Elaine Waller

Integrating Behavioral and Physical Health Care in the Real World: Early Lessons from Advancing Care Together

Background: More than 20 years ago the Institute of Medicine advocated for integration of physical and behavioral health care. Today, practices are integrating care in response to recent policy initiatives. However, few studies describe how integration is accomplished in real-world practices without the financial or research support available for most randomized controlled trials. Methods: To study how practices integrate care, we are conducting a cross-case comparative, mixed-methods study of 11 practices participating in Advancing Care Together (ACT). Using a grounded theory approach, we analyzed multiple sources of data (eg, documents, practice surveys, field notes from observation visits, semistructured interviews, online diaries) collected from each ACT innovator. Results: Integration requires making changes in organization and interpersonal relationships. During early integration efforts, challenges related to workflow and access, leadership and culture change, and tracking and using data to evaluate patient- and practice-level improvement emerged for ACT innovators. We describe the strategies innovators are developing to address these challenges. Conclusion: Integrating care is a fundamental and difficult change for practices and health care professionals. Research identifying common challenges that manifest in early efforts can help others attempting integration and inform state, local, and federal policies aimed at achieving wide-spread implementation.

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

BACKGROUND New approaches to enhance access in primary care necessitate change in the model for residency education. PURPOSE To describe instrument design, development and testing, and data collection strategies for residency programs, continuity clinics, residents, and program graduates participating in the Preparing the Personal Physician for Practice (P(4)) project. METHODS We developed and pilot-tested surveys to assess demographic characteristics of residents, clinical and operational features of the continuity clinics and educational programs, and attitudes about and implementation status of Patient Centered Medical Home (PCMH) characteristics. Surveys were administered annually to P(4) residency programs since the project started in 2007. Descriptive statistics were used to profile data from the P(4) baseline year. RESULTS Most P(4) residents were non-Hispanic white women (60.7%), married or partnered, attended medical school in the United States and were the first physicians in their families to attend medical school. Nearly 85% of residency continuity clinics were family health centers, and about 8% were federally qualified health centers. The most likely PCMH features in continuity clinics were having an electronic health record and having fully secure remote access available; both of which were found in more than 50% of continuity clinics. Approximately one-half of continuity clinics used the electronic health record for safety projects, and nearly 60% used it for quality-improvement projects. CONCLUSIONS We created a collaborative evaluation model in all 14 P(4) residencies. Successful implementation of new surveys revealed important baseline features of residencies and residents that are pertinent to studying the effects of new training models for the PCMH.

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

Perceptions of Becoming Personal Physicians within a Patient-CenteredMedical Home

5,240,516 over the entire study period, compared with

Faculty development needs in residency redesign for practice in patient-centered medical homes: A P4 report

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

Effect of Curriculum Innovation on Residency Applications and Match Performance

875,000, and the average was nearly

Measuring Family Physician Identity: The Development of a New Instrument

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.

Innovating within the ACGME regulatory environment is not an oxymoron.

Objective: Residency training is transforming how to teach residents about practicing as a personal physician in a Patient Centered Medical Home [PCMH], but little is known about how trainees experience these responsibilities. Methods: This study used an online survey with open-ended questions to assess residents experiences with curricular innovations as part of learning to practice as physicians in a PCMH. The survey questions were distributed every six to 12 months. This analysis focuses on responses to a single question administered once, “What does being a personal physician working in a medical home mean to you?” Two independent researchers analyzed text responses using an immersion-crystallization approach. The full research team met to discuss emerging themes. Principal findings: Sixty-two residents representing 78.6% of participating training programs responded to the online survey question that is the focus of this analysis. Overwhelmingly, resident respondents reported finding meaning in the humanistic and interpersonal aspects of medicine. In particular, residents reported that being a personal physician in a PCMH meant being the go-to person for patients’ healthcare needs. This included delivering patient-centered, continuous care in the context of a physician-patient relationship that broke down the traditional physician-patient hierarchy. Being a personal physician also included an important role for the physician and clinical team members in orchestrating the referral and care coordination process. To accomplish this, residents recognized that personal physicians needed to learn the art of practice. Conclusion: Physicians trained in newly redesigned residencies understand and embrace their role and relationships with patients and health care teams that emerge as part of the PCMH. Residency redesign efforts can inculcate new family physicians with key practice ideals and knowledge about how to achieve these in practice.