Healthcare workforce transformation: implementing patient-centered medical home standards in an academic medical center.

BACKGROUND: Large scale implementation of new strategies and healthcare delivery standards in academic medical centers (AMCs) requires training of healthcare workforce at different stages of their medical career. The patient-centered medical home (PCMH) model for healthcare delivery involves adoption by all members of the healthcare workforce, including seasoned professionals and trainees. Though widely known, the PCMH model has been implemented sporadically at large AMCs and methods to implement the model across healthcare workforce have not been well-documented. METHODS: To meet all PCMH standards and achieve sustainable level 3 recognition, the authors implemented in 2014-2015 a multi-pronged approach that capitalized on existing educational infrastructure among faculty, residents, and medical students. Within 18 months, the authors applied new interdisciplinary practices and policies, redesigned residency training in continuity practices and extensively modified medical school curricula. RESULTS: These innovative transformational education efforts addressed the six PCMH standards for faculty, residents, and undergraduate medical students. Faculty played a major role as system change agents and facilitators of learning. Residents learned to better understand patients' cultural needs, identify 'at-risk' patients, ensure continuity of care, and assess and improve quality of care. Medical students were exposed to PCMH core standards throughout their training via simulations, training in the community and with patients, and evaluation tasks. By implementing these changes across the healthcare workforce, the AMC achieved PCMH status in a short time, changed practice culture and improved care for patients and the community. Since then, the AMC has been able to maintain PCMH recognition annually with minimal effort. CONCLUSIONS: Successful strategies that capitalize on existing strengths in infrastructure complemented by innovative educational offerings and inter-professional partnerships can be adapted by other organizations pursuing similar transformation efforts. This widespread transformation across the healthcare workforce facilitate a deep-rooted change that enabled our academic medical center to sustain PCMH recognition.

Narrative Performance Level Assignments at Initial Entrustment and Graduation: Integrating EPAs and Milestones to Improve Learner Assessment.

PURPOSE: To determine which narrative performance level for each general pediatrics entrustable professional activity (EPA) reflects the minimum level clinical competency committees (CCCs) felt should be associated with graduation as well as initial entrustment and compare expected narrative performance levels (ENPLs) for each EPA with actual narrative performance levels (ANPLs) assigned to residents at initial entrustment. METHOD: A series of 5 narratives, corresponding to the 5 milestone performance levels, were developed for each of the 17 general pediatrics EPAs. In academic year (AY) 2015-2016, the CCCs at 22 Association of Pediatric Program Directors Longitudinal Educational Assessment Research Network member sites reported ENPLs for initial entrustment and at time of graduation. From AYs 2015-2016 to 2017-2018, programs reported ANPLs for initial entrustment decisions. ENPLs and ANPLs were compared using a logistic mixed effects model. RESULTS: ENPLs for graduation and entrustment were most often level 3 (competent) followed by level 4 (proficient). For 8 EPAs, the ENPLs for graduation and entrustment were the same. For the remaining 9, some programs would entrust residents before graduation or graduate them before entrusting them. There were 4,266 supervision level reports for initial entrustment for which an ANPL was provided. ANPLs that were lower than the ENPLs were significantly more likely to be assigned to the medical home-well child (OR = 0.39; 95% CI: 0.26-0.57), transition to adult care (OR = 0.43; 95% CI: 0.19-0.95), behavioral or mental health (OR = 0.36; 95% CI: 0.18-0.71), make referrals (OR = 0.31; 95% CI: 0.17-0.55), lead a team (OR = 0.34; 95% CI: 0.22-0.52), and handovers (OR = 0.18; 95% CI: 0.09-0.36) EPAs. CONCLUSIONS: CCCs reported lower ENPLs for graduation than for entrustment for 5 EPAs, possibly indicating curricular gaps that milestones and EPAs could help identify.

Using Motivational Interviewing to Address Tobacco Cessation: Two Standardized Patient Cases for Pediatric Residents.

Introduction: Motivational interviewing (MI) is a well-established evidence-based method of working with patients to promote health behavior change. Standardized patient (SP) simulation allows trainees to practice and receive feedback on clinical and communication skills and may be useful in applying MI techniques to address tobacco use and exposure. Methods: We developed two SP cases for pediatric residents to practice addressing tobacco use with parents of their patients. Results: Thirty-six residents participated, 26 of whom had prior MI training. Resident postencounter self-reflection identified MI-specific skills, including eliciting the SP's view on positive/negative aspects of smoking, identifying stressors/triggers associated with smoking, eliciting reasons for smoking, asking about motivation/willingness to quit, eliciting benefits of quitting smoking, letting the SP do the talking, and guiding the SP in making a quit plan. On paired-samples t tests, resident self-evaluation checklist scores averaged 6.79 out of 8.00 (SD = 1.018, SEM = 0.165), compared with SP checklist scores, which averaged 7.08 out of 8.00 (SD = 1.217, SEM = 0.197). Discussion: These two SP cases were useful in many ways, allowing residents with prior MI training the opportunity for practice/feedback on skills learned and introducing residents with no prior MI training to MI concepts through experience/feedback. Residents consistently identified using MI concepts on postencounter self-reflection; resident self-evaluation and SP evaluation of residents showed agreement. These sessions could be utilized within a communication/MI curriculum or as stand-alone sessions to introduce MI concepts/techniques for addressing tobacco cessation in the pediatric setting.