P4 Patient-Centered Medical Home Features

Resident Ratings of Importance*

Baseline (2007)Mean (SD)

Resident Ratings of Importance*

Midstride (2009)Mean (SD)

Difference between Baseline

and Midstride Results

EHR (Electronic Health Record) in practice 4.44 (0.89) 4.50 (0.86) +0.06 (2%)

Practice as paperless 3.99 (1.05) 4.07 (1.10) +0.08 (2%)

Fully secured remote access available 4.60 (0.85) 4.64 (0.66) +0.04 (1%)

Secure HIPPA-compliant email with patients 3.61 (1.31) 3.61 (1.30) 0

Ongoing population-based QA using an EHR 3.44 (1.44) 3.48 (1.43) +0.04 (2%)

Chronic disease management registries 4.01 (1.11) 3.93 (1.21) -0.08 (2%)

EHR-based preventive services registries 4.13 (1.14) 4.01 (1.14) -0.12 (3%)

Practice-based research done using an EHR 3.28 (1.40) 3.40 (1.33) +0.12 (4%)

Group visits 3.33 (1.35) 3.31 (1.49) -0.02 (1%)

Integrated "case management" and social services

4.32 (0.90) 4.32 (0.97) 0

Using teams to manage patient care

3.84 (1.19) 3.91 (1.18) +0.07 (2%)

Integrated behavioral health 4.12 (0.93) 4.14 (1.11) +0.02 (1%)

Innovations in Residency Training: Midstride Findings from the P4 Project

BACKGROUND

Larry Green, MD1; Patricia Carney, PhD, Patrice Eiff, MD, Elaine Waller2 ; James Puffer, MD3

1University of Colorado Denver, 2Oregon Health & Science University, 3American Board of Family Medicine

QUANTITATIVE CORE DATA Core Data are collected from all P4 sites: 1) Program Data; 2) Resident Survey; 3) Continuity Clinic Data; 4) Grad Survey

QUALITATIVE DATA

On-line diary entries from faculty, residents, staff

SITE SPECIFIC DATAEach program is additionally using specific measures designed to test their innovation-specific hypotheses

• P4 is an Observational Case Series Study of Revisions to FM Residency Training

• 14 Representative Residency Programs are Participating and are Nearing the 4th Year of the 6 Year project

• Key Innovations include: 4 Years of Training Different Ways of Teaching Elements

of the Patient Centered Medical Home Individualized Training Early Establishment of a Panel of Continuity Patients

Innovation Focus

No. of programs with this

focus

Total No. of residents training at sites with this focus

Programs

PCMH Practice Re-design 9 192

Baylor, Cedar Rapids, Colorado, Hendersonville, Lehigh Valley, Middlesex, Missouri, Rochester, West Virginia Rural

Individualized Curriculum “Intentional Diversification” 7 195

Cedar Rapids, Christiana, JPS, Lehigh Valley, Middlesex, Tufts-CHA, Waukesha

4 year Curriculum 6 186

JPS, Loma Linda, Middlesex, Missouri, Waukesha, West Virginia Rural

Team-based Care & Training in Teams 6 117

Baylor, Cedar Rapids, Hendersonville, Lehigh Valley, Middlesex, Rochester

Chronic Disease Management 5 108

Baylor, Cedar Rapids, Middlesex, Missouri, West Virginia Rural

Longitudinal Curriculum 4 93Colorado, Middlesex, Tufts-CHA, Waukesha

Re-Sequencing of Curriculum 4 78Baylor, Cedar Rapids, Colorado, Lehigh Valley

Less Inpatient Time & More Continuity Clinic Time (esp. PGY1) 4 87

Baylor, Christiana, Lehigh Valley, Missouri

Small Group Learning Labs/Problem-based Learning 4 84

Christiana, Hendersonville, Lehigh Valley, Missouri

Patient-Centered Care 4 96Lehigh Valley, Loma Linda, Missouri, West Virginia Rural

Learner Portfolios 3 66Lehigh Valley, Tufts-CHA, Waukesha

Community/Population Health Focus 3 57Colorado, Hendersonville, Loma Linda,

Community Practices as Training Sites 2 30 Hendersonville, Lehigh Valley

Resident Attitudes About Importance of PCMH

Features at Baseline and Midstride

*0=Don’t know, 1=Neutral/No Opinion; 2=Not at all important; 3=Somewhat important; 4=Moderately important; 5=Very important

MIDSTRIDE PRELIMINARY RESULTS

NEXT STEPS

Applicant and Match Experience of P4 Programs

Pre (2006/07) and Post (2008/09)

The mean number of US senior applicants increased more than

national trends

% of positions filled by US seniors higher than national average

(pre and post)

Programs that implemented customized training may have improved

performance in the match

P4 Recommendations to the FM-RC

Assess compliance with metrics other than time

Require continuing, comprehensive care to a panel of patients

Broaden definition of continuity beyond face-to-face contact in the

clinic (e.g. EHR, email, care teams)

Sustain core skills and expect customization to meet the needs of

individual learners

Allow more flexibility

Center FM training in the evolving model of the PCMH

Information management skills are essential

Training Residents in a PCMH is in Evolution

It’s unclear which approach is better: immerse residents in a

re-designed practice versus specific training to work in the PCMH

environment

New skills required that have been identified:

Working in teams

Managing chronic care

Population management

Process improvement skills

The Definition of Continuity of Care is Broadening Beyond

Face-to-Face Contact

Flexible Training Options that Address Individual Needs of

Learners While Addressing Core Skills are Educationally Valid

Shifting to Competency-based Assessment is Complex and Resource-Intensive

Educational learner portfolios can be a useful tool to

assess competency and enhance self-directed learning but

are faculty and resident time-intensive

Faculty Development Needs Are Paramount

Change fatigue and faculty burn-out are serious concerns

Faculty experience difficulty teaching the features of the PCMH

when the concept is emerging and changing and they themselves

are relative novices in practicing within a medical home

Residents are farther along than faculty in adopting new

information technology & the EMR

There is a shift required from the traditional pedagogical

approach to a “learning and discovering together” approach

Residency Re-design Requires Additional Financial Support

Rigorous Evaluation Must Accompany Innovation

Identify site-specific variables/measures that could be pooled to provide more power to assess common thematic intervention areas.

Disseminate the results of the Project through publications, presentations at national meetings and quarterly newsletters.

Secure additional funding to extend the project to years 6 and 7 to expand the number of cohorts of residents who have fully participated in the P4 project and for whom we have both core data and graduate survey data.

Continue to build the infrastructure necessary for a Primary Care Educational Research Network (PCERN) using P4 as the foundation to accomplish both practice transformation and translating research into practice via educational settings.

METHODS

For more information visit www.transformed.com/p4.cfm

P4 Manuscripts in Progress

Effect of curriculum innovation on residency applications and match performance: A P4 report

Preparing the Personal Physician for Practice (P4): Baseline innovations, hypotheses, measures and project trajectory

Designing Measures for Educational Innovation for the Preparing the Personal Physician for Practice (P4) Project: A Model for Centers of Excellence in Medical Education research

A report from Preparing the Personal Physician for Practice (P4): midstride preliminary results and emerging themes