Workforce Training for PCMH: What are We doing to Equip the Team?

1. Workforce Training for PCMH: What are We doing to Equip the Team? Jeffrey Borkan, MD, PhD Chair, Department of Family Medicine Brown University President, Association of Departments of Family Medicine

2. The Hope: a medical home in every community and a team for every home Thanks!

3. Rhode Island Morass • Primary care practices hard pressed • Patients not getting the care they need • 100,000 uninsured • $49,000,000 spent on Medicaid patients going to the ER last year • Getting the results our system designed

4. Background of the Medical Home Concept • The American Academy of Pediatrics (AAP) introduced the medical home concept in 1967, initially referring to a central location for archiving a child’s medical record. • 2002 AAP policy statement on operational characteristics: accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective care. • The American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP) have since developed their own models for improving patient care called the “medical home” (AAFP, 2004) or “advanced medical home” (ACP, 2006).

5. Joint 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 coordinatedand/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). • 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 culturally and linguistically appropriate manner.

6. Quality and safety are hallmarks of the medical home: • Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff. • Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home. The payment structure should be based on the following framework:

7. “Ideal Primary Care” goes Medical Home 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 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

8. What if… …the Congress and the Administration mandated Patient Centered Medical Homes to open around the country in one year…. • We would first celebrate…. • Then realize that we have few trained clinicians, administrators, or teams to staff them

9. Hope is on the way • Rapid expansion phase in educational, training, and consultation services • More demonstration projects on local, state, and regional • more experience • more mentors • New models on the horizon

10. What is out there today? What is in the planning stages? What new models are emerging? Nurses Nurse Practitioners Physician Assistants Pharmacists Psychologists Physicians AAP, AAFP, ACP, AOA Data Collection Disclaimer: apologies if your program or interdisciplinary group was missed – rapidly changing arena

11. Professional School Graduate education Fellowships Continuing Education Certification/Recertification Framework of Training Possibilities

12. Very, very few educational programs designed to specifically train for the medical home Harsh Reality But there is more to the story…

13. Essential Skills enable people to perform tasks required by their jobs as well as adapt to change Patient Centered/Whole person care System-based care Practice-based learning Communication & Professionalism Teamwork Chronic disease management Practice & Population Management Coordination & Transitions of Care Integration of Care Quality, Performance, & Practice Improvement Information Technology Essential Skills for PCMH “Domains of Competency”

15. Nursing • Many essential skills intrinsic to training and role

16. Nurse Practitioners • American Academy of Nurse Practitioners • American College of Nurse Practitioners • National Association of Pediatric Nurse Practitioners • Professional organizations members of the PCPCC • Medical Home resources Journal articles and conference presentations • Many essential skills intrinsic to training and role

17. Physicians Assistants • CME sessions offered at educational conferences • Journal and newsletter articles • Many essential skills intrinsic to training and role • team-based practice • coordination • integration of care

18. Pharmacists Innovative Educational Programs at select schools of pharmacy (Ohio, New Jersey, Minnesota, others) Expanded roles to include provider/medical service functions • Patient-Pharmacist-Physician Collaborative Relationship • Evidence based practice • Chronic disease management

19. Psychologists • Collaborative practice & inter-professional teams • Psychological services to be “key in primary care initiatives” Best Educational Practices • 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)

20. Osteopathy (DOs) Exposure at select PCMH clinical sites Discussion about curriculum Allopathy (MDs) Exposure at select PCMH clinical sites New C4 Core Clerkship Content Curriculum Handful of clerkship programs in place Medical and Osteopathic Students

21. Residency Education & PCMH • Individual & Networked Program Development: Pediatrics, Family Medicine, Internal Medicine • Washington State Medical Home Collaborative (11 residencies) • Idaho • South Carolina (25 programs: FM, IM, Peds) • AOA developing PCMH modules for graduate medical education

22. Preparing the Personal Physician for Practice • Designed to inspire and examine innovation in family medicine residency training and prepare “personal physicians of tomorrow”   • 14 residencies selected from 84 applicants • Intensive evaluation of outcomes • Different innovative approaches include general PCMH models and specific PCMH competencies Sponsors: American Board of Family Medicine, the Association of Family Medicine Residency Directors, and TransforMED. http://transformed.com/p4.cfm

23. Best Practice: Seattle (Swedish) FM Residency Site • Ballard health center opened its doors March 2009 • Primarily staffed by family medicine residents (2/2/2) and 2 FTEs of faculty • Meets NCQA and other criteria • Payment Reform a key component: negotiated flat rate with 2 private payers and uninsured pay 50% ($45 per month)

24. Fellowships • Broad Range of PCHM programs??? • “There are currently no [fellowship] opportunities.” PCMH Essentials: • Health Services Research • Quality improvement & chronic disease management • Medical Informatics • (Veteran Administration; University of New South Wales in Australia)

25. Continuing Education Major opportunity for intervention – life-long learning • Nurse Practitioners (esp. pediatric) • Pharmacists • Physician Assistants • PhysiciansAOA, AAFP, ACP, AAP

26. Certification/Recertification • Family Physicians: Maintenance of Certification:Performance in Practice • Internists: Evaluation of Performance in Practice; Recertification Resources - PIM Practice Improvement Module • Pediatricians: Maintenance of Certification: - EQIPPenhancing quality improvement in pediatric practice(launch in 2010)

27. Distance learning Teleconferences Podcasts Webinars Virtual consultants Local Assistance & Facilitation New Models On-line collaborative networks Cooperative Extension Services Advanced Models of Training Rays of Hope

28. American Academy of Pediatrics Transformation Initiatives : Building Blocks: • Care Partnership Support • Clinical Care Information • Care Delivery Management • Resources & Linkages • Practice Performance Measurement • Payment & Finance Toolkit (June 2009) • Promotes quality improvement & standards • Self-instructed “Building Blocks” • Podcasts, teleconferences, CME webinars • List-serve • Limited technical assistance • Branching out from focus on just children with special needs to all children National Center for Medical Home Initiatives

29. Broader Pediatric Information, tools, and resources to improve care of Children and Youth with Special Health Care Needs Toolkit and consultations • 0n-line & on-site • Pediatric & Adult care

30. American 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 & dynamically linked resources • Self-paced program guides through the ACP Practice Biopsy, then directs to resources & case studies for achieving goals • For individuals, groups, teams, practices, demonstration projects, IPAs, multi-organizational efforts, & residency training programs • Incremental quality improvement changes to significant transformation • Available for CME credit (internists)

31. The TransforMED Approach Practice-based Care Team Great Outcomes Health Information Technology Practice Management Care Management Access to Care and Information Quality and Safety Primary Care Quality Measures Practice Organization Patient Experience Health IT Practice Services Continuity of Care Services

32. Medical Home Transformation • Web-based toolkit • evaluates current medical home status • develops a strategy for transformation • Links to tools and resources for practice re-design • Coaching, facilitation, tailored training –on-site • Practice retreats • Delta Exchange: online, collaborative network

33. Why Facilitation is Important Nutting: Annals Family Med 2009

34. Cooperative Extension Program • Similar to agricultural extension services • Providing the expertise to organize PCHM • Based on New Mexico & other state models

35. Solutions • Professional schools to select, support, and train PCMH-ready clinicians • Team work/interdisciplinary training • Life-long learning of key skills to all clinical groups • Broad education/consultancy models that are on-line and on-the-ground – available everywhere • Linked payment reform

36. “Ideal Primary Care” goes Medical Home 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

37. The Hope: a medical home in every community and a team for every home Thanks! Thanks!