Empanelment in a Resident Teaching Practice: A Cornerstone to Improving Resident Outpatient Education and Patient Care.

BACKGROUND: Improving continuity is challenging in residency training practices. Studies have shown that empanelment enables high-performing primary care and is foundational to improve accountability and continuity. OBJECTIVE: An empanelment process was created in a large, urban, residency training practice as an effective approach to enhancing continuity among residents and their patients. METHODS: In 2016, we formed an empanelment committee that included stakeholders from the department of medicine, the internal medicine residency program, and hospital and IT leadership. This committee set goal panel sizes, selected an empanelment algorithm, determined which patients needed re-empanelment, and facilitated medical record integration. Empanelment was followed and reassessed quarterly for 2 years. We measured anticipated visit demand using visits in the prior year and continuity using the continuity for physician formula. RESULTS: Of 18 495 active patients in July 2016, 8411 (45%) were assigned a new PCP in the empanelment process. At baseline, panel sizes and expected visit demand were highly variable among residents (from 40 to 107 and 120 to 480, respectively). Empanelment led to more equivalent panel sizes and expected visit demand across same year residents (eg, PGY-3: 80-100 and 320-440, respectively). Continuity for all PCPs in the practice improved from 63% before empanelment to over 80% after empanelment, and improved from 55% to 72% for individual residents. CONCLUSIONS: In a large and complex practice environment, we were able to empanel resident clinic patients to improve continuity and maintain it over 2 years.

Using Nurse Practitioner Co-Management to Reduce Hospitalizations and Readmissions Within a Home-Based Primary Care Program.

Nurse practitioner (NP) co-management involves an NP and physician sharing responsibility for the care of a patient. This study evaluates the impact of NP co-management for clinically complex patients in a home-based primary care program on hospitalizations, 30-day hospital readmissions, and provider satisfaction. We compared preenrollment and postenrollment hospitalization and 30-day readmission rates of home-bound patients active in the Nurse Practitioner Co-Management Program within the Mount Sinai Visiting Doctors Program (MSVD) (n = 87) between January 1, 2012, and July 1, 2013. Data were collected from electronic medical records. An anonymous online survey was administered to all physicians active in the MSVD in July 2013 (n = 13).After enrollment in co-management, patients have lower annual hospitalization rates (1.26 vs. 2.27, p = .005) and fewer patients have 30-day readmissions (5.8% vs. 17.2%, p = .004). Eight of 13 physicians feel "much" or "somewhat" less burned out by their work after implementation of co-management. The high level of provider satisfaction and reductions in annual hospitalization and readmission rates among high-risk home-bound patients associated with NP co-management may yield not only benefits for patients, caregivers, and providers but also cost savings for institutions.

The team approach to home-based primary care: restructuring care to meet individual, program, and system needs.

Team-based models of care are an important way to meet the complex medical and psychosocial needs of the homebound. As part of a quality improvement project to address individual, program, and system needs, a portion of a large, physician-led academic home-based primary care practice was restructured into a team-based model. With support from an office-based nurse practitioner, a dedicated social worker, and a dedicated administrative assistant, physicians were able to care for a larger number of patients. Hospitalizations, readmissions, and patient satisfaction remained the same while physician panel size increased and physician satisfaction improved. The Team Approach is an innovative way to improve interdisciplinary, team-based care through practice restructuring and serves as an example of how other practices can approach the complex task of caring for the homebound.

Geriatric assistive devices.

Disability and mobility problems increase with age. Assistive devices such as canes, crutches, and walkers can be used to increase a patient's base of support, improve balance, and increase activity and independence, but they are not without significant musculoskeletal and metabolic demands. Most patients with assistive devices have never been instructed on the proper use and often have devices that are inappropriate, damaged, or are of the incorrect height. Selection of a suitable device depends on the patient's strength, endurance, balance, cognitive function, and environmental demands. Canes can help redistribute weight from a lower extremity that is weak or painful, improve stability by increasing the base of support, and provide tactile information about the ground to improve balance. Crutches are useful for patients who need to use their arms for weight bearing and propulsion and not just for balance. Walkers improve stability in those with lower extremity weakness or poor balance and facilitate improved mobility by increasing the patient's base of support and supporting the patient's weight. Walkers require greater attentional demands than canes and make using stairs difficult. The top of a cane or walker should be the same height as the wrist crease when the patient is standing upright with arms relaxed at his or her sides. A cane should be held contralateral to a weak or painful lower extremity and advanced simultaneously with the contralateral leg. Clinicians should routinely evaluate their patients' assistive devices to ensure proper height, fit, and maintenance, and also counsel patients on correct use of the device.

The Mount Sinai (New York) Visiting Doctors Program: meeting the needs of the urban homebound population.

The Mount Sinai Visiting Doctors program, a joint program of Mount Sinai Medical Center's Departments of Medicine and Geriatrics, is a large multidisciplinary teaching, research, and clinical care initiative serving homebound adults in Manhattan since 1995. Caring for more than 1,000 patients annually, the physicians of Visiting Doctors make more than 6,000 urgent and routine visits each year, making it the largest program of its kind in the country. Services include 24-hour physician availability, palliative care, social work case management, collaboration with nursing agencies, and in-home specialty consultation. The program serves many individuals who have previously received inadequate and inconsistent medical care. Patients are referred by social service agencies, localphysicians, and hospitals and are primarily frail older individuals with complex needs. Funded by Mount Sinai and private support, the program serves as a major teaching site for medical nursing, and social work trainees interested in home-based primary care.

Cyclobutenone-Based Syntheses of Polyquinanes and Bicyclo[6.3.0]undecanes by Tandem Anionic Oxy-Cope Reactions. Total Synthesis of (+/-)-Precapnelladiene.

The addition of ethenyllithium derivatives to the carbonyl of dialkyl squarate-derived bicycloheptenones, e.g., 1a and 6a, initiates a low-temperature anion-accelerated oxy-Cope rearrangement to provide polyquinanes by a transannular aldol reaction of the intermediate bicyclo[6.3.0]undecadienone 4. Additional functionality is introduced by alkylation of the enolate 3 resulting from the oxy-Cope rearrangement. Phosphorylation or triflation of enolate 3 provides an entry into the bicyclo[6.3.0]undecane ring system. An application of this new methodology is demonstrated by the total synthesis of the sesquiterpene natural product (+/-)-precapnelladiene from diisopropyl squarate (10 steps, 12%).