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
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
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