Table 1 Faculty development: Strategies addressing PCMH principles pre- and post-transformation

1. Team-Based Care

• Team members (i.e. faculty, nurses, and ancillary staff) at each site worked together ad hoc to complete a broad array of patient care tasks.

• All team members expected to role-model culturally competent practice skills by caring for a diverse patient population.

• Clearly defined roles for all team members: In particular, practice reception staff are responsible for demographic intake, nursing staff are responsible for managing patient throughout, and faculty are responsible for running daily huddles, directing practice staff, and identifying patients for care management.

• Each practice site has a designated faculty physician lead, clinical nursing lead, and office manager that meet formally every month to discuss ways to optimize practice operations.

• Faculty mentor residents to lead daily huddles and review pre-visit planning during continuity clinic.

2. Patient-Centered Access

• Patients required to follow cumbersome process to request medical records, including vaccination history and test results.

• Patients asked to specify provider when calling to make an appointment. Patient requests for same day sick appointments were managed by individual providers.

• Faculty supervise second and third year residents responding to overnight and weekend phone calls from patients without access to clinical records

• All faculty and patients have 24/7 remote access to EMR, including vaccination history and test results.

• Faculty order follow-up appointments at time of visit so that staff schedule patients to see that provider at subsequent visits. All staff have access to EMR to view patients’ visit histories and schedule visits with relevant providers to promote continuity of care.

• Faculty and residents utilize an EMR template that was instituted to document follow-up of overnight and weekend phone calls and ensure key elements (e.g. medications, chronic conditions, allergies, etc.) are reviewed.

3. Population Health Management/ Knowing and Managing Your Patients

• Ad hoc reports about clinical quality metrics rely on administrative data, manual chart reviews, and/or publicly available datasets.

• Faculty review pre-defined clinical quality metrics that are tracked regularly for specific populations (e.g., asthma, ADHD, lead screening) during division-wide meetings.

• Clinical decision-support tools implemented to support faculty in identifying patients with persistent asthma who are overdue for controller medication renewal, regular health maintenance visits, and vaccinations.

• Nursing intake includes assessment of patients’ health literacy and cultural needs (e.g., preferred language) at least once annually and key elements of social history (e.g., financial stressors, housing instability) at annual health maintenance visits. Faculty and all other team members are able to view these intakes at any time.

4. Care Management and Support

• Faculty collaborate with other healthcare personnel (e.g., social worker, nutritionist, etc.) for care coordination as needed.

• Faculty contribute to create patient-education materials and care plans for 0–6 month old infants, asthmatic and obese patients that are given to patients during check-out.

• Scheduling staff run reports to identify patients who are overdue for specific care services (e.g., regular health maintenance visits, asthma management visits, and lead/hemoglobin screening) and contact patients to schedule visits to address these care needs.

5. Care Coordination and Care Transitions

• Faculty collaborate with practice staff to assist families with care coordination and transitions as needed.

• Faculty offer enriched medical home service (i.e. home visitation by a trained community health worker and/or social worker support) to patients who are at-risk for poor health outcomes.

• Practice staff run reports to identify outstanding orders (e.g., specialist referrals, lab tests, etc.) and contact patients to address these care needs.

• When the practice is notified that patients have visited the ED/urgent care, practice staff call families to offer a follow-up appointment.

6. Performance Measurement and Quality Improvement (QI)

• Ad hoc reports about clinical quality metrics rely on administrative data, manual chart reviews, and/or publicly available datasets.

• All faculty, clinical nursing leads, and office managers trained in the Plan-Do-Study-Act model.

• All faculty participate in reviewing QI data regularly and some mentor residents’ QI projects and/or student scholarly projects in this area.