Beat D. Steiner

Community Care of North Carolina: Improving Care Through Community Health Networks

The United States leads the world in health care costs but ranks far below many developed countries in health outcomes. Finding ways to narrow this gap remains elusive. This article describes the response of one state to establish community health networks to achieve quality, utilization, and cost objectives for the care of its Medicaid recipients. The program, known as Community Care of North Carolina, is an innovative effort organized and operated by practicing community physicians. In partnership with hospitals, health departments, and departments of social services, these community networks have improved quality and reduced cost since their inception a decade ago. The program is now saving the State of North Carolina at least

International Crises and Global Health Electives: Lessons for Faculty and Institutions

160 million annually. A description of this experience and the lessons learned from it can inform others seeking to implement effective systems of care for patients with chronic illness.

Recognizing the value of community involvement by AHC faculty: A case study

Student participation in global health electives and community service initiatives is associated with a number of favorable outcomes, and student interest in participating in such experiences is high. Increasingly, medical schools are facilitating and supervising global health opportunities. The inherent risks and uncertainties of global community service deserve careful consideration as schools engage more actively in this area. This article presents how one institution managed three crises in three electives in a single year. The H1N1 flu epidemic impacted a group of students bound for Mexico, a political upheaval affected a student group working in Honduras, and a hurricane threatened a student group in Nicaragua. This article outlines lessons learned from responding to these crises. Well-defined institutional travel policies, clear communication plans in the event of an emergency, a responsible administrative entity for global experiences, and formal predeparture training for students and faculty can help institutions better respond to unpredictable events. A comprehensive examination of these lessons and reflections on how to institutionalize the various components may help other institutions prepare for such events and lessen negative impact on student learning.

Interim Evaluation of the Rural Health Scholars Program

Physicians seek connections to their communities. Some health care and academic leaders believe that facilitating the creation of more such community connections is one way to reverse the trend of waning social and political legitimacy for the U.S. medical profession. For academic health centers (AHCs), such connections can maintain local and state support crucial to their long-term success. Multiple barriers exist to such involvement, especially for physicians in AHCs, where work done beyond direct patient care, administration, and research rarely contributes to the tenure and promotion process. The authors present a case study to show how one department in an AHC, beginning in the late 1990s, has been overcoming these barriers to incorporate the scholarship of community engagement into its mission and structure. The case study incorporates theoretical underpinnings to crystallize the following lessons that the department has learned so far: (1) If academic departments wish community service to be a central part of their mission, they need ways to institutionalize community engagement within organizational structures. (2) Community engagement can be scholarly. (3) If faculty members are to be recognized for their service activities, measures are necessary to determine what constitutes “excellence” and “scholarship” in community service. (4) Scholarship of community engagement goes beyond performing service activities in the community.

Satisfaction, Motivation, and Future of Community Preceptors: What Are the Current Trends?

Background: The imperative to address physician maldistribution has been directed in part at medical schools. Description: The Rural Health Scholars Program (RHSP) is an enrichment initiative that has been implemented at 2 medical schools to increase the number of students likely to practice primary care in rural, underserved areas. It is a longitudinal program that includes a skill-building workshop; a 5-week summer preceptorship with community-based preceptors in rural, underserved areas; and opportunities to return to preceptorship sites during 3rd- and 4th-year rotations. Students also attend community-based and teleconference seminars and workshops, as well as informal social gatherings. Evaluation: A static-group comparison design was used to compare program participants with nonparticipants regarding residency program types and locations. Conclusions: The RHSP is meeting some interim objectives conducive to its long-term goal of developing physicians who will practice primary care medicine in rural, underserved areas of North Carolina.

Medication documentation in a primary care network serving North Carolina medicaid patients: results of a cross-sectional chart review

Purpose To measure overall satisfaction of community-based preceptors, their anticipated likelihood of continuing to teach, professional satisfaction, influence of having students, motivation for teaching, satisfaction with professional practice, and satisfaction with and value of incentives, and to compare results with those of a similar 2005 statewide survey. Method In 2011, the authors distributed a 25-item survey to all 2,359 community-based primary care preceptors (physicians, pharmacists, advanced practice nurses, physician assistants) served by the North Carolina Area Health Education Centers system’s Offices of Regional Primary Care Education. The survey targeted the same items and pool of eligible respondents as did the North Carolina Area Health Education Center 2005 Preceptor Survey. Results Of 2,359 preceptors contacted, 1,278 (54.2%) completed questionnaires. The data from 2011 did not differ significantly from the 2005 data. In 2011, respondents were satisfied with precepting (91.7%), anticipated continuing to precept for the next five years (88.7%), and were satisfied overall with their professional life (93.7%). Intrinsic reasons (e.g., enjoyment of teaching) remained an important motivation for teaching students. Physicians reported significantly lower overall satisfaction with extrinsic incentives (e.g., monetary compensation) and felt more negativity about the influence of students on their practices. Conclusions This study found that preceptors continue to be satisfied with teaching students. Intrinsic reasons remain an important motivation to precept, but monetary compensation may have increasing importance. Physicians responded more negatively than other health provider groups to several questions, suggesting that their needs might be better met by redesigned teaching models.

The Community Preceptor Crisis: Recruiting and Retaining Community-Based Faculty to Teach Medical Students—A Shared Perspective From the Alliance for Clinical Education

BackgroundMedical records that do not accurately reflect the patient’s current medication list are an open invitation to errors and may compromise patient safety.MethodsThis cross-sectional study compares primary care provider (PCP) medication lists and pharmacy claims for 100 patients seen in 8 primary care practices and examines the association of congruence with demographic, clinical, and practice characteristics. Medication list congruence was measured as agreement of pharmacy claims with the entire PCP chart, including current medication list, visit notes, and correspondence sections.ResultsCongruence between pharmacy claims and the PCP chart was 65%. Congruence was associated with large chronic disease burden, frequent PCP visits, group practice, and patient age ≥45 years.ConclusionAgreement of medication lists between the PCP chart and pharmacy records is low. Medication documentation was more accurate among patients who have more chronic conditions, those who have frequent PCP visits, those whose practice has multiple providers, and those at least 45 years of age. Improved congruence among patients with multiple chronic conditions and in group practices may reflect more frequent visits and reviews by providers.

Academic health centers and community health centers partnering to build a system of care for vulnerable patients: lessons from Carolina Health Net.

ABSTRACT Issue: Community-based instruction is invaluable to medical students, as it provides “real-world” opportunities for observing and following patients over time while refining history taking, physical examination, differential diagnosis, and patient management skills. Community-based ambulatory settings can be more conducive to practicing these skills than highly specialized, academically based practice sites. The Association of American Medical Colleges and other national medical education organizations have expressed concern about recruitment and retention of preceptors to provide high-quality educational experiences in community-based practice sites. These concerns stem from constraints imposed by documentation in electronic health records; perceptions that student mentoring is burdensome resulting in decreased clinical productivity; and competition between allopathic, osteopathic, and international medical schools for finite resources for medical student experiences. Evidence: In this Alliance for Clinical Education position statement, we provide a consensus summary of representatives from national medical education organizations in 8 specialties that offer clinical clerkships. We describe the current challenges in providing medical students with adequate community-based instruction and propose potential solutions. Implications: Our recommendations are designed to assist clerkship directors and medical school leaders overcome current challenges and ensure high-quality, community-based clinical learning opportunities for all students. They include suggesting ways to orient community clinic sites for students, explaining how students can add value to the preceptors practice, focusing on educator skills development, recognizing preceptors who excel in their role as educators, and suggesting forms of compensation.

Costs and benefits of transforming primary care practices: a qualitative study of North Carolina's Improving Performance in Practice.

Academic health centers (AHCs) are challenged to meet their core missions in a time of strain on the health care system from rising costs, an aging population, increased rates of chronic disease, and growing numbers of uninsured patients. AHCs should be leaders in developing creative solutions to these challenges and training future leaders in new models of care. The authors present a case study describing the development, implementation, and early results of Carolina Health Net, a partnership between an AHC and a community health center to manage the most vulnerable uninsured by providing access to primary care medical homes and care management systems. This partnership was formed in 2008 to help transform the delivery of health care for the uninsured. As a result, 4,400 uninsured patients have been connected to primary care services. Emergency department use by enrolled patients has decreased. Patients have begun accessing subspecialty care within the medical home. More than 2,200 uninsured patients have been assisted to enroll in Medicaid. The experience of Carolina Health Net demonstrates that developing a system of care with primary care and wrap-around services such as pharmacy and case management can improve the cost-effectiveness and quality of care, thereby helping AHCs meet their broader missions. This project can serve as a model for other AHCs looking to partner with community-based providers to improve care and control costs for underserved populations.

Preparing and retaining rural physicians through medical education

EXECUTIVE SUMMARY Primary care organizations must transform care delivery to realize the Institute for Healthcare Improvements Triple Aim of better healthcare, better health, and lower healthcare costs. However, few studies have considered the financial implications for primary care practices engaged in transformation. In this qualitative, comparative case study, we examine the practice‐level personnel and nonpersonnel costs and the benefits involved in transformational change among 12 primary care practices participating in North Carolinas Improving Performance in Practice (IPIP) program. We found average annual opportunity costs of