|Year : 2014 | Volume
| Issue : 2 | Page : 205-207
Course on care of patients with chronic illness: Patient-centered medical home model
Christopher Danford1, Barbara Sheline2, Viviana Martinez-Bianchi2, Melinda Blazar2, Patricia Dieter2, Nancy Weigle2
1 Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
2 Department of Community and Family Medicine, Duke University School of Medicine, Durham, North Carolina, USA
|Date of Web Publication||31-Oct-2014|
Resident, University of Wisconsin School of Medicine and Public Health, Madison, WI 53726
Source of Support: None, Conflict of Interest: The first author was a medical student in the Primary Care Leadership Track at Duke University School of Medicine during the writing of this article.
Background: In the United States, the Patient-centered Medical Home (PCMH) is an emerging concept in primary care that is guiding clinical reorganization to meet the needs of patients with chronic illness. We developed a one-semester curriculum to teach the principles and practice of PCMH to medical and physician assistant students during their clinical clerkship year. Methods: The mini-course on PCMH consists of three 3-h weekend sessions over 16 weeks and a student project to develop constructive planning ideas for an assigned clinical site. In the first two sessions, students receive didactics and engage in project development discussions. Subsequently, participants work with a faculty advisor and clinic site administrative staff to identify and analyze an area of interest for the student and clinic site. In the last session, students present their projects to the larger group. During the first year of implementation, student evaluations were collected after the first and last sessions. Results: At the end of the course, students reported confidence in their understanding of PCMH concepts and practical implementations of it. Completing a student project at their clinical sites posed challenges that were logistical, rather than conceptual, and was difficult to integrate with classroom learning. Discussion: We present an interprofessional PCMH curriculum for medical and physician assistant students during their clinical year. This course provides students a familiarity with principles of the medical home model and practical experience with practice redesign issues in the context of PCMH transformation.
Keywords: Interprofessional education, medical student, physician assistant student, Patient-centered medical home
|How to cite this article:|
Danford C, Sheline B, Martinez-Bianchi V, Blazar M, Dieter P, Weigle N. Course on care of patients with chronic illness: Patient-centered medical home model. Educ Health 2014;27:205-7
|How to cite this URL:|
Danford C, Sheline B, Martinez-Bianchi V, Blazar M, Dieter P, Weigle N. Course on care of patients with chronic illness: Patient-centered medical home model. Educ Health [serial online] 2014 [cited 2019 Nov 22];27:205-7. Available from: http://www.educationforhealth.net/text.asp?2014/27/2/205/143771
| Background|| |
In the United States, the Patient-centered Medical Home (PCMH) is a rapidly emerging concept that guides practices in updating their clinical, business, and technology strategies in a coordinated way to achieve evidence-based best practices. , Although the roots of the medical home model are decades old, it has become a focal point in current health reform discourses for those who seek to improve the quality of primary care, while simultaneously better meeting the needs of patients. In recognition of its importance, several key organizations representing physicians and medical educators have called for principles of PCMHs to be incorporated into medical training. , Many practices that precept our learners have recently become or are trying to achieve official recognition as PCMHs, and we believe that learners can contribute meaningfully to this process. Thus, Duke University School of Medicine launched a mini-course on PCMH in 2012 for the medical and physician assistant (PA) students enrolled in a longitudinal primary care curriculum.
Though other countries may not utilize the term PCMH, the concepts are universal for the care of patients with chronic illness. These concepts include a patient-centered approach, setting goals for care, measuring quality, and using a team approach to better achieve high quality care and are among those identified as distinctive features of primary care in the World Health Organization's 2008 report, "Primary Health Care: Now More Than Ever". 
Incorporating concepts from the PCMH into an already full medical education curriculum presents a challenge. For this reason, few students are exposed to the principles and practice of PCMH in a dedicated way. , However, we agree with the American Association of Medical Colleges and the American Academy of Family Physicians and others that new training is needed in order to prepare providers for an evolving care delivery system that embodies core principles of patient-centeredness, coordinated care, and team-based care. We developed and evaluated an interprofessional PCMH course embedded within a clerkship experience to fulfill this important role. This course provides brief didactics and discussion paired with a semester-long applied project that gives students a familiarity with principles of the medical home model and hands-on experience engaging with practices in the context of PCMH transformation.
The objectives of this experience were for students to explore those aspects of the advanced primary care practice that are embodied in the United States by the medical home model, apply this understanding to address a problem of practical concern for the clinic where the student is being precepted, and participate in a model for interprofessional medical learning. In particular, goals of this course were to allow students to: Define the concept of PCMH, describe its historical context and importance to primary care, and address a problem of practical concern for their longitudinal primary care practices. Although our course was developed at a time when the PCMH is a dominant organizing model for primary care change in the United States, the basic construct of the course could easily be adapted to other settings where this particular model is not applicable.
| Methods|| |
This course takes place within the context of two primary care-oriented training programs in the Duke University School of Medicine's predoctoral and PA programs. Participants included eight clinical-year PA and MD students taking part in longitudinal primary care experiences during their clerkship year. During this time, students have outpatient continuity placements over a period of several months in a variety of practice settings, from small privately owned family medicine groups to community health centers, as well as clinics that belong to an integrated primary care network for a university health system.
Format and timeline
The course consists of two in-person sessions, a site-based practical assignment, and a final report, all embedded during the spring of the clinical clerkship year. Prior to the first class, students collected basic characteristics of their practice and completed basic background readings. They used a survey document created for this class that included items such as the number of provider and nonprovider personnel, the estimated patient population, gender mix, and payer mix. The first class session was devoted to didactics on PCMH and collaborative discussion time with other students and advisors to begin identifying a topic of interest. Topics covered during the didactic session included definitions and historical development of the PCMH, the current national context for the PCMH including payment reform, evidence supporting the PCMH model, and basic principles of culture change during PCMH transformation.
Following the first session, students arranged meetings with staff at their clinic site to narrow down their topic of interest, identify a problem of practical concern to the practice, and begin analysis of the problem. Students communicated with advisors via email or phone for guidance and sharing findings, and met with advisors once at midterm to discuss recommendations (8 weeks later). During the final session, each student presented their findings and recommendations to each other and advisors, and then met again with advisors to plan for final revisions to their written report. The written report was due two weeks after the last session, and students were encouraged to share the final report with their practice. Reports were evaluated by each advisor as well as the course directors. They were revised until they were in a useful format to deliver back to the participating clinic. The final grade is pass/fail.
At the end of the first and last sessions, all students completed anonymous surveys. Surveys were intended for feedback and course improvement and were collected and tabulated by the authors. Responses to open-ended questions were grouped into themes. The study was exempt from local Ethics Committee requirements.
| Results|| |
After session 1, students were asked to fill out an informal, open-ended, and anonymous evaluation to promote constructive feedback. Some examples of student responses for ways to improve the initial class were to include case studies, "for example a hypothetical walkthrough of a patient at a PCMH versus standard of care." The questions that students left with reflected primarily logistical confusion: "Who should I communicate primarily with while doing this project? Am I supposed to be in close contact with my PA partner?"
Following the last session, students rated their confidence in several areas on a scale of 1 (least confident) to 5 (very confident). Results are presented in [Table 1].
|Table 1: Student self-confidence ratings regarding confidence in understanding patient-centered medical home concepts and implementation at the conclusion of a PCMH mini-course|
Click here to view
Open-ended student feedback after session 2 revealed a few themes: Organization, project expectations, practice setting comparisons, and advisor-student relationships. Several students noted that the presentations during the last session were a useful way to learn about different challenges practices face, and that they "enjoyed learning about other students' practices and their stage in PCMH." One last theme that arose from the student responses was that the advisor-student relationship was ill-defined. One respondent remarked that s/he wished "both advisor and student [understood] the purpose of the relationship."
The evaluations carried out for this first year were limited by lack of a pretest evaluation of students' confidence in defining the concept and history of the PCMH. More information on students' perspective was gathered four months after the end of the experience. Some of their comments included:
"You see all the principles and the [National Committee for Quality Assurance, NCQA] requirements and think of them as something vague. You don't see in a concrete way what practices do to actually meet the criteria until you work with them to address a needed area."
"The hands-on aspect of this exercise makes it a wonderful experience. The process converted something arid and difficult to grasp into something tangible and useful."
"Valuable experience, will put on resume and discuss at job interviews."
| Discussion|| |
Overall, the enthusiasm of the students for the topic and the importance of PCMH knowledge were motivations for continuing the course with the next cycle of students. Our key findings were that a very brief group educational intervention embedded during a clerkship experience can be satisfying to students and leave them with confidence in their understanding of medical home principles and their ability to implement these in practice. Key challenges were related to difficult logistics for individual students to complete their practical assignment. We hope the utility of these findings would be that it might motivate educators in other settings to pilot similar brief courses, either focused on the PCMH in particular or on health systems management in general. Future directions for our group are to complete pre- and posttesting of students to estimate whether their confidence and understanding increased after the course, to gather reflections by students on their learning with a focus on future employment or residency potential, and to open enrollment to learners from the wider population of our medical school, nursing school, and physical therapy programs.
| References|| |
Sia C, Tonniges TF, Osterhus E, Taba S. History of the medical home concept. Pediatrics 2004;113 (5 Suppl):1473-8.
Grundy P, Hagan KR, Hansen JC, Grumbach K. The multi-stakeholder movement for primary care renewal and reform. Health Aff (Millwood) 2010;29:791-8.
Joo P, Younge R, Jones D, Hove J, Lin S, Burton W. Medical student awareness of the Patient-centered Medical Home. Fam Med 2011;43:696-701.
Saultz JW, O′Neill P, Gill JM, Biagioli FE, Blanchard S, O′Malley JP, et al
. Medical student exposure to components of the patient-centered medical home during required ambulatory clerkship rotations: Implications for education. Acad Med 2010;85:965-73.