Transform residency training in chronic illness care -- now

Residents' Perspectives on Rewards and Challenges of Caring for Ambulatory Care Patients Living With Chronic Illness: Findings From Three Academic Health Centers

PURPOSE

To elicit residents' perspectives on rewards and challenges of caring for ambulatory patients with chronic illness and ways to improve their education in caring for these patients.

METHOD

The authors conducted a qualitative study with internal medicine residents during ambulatory medicine block rotations at three academic health centers from October 2011 through February 2012. Focus group questions covered rewards and challenges of caring for patients with chronic illness and strengths and weaknesses of residency education therein, and the Chronic Care Model provided a framework for interpretation. Qualitative analysis was used to identify themes.

RESULTS

Five focus groups were conducted with 28 residents. Discussions yielded 224 comments, which were categorized into 5 domains and 36 themes. Twelve themes related to perceptions of challenges in providing care, and 3 themes related to perceptions of rewards in providing care. Eight themes focused on strategies to improve the patient experience. Strengths of the residency program were identified in 7 themes. Six themes related to ways for improving learning about caring for patients with chronic disease in the ambulatory setting.

CONCLUSIONS

Residents perceived rewards, challenges, and barriers in caring for patients with chronic illness in the ambulatory setting, from providers' and patients' perspectives. They have developed strategies to provide effective patient care. Residents identified best practices in their residency for resident education and patient care and also made suggestions for improvement. Findings have significant implications for residency education and practice redesign in the 21st century for care of patients with chronic illness.

Training health care professionals for 21st-century practice: a systematic review of educational interventions on chronic care

PURPOSE

To systematically review the evidence for high-quality and effective educational strategies to train health care professionals across the education continuum on chronic disease care.

METHOD

A search of English-language publications and conference proceedings was performed in November 2013 and updated in April 2014. Studies that evaluated a newly developed curriculum targeting chronic disease care with learner outcomes were included. Two primary reviewers and one adjudicating reviewer evaluated the studies and assessed their quality using the validated Medical Education Research Study Quality Instrument (MERSQI). Studies were also mapped onto elements of Wagner's chronic care model (CCM) to evaluate their use of established evidence-based models for chronic care delivery. Miller's classification of clinical competence was used to assess the quality of learner achievements for each educational intervention.

RESULTS

A total of 672 articles were found for this review. Twenty-two met criteria for data extraction. The majority of studies were of moderate quality according to MERSQI scoring. Only three studies reported both learner and patient outcomes. The highest-quality studies incorporated more elements of Wagner's CCM and showed high-level learner competence according to Miller's classification. Successful interventions redesigned health care delivery systems to include team-based care, emphasized training of health care professionals on patient self-management, and included learner-based quality improvement initiatives.

CONCLUSIONS

The growing number of children and adults with chronic disease necessitates improved educational interventions for health care professionals that involve evidence-based models for restructuring chronic care delivery, aim for high-level learner behavioral outcomes, and evolve through quality improvement initiatives.

Determinants of Patient Satisfaction in Internal Medicine Resident Continuity Clinics: Findings of the Educational Innovations Project Ambulatory Collaborative

BACKGROUND

Many internal medicine programs have reorganized their resident continuity clinics to improve the ambulatory care experience for residents. The effect of this redesign on patient satisfaction is largely unknown.

METHODS

Our multi-institutional, cross-sectional study included 569 internal medicine residents from 11 programs participating in the Educational Innovations Project Ambulatory Collaborative. An 11-item patient satisfaction survey from the Consumer Assessment of Healthcare Providers and Systems was used to assess patient satisfaction, comparing patient satisfaction in traditional models of weekly continuity clinic with 2 new clinic models. We then examined the relationship between patient satisfaction and other practice variables.

RESULTS

Patient satisfaction responses related to resident listening and communication skills, knowledge of medical history, perception of adequate visit time, overall rating, and willingness to refer to family and friends were significantly better in the traditional and block continuity models than the combination model. Higher ambulatory workload was associated with reduced patient perception of respect shown by the physician. The percentage of diabetic patients with glycated hemoglobin < 8% was positively correlated with number of visits, knowledge of medical history, perception of respect, and higher scores for recommending the physician to others. The percentage of diabetic patients with low density lipoprotein < 100 mg/dL was positively correlated with the physician showing respect.

CONCLUSIONS

Patient satisfaction was similar in programs using block design and traditional models for continuity clinic, and both outperformed the combination model programs. There was a delicate balance between workload and patient perception of the physician showing respect. Care outcome measures for diabetic patients were associated with aspects of patient satisfaction.

Supporting primary care practices in building capacity to use health information data

Introduction:

Our objective was to describe essential support resources and strategies in order to advance the pace and scope of the use of health information technology (HIT) data.

Background and Context:

Primary data were collected between January 2011 and October 2012. The primary study population comprised 51 primary care practices enrolled in the Colorado Beacon Consortium in western Colorado.

Methods:

We used qualitative methods embedded in a mixed-method evaluation: monthly narrative reports from practices; interviews with providers and staff; and focused, group discussions with quality improvement (QI) advisors and staff from the Health Information Technology Regional Extension Center.

Findings:

Practices valued effective support strategies to assist with using HIT, including the following: translating rules and regulations into individual practice settings; facilitating peer-to-peer connections; providing processes and tools for practice improvement; maintaining accountability and momentum; and providing local electronic health record (EHR) technical expertise. Benefits of support included improved quality measures, operational improvements, increased provider and staff engagement, and deeper understanding of EHR data.

Discussion:

The findings affirm the utility of practice facilitation for HIT-focused aims with personalized attention and cross-fertilization among practices for improvements. Facilitation to sustain ongoing improvements and prepare for future HIT-intensive improvement activities was highly valued. In addition to the general practice facilitator, an EHR technical expert was critical to improving practice capacity to use electronic clinical data. Collaborative learning expands the pool of mentors and teachers, who can further translate their own lessons into practical advice for their peers, yielding the emergence of a stronger sense of community among the practices.

Conclusions:

Using HIT more effectively in primary care will require sustained, focused efforts by practices as regulations, incentives and HIT evolve. Ongoing support for community-based practice facilitators; collaborative learning; and local, personalized EHR advisors will help practices care for patients while more effectively deploying HIT to improve care.

Transforming primary care training--patient-centered medical home entrustable professional activities for internal medicine residents

INTRODUCTION

The U.S. faces a critical gap between residency training and clinical practice that affects the recruitment and preparation of internal medicine residents for primary care careers. The patient-centered medical home (PCMH) represents a new clinical microsystem that is being widely promoted and implemented to improve access, quality, and sustainability in primary care practice.

AIM

We address two key questions regarding the training of internal medicine residents for practice in PCMHs. First, what are the educational implications of practice transformations to primary care home models? Second, what must we do differently to prepare internal medicine residents for their futures in PCMHs?

PROGRAM DESCRIPTION

The 2011 Society of General Internal Medicine (SGIM) PCMH Education Summit established seven work groups to address the following topics: resident workplace competencies, teamwork, continuity of care, assessment, faculty development, 'medical home builder' tools, and policy. The output from the competency work group was foundational for the work of other groups. The work group considered several educational frameworks, including developmental milestones, competencies, and entrustable professional activities (EPAs).

RESULTS

The competency work group defined 25 internal medicine resident PCMH EPAs. The 2011 National Committee for Quality Assurance (NCQA) PCMH standards served as an organizing framework for EPAs.

DISCUSSION

The list of PCMH EPAs has the potential to begin to transform the education of internal medicine residents for practice and leadership in the PCMH. It will guide curriculum development, learner assessment, and clinical practice redesign for academic health centers.

Improving care in a resident practice for patients with diabetes

BACKGROUND

Curricular redesign and introduction of the Chronic Care Model in our residency clinic during 2005-2007 achieved limited success in glycemic (glycated hemoglobin level [A(1c)]), lipid (low-density lipoprotein fraction [LDL]), and blood pressure (BP) control for patients with diabetes.

INTERVENTION

Beginning in January 2008, ancillary staff performed previsit, protocol-driven reviews of medical records of patients with diabetes to identify those not at A(1c), LDL, and BP goals; inserted electronic prompts into the records regarding deficiencies; and obtained samples for A(1c) or lipid panel when needed. Faculty feedback regarding resident-specific panel reviews was added in May 2008, and point-of-care A(1c) testing was implemented in February 2009.

METHODS

We conducted a 2-year retrospective study of all patients at our facility with diabetes mellitus, who had at least 1 visit during January to June 2008 (baseline) and 1 visit during July to December 2009 (follow-up). Measures included the most current A(1c), LDL, and BP results. Paired outcome results were compared using the McNemar χ(2) test.

RESULTS

A total of 522 patients with diabetes mellitus were seen during the baseline and follow-up periods, and 456 patients (87.4%) had paired A(1c) results, with A(1c) < 7.0% for 138 of 456 patients (30.3%) at baseline and 166 of 456 patients (36.4%) at follow-up (P  =  .011). For LDL, 460 patients (88.1%) had paired results, with LDL < 100 mg/dL for 225 of 460 patients (48.9%) at baseline and 262 of 460 patients (57.0%) at follow-up (P  =  .004). A total of 513 patients (98.3%) had paired BP results in which the BP < 130/80 mm Hg for 124 of 513 patients (24.2%) at baseline and for 188 of 513 patients (36.6%) at follow-up (P < .001). There were 421 patients (80.7%) with paired results for all 3 measures, with 17 of 421 patients (4.0%) at goal at baseline and 41 of 421 patients (9.7%) at goal at follow-up (P  =  .001).

CONCLUSION

The interventions resulted in statistically significant improvements in the proportion of patients with diabetes who attained goal for A(1c), LDL, and BP levels. Our redesign elements may be useful in enhancing resident education and in improving patient care.

Integrating the Chronic Care Model into a Novel Medical Student Course

OBJECTIVE: To determine if integration of the Chronic Care Model into undergraduate medical education is associated with anticipated use of the Model and if student perceptions match actual integration of the Model into their community projects. DESIGN: This was a cross-sectional study using qualitative and quantitative data. SETTING: A novel fourth-year medical student community health improvement course. METHOD: The study included 45 students who had enrolled in the course before introduction of the Model and 32 formally introduced to the Model through a lecture. Perceptions were measured through a survey and a focus group with data analyzed amongst and between cohorts. Projects were reviewed for actual integration of Model elements and these data were compared with reported student perceptions. RESULTS: Although they were in general utilizing most elements of the Model, student perceptions of their use of Model elements significantly differed from actual use of particular elements (p<0.001). For instance, whereas the majority believed that their projects focused on the element of Community Resources, most projects actually focused on Self-Management Support. Students formally introduced to the Model trended toward the belief that it would enhance their ability to care for patients more than students without formal exposure to it (p=0.0516). CONCLUSIONS: Although medical students may not recognize it, they may already focus their actions and thinking regarding health improvement toward patient self-management of their chronic disease. Although students require education and training if the Model is to be widely used, they may be naturally attracted to it.

Chronic care education in medical school: a focus on functional health and quality of life

The healthcare system is faced with a rapidly increasing number of individuals with chronic conditions and disabilities. The need for a chronic care model of health care with interdisciplinary treatment involving the patient and family with a focus on functional health is recognized but not fully established in the medical community. The education of medical students in a chronic care model is essential so that physicians in all specialties may provide effective and efficient care to their patients. Physiatrists and physicians trained in the specialty of Physical Medicine and Rehabilitation are uniquely situated to be leaders in the education of medical students in the appropriate care for individuals with chronic conditions and disabilities. Academic physiatrists must be involved in the education of medical students. This involvement will result in a higher level of patient care for all patients with chronic conditions and disabilities. In 2007, the Association of Academic Physiatrists formed a task force to evaluate educational models and make recommendations regarding the education of medical students in the management of individuals with chronic conditions and disabilities. The task force also evaluated opportunities for physiatrists to participate in the education of medical students. This article summarizes the work of the task force.

Chronic illness needs educated doctors: An innovative primary care training program for chronic illness education

BACKGROUND

Medical educators need proven curriculum innovations that prepare trainees for the expanding number of patients with chronic illnesses.

PURPOSE

We describe and evaluate the effectiveness of a chronic illness training program, Chronic Illness Needs Educated Doctors (CINED).

METHOD

Forty-seven trainees completed four instructional components: (1) measurements of the health-related quality of life of patients with chronic illnesses; (2) didactic sessions in which they described chronically ill patients and their care; (3) written narratives describing the trainees' reactions for these patients; and (4) portfolios offering evidence of chronic illness learning. We measured the accuracy of the trainees' clinical skills at the end of CINED with an objective standardized clinical exercise (OSCE).

RESULTS

Forty-seven trainees scored the perceptions of mental and physical health of 414 chronic illnesses patients. In 47 didactic sessions and 93 written narratives, the trainees explained the relationship between the scores and their clinical observations. Accurate differential diagnoses of and communications with chronically ill patients were observed in an OSCE by standardized patients. The trainers rated 13 of the trainees' chronic illness portfolios as excellent and the remainder satisfactory.

CONCLUSION

Initial evaluations suggest that the CINED is an effective curriculum for promoting chronic illness learning among trainees.

Assessing Chronic Illness Care Education (ACIC-E): a tool for tracking educational re-design for improving chronic care education

BACKGROUND

Recent Breakthrough Series Collaboratives have focused on improving chronic illness care, but few have included academic practices, and none have specifically targeted residency education in parallel with improving clinical care. Tools are available for assessing progress with clinical improvements, but no similar instruments have been developed for monitoring educational improvements for chronic care education.

AIM

To design a survey to assist teaching practices with identifying curricular gaps in chronic care education and monitor efforts to address those gaps.

METHODS

During a national academic chronic care collaborative, we used an iterative method to develop and pilot test a survey instrument modeled after the Assessing Chronic Illness Care (ACIC). We implemented this instrument, the ACIC-Education, in a second collaborative and assessed the relationship of survey results with reported educational measures.

PARTICIPANTS

A combined 57 self-selected teams from 37 teaching hospitals enrolled in one of two collaboratives.

ANALYSIS

We used descriptive statistics to report mean ACIC-E scores and educational measurement results, and Pearson's test for correlation between the final ACIC-E score and reported educational measures.

RESULTS

A total of 29 teams from the national collaborative and 15 teams from the second collaborative in California completed the final ACIC-E. The instrument measured progress on all sub-scales of the Chronic Care Model. Fourteen California teams (70%) reported using two to six education measures (mean 4.3). The relationship between the final survey results and the number of educational measures reported was weak (R(2) = 0.06, p = 0.376), but improved when a single outlier was removed (R(2) = 0.37, p = 0.022).

CONCLUSIONS

The ACIC-E instrument proved feasible to complete. Participating teams, on average, recorded modest improvement in all areas measured by the instrument over the duration of the collaboratives. The relationship between the final ACIC-E score and the number of educational measures was weak. Further research on its utility and validity is required.

A multi-institutional quality improvement initiative to transform education for chronic illness care in resident continuity practices

BACKGROUND

There is a gap between the need for patient-centered, evidence-based primary care for the large burden of chronic illness in the US, and the training of resident physicians to provide that care.

OBJECTIVE

To improve training for residents who provide chronic illness care in teaching practice settings.

DESIGN

US teaching hospitals were invited to participate in one of two 18-month Breakthrough Series Collaboratives-either a national Collaborative, or a subsequent California Collaborative-to implement the Chronic Care Model (CCM) and related curriculum changes in resident practices. Most practices focused on patients with diabetes mellitus. Educational redesign strategies with related performance measures were developed for curricular innovations anchored in the CCM. In addition, three clinical measures-HbA1c <7%, LDL <100 mg/dL, and blood pressure <or=130/80-and three process measures-retinal and foot examinations, and patient self-management goals-were tracked.

PARTICIPANTS

Fifty-seven teams from 37 self-selected teaching hospitals committed to implement the CCM in resident continuity practices; 41 teams focusing on diabetes improvement participated over the entire duration of one of the Collaboratives.

INTERVENTIONS

Teaching-practice teams-faculty, residents and staff-participated in Collaboratives by attending monthly calls and regular 2-day face-to-face meetings with the other teams. The national Collaborative faculty led calls and meetings. Each team used rapid cycle quality improvement (PDSA cycles) to implement the CCM and curricular changes. Teams reported education and clinical performance measures monthly.

RESULTS

Practices underwent extensive redesign to establish CCM elements. Education measures tracked substantial development of CCM-related learning. The clinical and process measures improved, however inconsistently, during the Collaboratives.

CONCLUSIONS

These initiatives suggest that systematic practice redesign for implementing the CCM along with linked educational approaches are achievable in resident continuity practices. Improvement of clinical outcomes in such practices is daunting but achievable.

Transforming medical professionalism to fit changing health needs

BACKGROUND

The professional organization of medical work no longer reflects the changing health needs caused by the growing number of complex and chronically ill patients. Key stakeholders enforce coordination and remove power from the medical professions in order allow for these changes. However, it may also be necessary to initiate basic changes to way in which the medical professionals work in order to adapt to the changing health needs.

DISCUSSION

Medical leaders, supported by health policy makers, can consciously activate the self-regulatory capacity of medical professionalism in order to transform the medical profession and the related professional processes of care so that it can adapt to the changing health needs. In doing so, they would open up additional routes to the improvement of the health services system and to health improvement. This involves three consecutive steps: (1) defining and categorizing the health needs of the population; (2) reorganizing the specialty domains around the needs of population groups; (3) reorganizing the specialty domains by eliminating work that could be done by less educated personnel or by the patients themselves. We suggest seven strategies that are required in order to achieve this transformation.

SUMMARY

Changing medical professionalism to fit the changing health needs will not be easy. It will need strong leadership. But, if the medical world does not embark on this endeavour, good doctoring will become merely a bureaucratic and/or marketing exercise that obscures the ultimate goal of medicine which is to optimize the health of both individuals and the entire population.

Comparison of medicine resident diabetes care between Veterans Affairs and academic health care systems

BACKGROUND

Although others have reported national disparities in the quality of diabetes care between the Veterans Affairs (VA) and private health care delivery systems, it is not known whether these differences persist among internal medicine resident providers in academic settings.

OBJECTIVE

We compared the quality of diabetes primary care delivered by resident physicians in either a private academic health care system (AHS) or its affiliated VA health care system.

DESIGN

Cross-sectional observational study

PARTICIPANTS

We included patients who: had a diagnosis of diabetes, had >2 primary care visits with the same resident provider during 2005, and were not separately managed by an attending physician or endocrinologist. A total of 640 patients met our criteria and were included in the analysis.

MEASUREMENTS AND RESULTS

Compared to the VA, patients in the AHS were more likely to be younger, female, have fewer medications, and be treated with insulin, but had less comorbidity. Patients in the VA were more likely to be referred for an annual eye exam (94% vs. 78%), receive lipid screening (88% vs. 74%), receive proteinuria screening (63% vs. 34%), and receive a complete foot exam (85% vs. 32%) in analyses adjusted for patient demographics and comorbidities (p-value <0.001 for all comparisons). In adjusted analyses, there were no significant differences in HbA1(c), blood pressure, or LDL cholesterol control.

CONCLUSIONS

In spite of similar resident providers and practice models, there were substantial differences in the diabetes quality of care delivered in the VA and AHS. Understanding how these factors influence subsequent practice patterns is an important area for study.

The ambulatory long-block: an accreditation council for graduate medical education (ACGME) educational innovations project (EIP)

INTRODUCTION

Historical bias toward service-oriented inpatient graduate medical education experiences has hindered both resident education and care of patients in the ambulatory setting.

AIM

Describe and evaluate a residency redesign intended to improve the ambulatory experience for residents and patients.

SETTING

Categorical Internal Medicine resident ambulatory practice at the University of Cincinnati Academic Health Center.

PROGRAM DESCRIPTION

We created a year-long continuous ambulatory group-practice experience separated from traditional inpatient responsibilities called the long block as an Accreditation Council for Graduate Medical Education Educational Innovations Project. The practice adopted the Chronic Care Model and residents received extensive instruction in quality improvement and interprofessional teams.

PROGRAM EVALUATION

The long block was associated with significant increases in resident and patient satisfaction as well as improvement in multiple quality process and outcome measures. Continuity and no-show rates also improved.

DISCUSSION

An ambulatory long block can be associated with improvements in resident and patient satisfaction, quality measures, and no-show rates. Future research should be done to determine effects of the long block on education and patient care in the long term, and elucidate which aspects of the long block most contribute to improvement.