1. The Personal Medical Home and Maternity Care
Brooks Flood, DO, Brandy Deffenbacher, MD,
Annamarie Meeuwsen, MD, Suzanne Gomez, MD,
and Jay H. Lee, MD
University of Colorado Family Medicine Residency (UCFMR)

3. Objectives Describe the Patient Centered Medical Home (PCMH)
Describe the “current state” of maternity care at the UCFMR
Discuss the PCMH curriculum
Describe how residents use practice-based learning to assess change

4. PCMH Future of Family Medicine 2004 Evidence Based EMR’s
Described “New Model” of Care
Evidence Based
EMR’s
Asynchronous Communication
Office design
Advanced scheduling
Group Visits
Described Medical Home
P4 2006
How do we put these concepts into residency training?

5. P4 Make a better doctor for today’s and tomorrow's needs
Preparing the Personal Physician for Practice
CU Goals:
Make a better doctor for today’s and tomorrow's needs
Revamp Curriculum
“Intentionalize” Internship
Create a PCMH

6. PCMH
Prepare PGY2 residents to be effective participants in a practice that is a patient centered medical home by:
More consistent presence in clinic
More cohesive teams
Group visits
Community integration
Health behavior change counseling
New roles and relationships

7. Schedules Prior to PCMH Rotations dictated clinic days
No clinic days during certain rotations
Each month focused on specialty training
“training to be surgeon, internist, ob/gyn”

8. Mon Tue Wed Thurs Fri AM PM Fixed Clinic Clinic Fixed Clinic
Care Management
Practice Improvement
Fixed Clinic PM
Fixed Clinic
Elective
Didactics
Community
Fixed Clinic

9. PCMH Research Question
How does working in a PCMH residency affect our maternity care, especially in terms of continuity of care?

10. Methods
Suzy Gomez

11. Study Method
Retrospective chart review

12. Definition of Continuity and PCP
Continuity Requirement for Residency Review Committee (RRC)
Prenatal, natal, and postnatal
Primary Care Provider
Provider who saw the patient the most times

13. University of Colorado Family Medicine Residency
University Track
Academics and Research
6 Residents
Denver Health Track
Underserved
2 Residents

14. AF Williams Continuity clinic for the residents of the UH track
Part of the University of Colorado Hospital system

15. Lowry Continuity clinic for residents of the DH track
Part of the Denver Health and Hospitals system (eight community health centers)

16. Inclusion Criteria
Receiving prenatal care from August 2008 to Feb 2009
Delivered before Feb 1, 2009
Prior to PCMH
AFW included all OB patients
Lowry data included OB patients seen by a resident

17. Exclusion Criteria Two or less prenatal visits Non-prenatal visits
Ultrasounds
Acute sick visits

18. Data Collection Lowry AF Williams
Data gathered in central log from each OB patient seen by a resident
AF Williams
Obtained of all OB patients from medical records

19. Data Collection EMR search Age, Gravity, Parity LMP & EDC Insurance
Number of providers
Number of prenatal visits

20. Continuity Modified modified continuity index
MMCI = (1 - P/V)/(1 - 1/V)
P = # of providers who saw the patient
V = # of visits
J Fam Pract 1987; 24:

21. Results
Brandy Deffenbacher

22. Questions Is there a relationship between age and continuity?
Do primigravidas or multigravidas have better continuity?
Do non-resident providers have better continuity?
Do insured patients have better continuity?

23. AFW (33) Lowry (35) Total (68) Mean #visits 9.27 8.71 8.99 Mean MMCI
0.77
0.65
0.71
Mean Age
28.1
27.8
27.9
Multips 22 27 49
Primips 11 8 19
Insured 23 1 24
Uninsured 10 34 44
Resident 17 41
Nonresident 9 18

24. AFW (33) Lowry (35) Total (68) Mean #visits 9.27 8.71 8.99 Mean MMCI
0.77
0.65
0.71
Mean Age
28.1
27.8
27.9
Multips 22 27 49
Primips 11 8 19
Insured 23 1 24
Uninsured 10 34 44
Resident 17 41
Nonresident 9 18

25. Is there a relationship between age and continuity?

26. AFW
Lowry
Overall
Mean Age
28.1
27.8
27.9
Minimum age 16 42
Maximum age 15 41

27. Age and Continuity AFW Lowry Overall Spearman correlation=0.45
No correlation between age and continuity

28. Do multigravidas or primigravidas have better continuity?
Multip vs Primip
Do multigravidas or primigravidas have better continuity?

29. AFW (33) Lowry (35) Total (68) Mean #visits 9.27 8.71 8.99 Mean MMCI
0.77
0.65
0.71
Mean Age
28.1
27.8
27.9
Multips 22 27 49
Primips 11 8 19
Insured 23 1 24
Uninsured 10 34 44
Resident 17 41
Nonresident 9 18

30. Multip vs Primip AFW Lowry
Multips median MMCI: 0.80 (IQ range )
Primips median MMCI: 0.85 (IQ range )
P*=0.31
Lowry
Multips median MMCI: 0.67 (IQ range )
Primips median MMCI: 0.71 (IQ range )
P*= 0.62
*Wilcoxon Rank-Sum test (used for non-normally distributed data)

31. Multip vs Primip Overall
Multips median MMCI: 0.75 (IQ range )
Primips median MMCI: 0.75 (IQ range )
P*=0.21
No difference in continuity
* Wilcoxon Rank-Sum test

32. Nonresident vs Resident PCP
Do non-resident providers have better continuity?

33. AFW (33) Lowry (35) Total (68) Mean #visits 9.27 8.71 8.99 Mean MMCI
0.77
0.65
0.71
Mean Age
28.1
27.8
27.9
Multips 22 27 49
Primips 11 8 19
Insured 23 1 24
Uninsured 10 34 44
Resident 17 41
Nonresident 9 18

34. Nonresident vs Resident PCP
AFW
NR PCP: MMCI 0.83 (IQ range )
Res PCP: MMCI 0.80 (IQ range )
P*=0.54
Lowry
NR PCP: MMCI 0.71 (IQ range )
Res PCP: MMCI 0.67 (IQ range )
P*=0.34
*Wilcoxon Rank-Sum test

35. Nonresident vs Resident PCP
Overall
NR PCP: MMCI 0.71 (IQ range )
Res PCP: MMCI 0.75 (IQ range )
P*=0.88
No difference
*Wilcoxon rank-sum test

36. Level of Resident Training
Is there a difference in continuity between residents in different years of postgraduate training?

37. Level of Training n
AFW
Lowry
Overall
PGY1
PGY2 10 11 21
PGY3 14 6 20

38. Level of Training Overall: No difference No data for PGY1
PGY2 median MMCI: 0.67 ( )
PGY3 median MMCI: 0.78 ( )
P*= 0.08
No difference
*Wilcoxon rank-sum test

39. Do insured patients have better continuity?
Insured vs Uninsured
Do insured patients have better continuity?

40. AFW (33) Lowry (35) Total (68) Mean #visits 9.27 8.71 8.99 Mean MMCI
0.77
0.65
0.71
Mean Age
28.1
27.8
27.9
Multips 22 27 49
Primips 11 8 19
Insured 23 1 24
Uninsured 10 34 44
Resident 17 41
Nonresident 9 18

41. Insured vs Uninsured AFW Lowry Insured MMCI: 0.80 (IQ range 0.72-0.89)
Uninsured MMCI: 0.82 (IQ range )
P*=0.92
Lowry
Insured MMCI: 0.83
Uninsured MMCI: 0.67 (IQ range )
P*=0.30
*Wilcoxon rank-sum test

42. Insured vs Uninsured Overall Insured MMCI: 0.82 (IQ range 0.74-0.89)
Uninsured MMCI: 0.70 (IQ range )
P*= 0.001
*Wilcoxon rank-sum test

43. DISCUSSION
Brooks Flood

44. Outline How this evolved Flaws What we learned
Future plans for continued study

45. How this idea started
The original idea for this project presented as we pondered “What are the challenges and barriers for family medicine residents to reach the 10 continuity deliveries required by the RCC

46. The minimum requirements for a continuity patient
(program requirements IV.A.5.b.3.c)
at a minimum residents must provide antenatal, natal and post natal care for a delivery to be counted as a continuity delivery (program requirements IV.A.5.b.3.c)

47. What the idea evolved into:
How to provide better continuity in the care of our patients

48. Our new goal focused on how our new PCMH curriculum changes our OB continuity
So far we have gathered data for the ‘old’ curriculum only. Over the next (6) months we will gather data under our new curriculum design and compare our data sets.

49. Upon doing the study we came upon difficulties and realized flaws in our design

50. Definitions of continuity differed
RRC definition of continuity was more lenient
MMCI more strictly defined
The RCC definition of continuity is more open and lenient than the MMCI definition

51. Other variables that affected our data
Lowry and AFW collected data differently
Patients were excluded if not seen more than twice during the antenatal period
(Lowry used only OB pts seen by residents and we used a sticker method to track patients. At AFW Brandy and Anna collected data on all OB patients using their EMR) this changed our overall ‘continuity’

52. The MMCI numbers we came up with are actually better than we anticipated

53. Why our results may be different than what we expected:
Retrospective study design
Artificial designation of PCP
Inconsistent methods of collection
Poor handwriting on some charts
Providers having the same initials
The MMCI numbers we came up with are actually quite better than we anticipated, we think this may be influenced by many factors, including inconsistent methods of collection, poor handwriting on some charts making it difficult to assess who had seen the patient, and also some providers having the same initials

54. What we’ve learned
This preliminary look at data has been informative for us.
As we collect data, we learn how to improve our data collection methods for our future project

55. Poor communication = Poor continuity
One important thing we learned about the barriers to establishing continuity patients is that communication with clinic staff and non resident providers has been poor in the past.
Improved communication regarding the goals for continuity care has been an integral part of even the first phase of this study.

56. Future Directions

57. In the future Focus on improved clinic communication
Predictable presence in clinic
Collect nine more months of data while in PCMH

58. Thank you!

59. Acknowledgements Rachel Everhart Jay Lee