Practice and Curricula Transformation in Residency Practices: Are We Homes Yet?

1. Practice and Curricula Transformation in Residency Practices: Are We Homes Yet? Bonnie Jortberg, MS,RD,CDE University of Colorado Denver Department of Family Medicine Nicole Deaner, MSW Colorado Clinical Guidelines Collaborative

2. Who is Involved? • Funded by The Colorado Health Foundation • University of Colorado Dept of Family Medicine • Perry Dickinson MD: Project Director • Bonnie Jortberg: Project Coordinator, Curriculum Redesign • Doug Fernald, Evaluation • Frank deGruy MD • Larry Green MD

3. Who is Involved? • Colorado Clinical Guidelines Collaborative (CCGC) • Nicole Deaner: Practice Improvement Coach • Caitlin O’Neill: Practice Improvement Coach • Julie Schilz: Manager, IPIP and PCMH • Marjie Harbrecht : CCGC Executive Medical Director • Colorado Association of Family Medicine Residencies • Nine Family Medicine Residencies + one track • 10 residency practices • Tony Prado-Gutierrez: Director

4. What is Involved?Planning Phase • Preparation for practice and curricular redesign • Assistance with IT issues • Start working on forming improvement team • Practice/program discussions of PCMH • Sponsoring organization – look for support, try to remove barriers • Prepare for cultural transformation

5. Practice Coaching • Active coaching period – approximately 14 months • Assessment with feedback – 2 months • Active coaching with practice improvement team(s) – 12 months (or more) • Continued team meetings for PCMH changes, other practice improvement with coach “boosters”

6. Collaboratives • Meetings of representatives of all practices and programs • Planning, sharing, educational – highly interactive • Two collaboratives per year • First one May 2009 – 105 people from the practices • Second in October – over 130 from practices

7. What’s Provided? • Assistance with orientation to PCMH, initial planning, working with hospital leadership • Coaching team provided • IT consultation resources • PCMH consultation and support • NCQA PPC-PCMH certification paid for • Direct funding for the programs

8. Curricular Redesign Objectives Facilitation and consultation for PCMH-related curriculum changes Changes to free up residents to participate in PCMH and QI efforts Shared resource development across programs (lectures, modules, etc) Active involvement of residents in practice redesign process PCMH practices for residents to experience

9. Practice Outcomes • Achieve NCQA PPC-PCMH certification – hopefully at least level 2 • Improve level of medical homeness: • NCQA PCMH assessment • PCMH Clinician Assessment • Practice Staff Questionnaire • Improve quality measures in two clinically important areas to be chosen by the practices

10. Curricular Outcomes • Improved resident achievement of PCMH competencies • Improved resident use of PCMH elements as assessed by PCMH clinician assessment • Revision of residency curricula to allow resident participation in PCMH and QI efforts • Implementation of PCMH curricular elements • Will follow resident In-training Exam and Board Exam scores, but may not show up there

11. Two Parts of Project—Practice and Curriculum Redesign Curricular Redesign PCMH Residency Practice Practice Improvement

12. Practice PCMH Transformation NCQA Certification Iterative Practice Redesign Cultural Transformation

13. Baseline Assessment Process –Practice Improvement NCQA Self-Assessment – group or individual Key Informant Interviews Cycle Time Report Online surveys using survey monkey: PCMH - Clinician Assessment (PCMH-CA) Practice Staff Questionnaire (PSQ)

14. Baseline Assessment Report • Structure: • Narrative explanation and assessment on 7 core elements • Data tables for responses to NCQA Self-Assessment & responses to PSQ & PCMH-CA • Recommendation section • Approximately 10 pages long • Appendix: • PCMH-CA & PSQ graphic data (previous slides) with narrative explanation • NCQA Self-Assessment Report

15. Practice Redesign Lessons Learned • Leadership buy-in prior to project launch critical. • High-functioning teams build foundation for project. • Clinic flow - first entrée into working on teams & teaching QI principles. • QI teams big cultural shift for existing leadership structure; largest source of resistance. • Building communication infrastructure for all staff inclusion a local and important process. • Current: choosing clinically important conditions & registries • Next steps: Patient Involvement and Reporting & Posting Measures

16. Curriculum Redesign • Challenges and Opportunities • No organized, comprehensive PCMH curriculum or materials • No developed curriculum competencies • No tools to assess PCMH curricular activities or resident competency

17. Curriculum Redesign • Started with developing competencies (see handout) • Curriculum Assessment: • Developed Residency Curriculum Semi-Structured Interview Template to determine current PCMH curricular activities; identify gaps; set goals and establish plan

18. Curriculum Assessment • Competencies: • Who, what, where, when, how for each • Summary Questions: • Strengths/weaknesses of curriculum • What do they need the most help with for the curriculum? • Resource for other programs • How do they characterize their sponsor’s interest and support for this project? • Resident’s interest and support (scale 1-5) • Staff and faculty support

19. Resident PCMH Curriculum Competency Survey • Developed to assess resident baseline competence (See handout)

20. Results and Lessons Learned • Interview completed with 3 programs so far • Emerging Themes: • Interview process is an “intervention” for the program • Makes them take comprehensive look at what they are teaching • “We want to go from reactive teaching to intentional teaching” • Revealing that they are teaching many of the elements of the PCMH, just not in an organized manner • Resident participation on the QI teams an important curricular component

21. Results and Lessons Learned • Common areas meeting competencies (through resident involvement in QI teams) • Team approach • Integrated and coordinated care • Quality Improvement • Leadership skills • Common areas not meeting competencies • Population management • Access to care • Information systems to support PCMH • Self-management support

22. Results and Lessons Learned • Time-consuming process • Great qualitative data • Quantitative data still to be determined

23. Curriculum Redesign: Next Steps • Review feedback report • Goal setting for each practice • Actively developing curricular modules and tools • Integration of curricular modules and tools • Continuous evaluation

24. Questions? • Contact Information: • Bonnie Jortberg: bonnie.jortberg@ucdenver.edu • Nicole Deaner: ndeaner@coloradoguidelines.org