How To Train A Patient Centered Medical Home

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1 Applying Health Information Technology and Team-based Care to Residency Education Kristy K. Brown, DO; Tara A. Master-Hunter, MD; James M. Cooke, MD; Leslie A. Wimsatt, PhD; Lee A. Green, MD, MPH BACKGROUND AND OBJECTIVES: Training physicians capable of practicing within the Patient-centered Medical Home (PCMH) is an emerging area of scholarly inquiry within residency education. This study describes an effort to integrate PCMH principles into teaching practices within a university-based residency setting and evaluates the effect on clinical performance. METHODS: Using participant feedback and clinical data extracted from an electronic clinical quality management system, we retrospectively examined performance outcomes at two family medicine residency clinics over a 7-year period. Instructional approaches were identified and clinical performance patterns analyzed. RESULTS: Alumni ratings of the practice-based curriculum increased following institution of the PCMH model. Clinical performance outcomes indicated improvements in the delivery of clinical care to patients. Implementation of instructional methodologies posed some challenges to residency faculty, particularly in development of consistent scheduling of individualized feedback sessions. Residents required the greatest support and guidance in managing point-of-care clinical reminders during patient encounters. CONCLUSIONS: Teaching practices that take into consideration the integration of team-based care and use of electronic health technologies can successfully be used to deliver residency education in the context of the PCMH model. Ongoing assessment provides important information to residency directors and faculty in support of improving the quality of clinical instruction. (Fam Med 2011;43(10): ) Implementation of the Patientcentered Medical Home (PCMH) model has been described, 1-4 but knowledge of how the model is applied to residency education is limited. Studies support greater practice coordination, use of multidisciplinary teams, and other patient-centered approaches, yet not all residency sites embed ongoing training on use of integrated health information technology, 5,6 despite the fact that such technology has been linked to successful implementation of the PCMH model. 6,7 This study examines an approach to residency education that incorporates use of health information technology within a PCMH setting and evaluates its effect on clinical performance. Background In 2005, review of clinical practices in the University of Michigan (UM) Department of Family Medicine led to changes in patient care delivery. Challenges included managing provider coverage, continuity of care, and population management. Providers functioned in isolation rather than as members of physician-led, comprehensive patient care teams, and busy rotation schedules sometimes posed challenges to maintaining effective provider coverage. We wanted to effectively manage chronic medical conditions and provide immunizations but had a limited ability to improve the care provided to all patients, especially those not regularly scheduled for clinic visits. PCMH implementation addressed these challenges. It involved moving to open-access models for urgent care that allowed same/next day appointments and optimized transitions for recently hospitalized patients. Residency continuity clinics offered non-traditional hours, a designated urgent-care physician, group obstetrics visits, and team-based care with nurses trained as chronic-care coordinators. Both continuity clinics had on-site laboratories, advanced care coordination, and specialty services; one offered foreign language interpreters and a pharmacy. A preexisting clinical quality management system (CQMS) provided information critical to practice-based improvement. It monitored diagnostic test results and medication management for patients with chronic From the Department of Family Medicine, University of Michigan. (Dr Brown is now with Cape Cod Healthcare, Falmouth Hospital, Falmouth, MA.) 726 NOVEMBER-DECEMBER 2011 VOL. 43, NO. 10 FAMILY MEDICINE

2 conditions and delivered evidencebased reminders for preventive and chronic disease management needs at the point of care. Specialized tools permitted individual- and population-level patient management. Reporting features allowed tracking of provider responses to clinical reminders. Clinic teams consisted of an assistant residency director (ARD), two to four attending physicians, four to six residents, two to three medical assistants (MAs) along with a nurse and social worker, roughly the same composition that existed prior to PCMH implementation but with more equalized expectations for team members in terms of the delivery of patient care. Electronic in-boxes allowed coverage providers and teams to respond to and monitor the timeliness of response to patient messages. Adoption of the PCMH model brought the onset of monthly team meetings that initially focused on patient access and continuity of coverage. By early 2010, the meeting format expanded to include quarterly review of patient care and population management. Methods Using participant feedback and clinical data extracted from the CQMS, we retrospectively examined resident performance outcomes between 2003 and 2010 at two UM family medicine continuity clinics that train 28 to 30 residents annually. Residents used the CQMS to proactively manage patients with chronic conditions and to address prevention/health maintenance issues. Training occurred through orientation, precepting, ARD interactions, team meetings, and optional elective projects. Twenty faculty members functioned as preceptors, and 41 provided intermittent support through clinic precepting and didactic lectures. Data collection included capture of resident CQMS response and action rates through use of an electronic Patient Encounter Form (Figure 1). Forms were printed by the MAs in advance of each patient visit and preliminary issues addressed before the resident s arrival. Residents completed the forms in hard copy, and data were entered daily into the CQMS by office personnel. We also reviewed responses to an alumni survey item added in 2008 to gather feedback by mail regarding the practice-based learning and improvement (PBLI) curriculum. The IRB reviewed the study and issued a not-regulated determination. Clinical data were analyzed descriptively and by simple linear regression over time using PASW Statistics 18.0 (SPSS/IBM Company, Chicago). CQMS training took place during the first month of residency and its use and application were reviewed during 2-hour clinical orientations led by ARDs. Preceptors assessed resident CQMS use during resident-patient encounters and provided directed feedback and mentoring throughout the 3-year training period. Residents first applied the system in clinic by addressing problem lists and health maintenance and disease management reminders, later advancing to improvement strategies for chronic disease management and preventive care. They were evaluated at every precepting session immediately after presenting the patient. Each preceptor required residents to progress through the CQMS form and report what took place during the visit and then articulate a plan for addressing reminders, with PGY-2/PGY-3 residents also required to provide background on the most efficient and cost-effective approaches. Residents and clinical care teams received monthly reports to determine whether specific patient population needs were met. Care team members and ARDs regularly reviewed resident reminder response rates and followed up with discussion by or during team meetings. The ARDs also met with individual residents biannually to review CQMS return and action rates and ensured that residents met departmental expectations for completion of required forms and improvement of documentation skills. A 90% form return rate and 80% reminder action rate were required as minimum standards. Response and action rates were incorporated into a semi-annual evaluation and contributed to resident portfolios for promotion and graduation. Results Patient Care When the CQMS was first implemented, residents and faculty expressed concerns about clinic efficiency and awkwardness of addressing health maintenance issues outside of traditional health maintenance exam visits, especially for non-continuity patients. However, addressing chief complaints and health maintenance issues became standard after incorporation into the flow of clinical care due to very clear patient benefits and clinic efficiencies. The CQMS held every team member equally accountable from the moment our patients walked into clinic. Everyone knew what needed to be done to address health maintenance, chronic, and urgent care issues and worked together to accomplish common goals. Monthly minute team meetings occurred at lunchtime on a rotating schedule (by day of the week), and afternoon clinic start times were staggered to maximize attendance. Clinic team members shared performance feedback to improve chronic care management through investigation of below-average testing or treatment-compliance rates, then collaborated to design population-specific solutions. Discussion included performance review within and across clinical teams and practice locations. MAs typically led discussions regarding patient management while physicians responded to team questions and managed clinic-wide standing orders and orders for needed tests or immunizations. Evaluative data allowed residents to identify areas for improvement in managing their patients (eg, using FAMILY MEDICINE VOL. 43, NO. 10 NOVEMBER-DECEMBER

3 Figure 1: Sample Patient Encounter Form reminders to broaden nurse and medical assistant involvement in chronic care management, routine lab work, immunizations). This approach reinforced the importance of collective problem solving. As residents learned to work with the technology, we noted increased confidence in managing chronic care patients other than their own during urgent care visits. Residents found that the time to address reminders was minimal (usually less than 2 minutes) and that time spent gaining proficiency resulted in time saved at subsequent office visits. Interactions with preceptors revealed increased comfort in delivering patient care and increased appreciation of the benefit of using the CQMS in delivering care to patients. Deficiencies most often resulted from residents not receiving enough assistance from MAs, not returning CQMS paperwork in a timely fashion, or not responding to the clinical reminder system in a manner that most efficiently satisfied clinic requirements (ie, engaging in lengthy counseling sessions rather than simply reminding patients to schedule colonoscopies). 728 NOVEMBER-DECEMBER 2011 VOL. 43, NO. 10 FAMILY MEDICINE

4 Population Management Through practice management and health systems training, second- and third-year residents were able to participate in quality improvement and population management initiatives. CQMS data allowed care teams to design clinic- and population-specific solutions. For example, upon detecting a lower-than-average compliance rate with diabetic foot exams, one care team had medical assistants review management reminders with diabetic patients, prepare monofilaments, and ask patients to remove footwear before the physician s arrival. Other resident- and facultyled interventions included nutrition and diabetic educational groups, sitebased A1c testing, and incorporation of referral clerks into team meetings. Residents also directed and coordinated educational planning for preventive and prenatal group visits. Some residents used the CQMS to launch quality improvement projects (eg, developing reminders for childhood immunizations and human papilloma virus testing). Figure 2: Patient Encounter Forms Total Return Rate %, 2003 to 2010 (n=108,356) Figure 3: Returned Patient Encounter Forms With Addressable Reminders Total #, 2003 to 2010 (n=43,833) Evaluative Feedback Total return rates for our CQMS patient encounter forms significantly varied over 7 years, with an average increase of 5.0%/year (P=.002) (Figure 2). CQMS return rates represented the percentage of all patient encounter forms populated with data during arrived patient visits (ie, responses to one or more CQMS reminders, addition of one or more new diagnoses, deletion or change in one or more existing diagnoses, and/or indication that one or more existing diagnoses was addressed ). CQMS reminder volume grew in response to system upgrades, from 613 addressable reminders in 2003 to 9,648 in 2010 (Figure 3). Despite the increased complexity, reminder action rates significantly increased (2.7%/year, P<.001) (Figure 4). Action rates represented the percentage of CQMS reminders marked as done, ordered, declined or not a candidate. Following the institution of PCMH team-based care, alumni ratings of the PBLI curriculum increased from inadequate in 2008 to between adequate and excellent in 2010 (Table 1). Discussion This study describes an approach to applying team-based care and CQMS use in residency education. Analysis centered on clinical reminder use as a decision-support tool for patient care and population management. Reminders fostered rapid incorporation of clinical evidence into practice. Results indicate significant improvement in annual response and action rate changes, although future study is needed to determine generalizability to other residency settings. Residents participated as team members in improving chronic disease management and health screening compliance. Team-based care and CQMS use provided an effective framework for the delivery of residency education within the PCMH. FAMILY MEDICINE VOL. 43, NO. 10 NOVEMBER-DECEMBER

5 Figure 4 Reminders Addressed by Residents Average % Action Rates, 2003 to 2010 (n=43,833) Table 1: Alumni Rating of Practice Management Curriculum (n=37) Year Inadequate Adequate Excellent (54.5) 3 (27.3) 2 (18.2) (20.0) 7 (70.0) 1 (10.0) (6.3) 9 (56.3) 6 (37.5) Percentages may not total 100% due to rounding. CORRESPONDING AUTHOR: Address correspondence to Dr Brown, Falmouth Hospital, Cape Cod Healthcare, 100 Ter Heun Drive, Falmouth, MA Fax: kkedian@gmail.com. References 1. Paulus RA, Davis K, Steele GD. Continuous innovation in health care: implications of the Geisinger experience. Health Aff 2008;27(5): Reid RJ, Fishman PA, Yu O, et al. Patientcentered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. Am J Manag Care 2009;15(9): Wilhide S, Henderson T. Community care of North Carolina: a provider-led strategy for delivering cost-effective primary care to Medicaid beneficiaries. Washington, DC: American Academy of Family Physicians, June Grumbach K, Bodenheimer T, Grundy P. The outcomes of implementing patient-centered medical home interventions: a review of the evidence on quality, access and costs from recent prospective evaluation studies, August FINAL% _1.pdf. Accessed February 6, Association of American Medical Colleges (AAMC). Moving the medical home forward: innovations in primary care training and delivery. Washington, DC: AAMC, November Cordasco KM, Horta M, Lurie N, Bird CE, Wynn BO. How are residency programs preparing our 21st century internists? A review of internal medicine residency programs teaching on selected topics. RAND Health working paper series. Pittsburgh, PA: RAND Corporation, July Carney PA, Eiff MP, Saultz JW, et al. Aspects of the patient-centered medical home currently in place: initial findings from Preparing the Personal Physician for Practice. Fam Med 2009;41(9): NOVEMBER-DECEMBER 2011 VOL. 43, NO. 10 FAMILY MEDICINE