1. Geriatrics Curriculum to Model Characteristics of the
How to Design the
Geriatrics Curriculum
to Model Characteristics of the
Patient Centered Medical Home
Kathy Soch, M.D. and
Mike Bross, M.D.
Corpus Christi Family Medicine
Residency Program
May 2, 2008

2. Objectives
To describe key principles of the Patient- Centered Medical Home
To design the Geriatrics curriculum to teach these principles to FM residents
To discuss how these principles can be taught during specific patient encounters

3. Seven Key Principles of the Patient-Centered Medical Home
Personal Physician
Physician Directed Medical Practice
Whole Person Orientation
Care is Coordinated
Quality and Safety
Enhanced Access
Payment Reform

4. History The Future of Family Medicine Project, 2002
The model is an aspiration not currently found in practice
Endorsed by the AAFP, AAP, American College of Physicians and the American Osteopathic Association

5. Personal Physician
Patients value relationship above all else, often including poor service & inconvenience
More than half pay more to enroll in health plans that allow physician choice
People who have a usual source of care get better preventive services.
Having continuous care means better outcomes, less hospitalizations, lower cost
An example: a patient that you have known many years with panic disorder is much less likely to admitted to the hospital for an atypical chest pain presentation.

6. Physician Directed Medical Practice
The personal physician leads a team of individuals who are responsible for care
The team may include physician specialists, nurses, pharmacists, therapists, social workers, mental health providers, home providers
Patients are overwhelmed when care is not directed, saying, “These people are not my doctor…”

7. Whole Person Orientation
Include the patient’s life circumstances, priorities and quality of life
Continuity across all stages of life: acute and chronic illness, preventive care, end of life care
Remove barriers for treatment of mental health conditions

8. Care is Coordinated and/or Integrated
The health care system is increasingly complex
The challenge of getting medical records
Paperwork is excessive and inefficient (formularies, medical equipment and supplies, home health orders)‏
Avoid the “Gatekeeper” mistakes of managed care

9. Quality and Safety Evidence based medicine
Continuous quality improvement
Patient participation and feedback
Utilize information technology, including the electronic medical record
Practices go through voluntary recognition process by non government agency to be
certified as PCMH

10. Enhanced Access to Care
Open scheduling--same day
Expanded hours
New options of communication ( , telephone, group visits, home visits
Longer visits

11. Payment
Current financial disincentives toward primary care have to change
Pay for coordination of services, enhanced access (telephone, ), complex care, and QA processes.
“Care Management” fee for primary care patients, in addition to fee for service, with bonuses for quality and efficiency

12. How can we integrate PCMC Concepts?
Elders have multiple chronic conditions
“Care Teams” already in place
Patients in multiple care sites
Specialists not as enthusiastic about seeing frail elders

13. Teaching Opportunities: Personal Physician
Complex, frail patients with atypical presentations make a personal physician essential
Treatment goals change at the end of life

14. Teaching Opportunities: Physician Directed Medical Practice
Interdisciplinary Care Team
-Hospice
-Geriatrics Assessment Clinic
-Nursing Home
Home health referrals

15. Teaching Opportunities: Whole Person Orientation
Focus on quality of life issues
Stress functional assessment
End of life choices, advance directives
Emphasize the role of the family

16. Teaching Opportunities: Care is Coordinated and/or Integrated
Coordinate care
physician specialists
home health nurses, hospice
therapists
Medical equipment providers
Medical formularies

17. Teaching Opportunities: Quality and Safety
Resident attends QA meetings at the nursing home
“Metric” Geriatrics Chart Review
Evidence Based Medicine assignments

18. Teaching Opportunities Enhanced Access to Care
Nursing home rounds
Home visits
Frequent telephone calls and pages
Faxes to home health agencies, nursing home

19. Teaching Opportunities: Payment
Discuss with resident how to deliver comprehensive assessment over several short visits
Billing and coding for home and nursing home visits
Home health care oversight

20. A Typical Patient…
72 year old woman with multiple medical problems, seeing many physicians, confused about her medications and requires increasing help at home.

21. Frail Elders Comprehensive assessment (1, 3)‏
Activities of Daily Living
Instrumental Activities of Daily Living,
Memory Testing
Depression Screen
Advance Directives
Coordination of home care, limiting referrals and medications (2, 4)‏
Frequent short visits, home visits (6,7)‏

22. Frail Elders in Multiple Settings
An 84 year-old woman with dementia is transferred from the hospital to the nursing home after a hip fracture.

23. Frail Elders in Multiple Settings
Coordinate care between settings and doctors (2,4,5)‏
Interdisciplinary care team, including specialists, therapists, nurses (2, 4)‏
Focus on patient’s wishes, quality of life and role of the family (3)‏
Nursing home visits, telephone calls (6)‏
Ask resident to perform evidence based query on some aspect of care (5)‏

24. Contacts