New Report Highlights Medical School and Teaching Hospital Innovations In Primary Care Training
AAMC Reporter: March 2011
—By Sarah Mann
After the waters of Hurricane Katrina receded, New Orleans began the arduous task of rebuilding its tattered health care system. A new patient-centered medical home (PCMH) at Tulane Medical Center helped many patients put the pieces back together.
The medical home is a delivery model that emphasizes partnerships between patients and physicians, team-based care, and collaboration with specialists. Because many health professionals and policymakers believe models like this can improve quality and reduce costs, interest in providing training in medical home settings has been on the upswing.
In early 2010, the AAMC surveyed its member institutions to gauge whether medical schools and teaching hospitals have incorporated the PCMH and similar programs into resident training programs. The survey’s results and case studies of seven PCMH training sites across the country were published in a new AAMC report, Moving the Medical Home Forward: Innovations in Primary Care Training and Delivery. The report is available for free download at www.aamc.org/publications.
“What was once just a concept has now become part of the mainstream in many medical education programs. Patients are clearly benefiting as are learners all along the medical education continuum,” said AAMC Chief Academic Officer John Prescott, M.D.
According to the report, PCMHs are gaining momentum. By March 2010 there were about 450 PCMH practices in 24 states and Washington, D.C. In June 2010, 20 states had implemented or were sponsoring PCMH projects with their Medicaid programs.
National leaders also are encouraging exploration of PCMHs. The Affordable Care Act established the Center for Medicare and Medicaid Innovation (CMI) to administer and test patient-centered delivery models that encourage team-based care, including PCMHs. CMI will receive $10 billion from 2011 through 2019.
In Katrina’s aftermath, University Hospital and the still-shuttered Charity Hospital were among the casualties. In the days following the storm, Karen DeSalvo, M.D., set up a makeshift urgent care clinic to provide basic care to desperate city residents. Resident physicians, themselves with nowhere else to go, came to the clinic to help. Today the clinic has grown into the Tulane University Community Health Center at Covenant House (TUCHC), a PCMH that serves more than 10,000 New Orleanians and trains internal medicine residents.
TUCHC, which is included in the AAMC report, is a one-stop shop for uninsured, low-income people, many of whom would go without health care if the clinic did not exist. DeSalvo, a professor at Tulane University School of Medicine, works with Tulane researchers in social work, economics, and other related fields to continually develop new ways to make care at TUCHC better and more affordable.
“The university is a really great incubator for innovation,” DeSalvo said. “We’re developing a pipeline of trainees who can think outside the box.”
When discussing quality improvement with staff, DeSalvo uses real-world examples from TUCHC. If staff are learning how to improve care for diabetic patients, DeSalvo and other staff also go into local churches and community centers to extend that education to community members. Other topics have included HIV and hypertension.
One of the key features of PCMH is coordination between primary care providers and specialists. At Mattel Children’s Hospital at the University of California Los Angeles (UCLA) Health System, the Pediatric Medical Home Program does just that for children with complex, chronic conditions. Residents provide primary care to children throughout their residency and ensure they do not get lost in the system. At their first visit, all patients are assigned to a family liaison, who can help families schedule appointments, organize medical information, handle insurance issues, and, in many cases, act as a translator during appointments. Additionally, there is a medical director residents can consult with if they become overwhelmed by a complex case.
“We wanted to provide good primary care for these patients in a medical home but at the same time involve pediatric residents so that they can gain greater familiarity with this complex patient population and begin to play the roles we are hoping our primary care general pediatricians will play in the future as a medical home to these patients,” said Thomas Klitzner, M.D., Ph.D., chief of pediatric cardiology at UCLA’s David Geffen School of Medicine, who developed the program in 2003.
With these patients, Klitzner said, the teaching tool is less about the illnesses and more about nonmedical issues physicians face, such as co-management with subspecialists, cultural sensitivity, and socioeconomic challenges. Klitzner believes many pediatricians in the future will serve this type of role, acting as a consultant to patients who regularly see specialists.
Another hallmark of PCMH is team-based care. At the University of Cincinnati (UC) College of Medicine, Eric Warm, M.D., an assistant professor of internal medicine, noticed that patient outcomes in UC’s traditional internal medicine residency clinic were fairly poor.
“As far as chronic care delivery, patient satisfaction, readmission rates, it was not ideal,” Warm said. “When we realized we were giving poor care, it is really hard to say we were giving good education.”
The solution was a yearlong “ambulatory long block” at UC’s Hoxworth Ambulatory Center, the primary internal medicine residency clinic, in which residents see patients about three days per week and follow the same patients throughout the year to provide continuity. Because residents transition out of the program annually, they are divided into “mini-teams” with a single nurse, who continues to see the same patients when a new resident takes over each year.
Shawn Brickner, M.D., a second-year UC resident, said the experience helps residents understand the daily experience of primary care physicians.
“I think it gives me a lot of firsthand experience on what it will be like to be a primary care doctor,” Brickner said. “You get to form relationships with your patients. You have the time for them to come and see you every two weeks as opposed to a more traditional sense where you only have clinic a couple of times a month.”
According to DeSalvo, PCMH training sites prove their success when residents form relationships with their patients and want to continue that experience in their practice. At TUCHC, DeSalvo has recruited seven physicians and several nurses as full-time staff after they completed their training.
“They have a really great experience that gives them a taste of what really good care can be like, and they want to stay and work in it,” she said.