Workforce Training for PCMH: Workforce Training for PCMH:

What are What are We doing to Equip the Team? doing to Equip the Team?

Jeffrey Borkan, MD, PhDJeffrey Borkan, MD, PhDChair, Department of Family Medicine Brown UniversityChair, Department of Family Medicine Brown University

President, Association of Departments of Family MedicinePresident, Association of Departments of Family Medicine

The Hope: a medical home in every community and a team for every home

Thanks!

Rhode Island Morass Rhode Island Morass

Primary care practices hard pressedPrimary care practices hard pressed Patients not getting the care they Patients not getting the care they

needneed 100,000 uninsured 100,000 uninsured $49,000,000 spent on Medicaid $49,000,000 spent on Medicaid

patients going to the ER last yearpatients going to the ER last year Getting the results our system designedGetting the results our system designed

Background of the Medical Home Background of the Medical Home ConceptConcept

The American Academy of Pediatrics (AAP) introduced the The American Academy of Pediatrics (AAP) introduced the medical home concept in 1967, initially referring to a medical home concept in 1967, initially referring to a central location for archiving a child’s medical record. central location for archiving a child’s medical record.

2002 AAP policy statement on operational characteristics: 2002 AAP policy statement on operational characteristics: accessible, continuous, comprehensive, family-accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and centered, coordinated, compassionate, and culturally effective careculturally effective care..

The American Academy of Family Physicians (AAFP) and the The American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP) have since developed American College of Physicians (ACP) have since developed their own models for improving patient care called the their own models for improving patient care called the “medical home” (AAFP, 2004) or “advanced medical home” “medical home” (AAFP, 2004) or “advanced medical home” (ACP, 2006).(ACP, 2006).

Joint PrinciplesJoint Principles Personal physician - each patient has an ongoing relationship with a

personal physician trained to provide first contact, continuous and comprehensive care.

Interdisciplinary team, Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.

Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.

Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community

(e.g., family, public and private community-based services). (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other Care is facilitated by registries, information technology, health information exchange and other

means to assure that patients get the indicated care when and where they need and want it in a means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.culturally and linguistically appropriate manner.

Quality and safetyQuality and safety are hallmarks of the medical are hallmarks of the medical home:home:

Enhanced accessEnhanced access to care is available through to care is available through systems such as open scheduling, expanded systems such as open scheduling, expanded hours and new options for communication hours and new options for communication between patients, their personal physician, and between patients, their personal physician, and practice staff.practice staff.

PaymentPayment appropriately recognizes the added appropriately recognizes the added value provided to patients who have a patient-value provided to patients who have a patient-centered medical home. The payment structure centered medical home. The payment structure should be based on the following framework:should be based on the following framework:

““Ideal Primary Care” goes Medical HomeIdeal Primary Care” goes Medical Home 2008 2008

Unfortunately, no-one has any training or background

They search the internet, find “consultants”, spend $25,000, plus another $10,000 for the promise of NCQA certification, purchase a $120,000 medical record, and

join 4 chronic care collaboratives

Bedlam ensuesBedlam ensues::

None of it seems to work, the staff begins to revolt, the partners begin to bicker, the patients get poorer care from

the demoralized and disorganized practice, …which closes 10 months later

What if…What if…

……the Congress and the the Congress and the Administration mandated Administration mandated Patient Centered Medical Patient Centered Medical Homes to open around Homes to open around the country in one year….the country in one year….• We would first celebrate….We would first celebrate….• Then realize that we have Then realize that we have

few trained clinicians, few trained clinicians, administrators, or teams to administrators, or teams to staff themstaff them

Hope is on the wayHope is on the way

Rapid expansion phase in Rapid expansion phase in educational, training, and educational, training, and consultation servicesconsultation services

More demonstration projects More demonstration projects on local, state, and regionalon local, state, and regional• more experiencemore experience• more mentors more mentors

New models on the horizonNew models on the horizon

Data Collection Data Collection

What is out there What is out there today?today?

What is in the What is in the planning stages?planning stages?

What new models What new models are emerging?are emerging?

Nurses Nurses Nurse PractitionersNurse Practitioners Physician AssistantsPhysician Assistants PharmacistsPharmacists PsychologistsPsychologists PhysiciansPhysicians

• AAP, AAFP, ACP, AOAAAP, AAFP, ACP, AOA

Disclaimer: apologies if your program or interdisciplinary group was missed – rapidly changing arena

Framework of Training PossibilitiesFramework of Training Possibilities

Professional SchoolProfessional School Graduate educationGraduate education FellowshipsFellowships Continuing EducationContinuing Education Certification/RecertificationCertification/Recertification

Harsh Reality Harsh Reality

Very, very few Very, very few educational programs educational programs designed to specifically designed to specifically train for the medical train for the medical homehome

But there is more to the story…

Essential Skills for PCMHEssential Skills for PCMH“Domains of Competency”“Domains of Competency”

Essential Skills Essential Skills enableenable people to people to perform tasks perform tasks required by their required by their jobs as well as jobs as well as adapt to change adapt to change

Patient Centered/Whole person care Patient Centered/Whole person care System-based care System-based care Practice-based learningPractice-based learning Communication & ProfessionalismCommunication & Professionalism TeamworkTeamwork Chronic disease management Chronic disease management Practice & Population Management Practice & Population Management Coordination & Transitions of Care Coordination & Transitions of Care Integration of Care Integration of Care Quality, Performance, & Practice Quality, Performance, & Practice

ImprovementImprovement Information TechnologyInformation Technology

NursingNursing

Many essential skills intrinsic to Many essential skills intrinsic to training and roletraining and role

Nurse Practitioners Nurse Practitioners

American Academy American Academy of Nurse Practitionersof Nurse Practitioners

American College of American College of Nurse PractitionersNurse Practitioners

National Association National Association of Pediatric Nurse of Pediatric Nurse Practitioners Practitioners

Professional organizations members of the PCPCC

Medical Home resources Journal articles and conference presentations

Many essential skills intrinsic to training and role

Physicians AssistantsPhysicians Assistants CME sessions offered at CME sessions offered at

educational conferenceseducational conferences

Journal and newsletter articles Journal and newsletter articles

Many essential skills intrinsic to Many essential skills intrinsic to training and roletraining and role• team-based practiceteam-based practice• coordinationcoordination• integration of care integration of care

PharmacistsPharmacists

Innovative Educational Innovative Educational Programs Programs at select schools of at select schools of pharmacy pharmacy (Ohio, New Jersey, Minnesota, (Ohio, New Jersey, Minnesota, others)others)

Expanded roles to include provider/medical service functions

Patient-Pharmacist-Physician Collaborative Relationship

Evidence based practice Chronic disease management

PsychologistsPsychologists

Collaborative practice & inter-professional teams

Psychological services to be “key in primary care initiatives”

Best Educational Best Educational PracticesPractices

Primary Care Behavioral Health Certificate Program (UMass Medical School -- onsite or live web-conference)

The Collaborative Family Healthcare Association Annual Conference (Oct 22-24, 2009 in San Diego, CA)

Medical and Osteopathic StudentsMedical and Osteopathic Students

Osteopathy (DOs)Osteopathy (DOs) Exposure at select Exposure at select

PCMH clinical sitesPCMH clinical sites Discussion about Discussion about

curriculumcurriculum

Allopathy (MDs)Allopathy (MDs) Exposure at select PCMH Exposure at select PCMH

clinical sitesclinical sites New C4 Core Clerkship New C4 Core Clerkship

Content CurriculumContent Curriculum Handful of clerkship Handful of clerkship

programs in place programs in place

Residency Education & PCMHResidency Education & PCMH

Individual & Networked Program Individual & Networked Program Development: Pediatrics, Family Development: Pediatrics, Family Medicine, Internal MedicineMedicine, Internal Medicine• Washington State Medical Home Washington State Medical Home

Collaborative (11 residencies)Collaborative (11 residencies)• Idaho Idaho • South Carolina (South Carolina (25 programs: FM, IM, Peds)25 programs: FM, IM, Peds)

AOA developing PCMH modules for AOA developing PCMH modules for

graduate medical educationgraduate medical education

Preparing the Personal Physician for PracticePreparing the Personal Physician for Practice

Designed to inspire and examine innovation in family Designed to inspire and examine innovation in family medicine residency training and prepare “personal medicine residency training and prepare “personal physicians of tomorrow”   physicians of tomorrow”  

14 residencies selected from 84 applicants 14 residencies selected from 84 applicants

Intensive evaluation of outcomesIntensive evaluation of outcomes

Different innovative approaches include general PCMH Different innovative approaches include general PCMH models and specific PCMH competenciesmodels and specific PCMH competencies

Sponsors: American Board of Family Medicine, the Association of Family Medicine Sponsors: American Board of Family Medicine, the Association of Family Medicine Residency Directors, and TransforMED. Residency Directors, and TransforMED. http://transformed.com/p4.cfmhttp://transformed.com/p4.cfm

Best Practice: Best Practice: Seattle (Swedish) FM Residency Site Seattle (Swedish) FM Residency Site

Ballard health center opened its doors March 2009Ballard health center opened its doors March 2009

Primarily staffed by family medicine residents (2/2/2) and 2 Primarily staffed by family medicine residents (2/2/2) and 2 FTEs of facultyFTEs of faculty

Meets NCQA and other criteriaMeets NCQA and other criteria

Payment Reform a key component: negotiated flat rate with Payment Reform a key component: negotiated flat rate with 2 private payers and uninsured pay 50% 2 private payers and uninsured pay 50% ($45 per month) ($45 per month)

Fellowships Fellowships

Broad Range of PCHM programs???Broad Range of PCHM programs???

““There are currently no [fellowship] There are currently no [fellowship] opportunities.”opportunities.”

PCMH Essentials: PCMH Essentials: Health Services ResearchHealth Services Research Quality improvement & chronic Quality improvement & chronic

disease managementdisease management Medical Informatics Medical Informatics

(Veteran Administration; University of New South Wales in Australia)(Veteran Administration; University of New South Wales in Australia)

Continuing EducationContinuing Education

Major opportunity for intervention – Major opportunity for intervention – life-long learninglife-long learning

• Nurse Practitioners Nurse Practitioners (esp. pediatric)(esp. pediatric)

• PharmacistsPharmacists• Physician Assistants Physician Assistants • PhysiciansPhysicians

AOA, AAFP, ACP, AAPAOA, AAFP, ACP, AAP

Certification/RecertificationCertification/Recertification

Family PhysiciansFamily Physicians: : Maintenance of Maintenance of

Certification:Certification: Performance in PracticePerformance in Practice

InternistsInternists: : Evaluation of Performance in Evaluation of Performance in PracticePractice; Recertification Resources - ; Recertification Resources - PIMPIM Practice Improvement Module Practice Improvement Module

PediatriciansPediatricians: : Maintenance of Certification:Maintenance of Certification: - - EQIPPEQIPP enhancing quality improvement enhancing quality improvement in pediatric practicein pediatric practice (launch in 2010)(launch in 2010)

Advanced Models of TrainingAdvanced Models of Training

Distance learning Distance learning TeleconferencesTeleconferences Podcasts Podcasts WebinarsWebinars Virtual consultantsVirtual consultants

Local Assistance & FacilitationLocal Assistance & Facilitation

New ModelsNew Models On-line collaborative networks On-line collaborative networks Cooperative Extension ServicesCooperative Extension Services

Rays of HopeRays of Hope

American Academy of Pediatrics American Academy of Pediatrics Transformation Initiatives :Transformation Initiatives :

Toolkit (June 2009)Toolkit (June 2009) Promotes quality improvement & Promotes quality improvement &

standardsstandards Self-instructed “Building Blocks”Self-instructed “Building Blocks” Podcasts, teleconferences, CME Podcasts, teleconferences, CME

webinarswebinars List-serveList-serve Limited technical assistance Limited technical assistance Branching out from focus on just Branching out from focus on just

children with special needs to all children with special needs to all childrenchildren

Building Blocks:• Care Partnership Support• Clinical Care Information• Care Delivery Management• Resources & Linkages• Practice Performance Measurement• Payment & Finance

National Center for Medical Home InitiativesNational Center for Medical Home Initiatives

Broader PediatricBroader Pediatric

Information, tools, and Information, tools, and resourcesresources to improve to improve care of Children and Youth care of Children and Youth with Special Health Care with Special Health Care NeedsNeeds

Toolkit and consultations Toolkit and consultations

• 0n-line & on-site0n-line & on-site • Pediatric & Adult carePediatric & Adult care

American College of PhysiciansAmerican College of Physicians

Practice Biopsy & Modules Patient-Centered Care & Communication Access & Scheduling Organization of Practice Care Coordination & Transitions in Care Use of Technology Population Management Quality Improvement & Performance

Improvement

On-line practice assessment & On-line practice assessment & dynamically linked resources dynamically linked resources

Self-paced program guides through Self-paced program guides through the ACP Practice Biopsy, then directs the ACP Practice Biopsy, then directs to resources & case studies for to resources & case studies for achieving goalsachieving goals

For individuals, groups, teams, For individuals, groups, teams, practices, demonstration projects, practices, demonstration projects, IPAs, multi-organizational efforts, & IPAs, multi-organizational efforts, & residency training programs residency training programs

Incremental quality improvement Incremental quality improvement changes to significant transformation changes to significant transformation

Available for CME credit (internists)Available for CME credit (internists)

Quality and Safety

Health Information Technology

Practice Management

Practice-based Care Team

Practice Services

Continuity of Care Services

Care Management

Access to Care and

Information

The TransforMED Approach

Great Outcomes

Patient Experience

Quality Measures

Health ITPractice Organization

Primary Care

Medical Home TransformationMedical Home Transformation Web-based toolkitWeb-based toolkit

• evaluates current medical home status evaluates current medical home status • develops a strategy for transformationdevelops a strategy for transformation

Links to tools and resources for practice re-design Links to tools and resources for practice re-design Coaching, facilitation, tailored training –on-siteCoaching, facilitation, tailored training –on-site Practice retreatsPractice retreats Delta Exchange: online, collaborative networkDelta Exchange: online, collaborative network

Why Facilitation is ImportantWhy Facilitation is Important

Nutting: Annals Family Med 2009

Cooperative Extension ProgramCooperative Extension Program

Similar to Similar to agricultural agricultural extension servicesextension services

Providing the Providing the expertise to organize expertise to organize PCHMPCHM

Based on New Based on New Mexico & other state Mexico & other state modelsmodels

SolutionsSolutions

Professional schools to select, support, and train Professional schools to select, support, and train PCMH-ready cliniciansPCMH-ready clinicians

Team work/interdisciplinary trainingTeam work/interdisciplinary training

Life-long learning of key skills to all clinical groupsLife-long learning of key skills to all clinical groups

Broad education/consultancy models that are on-Broad education/consultancy models that are on-line and on-the-ground – available everywhere line and on-the-ground – available everywhere

Linked payment reform Linked payment reform

““Ideal Primary Care” goes Medical HomeIdeal Primary Care” goes Medical Home 2010… 2010…

All members of the interdisciplinary team received PCMH training at each stage

Local PCHM practices offer to mentor them

Premier consultancy agency provides on-line and on-the-ground guidance

Cooperative extension service sends their extension agent to provide continuing advice and assistance

Insurers change their compensation model

The practice successfully makes the transition to the PCHM, increases not only the satisfaction of patients and clinicians, but health outcomes and the bottom line

They become mentors and their children join the 4H club (health, humanism, (medical) home, and happiness) and win first prize at the State Health Fair

The Hope: a medical home in every community and a team for every home

Thanks!Thanks!