1. How Does One Translate “PCMH”? Let Us Count The Ways
Greg Kirschner MD, MPH, FAAFP, WACP,
Advocate Lutheran General Hospital Park Ridge, IL, USA
Musa Dankyau, BM.BCH, FWACP,
Bingham University Teaching Hospital
Jos, Nigeria

2. The Patient Centered Medical Home
Being actively pursued as the transformative model for family medicine practice in the US
Our need for reform of the American medical system extending into the fundamental way we organize and deliver primary care
The promise of quality, engagement, integration, and enjoyment for patients, associates, providers

3. The Patient Centered Medical Home
Yet we also know that PCMH implementation is revolutionary, disruptive, intensive, and carries its own costs
For those involved in residency education, we have been positioned to necessarily embrace this change. . .sooner rather than later
Opportunity and Challenge

4. The Patient-Centered Medical Home Lexicon
Access and communication processes/results
Clinical data organization/charting/registries
Guidelines for important conditions
Self management support
Test and referral tracking
Measures of performance
Team building, electronic health record, portal, registry, patient advisory panel,

5. The Patient-Centered Medical Home Culture
Access and communication processes/results
Clinical data organization/charting/registries
Guidelines for important conditions
Self management support
Test and referral tracking
Measures of performance

6. As we share our ideas internationally, we look for areas of mutual opportunity.
Ask the question: How could this benefit our patients and systems?
At what cost?
Is it really feasible?
How would this work in a different cultural context?
How would it be taught?
Can we discern in advance what to try and what to leave alone?
What is learned by just jumping in the water?
Are there some things best left not translated?
Or perhaps translated but not used in day-to-day language?

7. Share a glimpse of what our personal collaboration is learning
The change process itself
Intentional patient centeredness
Quality initiatives in patient satisfaction and chronic disease management
Pilot programs in group visits for chronic disease management
Challenges to continuity as a core value

8. The Change Process Takes leadership
Engagement takes time. . .and doesn’t always happen
Staff/Associates want to see results from the changes; not as engaged over the whole concept
Team meetings in the BHUTH Outpatient Dept.
Huddles in ALGH residency office
DO WANT TO TREAT PATIENTS BETTER AND FEEL BETTER ABOUT THEIR WORK

9. QUALITY Quality initiatives
Getting ALL to recognize the pursuit of quality as central to the way work is done
For business reasons
As the right thing to do
The realities of focusing on quality
Lack of experience with tools and availability of tools
The cost of measurement
e.g.—Patient satisfaction measurement in the Nigerian and American context

10. A challenge to our cultures
Moving to system thinking, rather than laying blame on individuals
Guilt and shame
Removing barriers related to patient safety initiatives
Being proactive/preventive
Avoiding “fatalism” , pride, individualism
Making change stick
“not just words”
“It seems like we’re always meeting—but when do we do the work?”

11. Patient Centeredness
A movement of our medical cultures with some parallels
Issues of power and control. . .that may have intensified over time with modern medicine
Now an intentional need to put the patient at the center and to partner
The Patient Centered Clinical Method
Taught, examined in the Nigerian context

12. Patient Centeredness And yet. . .
Often fall back to focusing on staff/doctor comfort
What we can/can’t do
Not really part of our core thinking in fullest sense
How are patients included in data gathering, planning
How do we really hard-wire patient centeredness in resource challenged environments

13. Experience with Group Visits
A bit of Nigerian context. . .
All residents must do research projects for a dissertation
Always looking for ideas
Some large group teaching done out of necessity in Nigeria;
Antenatal clinic
A significant burden of chronic disease
A more communal culture, which less emphasis on privacy/autonomy

14. Group Visits Dr Joy Shu’aibu, Senior Registrar in Family Medicine
RCT of group visits patients with diabetes

15. Group Visits Yet to be published, but. . .
Further ahead than ALGH over the past 2 years

16. The Challenge of Chronic Disease Care
Group Visits may be a very appropriate model for the Nigerian context
But there are interesting cultural challenges
Has not been a culture of looking to prevent problems, or limit future complications
Disease destroys balance, which must be restored
It is not acceptable to live with chronic disease
“a wider gap between acute and chronic care”
Looking for imbalance in the physical/social/spiritual world

17. The Challenge of Continuity
Perhaps a bigger problem than in the past as systems and training become more complex, coupled with urbanization
In Nigerian context, specialists don’t understand the concept of continuity clinic experiences for the residents. . .
Moving from “acute care” visits only to a mix of acute/chronic, and even some preventive
How much of a priority in either culture?

18. Distinct challenges Primary Care/Hospital infrastructure
Payment models
Electronic Medical Record
Are experiments: Ehealth Nigeria (open source system, Kano Maternity Hospital)
But also opportunity
The use of cell/mobile phones
Used in the group visits with great success

19. Distinct challenges Violence
Lots of talk about long term things. . .but really focusing on the short term because not sure what tomorrow will be like

20. Anything we shouldn’t translate?
Perhaps a difference between translated for curiosity/interest, and use in everyday language
Difficult to discern what might not be useful
Look for honest, free flow of dialogue
Be careful about imposing standards
Examples of difficult translation: finances, demands on IT, working to limits of license, role of physician, integration into broader system of care

21. Collaboration Anything good has always worked both ways
Examples:
Learning about seriousness of measurement
Don’t take training/background for granted
Be intentional about relationship/sharing
Take advantage of cell phones, Skype