1. Stephanie Nader, MSW, LCSW snader@ecommunity.com Community Health Network FMR Indianapolis, IN September 28th 2012 STFM Behavioral Forum

2.   Introduce a new and innovative longitudinal Patient Centered Medical Home residency curriculum  Share the template for this curriculum and how specific behavioral educational requirements are being met in a longitudinal format.  Learn about the strengths and challenges of having a longitudinal curriculum in a Patient Centered Medical Home. Objectives

3.   8-8-8 residency program  10 physician faculty, 1 behavioral faculty  1 NP, 2 pharmacists, 1 social worker  Community hospital, unopposed program  35 year history  FMC with 30,000 patient visits a year Our Program

4.  At a Local level:  PCMH focus: at our program we received a $1.3 million HRSA grant to transform our practice and residency in the fall of 2010  Duty hours limiting education over time  Residents pulled to cover services over clinic  Some weak rotations  “Patients last” Why a new curriculum?

5.  At a National level:  Family Medicine education leaders BEGGING for innovation  For the first time ABFM pass rates have been lower for first time takers than recertifiers  Traditional FM education has not changed significantly in 40 years  National interest in a 4 year FM residency Why a new curriculum?

6.  An Idea……

7.  Lets Blow Up The Curriculum!

8.  We had to ask ourselves the miracle question …… ”If we woke up one day and a miracle had occurred and our curriculum was providing the best education possible what would it look like?” If you could make changes to your curriculum what would you change? What did we want?

9.   More time in FMC for residents  Patients First!!!!  Residents working in teams to emulate private practice  More teaching from family physicians  Less LOW YIELD learning activities  Subspecialty rotations supporting, not core  Team based population management  Residents to learn PCMH leadership skills  Longitudinal learning instead of block learning  Specialty clinics at our FMC What did we want?

10.   Enlist faculty leads to work on this project  Residents identify learning needs  Reduction of in house responsibilities  Identify highest yield learning experiences  Already existing  New experiences  Achieve buy-in from key stakeholders (faculty, residents, preceptors, and administrators)  Scheduled many meetings with stake holders So how do we get what we want?

11.  So what does our miracle look like

12.   Longitudinal 36 month experience  Increased resident presence in FMC  50% of time in FMC (one half day daily)  Chronic & Preventive modules  PGY2 and PGY3 Individualized Modules  Reduction in FMC clinic for certain experiences  Inpatient Service  Inpatient Pediatrics  OB days  Night Float Family Medicine Center

13.  TEAMWINTERSNOWSPRINGRAIN Care Manager KatieBarb RNCindy/KarenNancy/Karen MADianne/JeanKaylee ReferralDachelleJenny Faculty: Leins/Knight R3 Cerjak R2 Callahan R1 Shaver Faculty: Shockley R3 Eglen R2 Bodden R1 Holland Faculty: Lisby/Burtea R3 Hollen R2 Makombe R1 Auman Faculty: Hern/Jumper R3 Abel** R2 Bolden R1 Hunt TEAMAUTUMNWINDSUMMERSUN Care Manager KatieBarb RNCindy/KarenNancy/Karen MABrigitteSean/Amber ReferralDachelleJenny Faculty: Arrizabalaga R3 Fisher** R2 Wheeler** R1 Baig Faculty Mathew/DaRosa R3 Williams A R2 Paz R1 Abratigue Faculty: Helsel R3 Huggins R2 Demaree R1 Polly Faculty: Curry R3 Huddleston R2 Walcott R1 Burns Team Structure

14.   Inpatient Adult Medicine  6 weeks per year (18 weeks total)  Inpatient Pediatric Medicine  3 weeks PGY1, PGY2 (6 weeks total)  Emergency Department  3 weeks per year (9 weeks total)  Urgent Care/Occupational Health  3 weeks PGY3 (3 weeks total) Acute Care Module

15.   Musculoskeletal/Sports Medicine  Rheumatology, Podiatry, Sports Medicine, Spine Center, Peds/Adult Ortho, OMT  Ambulatory Pediatrics  Gynecology  Gyn procedures (colpo, EMBx, Implanon, IUD)  Ambulatory gyn evals  Procedures  FMC Procedure Clinic  Community Medicine Preventative Module

16.   PGY 1 year:  OB floor days (6 weeks)  Surgery (6 weeks)  PGY 2 & 3 year:  Prenatal Focused/Advanced OB time  Electives (18, 14, or 10 weeks depending on OB track)  Scholarly Activity Individualized Module

17.   Basic: 20 deliveries, 3 continuity  Prenatal Focused: 20 deliveries, 10 continuity, 1 month outpatient OB  Advanced: 80 deliveries, 15 continuity, 2 Chief of OB Service months  Participation in Centering Pregnancy group OB Tracks

18.   Behavioral Longitudinal Curriculum  Chronic Disease Clinics  Cardiology, Asthma/Allergy, Diabetes Care Center, Pharmacy Clinic, Endocrinology, Neurology  Geriatrics  Neuropsych Evaluations, Hospice, Nursing Home, Geriatrician, Tele-health/Home Health, Chronic Care Module

19.   Scheduled team time during Preventive and Chronic Care Modules  Team based population management  AAFP Metric/QI activities  Team Staffings (including RN’s, pharmacy, social workers)  Nursing Home  Pharmacy Didactics Team Time

20.   MORE TIME WITH RESIDENTS!!!  Residents get behavioral training every year/No more intense blocks of behavioral!  Residents will build on skills each year  Peer learning  Variety of experiences, some year specific. What does all this change mean for behavioral curriculum?

21.   Residents see patients in a our Mental Health Clinic and staff with psychiatrist  2-3 times per year  Residents see patients in our chronic pain clinic and staff with an NP  2-3 times per year Experiences in the Behavioral Curriculum

22.   Residents participate in a community service project  Residents visit community resources  PGY 2&3 residents get exposure to addictions treatment  Residents have the opportunity to staff “difficult patients” Experiences in the Behavioral Curriculum

23.   Residents participate in small group interactive didactics  Residents bring difficult patients in for extended “counseling” appointment that is observed /videotaped and live feedback is given.  Residents use skills practiced at the beginning of the module  Residents also receive feedback from their peers Experiences in the Behavioral Curriculum

24.  Rotation of Didactic Topics  Every Year  Genograms – Residents complete their own  Eco – Maps  Year 1  Solutions Focused Brief Counseling Skills  Group Visits  Commonly Used Therapy Models Plans for Longitudinal Curriculum

25.  Rotation of Didactic Topics  Year 2  Eating Disorders  Conflict Management  Pt Physician Relationship  Year 3  Professionalism/Self Care  Personality Disorders (jeopardy game)  Appropriate Resources Utilization/Pt assistance Plans for Longitudinal Curriculum

26.  Year Specific Experiences  Year 1  Observe videotaping  Year 2  Bring 1 - 2 patients in for videotaping  Addictions  Year 3  Bring in 1 – 2 patients for videotaping  Addictions  Lead community service project Plans for Longitudinal Curriculum

27.   Behavioral presence on rounds weekly  Residents participate in behavioral activities during Tuesday conference  Focus group  Balint Group  Quarterly Didactics  Team Staffings Consistent Behavioral Involvement

28.   New EMR  Increase in patient appointments in the office almost immediately  Scheduling issues  Culture change Challenges

29.   Not enough time in the hospital  2 people in the hospital instead of 3  Different schedule each day  Less time with specialists  Home call pager with resident at home  Loss of elective time  More work for FM core faculty  Fear of the unknown Areas of concern from residents and faculty

30.   More continuity of patient care  More time in the office setting  More longitudinal learning, residents can build upon skills each year  Preceptor satisfaction  More time for residents to work with interdisciplinary staff in the management of difficult patients.  More opportunities for residents to see their own patients with specialists Benefits of New Curriculum

31.  Questions and Discussion

32.  THANK YOU