2012 Annual Report

2 3

Patient-Centered Medical Home (PCMH) Project

Manager Heather Strother designed the word

cloud graphic on the reports cover. Providers

and staff at the six pilot PCMH practices were

asked the question: Since your practice

started its PCMH transformation journey,

what accomplishment do you feel most proud

of? Based on the number of mentions by

respondents, the words are larger both

Patients and Care are prominent.

n The United States Supreme Court decision to uphold the Affordable Care Act (ACA)

n The Commonwealth of Massachusetts enactment of Chapter 224: An Act Improving the Quality of

Health Care and Reducing Costs through Increased

Transparency, Efficiency and Innovation

n The reelection of Barack Obama

Each event will have long-term impacts on the delivery

of and payment for health care in the United States

and Massachusetts. They will shape the redesign of the

primary care model and will influence the characteristics

of the primary care workforce of the future.

Many provisions in the ACA are linked specifically to

primary care, such as:

Increased Medicaid payments to primary care

physicians (PCPs)

Coverage of preventative health services

Increased access to PCPs in primary care shortage

areas through Medicare payment bonuses

Enhancements to federally supported student loan

programs and health care workforce loan repayment

programs

Scholarships for disadvantaged students who commit

to serving as PCPs in underserved areas

Distribution of additional residency positions for

training PCPs

Increases to the authorization of spending for the

National Health Service Corps

Establishment of a Medicare payment system for

Federally Qualified Health Centers

2012. The year of: Six years after the passage of the Massachusetts health care coverage reform law, Chapter 224

promotes value-based health care through the

improvement of quality and reduction of costs. PCPs

and the relationships they have with their patients are

instrumental to the achievement of these goals.

Chapter 224 identifies the critical importance of

investing in primary care through the establishment

of a Health Care Workforce Transformation Fund and

support of programs such as: Health Care Workforce

Loan Repayment Program; a new Primary Care

Residency Grant Program, established to finance the

training of PCPs at community health centers (CHCs);

and a new Primary Care Workforce Development and

Loan Forgiveness Grant Program, designed to enhance

recruitment and retention of PCPs and other clinicians

at CHCs.

The work of the Center for the Advancement of

Primary Care (CAPC), a joint initiative of the University

of Massachusetts Medical School and UMass Memorial

Health Care, is well aligned with the new national and

Massachusetts paradigms for the delivery of health

care. Since CAPCs inception, it has focused on primary

care workforce issues by:

Studying the supply and demand of PCPs in Central

Massachusetts;

Working with medical students and practicing

clinicians to identify attitudes toward careers in

primary care;

Tracking net growth in PCPs for the clinical systems

primary care network;

Serving as a resource in developing policies for

the Medical Schools primary care service learning

contract program; and

Collaborating with other departments to support

faculty level quality improvement training through

the Quality Scholars Program.

CAPC has supported and tested new models of

primary care delivery. We are pleased to announce

that two of our primary care practices, Barre Family

Health Center, a Family Medicine residency site, and

Hahnemann Internal Medicine Group, a community-

based site, both achieved NCQA Level 3 Patient

Centered Medical Home recognition in 2012. Several

other practices in our network are on the way to

applying for this recognition. Others are transforming

in ways that build on their individual practice

strengths. Much exciting work remains to spread these

innovations to meet our goal of providing patient- and

family-centered, value-based care.

This annual report summarizes CAPCs work from

September 2011 to December 2012 in the following

areas:

Primary Care Redesign

Workforce

Data and Analysis

Quality Improvement

Communication and Promotion

Education and Outreach

4 5

Primary Care RedesignThe drive to identify sustainable, cost-effective ways to deliver high quality patient-centered care

continues at the national and state levels; the primary care practice remains at the core of these efforts.

In Central Massachusetts, the Center for the Advancement of Primary Care (CAPC) continues to help

practices transform and redesign their work to focus on: improving access; managing populations;

increasing coordination and tracking of referrals; engaging and motivating patients; and better aligning

physician and staff resources with the services being provided.

Practice Redesign ToolsPractice improvement facilitators (PIFs) providing experience and training in quality improvement brought

tools such as Lean Manufacturing methods and Plan-Do-Study-Act cycles to staff at primary care

practices. Practice-specific protocols were developed to manage patient care at the time of appointment

as well as through outreach. CAPC facilitated the sharing of best practices, such as for standard tasking

protocols, through the PIFs and regular webinars. Training in Motivational Interviewing was promoted to

support the process of engaging and motivating patients. CAPC supported practice training in the use

of Patient Care Registries produced by the Office of Clinical Integration and piloted care management

tools such as a high-risk registry and patient-specific care plans.

Patients: The Largest Health Care Workforce Available Investing in patients to give them the knowledge, confidence and tools

that enable them to become an effective and reliable workforce will be essential to maintain, and hopefully improve, the quality of care for most long-term illnesses. ~ Cleland, JGF, Ekman, I. JAMA, 2010;304(12):1383-4.

Patient-Centered Medical Home Programs: Active practice redesign continued at six UMass Memorial Health Care primary care sites caring for more than 30,000 patients. CAPC, in

collaboration with the Office of Clinical Integration, provided infrastructure, personnel (PIFs, care

managers and a nutritionist), training and financial support to the Barre Family Health Center and the

Benedict Pediatrics Practice (both participants in the Massachusetts statewide Patient Centered Medical

Home Initiative), Hahnemann Family Health Center, Plumley Village Health Services, Hahnemann Internal

Medicine Group and Nashaway Pediatrics Clinton.

The Barre Family Health Center, a family medicine residency

teaching site serving more than 6,000 patients, received

National Committee for Quality Assurance (NCQA)

recognition as a Level III (the highest) Patient Centered

Medical Home in July; the Hahnemann Internal Medicine

Group, a community-based internal medicine practice,

received its Level III designation in December. The two

practices represent the first primary care sites in the UMass

Memorial system to receive NCQA PCMH recognition.

Saturday Urgent Care: CAPC facilitated a multi-department UMass Memorial Medical Center and

UMass Memorial Medical Group initiative to develop

and expand urgent care access on Saturday mornings.

The main goal of the initiative: Provide non-emergency

department access for urgent care to our patients

on Saturdays. The initiative built on existing access to

pediatric urgent care services on Saturdays for patients

of the Benedict Pediatric practice. The initiative was

expanded to include adult urgent care services and was

offered to all patients at Medical Group practices in

the greater Worcester service areas. From May through

December, the Saturday Urgent Care service provided

care to more than 700 pediatric and adult patients.

UMass MemorialPatient-Centered Medical Home

Where the focus is on you and your health

Barre Family Health CenterA Family Medicine Residency PracticeRecognized by the National Committee for Quality Assurance

UMass MemorialPatient-Centered Medical Home

Where the focus is on you and your health

Hahnemann Internal Medicine GroupRecognized by the National Committee for Quality Assurance

6 7

Data & AnalysisThe Center for the Advancement of Primary Care (CAPC) provided

data-driven analysis in support of the strategic goals of UMass

Memorial Health Care and for decisions affecting primary care.

Support for one-time analysis and ongoing tracking reports was

provided to multiple departments.

Patient Population: In partnership with the Information

Services Department, CAPC produced an estimate of the patient

population attributed to employed primary care physicians.

Quarter-to-quarter changes were tracked and reported to the

UMass Memorial board of trustees. Discussions commenced with

representatives of UMass Memorial Medical Group and the Office

of Clinical Integration (OCI) to develop physician-specific covered

lives estimates using the OCI Patient Care Registries.

Primary Care Physician Database: Francis Wanjau, practice

improvement facilitator, maintained and refined information about

all primary care physicians with affiliations to UMass Memorial

Health Care. The information was used to enhance recruitment

tracking, target communication activities and support analysis to

estimate patient population.

Expanded Primary Care Access: CAPC provided analytical

support in the development and expansion of Saturday Urgent

Care Access for adults and children. Analysis included volume

trends; emergency department usage; and financial results.

Practice Redesign: CAPC developed and had oversight for

production of reports contractually required for the Massachusetts

Multi-Payer Patient-Centered Medical Home Initiative. CAPC also

piloted the use of a high-risk registry in several medical home sites.

WorkforceHealth care reform efforts at the national and

state level include provisions for increased funding

support for the training of physicians who choose

primary care careers, underscoring the compelling

evidence that health care outcomes and costs are

strongly linked to the availability of primary care.

Today, the 500 primary care physicians and their

staffs who are employed by or affiliated with

UMass Memorial Health Care represent a large

workforce providing patient-centered care in Central

Massachusetts. In the future, a number of students

at UMass Medical School and the Graduate School

of Nursing will also join the primary care workforce.

Recruitment: In collaboration with the Physician

Recruitment Office, the Center for the Advancement

of Primary Care (CAPC) produced a dashboard

to track growth of primary care physicians in the

UMass Memorial Health Care system. The Primary

Care Recruitment and Retention Advisory Group,

comprising representatives from multiple primary

care disciplines, met regularly to coordinate

recruitment activities across all hiring departments,

review quarterly results, and share hiring and

retention strategies.

Retention: CAPC supported 10 physicians who

were members of the third class of Quality Scholars;

four of those scholars were in primary care-related

departments. The program provides continuous

learning opportunities to practicing physicians,

which supports a strong retention strategy.

Medical Education: Barbara Weinstein served as

an advisor to two student leaders for the Primary

Care Principles (PCP) Group, formerly the Generalist

Physician Program Interest Group. She also

represented CAPC on the Medical School Learning

Contract Committee, which reviews requests for

tuition forgiveness based on post-training careers

in primary care, public service or underserved

communities.

CAPC contacted all applicants offered admission

to UMass Medical School, welcoming them in an

email. The communication emphasized the schools

resources in primary care and offered to connect

students with a member of the primary care faculty.

Student Survey on Choice of Specialty: CAPC

facilitated the administration of an annual survey

of fourth-year UMass Medical School students.

The survey asks students to share how they

arrived at their career decisions and what their

experience with the primary care specialties has

been throughout medical school. The survey

design and analysis were developed by members

of the Department of Family Medicine and

Community Health, and the surveys distribution

was undertaken by former student leaders of the

Primary Care Principles interest group.

As a primary care physician, I have the chance to make a real difference in my patients lives. I value the relationships we have, and view every encounter as a learning opportunity.

Allen Chang, MD, Benedict Internal Medicine, Worcester

Being a primary care doctor is more than just being a physician; its being a partner, an ally and a friend.

Mohmmad Hajjiri, MDMontachusett Internal Medicine,

Leominster

8 9

Quality ImprovementThe Center for the Advancement of Primary Care

(CAPC) continued to integrate principles and tools

endorsed and supported by UMass Medical School

and UMass Memorial Health Care into its primary

care redesign work to engage physicians and staff in

quality improvement at the practice/department level.

Quality Scholars Program: The Quality Scholars

Program graduated its third class of scholars in June.

The program, co-directed by the UMass Memorial

Department of Quality and Patient Safety and CAPC,

originated with support from a HRSA training grant

to bring quality improvement and patient safety

curriculum into UMass Medical School, primary care

residencies and faculty development; it is now entirely

supported with internal funding. The 10 scholars

and their mentors represent a mix of primary care

and specialty departments working and teaching in

inpatient and ambulatory settings, underscoring the

opportunities to incorporate quality improvement

across the continuum of care.

2012 Quality Scholars

Bronwyn Cooper, MD (Anesthesiology), Reducing

Late First Start Times of Caesarean Sections

Alan Picarillo, MD, mentor, Department of Pediatrics

Christine Donahue, MD (Hospital Medicine),

Reducing Time to Admission Orders: An ED Transition

to Inpatient Flow Initiative

Peter Paige, MD, mentor, Department of Emergency

Medicine

David Geist, MD (Dermatology), Reducing Post-

Mohs Surgical Infections

Elizabeth Murphy, MD, mentor, Department of

Medicine

Richard Lerner, MD (Internal Medicine/Primary

Care), Using an Exercise Prescription to Increase

Physical Activity Level

Mitchell Gitkind, MD, mentor, Departments of

Medicine and Surgery

Peter McConarty, MD (Family Medicine/Primary

Care), Optimizing Influenza Immunization of Diabetics

Rocco Perla, EdD, mentor, Department of Family

Medicine and Community Health

Elise Pyun, MD (Rheumatology), Improving Patient

Flow in the Rheumatology Center

Lisa Allen, PhD, mentor, Department of Quality and

Patient Safety

Jennifer Reidy, MD (Palliative Care), Improving the

Use of Patient-Controlled Analgesia

Trudy Manchester, MD, mentor, Department of

Medicine

Shahrzad Shidfar, MD (Hospital Medicine),

Improving Fluid Resuscitation in Patients with

Sepsis-Induced Hypotension

Roger Luckmann, MD, MPH, mentor, Department of

Family Medicine and Community Health

Theodore Shoemaker, MD (Family Medicine/

Primary Care), Increasing the Accuracy of Preventive

Health Documentation in an Electronic Medical

Record

Judith Savageau, MPH, mentor, Department of Family

Medicine and Community Health

Marie Anne Sosa, MD (Hospital Medicine),

Improving the Management of Patients with

Severe Hyponatremia; Peter Gibson, MD, mentor,

Department of Medicine

My goal is to empower patients with knowledge about their illness and partner with them in their treatment and recovery plan.

Afroz Saquib, MDShrewsbury Primary Care,

Shrewsbury

Effective primary care is rooted in the ability to communicate, not only with the patient, but also with the entire care team.

Nancy Skehan, MDBenedict Internal Medicine,

Worcester

10 11

Communication & PromotionHealth care reform efforts are beginning to recognize the value of primary care in meaningful ways, yet

it remains a challenge to demonstrate that value to numerous constituencies, including medical students,

provider and payers. In a previous Center for the Advancement of Primary Care (CAPC) Needs Assessment

Survey of primary care physicians, improving the image of primary care at UMass Memorial Health Care and

UMass Medical School was the number one area respondents requested that CAPC address. See Survey Finds

Elements of High Career Satisfaction Primary Care News, January 2009.

CAPC organized and supported activities designed to promote the value and diversity of primary care and

disseminated information to primary care practices and patients through webinars and e-newsletters.

National Primary Care Week: UMass Medical School and UMass Memorial Health Care celebrated National Primary Care Week during the first week of October in 2011 and 2012. The activities represented an

opportunity for students to learn more about primary care and for the Medical School and clinical system to

express appreciation to the many physicians, clinicians, nurses and staff who care for patients through a primary

care relationship and who are teaching the next generation of caregivers.

At the Medical School, CAPC coordinated programming for the

observances with the MassAHEC Network; Meyers Primary Care

Institute; the Office of Medical Education; the Office of Educational

Affairs; the Graduate School of Nursing; the Humanities in Medicine

Committee of the Lamar Soutter Library; and many student interest

groups, led by the Primary Care Principles Group.

At UMass Memorial Health Care, grand rounds during the week

featured topics relevant to primary care (2011 Medicine Grand

Rounds, Quality Scholars presentations; 2012 Pediatrics Grand

Rounds, Chapter 224 Payment Reform in Massachusetts). Public

ads thanking clinical professionals and staff at employed and

affiliated primary care practices appeared in newspapers in all UMass

Memorial service areas; each practice also received a letter of thanks from the CEO. Primary care physicians

were featured in computer screensavers, visible to staff and patients. The family medicine, general pediatrics

and internal medicine practices located on the University Campus coordinated a community flu clinic during the

2012 celebration.

Annual Medical Student Primary Care Dinner: The CAPC, Meyers Primary Care Institute and the Office of Educational Affairs sponsored

the 18th and 19th Medical Student Primary Care Dinners, organized by

the PCP Group student leaders. The 2011 speaker was David Hatem, MD,

associate professor, Department of Medicine and a practicing physician at

the Benedict Adult Internal Medicine practice; the 2012 speaker was Frank

Domino, MD, professor, Department of Family Medicine and Community

Health and a practicing Family Medicine physician in a community practice.

Webinars: Prime Time Conversations and Pathways to PCMH Success, two interactive webinar programs, were broadcast more than 50 times. The

programs, available for on-demand listening in podcast format, covered topics

of general interest to primary care practices and topics targeted specifically

to redesigning care processes for success in transforming to patient-centered

medical homes and in achieving pay for performance goals.

Newsletters: The CAPC distributed Primary Care News, its general primary care quarterly electronic newsletter, to the broad primary

care community and interested parties. It continued to produce two

patient education newsletters, Stick to It (diabetes) and Pressure Points

(hypertension). The patient newsletters highlight the important partnership in

caring for chronic disease between primary care and two specialties at UMass

Memorial: the Diabetes Center of Excellence and the Heart and Vascular

Center of Excellence. The PCMH program also produced an email newsletter

which included care redesign best practices, Massachusetts and national

medical home updates and other announcements.

The Primary Care Dinner brought together the following physicians and students (top): Elizabeth Murphy, MD, Benedict Internal Medicine, and Caleb Dresser, Medical School Class of 2015. Benjamin Vaughan, one of two student co-leaders of Primary Care Principles Group, with Frank Domino, MD, professor, family medicine and community health and 2012 speaker.

12 13

Education & Outreach

January 2012Massachusetts Patient-Centered Medical Home

Initiative, Learning Session 4, Worcester, MA

Diabetes Process and Outcome Measures: Achieving

Improvement

Overcoming Analysis Paralysis: Just Do It

Ronald Adler, MD Integrating Behavioral Health: Practical Strategies for

PCPs and Mental Health Providers

F. Alexander Blount, EdD, and Ronald Adler, MD UMass Worcester Graduate School of Nursing

Teaching Track Team Building: Mr. Potato Head

Simulation

Lisa Ogawa, RN, PhD, and Francis Wanjau, MS

March 2012 Academic Pediatric Association Region 1 Meeting,

Sturbridge, MA

Think QuiC! Using Mr. Potato Head to Teach Quality

Improvement

Ronald Adler, MD, and Beth Murphy, MD Hahnemann Internal Medicine Group, Shared Medical

Appointments

Margaret Apura, MPH, RD, LDN, Brenda King, PsyD,

LMHC, LCC, and Janice Polletta, NP University of Massachusetts Medical School

Be Mentally Well Managing the Impact of

Alzheimers Disease

Brenda King, PsyD, LMHC, LCC

Plumley Village Health Services, Worcester, MA

Six-week external program Cooking Matters!

Margaret Apura, MPH, RD, LDN

April 2012Quinsigamond Community College

UMass Memorial Community Relations

Healthy Eating Presentation for ESL students

Margaret Apura, MPH, RD, LDN Clinton Resource Center

Healthy Eating Presentation for parents and families

Margaret Apura, MPH, RD, LDN, and

Lucy Kanjer-Larson, MD

May 2012Rhode Island Quality Institute, Keynote Address

Addressing the Challenges of Practice Transformation

Ronald Adler, MD Belmont Street Community School

UMass Memorial Community Relations

Healthy Eating Presentation

Margaret Apura, MPH, RD, LDN

June 2012Connecticut AHEC, University of Connecticut School

of Medicine and Connecticut Department of Public

Health

Diabetes Care in the Patient-Centered Medical Home

Ronald Adler, MD American Academy of Medical Colleges Workshop

Quality Improvement and Medical Education,

Chicago, IL

Workshop Participant

Judith Savageau, MPH

July 2012High School Health Careers Program

Contemporary and Cultural Health Issues Seminar

Educational Experiences from a Third World

Perspective

Francis Wanjau, MS

August 2012National Night Out

UMass Memorial Medical Center, Worcester, MA

September 2012The Fairbridge Project International/The AIDS Project

Worcester

Healthy Eating Table

Margaret Apura, MPH, RD, LDN Hahnemann Internal Medicine Group

Shared Medical Appointments

Margaret Apura, MPH, RD, LDN, Brenda King, PsyD,

and Janice Polletta, NP

October 2012Worcester Partnership for Quality Elder Mental Health

Care, Worcester Senior Center

Tis Better to Have Loved and Lost: Successfully

Navigating the Waves of Change in Late Life

Brenda King, PsyD UMass Memorial Community Relations

Worcester YWCA

Healthy Eating presentation for teen mothers

Margaret Apura, MPH, RD, LDN

December 2012STFM/AAFP Conference on Practice Improvement,

Greenville, SC

Addressing the Challenges of Practice Transformation:

Lessons Learned on the Journey from Disease-specific

Collaboratives to Patient-Centered Medical Homes

Ronald Adler, MD

Center for the Advancement of Primary Care (CAPC) staff and others supported by CAPC had numerous

opportunities during the year to share their experiences in practice transformation, quality improvement,

and to engage patients and the community in wellness and prevention activities.

I chose to practice primary care at UMass Memorial because it feels like a tangible way to serve my community.

Carolyn Keiper, MDPediatric Primary Care Associates,

Worcester

At National Night Out in August, from left: Dieticians Margaret Apura, MPH, RD, LDN, from CAPC, and Linda DeNering, MS, RD, LDN, and Sara Graves, MA, RD, LDN, RN, from the Memorial Campus of the Medical Center.

14 15

Janet Hale, PhD, APRN, BC, FNP Associate Dean for Academic Programs, Graduate School of Nursing

Robert Klugman, MD Chief Quality Officer; Medical Director, Managed Care, UMass Memorial

Medical Center

Daniel Lasser, MD, MPH* Senior Vice President, Center for the Advancement of Primary Care;

Chair, Department of Family Medicine and Community Health

Andrew Miller, MD Clinical Chief, Community Internal Medicine

Michele Pugnaire, MD Senior Associate Dean for Educational Affairs, UMass Medical School

Linda Sagor, MD, MPH* Division Director, General Pediatrics

Barbara Weinstein, MBA* Senior Director, Center for the Advancement of Primary Care

Bruce Weinstein, MD Clinical Chief, General Medicine and Primary Care

Lynda Young, MD Division Director, Community Pediatrics

Douglas Ziedonis, MD, MPH Chair, Department of Psychiatry

Jeremy Konstam UMass Medical School student, Class of 2015

Benjamin Vaughan UMass Medical School student, Class of 2015

With thanks to the following Advisory Committee members who served during the year:

Nicholas Avgerinos UMass Medical School student, Class of 2014

Jessica Boatman UMass Medical School student, Class of 2014.

Primary Care Recruitment and Retention Advisory Group

Julia Andrieni, MD, FACP

Arnold (A.J.) Avila, MEd

William Corbett, MD

Daniel Lasser, MD, MPH

Katherine Pryor

Michele Streeter, CPA

Barbara Weinstein, MBA

With thanks to Lynne Kosloski and Paul Wesolowski for their service during the year.

Center for the Advancement of Primary CareUniversity of Massachusetts Medical School | UMass Memorial Health Care

Organization

Daniel Lasser, MD, MPH Senior Vice President

Barbara Weinstein, MBA Senior Director

Ronald Adler, MD, FAAFP Director, Primary Care Practice Improvement

Margaret Apura, MPH, RD, LDN Dietitian

Brenda King, PsyD, LMHC, NCC Medical Home Care Advisor

Jason Nigrosh, MM Practice Improvement Facilitator

Francis Wanjau, MS Practice Improvement Facilitator

Jennifer Masoud Administrative Assistant

Advisory Committee (*Also serves on the Executive Committee)

Ronald Adler, MD, FAAFP* Director, Primary Care Practice Improvement, Center for the

Advancement of Primary Care

Julia Andrieni, MD, FACP* Vice Chair of Medicine (Clinical Services); Chief, Division of General

Internal Medicine

Joseph Antaki, MD Tri-River Family Health Center

Robert Baldor, MD Vice Chair of Education, Department of Family Medicine and

Community Health

Charles Cavagnaro, MD President and CEO, Wing Memorial Hospital and Medical Centers

Alan Chuman, MPH* Academic Administrator, Department of Family Medicine and

Community Health

William Corbett, MD* Vice President of Community Practices, UMass Memorial Medical Group

Sheila Daly, MS President and CEO, Clinton Hospital

Eric Dickson, MD, MHCP, FACEP Interim President, UMass Memorial Medical Group

Dennis Dimitri, MD, FAAFP* Vice Chair of Clinical Services, Department of Family Medicine and

Community Health

David Fairchild, MD, MPH Senior Vice President Clinical Integration, UMass Memorial Health Care

Barbara Fisher, MBA Senior Vice President, Operations, UMass Memorial Medical Center

Jerry Gurwitz, MD* Executive Director, Meyers Primary Care Institute

16 17

2012 Quality Scholars Program

Graduates

Bronwyn Cooper, MD Assistant Professor, Department of Anesthesiology, UMass Memorial

Medical Center University Campus

Christine Donahue, MD Assistant Professor, Department of Medicine, Marlborough Hospital

David Geist, MD Assistant Professor, Department of Medicine, UMass Memorial Medical

Center Hahnemann Campus

Richard Lerner, MD Assistant Professor, Department of Medicine, UMass Memorial Medical

Center University Campus

Peter McConarty, MD Associate Professor, Department of Family Medicine and Community

Health, Community Health Connections, Fitchburg Community Health

Center

Elise Pyun, MD Clinical Associate Professor, Department of Medicine, UMass Memorial

Medical Center Memorial Campus

Jennifer Reidy, MD Assistant Professor, Department of Family Medicine and Community

Health, UMass Memorial Medical Center Memorial Campus

Shahrzad Shidfar, MD Assistant Professor, Department of Medicine, UMass Memorial Medical

Center Memorial Campus

Theodore Shoemaker, MD Assistant Professor, Department of Family Medicine and Community

Health, Family Health Center

Marie Anne Sosa, MD Assistant Professor, Department of Medicine, UMass Memorial Medical

Center University Campus

Co-directors

Mitchell Gitkind, MD Associate Chief Quality Officer, Clinical Associate Professor of Medicine

and Surgery

Judith Savageau, MPH Associate Professor of Family Medicine and Community Health

Patient Centered Medical Home (PCMH) Program

Staff and Committee Members

Ronald Adler, MD, FAAFP

Margaret Apura, MPH, RD, LDN

Dianna Caffarena, MBA

Christine Cernak, RN, CDE

William Corbett, MD

Elaine Fontaine

Daniel Lasser, MD, MPH

Jason Nigrosh, MM

Heather Strother, MPH

Francis Wanjau, MS

Barbara Weinstein, MBA

Qiyao Zhang, MD, PhD

With thanks to the following who served during the year:

Arlene Ash, PhD

Alexander (Sandy) Blount, EdD

Amy Finn, PharmD, PhD, MBA

David Keller, MD

Edward Westrick, MD

Participating PCMH Practices

Barre Family Health Center*, designated as a Level III Patient Centered Medical Home and Residency Site

by the NCQA (National Committee for Quality Assurance)

Benedict Pediatrics*

Hahnemann Family Health Center

Hahnemann Internal Medicine Group, designated as a Level III Patient Centered Medical Home by the

NCQA

Nashaway Pediatrics Clinton

Plumley Village Health Services

*Participants in the Massachusetts PCMH Initiative

Caring for patients always includes listening. The best treatment plan starts with understanding your patient and where theyre coming from.

Kristin Mallett, MDBenedict Family Medicine,

Worcester

Center for the Advancement of Primary Care

55 Lake Avenue North, Benedict Building A3-221

Worcester, MA 01655

Tel: 508-442-7050

capc@umassmemorial.org www.umassmemorial.org/capc