A novel longitudinal interprofessional ambulatory training practice: the improving patient access care and cost through training (IMPACcT) clinic.

Few graduating health professionals choose primary care. Trainees satisfied with continuity ambulatory experiences are more likely to pursue primary care. The authors developed a longitudinal interprofessional ambulatory training program to improve team-based care and encourage primary care careers. The Improving Patient Access Care and cost through Training (IMPACcT) clinic, launched in 2016, includes physician, physician assistant, pharmacy, and psychology trainees. Residents, faculty, and interprofessional trainees complete "on-service" weeks together. Co-located administrative team members coordinate care and lead team "huddles." Interprofessional signout facilitates patient follow-up. The initial evaluation included process and quality indicators compared to the traditional resident practice. Learners reported increased perceived competence in interprofessional communication and teamwork after completing their training. Clinical quality outcomes suggested improved provider continuity and arrival rate compared to traditional resident practice (56.5% vs. 32.9%; 66.3% vs. 62.2%, p < .01). Patient satisfaction was higher in the IMPACcT clinic in the areas of coordinated care and team functioning. Ten of eighteen physician graduates in the program chose further training in primary care compared to 20 of 150 graduates not in the program (55.6% vs. 13.3%, p < .01). Implementing a longitudinal team-based ambulatory interprofessional training practice was associated with improved continuity of care and improved patient satisfaction indicators.

Association of an Advance Care Planning Video and Communication Intervention With Documentation of Advance Care Planning Among Older Adults: A Nonrandomized Controlled Trial.

Importance: COVID-19 has disproportionately killed older adults and racial and ethnic minority individuals, raising questions about the relevance of advance care planning (ACP) in this population. Video decision aids and communication skills training offer scalable delivery models. Objective: To assess whether ACP video decision aids and a clinician communication intervention improved the rate of ACP documentation during an evolving pandemic, with a focus on African American and Hispanic patients. Design, Setting, and Participants: The Advance Care Planning: Communicating With Outpatients for Vital Informed Decisions trial was a pre-post, open-cohort nonrandomized controlled trial that compared ACP documentation across the baseline pre-COVID-19 period (September 15, 2019, to March 14, 2020), the COVID-19 wave 1 period (March 15, 2020, to September 14, 2020), and an intervention period (December 15, 2020, to June 14, 2021) at a New York metropolitan area ambulatory network of 22 clinics. All patients 65 years or older who had at least 1 clinic or telehealth visit during any of the 3 study periods were included. Main Outcomes and Measures: The primary outcome was ACP documentation. Results: A total of 14 107 patients (mean [SD] age, 81.0 [8.4] years; 8856 [62.8%] female; and 2248 [15.9%] African American or Hispanic) interacted with clinicians during the pre-COVID-19 period; 12 806 (mean [SD] age, 81.2 [8.5] years; 8047 [62.8%] female; and 1992 [15.6%] African American or Hispanic), during wave 1; and 15 106 (mean [SD] 80.9 [8.3] years; 9543 [63.2%] female; and 2535 [16.8%] African American or Hispanic), during the intervention period. Clinicians documented ACP in 3587 patients (23.8%) during the intervention period compared with 2525 (17.9%) during the pre-COVID-19 period (rate difference [RD], 5.8%; 95% CI, 0.9%-7.9%; P = .01) and 1598 (12.5%) during wave 1 (RD, 11.3%; 95% CI, 6.3%-12.1%; P < .001). Advance care planning was documented in 447 African American patients (30.0%) during the intervention period compared with 233 (18.1%) during the pre-COVID-19 period (RD, 11.9%; 95% CI, 4.1%-15.9%; P < .001) and 130 (11.0%) during wave 1 (RD, 19.1%; 95% CI, 11.7%-21.2%; P < .001). Advance care planning was documented for 222 Hispanic patients (21.2%) during the intervention period compared with 127 (13.2%) during the pre-COVID-19 period (RD, 8.0%; 95% CI, 2.1%-10.9%; P = .004) and 82 (10.2%) during wave 1 (RD, 11.1%; 95% CI, 5.5%-14.5%; P < .001). Conclusions and Relevance: This intervention, implemented during the evolving COVID-19 pandemic, was associated with higher rates of ACP documentation, especially for African American and Hispanic patients. Trial Registration: ClinicalTrials.gov Identifier: NCT04660422.

The Financial Cost of Interprofessional Ambulatory Training: What's the Bottom Line?

BACKGROUND: Team-based care is recommended as a building block of high-performing primary care but has not been widely adapted in training sites. Cost may be one barrier to a team-based approach. OBJECTIVE: We quantified incremental annual faculty and staff costs as well as potential cost savings associated with an interprofessional (IP) ambulatory training program compared to a traditional residency clinic at the same site. METHODS: Cost calculations for the 2017-2018 academic year were made using US Department of Labor median salaries by profession and divided by the number of residents trained per year. Cost implications of lower no-show rates were calculated by multiplying the difference in no-show rate by the number of scheduled appointments, and then by the weighted average of the reimbursement rate. RESULTS: A total of 1572 arrived appointments were seen by the 10 residents in the IP program compared with 8689 arrived appointments seen by 57 residents in the traditional clinic. The no-show rate was 11.5% (265 of 2311) in the IP program and 19.2% (2532 of 13 154) in the traditional clinic (P < .001). Total cost to the health system through higher staffing needs was $113,897, or $11,390 per trained resident. CONCLUSIONS: Total costs of the IP model due to higher faculty and staff to resident ratios totaled $11,390 per resident per year. Understanding the faculty and staff costs and potential cost-saving opportunities associated with transformation to an IP model may assist in sustainability.

Enhanced Scheduling Support to Improve Continuity of Care in a Resident Training Clinic.

BACKGROUND: Clinical continuity is recognized as a driver of satisfaction for patients and physicians. Greater continuity may positively affect trainee decisions to enter primary care. Maintaining clinical continuity remains a challenge in residency clinics. OBJECTIVE: We determined whether enhanced scheduling support was associated with improvement in internal medicine resident continuity with patients. METHODS: This study was conducted from June 2017 to December 2018. In the intervention clinic, a single scheduling staff member (ratio of 10 residents to 1 scheduler) was colocated within the clinical space, allowing the scheduler to participate in clinical discussions and direct communication with physicians regarding future appointments. In the comparison clinic, scheduling staff (19:1 ratio) were located at a remote front desk area and relied on patient reports or electronic health record orders to identify appointment needs and arrange follow-up appointments. The main outcome of the intervention was resident continuity, calculated using the continuity for physician formula. RESULTS: During the study period, mean resident continuity was 23% (range 13%-37%) in the comparison clinic (57 residents) and 54% (range 38%-66%) in the intervention clinic (10 residents). Resident continuity was significantly higher in the intervention clinic compared with the traditional control clinic for every quarter measured (P < .001 for all comparisons). CONCLUSIONS: Enhancing scheduling support through colocation and a lower resident to scheduler ratios was associated with significantly higher rates of resident continuity compared with a traditional front desk model, with results sustained over 18 months.