|Former State||Current State|
|1. Team-Based Care|
• Residents assigned to same practice site for entire duration of residency training.|
• 100 % dedicated time in outpatient setting during general ambulatory rotation.
• Residents collaborate ad hoc with nurse and patient-care technicians during continuity clinic patient care sessions.
• Arrangement of schedules to allow for weekly resident clinic at specific continuity site with the same preceptor for the duration of their residency.|
• Staff schedule follow-up appointments with the same resident/preceptor pair whenever possible.
• Residents mentored by faculty to lead daily huddles with nursing staff to proactively plan care and review pre-visit planning information during continuity clinic patient care sessions.
|2. Patient-Centered Access|
|• Primary management of overnight and weekend phone calls by second and third year residents under the supervision of an attending physician.||
• 24/7 remote access to EMR for overnight and weekend calls transformation.|
• Institution of a process leveraging an EMR template for PCPs to follow up on overnight and weekend phone calls.
|3. Population Health Management/ Knowing and Managing Your Patients|
• Institution of a primary care track that includes 1–2 months dedicated to continuity clinic and outpatient primary care.|
• Faculty role model culturally competent practice skills to residents through exposure to a diverse patient population.
• 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|
|• Obtaining first-hand experience in the navigation and utilization of community resources during community medicine rotation.||
• Identification of high risk patients to offer proactive care management.|
• Accompany trained community health workers on home visits and/or social worker consultation provided as an enriched medical home service.
• Residents mentored by faculty participate in the creation of patient-education materials and care plans for 0–6 month old, asthmatic and obese patients.
|5. Care Coordination and Care Transitions|
• Collaboration with non-physician staff such as social worker, nutritionist, etc. for care coordination.|
• Enriched medical home service offered to patients at risk for poor health outcomes.
• Institution of a formal sign-out procedure for graduating residents to handoff more complicated patients from their panel to incoming interns.|
• Creation of a resident lab pool for tracking consultations and outstanding lab/imaging test results.
|6. Performance Measurement and Quality Improvement|
|• Training in the Plan-Do-Study-Act model.||
• Refined structure of clinical practice for residents to participate in quality improvement projects.|
• Residents participate in departmental quality assurance meetings and high reliability units.