Assessing the impact of innovative training of family physicians for the patient-centered medical home

United States Physician Preferences Regarding Healthcare Financing Options: A Multistate Survey

Background: Not much is currently known about United States (US) physicians’ opinions about healthcare financing, specifically subsequent to the creation and implementation of the Affordable Care Act (ACA). Objectives: A four state survey of practicing US based physicians’ opinions about healthcare financing following ACA passage and implementation. Methods: Physician leaders practicing in the state of New York, Texas, Colorado and Mississippi were surveyed. Two factor analyses (FA) were conducted to understand the underlying constructs. Results: We determined the final response rate to be 26.7% after adjusting it for a variety of factors. Most physicians favored either a single payer system (43.8%) or individualized insurance coverage using health savings accounts (33.2%). For the single-payer system, FA revealed two underlying constructs: System orientation (how the physicians perceived the impact on the healthcare system or patients) and individual orientation (how the physicians perceived the impact on individual physicians). Subsequently, we found that physicians who were perceived neutral in their attitudes towards physician-patient relationship and patient conflict were also neutral in reference to system orientation and individual orientation. Physicians who were perceived as stronger on the physician-patient relationship were more supportive of a single-payer system. Conclusion: This study brings attention to the paradox of social responsibility (to provide quality healthcare) and professional autonomy (the potential impact of a healthcare financing structure to negatively affect income and workload). Efforts to further reform healthcare financing and delivery in the US may encounter resistance from healthcare providers (physicians, mid-level prescribers, pharmacists, or nurses) if the proposed reform interferes with their professional autonomy.

Patient-Centered Medical Home Status and Preparedness to Assess Resident Milestones: A CERA Study

Purpose

The patient-centered medical home (PCMH) model has been proposed as the ideal model for delivering primary care and is focused on improving patient safety and quality, reducing costs, and enhancing patient satisfaction. The mandated Accreditation Council for Graduate Medical Education educational milestones for evaluation of resident competency represent the skills graduates will utilize after graduation. Many of these skills are reflected in the PCMH model. We sought to determine if residency programs whose main family medicine (FM) practice sites have achieved PCMH recognition are therefore more prepared to evaluate milestones.

Method

A national Council of Academic Family Medicine Educational Research Alliance (CERA) survey of family medicine program directors (PDs) was conducted during June and July 2015 to determine if PCMH recognition influences PDs' ability to evaluate training methods and their level of preparedness to evaluate milestones.

Results

The response rate for the survey was 53.3% (252/473). Nearly two-thirds of the PDs (62.7%) reported that their main FM practice site had earned PCMH recognition. There was no statistical difference between non-PCMH-recognized vs PCMH-recognized programs in how PDs perceived that their program was prepared to assess residents' milestone levels overall (P=0.414). Residents of PCMH-recognized programs were more likely to receive training for team-based care (P=0.009), system improvement plans (P<0.001), root-cause analysis (P=0.002), and health behavior change (P=0.003).

Conclusions

PCMH recognition itself did not improve preparedness of FM residency programs to assess milestones. Residents from programs whose main FM practice site is PCMH-recognized are more likely to be trained in the key concepts and tasks associated with the PCMH model, tools that they are expected to utilize extensively after graduation.

Patient centred medical home (PCMH) and patient-practitioner orientation: Is there a relationship?

BACKGROUND

The patient-centred medical home (PCMH) and utilisation of a patient-centred care approach have been promoted as opportunities to improve healthcare quality while controlling expenditures.

OBJECTIVES

To determine the penetration of PCMH within physician practices, and to evaluate physician attitudes towards patient-practitioner orientation. The ultimate objective was to explore relationships between the patient-practitioner orientation of respondents and the presence of PCMH elements within their practice.

METHODS

A survey instrument was developed following a comprehensive literature review. Lead physicians practicing in four states were surveyed.

RESULTS

The adjusted response rate was 26.7%. Responses indicated increased utilisation of PCMH elements (electronic medical records, e-mail and telephone consultations, and physician performance monitoring and feedback) compared with previous research. Within a logistic regression model, medical school graduation year (1990 or later >prior to 1990), practice size (group >solo), and percentage of time allocated to patient care (less >more) were significant predictors of working in a high PCMH alignment setting. Physician and practice characteristics did not predict the level of patient-practitioner orientation, though rural physicians were more patient-centred than urban physicians. A non-linear correlation between patient-practitioner orientation and the likelihood of practicing in a low or high PCMH-aligned practice was observed.

CONCLUSIONS

There is a non-linear correlation between patient-practitioner orientation and the likelihood of a physician practicing in a low or high PCMH-aligned practice. The ability of a physician to work in a PCMH setting or practicing patient-centred care can go beyond a physician's aspirations to work and practice in that manner.

Effects of adding a new PCMH block rotation and resident team to existing longitudinal training within a certified PCMH: primary care residents' attitudes, knowledge, and experience

BACKGROUND

Although the patient-centered medical home (PCMH) model is considered important for the future of primary care in the USA, it remains unclear how best to prepare trainees for PCMH practice and leadership. Following a baseline study, the authors added a new required PCMH block rotation and resident team to an existing longitudinal PCMH immersion and didactic curriculum within a Level 3-certified PCMH, aiming for "enhanced situated learning". All 39 residents enrolled in a USA family medicine residency program during the first year of curricular implementation completed this new 4-week rotation. This study examines the effects of this rotation after 1 year.

METHODS

A total of 39 intervention and 13 comparison residents were eligible participants. This multimethod study included: 1) individual interviews of postgraduate year (PGY) 3 intervention vs PGY3 comparison residents, assessing residents' PCMH attitudes, knowledge, and clinical experience, and 2) routine rotation evaluations. Interviews were audiorecorded, transcribed, and analyzed using immersion/crystallization. Rotation evaluations were analyzed using descriptive statistics and qualitative analysis of free text responses.

RESULTS

Authors analyzed 23 interviews (88%) and 26 rotation evaluations (67%). Intervention PGY3s' interviews revealed more nuanced understanding of PCMH concepts and more experience with system-level PCMH tasks than those of comparison PGY3s. More intervention PGY3s rated themselves "extremely prepared" to implement PCMH than comparison PGY3s; however, most self-rated "somewhat prepared". Their reflections demonstrated deeper understanding of PCMH implementation and challenges than comparison PGY3s but inadequate experience to directly see the results of successful solutions. Rotation evaluations from PGY1, PGY2, and PGY3s revealed strengths and several areas for improvement.

CONCLUSION

Adding one 4-week block rotation to existing longitudinal training appears to improve residents' PCMH knowledge, skills, and experience from "basic" to "intermediate". However, this training level appears inadequate for PCMH leadership or for teaching junior learners. Further study is needed to determine the optimum training for different settings.

Patient-Centered Medical Home Knowledge and Attitudes of Residents and Faculty: Certification Is Just the First Step

BACKGROUND

The patient-centered medical home (PCMH) is an accepted framework for delivering high-quality primary care, prompting many residencies to transform their practices into PCMHs. Few studies have assessed the impact of these changes on residents' and faculty members' PCMH attitudes, knowledge, and skills. The family medicine program at Brown University achieved Level 3 PCMH accreditation in 2010, with training relying primarily on situated learning through immersion in PCMH practice, supplemented by didactics and a few focused clinical activities.

OBJECTIVE

To assess PCMH knowledge and attitudes after Level 3 PCMH accreditation and to identify additional educational needs.

METHODS

We used a qualitative approach, with semistructured, individual interviews with 12 of the program's 13 postgraduate year 3 residents and 17 of 19 core faculty. Questions assessed PCMH knowledge, attitudes, and preparedness for practicing, teaching, and leading within a PCMH. Interviews were analyzed using the immersion/crystallization method.

RESULTS

Residents and faculty generally had positive attitudes toward PCMH. However, many expressed concerns that they lacked specific PCMH knowledge, and felt inadequately prepared to implement PCMH principles into their future practice or teaching. Some exceptions were faculty and resident leaders who were actively involved in the PCMH transformation. Barriers included lack of time and central roles in PCMH activities.

CONCLUSIONS

Practicing in a certified PCMH training program, with passive PCMH roles and supplemental didactics, appears inadequate in preparing residents and faculty for practice or teaching in a PCMH. Purposeful curricular design and evaluation, with faculty development, may be needed to prepare the future leaders of primary care.

Five Key Leadership Actions Needed to Redesign Family Medicine Residencies

BACKGROUND

New skills are needed to properly prepare the next generation of physicians and health professionals to practice in medical homes. Transforming residency training to address these new skills requires strong leadership.

OBJECTIVE

We sought to increase the understanding of leadership skills useful in residency programs that plan to undertake meaningful change.

METHODS

The Preparing the Personal Physician for Practice (P4) project (2007-2014) was a comparative case study of 14 family medicine residencies that engaged in innovative training redesign, including altering the scope, content, sequence, length, and location of training to align resident education with requirements of the patient-centered medical home. In 2012, each P4 residency team submitted a final summary report of innovations implemented, overall insights, and dissemination activities during the study. Six investigators conducted independent narrative analyses of these reports. A consensus meeting held in September 2012 was used to identify key leadership actions associated with successful educational redesign.

RESULTS

Five leadership actions were associated with successful implementation of innovations and residency transformation: (1) manage change; (2) develop financial acumen; (3) adapt best evidence educational strategies to the local environment; (4) create and sustain a vision that engages stakeholders; and (5) demonstrate courage and resilience.

CONCLUSIONS

Residency programs are expected to change to better prepare their graduates for a changing delivery system. Insights about effective leadership skills can provide guidance for faculty to develop the skills needed to face practical realities while guiding transformation.

Financing Residency Training Redesign

BACKGROUND

Redesign in the health care delivery system creates a need to reorganize resident education. How residency programs fund these redesign efforts is not known.

METHODS

Family medicine residency program directors participating in the Preparing Personal Physicians for Practice (P(4)) project were surveyed between 2006 and 2011 on revenues and expenses associated with training redesign.

RESULTS

A total of 6 university-based programs in the study collectively received $5,240,516 over the entire study period, compared with $4,718,943 received by 8 community-based programs. Most of the funding for both settings came from grants, which accounted for 57.8% and 86.9% of funding for each setting, respectively. Department revenue represented 3.4% of university-based support and 13.1% of community-based support. The total average revenue (all years combined) per program for university-based programs was just under $875,000, and the average was nearly $590,000 for community programs. The vast majority of funds were dedicated to salary support (64.8% in university settings versus 79.3% in community-based settings). Based on the estimated ratio of new funding relative to the annual costs of training using national data for a 3-year program with 7 residents per year, training redesign added 3% to budgets for university-based programs and about 2% to budgets for community-based programs.

CONCLUSIONS

Residencies undergoing training redesign used a variety of approaches to fund these changes. The costs of innovations marginally increased the estimated costs of training. Federal and local funding sources were most common, and costs were primarily salary related. More research is needed on the costs of transforming residency training.