Harmonizing the Tripartite Mission in Academic Family Medicine: A Longitudinal Case Example.

Academic practices and departments are defined by a tripartite mission of care, education, and research, conceived as being mutually reinforcing. But in practice, academic faculty have often experienced these 3 missions as competing rather than complementary priorities. This siloed approach has interfered with innovation as a learning health system in which the tripartite missions reinforce each other in practical ways. This paper presents a longitudinal case example of harmonizing academic missions in a large family medicine department so that missions and people interact in mutually beneficial ways to create value for patients, learners, and faculty. We describe specific experiences, implementation, and examples of harmonizing missions as a feasible strategy and culture. "Harmonized" means that no one mission subordinates or drives out the others; each mission informs and strengthens the others (quickly in practice) while faculty experience the triparate mission as a coherent whole faculty job. Because an academic department is a complex system of work and relationships, concepts for leading a complex adaptive system were employed: (1) a "good enough" vision, (2) frequent and productive interactions, and (3) a few simple rules. These helped people harmonize their work without telling them exactly what to do, when, and how. Our goal here is to highlight concrete examples of harmonizing missions as a feasible operating method, suggesting ways it builds a foundation for a learning health system and potentially improving faculty well-being.

Expanding Family Medicine Scholarship to All Faculty: The Minnesota Model for Harmonizing Clinical Care, Education, and Research Missions.

BACKGROUND: The Department of Family Medicine and Community Health at the University of Minnesota engaged in a 5-year transformation to expand research and scholarship opportunities to all faculty. A harmonization framework was used to integrate the 3 missions of clinical care, education, and research to ensure that research and scholarship were an ongoing focus of the department. METHODS: The key elements of our transformation included as follows: (1) a general culture of inquiry, (2) harmonized leadership, (3) training and mentoring, and (4) infrastructure and resources. Components of each of these elements were intentionally instituted simultaneously and iteratively across the 5 years to provide robust and sustainable research and scholarship opportunities for all faculty. RESULTS: Outputs and outcomes of the harmonized transformation indicated that clinical and research faculty publications increased, and the percentage of clinical faculty trained in research and scholarship skills increased across the 5 years. CONCLUSIONS: Important lessons learned during the harmonized transformation included the following: (1) key elements of the transformation need to be balanced as an ensemble, (2) cultural and organizational shifts take concerted effort and time, (3) embrace iteration: allow "bumps in the road" to propel the work forward, (4) transformation is financially feasible, (5) career research faculty can mutually benefit from clinical faculty engaging in scholarship, and (6) honor skepticism or disinterest and let people cultivate enthusiasm for research and scholarship rather than being forced.

Michelle's Story: The Complexity of Patient Care in a Family Medicine Residency Clinic.

Family medicine covers all ages and specializes in chronic disease management as well as acute care medicine. As the health of the population continues to grow in complexity, treating patients appropriately and efficiently is imperative to improving health outcomes and managing health care costs. Family medicine physicians are uniquely poised to provide this type of care. A patient story plus a look at the patients seen over the course of a day within a family medicine residency clinic explores the complexity of care and the ability of family medicine physicians to provide the necessary care. Taking a close look at who comes through our door on a particular day highlights 3 points: primary care physicians are seeing patients with an increasing complexity of needs, our society is witnessing an extreme increase in patients suffering with mental health problems and substance use disorders, and addressing social determinants of health must be part of the solution.

Coming Together in Action for Equity, Diversity, and Inclusion.

THE CHALLENGE: Family medicine departments see elevating equity, diversity, and inclusion (EDI)* as socially necessary and as powerful in achieving core missions. The importance and timeliness of this longstanding issue in medicine are magnified by the COVID-19 pandemic with its disproportionate effect on communities of color and by civil unrest focused on racial justice. EDI plays out in three pillars: (1) care delivery and health, (2) workforce recruitment and retention, and (3) learner recruitment and training. People are at very different places with EDI work with regard to knowledge, experience, comfort and confidence. This is a wide-ranging developmental challenge, not a narrow, technical, or quick fix. The Immediate Goal: To make a strong start in taking all faculty and staff on a participatory journey that brings changes in everything they do, using inclusive means to this inclusive end. Initial Achievements: An inclusive process that resulted in (1) a shared intellectual framework-definitions with "north star" goals across the three pillars of EDI action, (2) shared acceptance of need for change, (3) top growth areas with actions to take, and (4) harnessing the energy for action-many volunteers, a visible leader, and charge. Ongoing Action: Application of an equity lens to department relationships, specific incidents, tools and education, policy review, and measures development. Invitation to Further Conversation Among Departments: EDI work can quickly create a shared intellectual framework and broadly engage people in taking a department down its developmental path. Operating principles for undertaking such work are offered for conversation among departments.

State of the Science: Interprofessional Approaches to Aging, Dementia, and Mental Health.

Interprofessional education (IPE) is essential to develop the healthcare workforce of the future. Geriatrics healthcare professionals have long championed innovations in IPE and patient care, but there is increased urgency to address challenges in aging, dementia, and geriatric mental health in America. In 2010, the Partnership for Health in Aging multidisciplinary competencies and a related position statement in the Journal of the American Geriatrics Society addressed interdisciplinary team (IDT) training in geriatrics. The position statement reported that training in higher education, academic, and continuing education settings has not been sufficiently responsive to workforce needs. In recent years, health professions educators and health systems leaders have increasingly recognized that IPE should be integrally linked with, and performed within, emerging models of team-based, value-driven health care. In this way, IPE will align with learning healthcare systems' pursuit of the Quadruple Aim: improving patient experience, provider experience, and the health of populations, and reducing per capita health care costs. Backed by decades of developing effective team care models and the skill set needed to care for older adults with complex needs, geriatrics healthcare providers from multiple disciplines are uniquely positioned to lead learning healthcare systems in a new effort to develop, implement, and sustain IPE and practice models congruent with these Aims. We provide recommendations for health professions educators, healthcare systems leaders, and policymakers to realize the potential of IPE and interprofessional collaborative practice (IPCP) to improve the health of all Americans in aging, dementia, and mental health.

Reduced Healthcare Use and Apparent Savings with Passive Home Monitoring Technology: A Pilot Study.

OBJECTIVES: To conduct a cost analysis of ambient assisted living technology, which is promising for improving the ability of individuals and care providers to monitor daily activities and gain better awareness through proactive management of health and safety. DESIGN: Three-arm cohort study. SETTING: Homes of enrollees of a state-based healthcare plan for older adults. PARTICIPANTS: Enrollees dually eligible for Medicare and Medicaid (N = 268). INTERVENTION: Health and safety passive remote patient monitoring (PRPM) systems were installed in enrollees' homes (the intervention group) with monitoring and proactive intervention of a case manager when deviation from baseline subject behavior was detected. MEASUREMENTS: Claims data were collected over 12 months to assess healthcare use and costs in the intervention group and to compare use and costs with those of two control groups: a concurrent group of enrollees who declined the technology and a historical cohort matched on age to the participation group. RESULTS: Although the small sample size precluded cost differences that were statistically significant, the participant group used substantially less custodial care, emergency department (ED) services, inpatient stays, and ED costs than the two control groups. CONCLUSION: In this pilot study, the PRPM system was associated with apparent healthcare cost savings. Although more cost analyses are warranted, ambient assisted living technologies are a potentially valuable investment for older adult care.

Hearing deficits in the older patient: "I didn't notice anything".

Hearing loss is common in older adults. Patients, clinicians, and health care staff often do not recognize hearing loss, particularly in its early stages, and it is undertreated. Age-related hearing loss or presbycusis, the most common type of hearing loss in older adults, is a multifactorial sensorineural loss that frequently includes a component of impaired speech discrimination. Simple office-based screening and evaluation procedures can identify potential hearing disorders, which should prompt audiologic referral to confirm the diagnosis with audiometric testing. The mainstay of treatment is amplification. For many older adults, accepting the need for amplification, selecting and purchasing a hearing aid, and getting accustomed to its use is a daunting and often frustrating process. There are numerous barriers to hearing aid use, the most common of which is dissatisfaction with its performance across a range of sonic environments. Newer digital hearing aids have many features that improve performance, making them potentially more acceptable to users, but they are expensive and are not covered by Medicare. Hearing aids have been demonstrated to improve hearing function and hearing-related quality of life (QOL), but evidence is less robust for improving overall QOL. Depending upon the etiology of the hearing loss, other medical and surgical procedures, including cochlear implantation, may benefit older adults. Older adults with multiple morbidities and who are frail pose specific challenges for the management of hearing loss. These patients may require integration of hearing assessment and treatment as part of functional assessment in an interdisciplinary, team-based approach to care.

Successful models of comprehensive care for older adults with chronic conditions: evidence for the Institute of Medicine's "retooling for an aging America" report.

The quality of chronic care in America is low, and the cost is high. To help inform efforts to overhaul the ailing U.S. healthcare system, including those related to the "medical home," models of comprehensive health care that have shown the potential to improve the quality, efficiency, or health-related outcomes of care for chronically ill older persons were identified. Using multiple indexing terms, the MEDLINE database was searched for articles published in English between January 1, 1987, and May 30, 2008, that reported statistically significant positive outcomes from high-quality research on models of comprehensive health care for older persons with chronic conditions. Each selected study addressed a model of comprehensive health care; was a meta-analysis, systematic review, or trial with an equivalent concurrent control group; included an adequate number of representative, chronically ill participants aged 65 and older; used valid measures; used reliable methods of data collection; analyzed data rigorously; and reported significantly positive effects on the quality, efficiency, or health-related outcomes of care. Of 2,714 identified articles, 123 (4.5%) met these criteria. Fifteen models have improved at least one outcome: interdisciplinary primary care (1), models that supplement primary care (8), transitional care (1), models of acute care in patients' homes (2), nurse-physician teams for residents of nursing homes (1), and models of comprehensive care in hospitals (2). Policy makers and healthcare leaders should consider including these 15 models of health care in plans to reform the U.S. healthcare system. The Centers for Medicare and Medicaid Services would need new statutory flexibility to pay for care by the nurses, social workers, pharmacists, and physicians who staff these promising models.

Ten years' experience conducting the Aging Game workshop: was it worth it?

In the Aging Game, medical students experience simulated physical, sensory, and cognitive deficits that are associated with disability from chronic diseases. Since 1994, the University of Minnesota has presented an innovative version of the Aging Game as part of the curriculum in a required clinical clerkship. The experiences conducting the Aging Game over the past decade were reviewed, focusing on the resources necessary to produce it and on its worth as an educational tool. Because many of the reusable props were obtained free as donations, start-up material costs were calculated at 530 dollars. Personnel necessary for each half-day presentation of the Aging Game included two faculty and a minimum of five nonfaculty serving as facilitators; a staff coordinator was also essential. Quantitative student evaluations (N=673) exhibited mean ratings of 1.41, 1.35, and 1.40 (1=excellent) for overall value, teaching effectiveness, and quality of a postsimulation discussion. Written student comments regarding the strengths of the Aging Game centered on three major themes: mode of learning, especially using role playing and simulating deficits (total of 192 comments); attitudinal change, specifically raising awareness and stimulating reflection on the experiences of disabled older adults (121 comments); and educational value, particularly the Aging Game's capacity for creating a memorable impression (56 comments). Despite consuming significant personnel resources, the Minnesota version of the Aging Game is an effective tool for stimulating long-lasting awareness and understanding of key issues related to aging and geriatrics.

Health care economics, financing, organization, and delivery.

BACKGROUND: The US health care system is in a state of rapid evolution, with changing payment, organizational, and management structures. To learn how to function optimally in a system in which care is increasingly managed and competitive, today's medical students must understand the structural and economic underpinnings of the system within which they will practice. At the outset of the Undergraduate Medical Education for the 21st Century (UME-21) project, the great majority of medical school curricula were lacking in areas of health care financing and organizational structure. The institutions involved in the UME-21 project sought to address curricular deficiencies in two broad areas: (1) the structure and financing of the US health care system ("health policy") and (2) the manner in which this system is reflected in the organization and activities of health care providers ("care delivery"). This article discusses the development, implementation, and evaluation of the first of the two areas. METHODS: Data were abstracted from written reports provided by each of the UME-21 schools to the project's Executive Committee and sponsor. In selected cases, additional data were obtained by personal communications with project directors and evaluators. Local UME-21 project leaders verified all data presented. RESULTS: Curricular philosophy and teaching methods varied widely, but health policy curricula were predominantly preclinical and didactic in nature. At the school level, much was achieved in terms of student knowledge, curricula were generally well received by students, attitudes toward managed care generally moved in a positive direction, and behavior may have been positively influenced as well. At the project level, many potentially interesting changes exist within the 18 schools and between the UME-21 and other schools, but it is not clear whether or what parts of the health policy curricula were responsible for these changes. Nonetheless, as measured by changes in health policy-related items on the Association of American Medical Colleges Graduation Questionnaire, it appears that UME-21 schools outperformed their non-UME-21 counterparts. All of the UME-21 schools were enthusiastic about their health policy innovations, and this extended across all key stakeholders. Most schools avoided focusing on managed care and instead adopted more neutral themes that introduced the same material. Integrating the new material in conjunction with the more traditional aspects of the curriculum was also an effective implementation strategy. CONCLUSIONS: Health policy should be incorporated into both the preclinical and clinical years. The former emphasizes health care economics as one of the foundations of medical practice, whereas the latter provides the opportunity for its use on a daily basis in clinical settings. However, like any new curriculum, to achieve equal status with the traditional biomedical curriculum, it must be presented in a scholarly, rigorous, and reasonably comprehensive fashion. Mounting a scholarly health policy curriculum requires a wide-ranging, interdisciplinary faculty. If it is to become a central component of the medical school curriculum, creative approaches to faculty recruitment and development will be needed. This will require both careful educational policy formulation and new investment.

Using self-reported data to predict expenditures for the health care of older people.

OBJECTIVES: To create and test a method for using self-reported data to predict future expenditures for the health care of older people. DESIGN: A two-stage regression model of the relationship between self-reported data and Medicare expenditures during the following year was constructed from a randomly selected (derivation) half of a cohort of fee-for-service Medicare beneficiaries. For the other (validation) half of the cohort, two sets of predictions of 12-month Medicare expenditures were generated, one using the new two-stage model and the other using the principal inpatient diagnostic cost group (PIP-DCG) method now used to risk-adjust capitation payments to Medicare + Choice health plans. Both sets of predictions were compared with Medicare's actual 12-month expenditures for the validation cohort. SETTING: Ramsey County, Minnesota. PARTICIPANTS: Community-dwelling Medicare beneficiaries aged 70 and older (N = 13,682) who responded to a mailed survey. MEASUREMENTS: Predicted-to-observed ratio (PTOR) of Medicare expenditures. RESULTS: For the validation cohort, Medicare's actual 12-month expenditures totaled $26.5 million. The two-stage model predicted Medicare expenditures of $26.4 million (PTOR = 1.00); the PIP-DCG method predicted $31.2 million (PTOR = 1.18). Within subpopulations of healthy and ill beneficiaries, the two-stage model's predictions remained considerably more accurate than the PIP-DCG predictions. CONCLUSION: Self-reported data may predict future Medicare expenditures more accurately than administrative data about beneficiaries' demographic characteristics, and previous hospitalizations.

One school's strategy to assess and improve the vitality of its faculty.

The authors report how one medical school took an evidence-based, collaborative approach to assessing and improving faculty vitality by building on previous research and including important shareholders (e.g., faculty and administrators). In 1999, the dean and faculty senate asked all full-time faculty (615) at the University of Minnesota Medical School-Twin Cities to complete a survey to (1) identify vitality areas (individual, institutional, or leadership) in which the school was strong and ones that needed improvement, (2) identify strategies for addressing weak areas, and (3) provide a baseline against which to measure the impact of any vitality efforts initiated. The survey was based on features that research studies have found to be associated with academic productivity. Seventy-six percent responded. Summaries of the survey findings were prepared for use at the school level, department level, and special group level (e.g., women, clinical-scholar-track faculty). Three key school-level findings were that (1) there is a disconnect between the stated vision of the school and the departments' visions and actions, (2) there is not enough time for scholarly activity, particularly in the clinical departments, and (3) faculty lack the support of a collegial atmosphere and appreciation for the work they do. In response to the survey's findings every department identified priority faculty needs and initiated tailored development strategies. School-wide strategies were also initiated to address faculty needs common across departments and needs unique to special groups. Together these strategies provide a multi-level, systematic approach to maintaining faculty vitality.