local, state, national organizations) – Leadership/ collaboration (individualized) 27

28. PGY 3 – Final Year General/All Domains Project completion Reinforcing modules and follow-up discussions Co-lead sessions with course faculty Write up project for publication 28

29. PGY3 – Public Health* Public Health Department - Partnership for A Healthy Durham meetings Prevention Course instructors 29

30. PGY 3 - CE Continuity patients in community clinic. Professionalism and cross- cultural communications. Poster Presentation at Community Health day 30 We learned a lot with our project

31. PGY 3 - CT Journal club Perform data analysis of own patient population, compare to Durham community data, other clinicians data QI Project 31

32. PGY 3 - TS Participation in clinical teams – Team training and leadership development Communication skills development, including – challenging conversations, limit setting and agenda setting, negotiation skills, feedback (giving and receiving) Resident as Clinic Director Rotation Co-lead Clinical Team at Family Medicine Center 32

33. Please break into small groups It is time for a small group exercise! You’ll need a person to record your group’s thoughts and ideas

34. Small Group Question You are a Family Physician. You have noticed that your older adult patients in clinic do not consistently take their BP medications. Others in clinic have noted this as well. After discussing this in a faculty meeting you realize the need to improve adherence to BP medications. What do you do?

35. Competencies to Consider (1) Identify socioeconomic, environmental, cultural, and other population-level determinants of health that may be affecting medication adherence for older patients with BP in your clinic. (2) Identify community partners who might be able to help you understand and address barriers to medication adherence in your clinic. (3) Identify ways in which the peer-reviewed medical and public health literature might help you with this issue, and what types of literature you might look for. (4) Identify ways in which you can utilize the inter-professional care team within your clinic and within the community to address this issue.

36. Get to it! Each group please choose one focus of the problem based on one of the four competencies on the slide

37. Competencies to Consider (1) Identify socioeconomic, environmental, cultural, and other population-level determinants of health that may be affecting medication adherence for older patients with BP in your clinic. (2) Identify community partners who might be able to help you understand and address barriers to medication adherence in your clinic. (3) Identify ways in which the peer-reviewed medical and public health literature might help you with this issue, and what types of literature you might look for. (4) Identify ways in which you can utilize the inter-professional care team within your clinic and within the community to address this issue.

38. Come together Volunteers to share what they learned of the process Other comments

39. PHIL - Successes Residents endorse the relevance of this material for their careers – whether in clinical practice or academic research – One  Robert Wood Johnson Clinical Scholar – A self-described “Sport oriented not researcher”  has actively engaged in 5 different research projects – One  Using PHIL in developing a new educational/ clinical project around care transitions; also working with Medicaid Care Management Network (one of our current faculty) – One  future job permits ¼ time to work with populations 39

40. PHIL - Successes Focus Group Results – participants: – Positive perception of need for population health and engaging communities – More prepared to bridge gap of factors that impact health (solid foundation) – Exposed from theoretical to practical (want more)

41. PHIL - Successes Lively, insightful discussion relative to population health and in journal club Projects providing useful, relevant information

42. Lessons Learned/ Challenges Schedules! Resources - Make sure residents have the tools they need to carry out their projects Reading load too heavy Faculty need training too Balancing the need to make this relevant to clinicians (especially faculty maybe) while still getting outside the clinic walls Enthusiasm for the curriculum Multi-disciplinary leadership team to develop and implement curriculum 42

43. Evaluation of Curriculum Standard rotation evaluation Focus group following core course Alumnae survey Ability of participants to pass final exam 43

44. Next Steps PHIL  PHIT – Teamwork instead of Leadership Increased utilization of Practical Playbook Ongoing evolution – Leadership in particular Fullerton – PHIL and CDC - AAMC

45. Questions? 45

46. Selected References (1) Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century http://www.nap.edu/catalog.php?record_id=10542#toc Institute of Medicine. Training Physicians for Public Health Careers. Washington, DC: National Academy Press; 2007 Council on Graduate Medical Education Twentieth Report, Advancing Primary Care, 2010 http://www.cogme.gov/20thReport/cogme20threport.pdf AAMC Report II Contemporary Issues in medicine: Medical Informatics and Population Health. Medical School Objectives Project, June 1998 https://services.aamc.org/publications/showfile.cfm?file=version88.pdf&prd_id=199&prv_id =240&pdf_id=88 46

47. Selected References (2) Summary of the Meeting: Developing a Strong Primary Care Workforce. Macy Foundation Report http://www.macyfoundation.org/docs/macy_pubs/jmf_primarycare_summary.pdf Educating Nurses and Physicians: Toward New Horizons. Advancing Inter- professional Education in Academic Health Centers, June 2010 http://www.macyfoundation.org/docs/macy_pubs/JMF_Carnegie_Summary_WebVersion_% 283%29.pdf Kindig D and Stoddart S (2003). What is population health? AJPH 93 (3): 380-383 Centers for Disease Control and Prevention. Principles of community engagement (1st ed.). Atlanta (GA): CDC/ATSDR Committee on Community Engagement; 1997 Stokols D. Translating social ecological theory into guidelines for community health promotion. American Journal of Health Promotion 1996;10(4):282-298. www.practicalplaybook.org 47