|Year : 2015 | Volume
| Issue : 1 | Page : 74-78
Implementing the patient-centered medical home in residency education
Benjamin R Doolittle1, Daniel Tobin2, Inginia Genao2, Matthew Ellman2, Christopher Ruser3, Rebecca Brienza3
1 Department of Internal Medicine and Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
2 Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
3 Department of Internal Medicine, Yale University School of Medicine, New Haven, CT and West Haven Veterans Association, West Haven, Connecticut, USA
|Date of Web Publication||31-Jul-2015|
Benjamin R Doolittle
Department of Internal Medicine and Pediatrics, Yale University School of Medicine, PO BOX 8033 Yale Station, 333 Cedar Street - 1091 LMP, New Haven, CT 06520-8033
Source of Support: None, Conflict of Interest: None
Background: In recent years, physician groups, government agencies and third party payers in the United States of America have promoted a Patient-centered Medical Home (PCMH) model that fosters a team-based approach to primary care. Advocates highlight the model's collaborative approach where physicians, mid-level providers, nurses and other health care personnel coordinate their efforts with an aim for high-quality, efficient care. Early studies show improvement in quality measures, reduction in emergency room visits and cost savings. However, implementing the PCMH presents particular challenges to physician training programs, including institutional commitment, infrastructure expenditures and faculty training. Discussion: Teaching programs must consider how the objectives of the PCMH model align with recent innovations in resident evaluation now required by the Accreditation Council of Graduate Medical Education (ACGME) in the US. This article addresses these challenges, assesses the preliminary success of a pilot project, and proposes a viable, realistic model for implementation at other institutions.
Keywords: Interprofessional care, residency education, patient-centered medical home
|How to cite this article:|
Doolittle BR, Tobin D, Genao I, Ellman M, Ruser C, Brienza R. Implementing the patient-centered medical home in residency education. Educ Health 2015;28:74-8
| Background|| |
In recent years, physician leaders, government and third party payers in the United States have promoted a Patient-centered Medical Home (PCMH) model of care described as a "health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient's family."  In 2007, the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association, together representing more than 300,000 physicians, formally endorsed the Joint Principles of the PCMH, which are characterized as: An ongoing relationship with a personal physician; physician-directed team medical practice; whole-person orientation of care; care that is coordinated and/or integrated; an emphasis on quality and safety; enhanced access to care; and payment that appropriately recognizes the added value of PCMH care. 
Conceptually, the PCMH model shifts the older "gatekeeper" model of primary care into an inter-connected, comprehensive approach that incorporates the contributions of pharmacists, mental health providers, social workers, nurses, other allied health professionals and support staff. This new model shows promise to address the "triple aim" of healthcare reform as outlined by Donald Berwick: Improving the experience of patient care, improving the health of populations and reducing per capita costs of health care. 
To this end, several studies demonstrate improved outcomes, savings, and patient satisfaction. At a time when healthcare accounts for 17.6% of gross domestic product (GDP) and more than 2.7 trillion dollars per year, the medical home model offers a promising solution for runaway costs.  An evaluation conducted by the Patient-centered Primary Care Collaborative (PCPCC) reviewed 46 medical home initiatives and revealed a 70% reduction in emergency department visits, 40% fewer hospital readmissions, and hundreds of millions of dollars in savings.  Another study by Baskerville et al. demonstrated that medical home practices are three times as likely to implement evidence-based guidelines as non-medical home practices. 
And yet, despite the early success and widespread advocacy of the PCMH model, , few residency training programs have evaluated their curricula to assess how well they are preparing their trainees to practice medicine in this manner.  In particular, there has been little analysis of how the Joint Principles integrate with the Core Competencies defined by the Accreditation Council for Graduate Medical Education (ACGME) or how to best implement training across different practice settings.  Nationally, the Medical Home model shows great promise, but will the next generation of physicians be ready to practice in a PCMH? Are medical educators equipped to teach this new model? This paper explores these challenges and presents one successful model of integration of trainees into the PCMH. Although, unique to the Veterans Administration, the model illustrates several principles that are applicable to other residency settings. The Veterans Administration (VA) is a federally funded, national healthcare system that provides comprehensive in-patient and out-patient care for those who have served in the US armed forces.
Challenges implementing a PCMH in a Residency-based clinic
Implementing the PCMH into an academic residency clinic poses special challenges and opportunities compared with independent private-office practice. For example, Narayan et al. surveyed pediatric residency program directors about medical home education and found that only half of programs had a faculty champion and the resources to implement appropriate education in modeling a medical home.  Resident schedules (80%), faculty time (69%), lack of expertise (53%) and finances (47%) were cited as the major barriers to implementing a medical home.  Undoubtedly some of these barriers exist in other practice settings as well, but the current 80-h restriction on residents' work-hours and the logistics of an academic hierarchy pose unique challenges. Rarely is a PCMH launched in any practice setting without provider buy-in and support.
Lack of funds represents another challenge. The initial capital investment to launch a PCMH can be significant and prohibitory for private practices and residency programs alike; purchasing a certified electronic medical record (EMR) and recruiting appropriate support staff requires significant capital and organizational commitment. Further, many recent EMRs do not meet the certification standards of a PCMH, requiring an expensive, often premature upgrade. Lack of funds impacts other essential components of a PCMH, such as enhanced care coordinators and nursing support.
Continuity of care presents another special challenge to academic residency clinics. Work-hour limits mandated by the ACGME and in-patient responsibilities both limit the availability of individual trainees to the clinic; consistent follow-up with the same provider can be challenging. Further, faculty supervision may not be adequate to overcome this continuity challenge. Academic faculty often engage in scholarship beyond direct patient care and therefore may be clinically part-time, face competing professional priorities, resulting in limited availability. To overcome the limited availability of trainees and faculty, and to successfully manage care transitions and between-visit care, a teaching clinic may require additional on-site personnel beyond that required in private practice.
Equally important is lack of knowledge about systems of care delivery. The Deloitte 2013 Survey of U.S. Physicians noted "just one in three of the nation's physicians reported they were familiar with accountable care organizations, episode-based payments and patient-centered medical home".  This knowledge gap begins in residency training and represents a "teachable moment" for residency programs to prepare their trainees to practice in the medical world of the future.
Despite the many challenges that residency programs face, they may have advantages over private practices. Hospital-based programs may have more institutional resources and incentive to invest in EMR technology and support. Hospital-sponsored practices may also have access to additional shared resources such as care coordination, quality improvement teams and core measure analysis. Similarly, hospital-based practices may have significant incentive to reduce inappropriate ER visits and admissions thus motivating the support of a well-developed PCMH.
Case study: The west haven VA connecticut healthcare system
In 2010, the Department of Veterans Affairs (VA) implemented a national medical home model called the Patient Aligned Care Team (PACT). Though the Veterans Heath Administration (VHA) long-emphasized certain medical-home principles and had one of the first nationally integrated EMRs, the VHA recognized shortfalls in access to care, continuity, and coordination of care within the previous model. Under the PACT initiative, large-scale changes were made to the organization of primary care, focusing on adequate staff-to-provider ratios, and reorganizing care providers into interdisciplinary teams.
PACT teams are charged with providing patient-centered care, focusing on two core domains: Access to Care, and Coordination of Care and Practice Re-Design. Each PACT "teamlet" is composed of four health professionals: A primary care physician or Nurse Practitioner (NP), a Registered Nurse, a Licensed Practical Nurse or equivalent, and other medical support staff who together share responsibility for providing acute and chronic care as well as health promotion and disease prevention to a panel of patients. In many settings, pharmacists, social workers, nutritionists and psychologists also support the PACT teamlet. Although the VA successfully reorganized healthcare professionals into PACT teams, integration of trainees into the model remained a challenge due to individual training program requirements, structures, and cultures.
The West Haven VA Medical Center is located in the largely urban/suburban state of Connecticut in the northeastern United States and serves the needs of more than 200,000 veterans. The West Haven VA is also the continuity practice for approximately 30 of the Yale-New Haven Hospital Categorical Internal Medicine (IM) residents. The structure for the IM residents' continuity clinic at this site was one half-day each week, with the exception of ICU, away rotations and vacation. Faculty preceptors supervised residents and schedulers attempted to maintain faculty-trainee-patient continuity when possible based on resident inpatient and call schedules. On average, categorical IM residents spent 8 weeks per year and primary care IM residents spent 12 weeks per year on ambulatory block rotations in various settings that included didactics, continuity sessions, urgent care visits and subspecialty clinics. Not surprisingly, patients and faculty experienced unpredictable continuity with residents.
Center of excellence in primary care education: Key innovations
West Haven's priority in designing the Center of Excellence in Primary Care Education (CoEPCE) program was to re-design the structure of the resident training model. To address the challenges of patient-provider continuity and integration with multiple health professional trainee groups, key changes were required. First, a dramatic revision of Internal Medicine resident schedules was necessary. With support of the residency program leadership, a longitudinal/block immersion hybrid model was developed, that includes four one-month immersion blocks per training year where residents work full time alongside their interprofessional colleagues and within their PACT teamlet providing both direct and indirect patient care (50% time) with the remaining time spent participating in educational seminars, real-time performance improvement projects and other scholarly projects. Importantly, these blocks were specifically designed to allow trainees to focus exclusively on their ambulatory educational experience by eliminating any inpatient or on-call duties during these months. Each CoEPCE site required residents to commit more than 30% of their total training time to dedicated CoEPCE experiences. Residents were informed about the CoEPCE during recruitment season and volunteered to participate in the program after matching with the residency program.
The second important innovation to our program was the development of the first interprofessional nurse practitioner fellowship. In the US, nurse practitioners are nurses with advanced training to practice with more autonomy, usually in collaboration with a physician. These nurse practitioner fellows were assigned to practice partnerships with their internal medicine resident colleagues. The nurse practitioner fellows provide collaborative team continuity when the internal medicine residents are unavailable. As residents rotate off their CoEPCE blocks, team continuity is preserved via assignment of resident and nurse practitioner partnerships who are part of the same team and provide a bridge to patient coverage and team continuity. Trainees meet with their team at the end of each block to formally review and sign out their patients with an emphasis on high-utilizers.
Our third important innovation is a core curriculum focused around the patient-centered core educational domains specified within the grant: Shared Decision Making, Interprofessional Collaboration, Sustained Relationships and Performance Improvement. At our site, we also developed a health policy/leadership and advocacy curriculum, where trainees learn key skills necessary for leadership roles.  Team development and role clarification is integrated throughout the learning sessions.
As evidence of the early success of this site's CoEPCE, the program has tripled in size since inception. The program has many more resident and nurse practitioner fellow applicants than available slots each year. Multiple health professionals have been added to the teams - including medical, physician associate and nurse practitioner students, pharmacy residents and health psychology trainees.
Furthermore, themes from semi-structured qualitative interviews indicate that since participation in the CoEPCE program, trainees have an improved sense of "team", an improved understanding of interprofessional roles and an enhanced sense of interprofessional collaboration.  Preliminary evaluation of routinely collected performance data after the first year of implementation of this model indicate that since the CoEPCE inception, numbers of patients seen and access for patients has more than doubled from 4236 in fiscal year 2010 to 8613 in fiscal year 2012. In addition, we analyzed data obtained after implementation of the PACT model from the (WHVA) West Haven Veterans Administration and found in multivariate analyses that strong continuity of care (by both individual provider and team) is associated with decreased emergency department utilization.  As part of a COEPCE five site performance improvement workgroup, our site developed a project to reduce emergency department visits by our primary care patients during business hours. In the most recent six-month period, the CoEPCE has observed a 70% decrease in the number of team patients that present to the emergency department during business hours. 
These results are likely multifactorial but contributors include dramatic changes in faculty and trainee work structure allowing for more patient visits, patient sessions with assigned urgent visit coverage within teams, trainee practice partnerships and improved communication across team members about high utilizing patients and communication to patients about the CoEPCE team structure and availability. Based on this preliminary data as well as our experience with trainee recruitment and satisfaction, we believe that our model, including the creation of an adult interprofessional nurse practitioner fellowship, comprises a cohesive strategy for interprofessional teamwork training that could be transported to other sites seeking to implement PCMH and interprofessional training.  Evaluation efforts are ongoing and will focus on patient, staff, faculty and trainee outcomes. Because the CoEPCE includes only a subset of the total pool of internal medicine trainees, we will be comparing outcomes for these trainees with those in the traditional training model. 
| Discussion|| |
The PCMH model has demonstrated significant early success to improve the quality of care delivery in an integrative, patient-centered, cost-effective and data-driven manner. , This success and the synergy between the Joint Principles of the PCMH and the core competences of residency training makes it very appealing to implement the PCMH within residency training programs. As described above, the challenges are many, but the process is not insurmountable.
We propose several essential elements required to build a PCMH within a residency training program [Table 1]. First, major schedule and curricular changes must be implemented in residency training programs to improve both individual provider and team continuity of care. These changes are essential for meaningful interprofessional collaboration and faculty-trainee-patient relationships. In light of ACGME duty-hour restrictions, continuity of care may be most easily achieved by implementing an interprofessional team and practice partnership model similar to that implemented at the West Haven VA CoEPCE site with dedicated time to immersion PCMH model training. This model involves integration of different types of health professional faculty and trainees into the care team. For true interprofessional teamwork and collaboration the PCMH model need not be physician led and may, in fact, be better led by those who are present within the team more continuously. Second, commitment to the project is time and resource intensive so collaboration between residency program and clinical leadership is essential; project champions are needed on both sides. Adequate faculty development and buy-in is critical; and local opinion leaders within the training program need to mobilize enthusiasm and reinforce the importance of the model. Third, implementation of a PCMH model will be facilitated by use of integrated resources across the institution such as a certified EMR that allows for care coordination and panel management even when trainees are not physically at their clinic sites. Fourth, and perhaps most importantly, institutional support must transcend moral backing alone and also include the capital investment required to get the project started. Without support from the wider institution, a dedicated faculty is still an island of activity.
|Table 1: Essential elements for implementing a medical home in a residency|
Click here to view
The PCMH model offers a real-world, practical model by which affordable quality care may be implemented and this approach has been increasingly embraced as the new standard of care in the United States. The collaborative, inter-disciplinary spirit of the patient-centered medical home may be readily adopted in international settings. As such, resident trainees must be educated in this model. To achieve this, health professional learners must be integrated into a workplace where education meets practice re-design (e.g., workplace learning). While the initial investment to implement a residency-based PCMH may be costly, can we afford not to?
| References|| |
American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Osteopathic Association (AOA), Joint Principles of the Patient-Centered Medical Home, March 2007.
Berwick DM, Nolan TW, Whittington J. The triple aim: Care, health, and cost. Health Aff 2008;27:759-69.
Martin AB, Lassman D, Washington B, Catlin A; National Health Expenditure Accounts Team. Growth In US Health Spending Remained Slow In 2010; Health Share Of Gross Domestic Product Was Unchanged From 2009. Health Aff 2012;31:208-19.
Nielsen M, Langner B, Zema C, Hacker T, Grundy P. Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost and Quality Results, 2012, Patient-Centered Primary Care Collaborative. 2012.
Baskerville NB, Liddy C, Hogg W. Systematic review and meta-analysis of practice facilitation within primary care settings. Ann Fam Med 2012;10:63-74.
Narayan AP, Turchi RM, Esquivel MZ, Nehal US. State of Medical Home Education in Pediatric Residency Programs. Acad Pediatr 2012;12:e9-10.
Keckley PH, Coughlin S, Stanley EL. Deloitte 2013 Survey of U.S. Physicians: Physician perspectives about health care reform and the future of the medical profession, Deloitte Center for Health Solutions, 2013.
Zapatka SA, Conelius J, Edwards J, Meyer EM, Brienza RS. Pioneering a primary care adult nurse practitioner interprofessional fellowship. J Nurse Pract 2014;10:378-86.
Long T, Dann S, Wolff ML, Brienza RS. Moving from silos to teamwork: Integration of interprofessional trainees into a medical home model. J Interprof Care 2014;28:473-4.
Meyer EM, Zapatka S, Brienza RS. Professional identity development and the formation of VA Connecticut Healthcare System Center of Excellence in Primary Care Education (VACHS CoEPCE) teams. Acad Med [In Press].
Chaiyachati KH, Gordon K, Long T, Levin W, Khan A, Meyer E, et al.
VA Patient Centered Medical Home: Continuity in a VA patient-centered medical home reduces emergency department visits, PLoS One 2014;9:e96356.
Hyson AH, Norcott A, Dann S, Anderson E, Meyer E, Luco C. et al
. WHVA CoEPCE performance improvement workgroup data, unpublished.
Brienza RS, Luco C, Anderson E, WHVA CoEPCE performance improvement workgroup data, manuscript in preparation.