Advancing Primary Care Access: Exploring the Impact of the Virtual Waiting Room on the Quadruple Aim.

BACKGROUND: Community health centers grapple with high no-show rates, posing challenges to patient access and primary care provider (PCP) utilization. AIM: To address these challenges, we implemented a virtual waiting room (VWR) program in April 2023 to enhance patient access and boost PCP utilization. SETTING: Academic community health center in a small urban city in Massachusetts. PARTICIPANTS: Community health patients (n = 8706) and PCP (n = 14). PROGRAM DESCRIPTION: The VWR program, initiated in April 2023, involved nurse triage of same-day visit requests for telehealth appropriateness, then placing patients in a standby pool to fill in as a telehealth visit for no-shows or last-minute cancellations in PCP schedules. PROGRAM EVALUATION: Post-implementation, clinic utilization rates between July and September improved from 75.2% in 2022 to 81.2% in 2023 (p < 0.01). PCP feedback was universally positive. Patients experienced a mean wait time of 1.9 h, offering a timely and convenient alternative to urgent care or the ER. DISCUSSION: The VWR is aligned with the quadruple aim of improving patient experience, population health, cost-effectiveness, and PCP satisfaction through improving same-day access and improving PCP schedule utilization. This innovative and reproducible approach in outpatient offices utilizing telehealth holds the potential for enhancing timely access across various medical disciplines.

Patients, Nurses, and Physicians Working Together to Develop a Discharge Entrustable Professional Activity Assessment Tool.

PROBLEM: The Accreditation Council for Graduate Medical Education milestones were written by physicians and thus may not reflect all the behaviors necessary for physicians to optimize their performance as a key member of an interprofessional team. APPROACH: From April to May 2013, the authors, Educational Research Outcomes Collaborative leaders, assembled interprofessional team discussion groups, including patients or family members, nurses, physician trainees, physician educators, and other staff (optional), at 11 internal medicine (IM) programs. Led by the site's principal investigator, the groups generated a list of physician behaviors related to the entrustable professional activity (EPA) of a safe and effective discharge of a patient from the hospital, and prioritized those behaviors. OUTCOMES: A total of 182 behaviors were listed, with lists consisting of between 10 and 29 behaviors. Overall, the site principal investigators described all participants as emerging from the activity with a new understanding of the complexity of training physicians for the discharge EPA. The authors batched behaviors into six components of a safe and effective discharge: medication reconciliation, discharge summary, patient/caregiver communication, team communication, active collaboration, and anticipation of posthospital needs. Specific, high-priority behavior examples for each component were identified, and an assessment tool for direct observation was developed for the discharge EPA. NEXT STEPS: The authors are currently evaluating trainee and educator perceptions of the assessment tool after implementation in 15 IM programs. Additional next steps include developing tools for other EPAs, as well as a broader evaluation of patient outcomes in the era of milestone-based assessment.

Practice Transformation: Professional Development Is Personal.

Current efforts to achieve practice transformation in our health care delivery system are, for good reason, primarily focused on technical change. Such efforts include meaningful use, population health metrics reporting, and the creation and sustaining of team-based patient-centered medical home delivery sites. If practice transformation is meant to ultimately and fundamentally transform the health care system and its culture to achieve the quadruple aim of better health, better care, affordability, and satisfaction of patients and providers, these technical changes are necessary but not sufficient. Systemic transformation is contingent on the transformation of the individuals who make up the systems. Therefore, if the goal is to authentically transform medical practice in the United States, transformation of those who practice it is also required.

TRACER: an 'eye-opener' to the patient experience across the transition of care in an internal medicine resident program.

BACKGROUND: A safe patient transition requires a complex set of physician skills within the interprofessional practice. OBJECTIVE: To evaluate a rotation which applies self-reflection and workplace learning in a TRAnsition of CarE Rotation (TRACER) for internal medicine (IM) residents. TRACER is a 2-week required IM resident rotation where trainees join a ward team as a quality officer and follow patients into postacute care. METHODS: In 2010, residents participated in semistructured, one-on-one interviews as part of ongoing program evaluation. They were asked what they had learned on TRACER, the year prior, and how they used those skills in their practice. Using transcripts, the authors reviewed and coded each transcript to develop themes. RESULTS: Five themes emerged from a qualitative, grounded theory analysis: seeing things from the other side, the 'ah ha' moment of fragmented care, team collaboration including understanding nursing scope of practice in different settings, patient understanding, and passing the learning on. TRACER gives residents a moment to breathe and open their eyes to the interprofessional practice setting and the patient's experience of care in transition. CONCLUSIONS: Residents learn about transitions of care through self-reflection. This learning is sustained over time and is valued enough to teach to their junior colleagues.

Found in transition: applying milestones to three unique discharge curricula.

Introduction. A safe and effective transition from hospital to post-acute care is a complex and important physician competency. Milestones and Entrustable Professional Activities (EPA) form the new educational rubric in Graduate Medical Education Training. "A safe and effective discharge from the hospital" is an EPA ripe for educational innovation. Methods. The authors collaborated in a qualitative process called mapping to define 22 of 142 Internal Medicine (IM) curricular milestones related to the transition of care. Fifty-five participant units at an Association for Program Directors in Internal Medicine (APDIM) workshop prioritized the milestones, using a validated ranking process called Q-sort. We analyzed the Q-sort results, which rank the milestones in order of priority. We then applied this ranking to three innovative models of training IM residents in the transitions of care: Simulation (S), Discharge Clinic Feedback (DCF) and TRACER (T). Results. We collected 55 Q-sort rankings from particpants at the APDIM workshop. We then identified which milestones are a focus of the three innovative models of training in the transition of care: Simulation = 5 of 22 milestones, Discharge Clinic Feedback = 9 of 22 milestones, and TRACER = 7 of 22 milestones. Milestones identified in each innovation related to one of the top 8 prioritized milestones 75% of the time; thus, more frequently than the milestones with lower priority. Two milestones are shared by all three curricula: Utilize patient-centered education and Ensure succinct written communication. Two other milestones are shared by two curricula: Manage and coordinate care transitions across multiple delivery systems and Customize care in the context of the patient's preferences. If you combine the three innovations, all of the top 8 milestones are included. Discussion. The milestones give us a context to share individual innovations and to compare and contrast using a standardized frame. We demonstrate that the three unique discharge curricula in aggregate capture all of the highest prioritized milestones for this discharge EPA.

Nurturing 21st century physician knowledge, skills and attitudes with medical home innovations: the Wright Center for Graduate Medical Education teaching health center curriculum experience.

Purpose. The effect of patient centered medical home (PCMH) curriculum interventions on residents' self-reported and demonstrated knowledge, skills and attitudes in PCMH competency arenas (KSA) is lacking in the literature. This study aimed to assess the impact of PCMH curricular innovations on the KSA of Internal Medicine residents. Methods. Twenty four (24) Internal Medicine residents-12 Traditional (TR) track residents and 12 Teaching Health Center (THC) track residents-began training in Academic Year (AY) 2011 at the Wright Center for Graduate Medical Education (WCGME). They were followed through AY2013, covering three years of training. PCMH curricular innovations were focally applied July 2011 until May 2012 to THC residents. These curricular innovations were spread program-wide in May 2012. Semi-annual, validated PCMH Clinician Assessments assessing KSA were started in AY2011 and were completed by all residents. Results. Mean KSA scores of TR residents were similar to those of THC residents at baseline for all PCMH competencies. In May 2012, mean scores of THC residents were significantly higher than TR residents for most KSA. After program-wide implementation of PCMH innovations, mean scores of TR residents for all KSA improved and most became equalized to those of THC residents. Globally improved KSA scores of THC and TR residents were maintained through May 2014, with the majority of improvements above baseline and reaching statistical significance. Conclusions. PCMH curricular innovations inspired by Health Resources and Services Administration (HRSA's) Teaching Health Center funded residency program expansion quickly and consistently improved the KSA of Internal Medicine residents.

Playing with curricular milestones in the educational sandbox: Q-sort results from an internal medicine educational collaborative.

PURPOSE: In competency-based medical education, the focus of assessment is on learner demonstration of predefined outcomes or competencies. One strategy being used in internal medicine (IM) is applying curricular milestones to assessment and reporting milestones to competence determination. The authors report a practical method for identifying sets of curricular milestones for assessment of a landmark, or a point where a resident can be entrusted with increased responsibility. METHOD: Thirteen IM residency programs joined in an educational collaborative to apply curricular milestones to training. The authors developed a game using Q-sort methodology to identify high-priority milestones for the landmark "Ready for indirect supervision in essential ambulatory care" (EsAMB). During May to December 2010, the programs'ambulatory faculty participated in the Q-sort game to prioritize 22 milestones for EsAMB. The authors analyzed the data to identify the top 8 milestones. RESULTS: In total, 149 faculty units (1-4 faculty each) participated. There was strong agreement on the top eight milestones; six had more than 92% agreement across programs, and five had 75% agreement across all faculty units. During the Q-sort game, faculty engaged in dynamic discussion about milestones and expressed interest in applying the game to other milestones and educational settings. CONCLUSIONS: The Q-sort game enabled diverse programs to prioritize curricular milestones with interprogram and interparticipant consistency. A Q-sort exercise is an engaging and playful way to address milestones in medical education and may provide a practical first step toward using milestones in the real-world educational setting.

There is no "i" in teamwork in the patient-centered medical home: defining teamwork competencies for academic practice.

Evidence suggests that teamwork is essential for safe, reliable practice. Creating health care teams able to function effectively in patient-centered medical homes (PCMHs), practices that organize care around the patient and demonstrate achievement of defined quality care standards, remains challenging. Preparing trainees for practice in interprofessional teams is particularly challenging in academic health centers where health professions curricula are largely siloed. Here, the authors review a well-delineated set of teamwork competencies that are important for high-functioning teams and suggest how these competencies might be useful for interprofessional team training and achievement of PCMH standards. The five competencies are (1) team leadership, the ability to coordinate team members' activities, ensure appropriate task distribution, evaluate effectiveness, and inspire high-level performance, (2) mutual performance monitoring, the ability to develop a shared understanding among team members regarding intentions, roles, and responsibilities so as to accurately monitor one another's performance for collective success, (3) backup behavior, the ability to anticipate the needs of other team members and shift responsibilities during times of variable workload, (4) adaptability, the capability of team members to adjust their strategy for completing tasks on the basis of feedback from the work environment, and (5) team orientation, the tendency to prioritize team goals over individual goals, encourage alternative perspectives, and show respect and regard for each team member. Relating each competency to a vignette from an academic primary care clinic, the authors describe potential strategies for improving teamwork learning and applying the teamwork competences to academic PCMH practices.

From theory to actual practice: creation and application of milestones in an internal medicine residency program, 2004-2010.

BACKGROUND: In the USA, the Accreditation Council of Graduate Medical Education, Educational Innovations Project is a partner in reshaping residency training to meet increasingly complex systems of health care delivery. AIM: We describe the creation and implementation of milestones as a vehicle for translating educational theory into practice in preparing residents to provide safe, autonomous patient care. METHOD: Six program faculty leaders, all with advanced medical education training, met in an iterative process of developing, implementing, and modifying milestones until a final set were vetted. RESULTS: We first formed the profile of a Master Internist. We then translated it into milestone language and implemented its integration across the program. Thirty-seven milestones were applied in all settings and rotations to reach explicit educational outcomes. We created three types of milestones: Progressive, build one on top of the other to mastery; additive, adding multiple behaviors together to culminate in mastery; and descriptive, using a proscribe set of complex, predetermined steps toward mastery. CONCLUSIONS: Using milestones, our program has enhanced an educational model into explicit, end of training goals. Milestone implementation has yielded positive results toward competency-based training and others may adapt our strategies in a similar effort.

The increased financial burden of further proposed orthopaedic resident work-hour reductions.

BACKGROUND: Increased funding for graduate medical education was not provided during implementation of the eighty-hour work week. Many teaching hospitals responded to decreased work hours by hiring physician extenders to maintain continuity of care. Recent proposals have included a further decrease in work hours to a total of fifty-six hours. The goal of this study was to determine the direct cost related to a further reduction in orthopaedic-resident work hours. METHODS: A survey was delivered to 152 residency programs to determine the number of full-time equivalent (FTE) physician extenders hired after implementation of the eighty-hour work-week restriction. Thirty-six programs responded (twenty-nine university-based programs and seven community-based programs), encompassing 1021 residents. Previous published data were used to determine the change in resident work hours with implementation of the eighty-hour regulation. A ratio between change in full-time equivalent staff per resident and number of reduced hours was used to determine the cost of the proposed further decrease. RESULTS: After implementation of the eighty-hour work week, the average reduction among orthopaedic residents was approximately five work hours per week. One hundred and forty-three physician extenders (equal to 142 full-time equivalent units) were hired to meet compliance at a frequency-weighted average cost of $96,000 per full-time equivalent unit. A further reduction to fifty-six hours would increase the cost by $64,000 per resident. With approximately 3200 orthopaedic residents nationwide, sensitivity analyses (based on models of eighty and seventy-three-hour work weeks) demonstrate that the increased cost would be between $147 million and $208 million per fiscal year. For each hourly decrease in weekly work hours, the cost is $8 million to $12 million over the course of a fiscal year. CONCLUSIONS: Mandated reductions in resident work hours are a costly proposition, without a clear decrease in adverse events. The federal government should consider these data prior to initiating unfunded work-hour mandates, as further reductions in resident work hours may make resident education financially unsustainable.

Early medical and behavioral characteristics of NICU infants later classified with ASD.

OBJECTIVES: Recent evidence suggests higher prevalence of autism spectrum disorder (ASD) in NICU graduates. This aim of this study was to identify retrospectively early behaviors found more frequently in NICU infants who went on to develop ASD. METHODS: Twenty-eight NICU graduates who later received a diagnosis of ASD were compared with 2169 other NICU graduates recruited from 1994 to 2005. They differed in gender, gestational age, and birth cohort. These characteristics were used to draw a matched control sample (n=112) to determine which, if any, early behaviors discriminated subsequent ASD diagnosis. Behavioral testing at targeted ages (adjusted for gestation) included the Rapid Neonatal Neurobehavioral Assessment (hospital discharge, 1 month), Arousal-Modulated Attention (hospital discharge, 1 and 4 months), and Bayley Scales of Infant Development (multiple times, 4-25 months). RESULTS: At 1 month, children with ASD but not control children had persistent neurobehavioral abnormalities and higher incidences of asymmetric visual tracking and arm tone deficits. At 4 months, children with ASD had continued visual preference for higher amounts of stimulation than did control children, behaving more like newborns. Unlike control children, children with ASD had declining mental and motor performance by 7 to 10 months, resembling infants with severe central nervous system involvement. CONCLUSIONS: Differences in specific behavior domains between NICU graduates who later receive a diagnosis of ASD and matched NICU control children may be identified in early infancy. Studies with this cohort may provide insights to help understand and detect early disabilities, including ASD.

Effect of a clinical pharmacist's interventions on duration of antiretroviral-related errors in hospitalized patients.

PURPOSE: The effect of a clinical pharmacist's interventions on the duration of antiretroviral-related errors in hospitalized patients was studied. METHODS: Between August 4, 2005, and February 4, 2006, all patients at least 18 years of age who were admitted to a 651-bed tertiary care teaching hospital and prescribed highly active antiretroviral therapy (HAART) were identified by one clinical pharmacist. If a HAART error was suspected, the pharmacist intervened with the house staff or outpatient physician to discuss and resolve the problem. The pharmacist also retrospectively identified potential HAART errors among patients with human immunodeficiency virus (HIV) admitted between January 2 and June 30, 2005. HAART errors included the following: incomplete regimen, incorrect dosage, incorrect schedule, medication-disease interaction, incorrect formulation, incorrect antiretroviral, duplication of therapy, and drug-drug interaction. The duration of each error was measured from the time of the initial incorrect order until a correct order was placed or until the patient was discharged. RESULTS: A total of 199 admissions for patients with an order for HAART were identified during the study periods. A total of 73 HAART errors were confirmed in 41 patients. The most common type of error was incomplete regimen. There was no significant difference in the frequency or type of prescribing when comparing the preintervention and intervention phases. The median length of time until an error was corrected, however, was significantly shorter during the intervention phase (15.5 hours) than the preintervention phase (84 hours) (p < 0.0001). CONCLUSION: The duration of prescribing errors was decreased when a clinical pharmacist monitoring patients receiving HAART intervened to resolve errors.