Rejuvenated Duke Family Medicine Residency Blossoms

Like dogwood in the spring, the Duke University Family Medicine Residency in Durham, N.C., is blooming -- just two years after the residency's faculty and administrators completely redesigned the program to emphasize community-based medicine and other innovative models of care.

In fact, according to program director Brian Halstater, M.D., the National Committee for Quality Assurance, or NCQA, in March recognized the program's core residency clinic, The Duke Family Medicine Center, as a Level 3 Physician Practice Connections-Patient-Centered Medical Home, or PPC-PCMH -- the NCQA's highest designation.

Perhaps even more impressive is that the NCQA recognition comes just three years after the residency program announced its closing in 2006. The program reopened in 2008 with a revitalized program and a strong commitment from Duke University administrators.

"We're very excited about the medical home recognition," Halstater told AAFP News Now. "It remains to be seen if it attracts applicants."

The auspices seem encouraging. Four first-year residents are expected to start training in July, joining four second-year residents plus a fourth-year fellow seeking a master's degree in clinical leadership, a feature of the Duke program. Overall, the residency seeks to train 12 residents in its three-year program and might take more residents in the future, Halstater said.

Kimberly Yarnall, M.D., is medical director of the division of community health within the Duke University Medical Center Department of Community and Family Medicine. She said the residency has been trying out new models of care based on the premise that there's not enough time for a primary care physician to manage chronic care, preventive care and acute care for 2,500 patients, the average patient panel.

"The reason we can't go back to the old model of one physician, one patient and one office is that it doesn't work. We're trying to find a model that fits what the patient needs. The doctor manages all the resources available to get patients what they need to be healthy," she said.

Residents in the program now are trained in a model that keeps physicians in a central position of care, but doesn't require them to do everything, Yarnall said. Instead, teams that include nurses, physician assistants and other mid-level practitioners, as well as a nutritionist, a physical therapist, a social worker and a case manager, assist them.

For example, Yarnall said she takes care of difficult patients who have more complicated diseases and the potential of having more drug interactions. She also looks at disease registries and areas in which the practice and all its health care providers can improve.

"This is the model we're trying to teach residents -- how to supervise mid-level practitioners, how to set up disease registries, how to analyze data in disease registries, how to figure out what certain groups in the community need," she said.

Yarnall noted that in some communities outside of Durham, children with asthma go to the ER frequently because they don't get their medications filled on a routine basis. For these patients, physicians have to figure out ways they and their families can obtain the child's asthma medications more easily and consistently.

If an elderly family member already is getting his or her medications regularly, then home delivery of medications could be arranged for both the asthmatic child and the senior at the same time, she said. This keeps the family from having to go to the ER for the child's asthma exacerbations.

Other important elements of the residency program involve team-based care delivered outside the office. Yarnall said Duke has an agreement with the federally qualified Lincoln Community Health Center in Durham to jointly set up and operate four satellite "practices."

One of these practices actually is a home care program for low-income elderly and disabled people known as Just for Us. In this program, a resident pairs up with an attending physician to provide care in the homes and apartments of elderly and disabled adults, many of whom are in Medicare and Medicaid programs.

"We take the medical home to the home, and medical care becomes part of everyday life," Yarnall said.

Residents also get experience providing care to patients at community-based clinics that were set up in areas with the greatest need. One, the Walltown Neighborhood Clinic, is located in a renovated old house, and another, the Lyon Park Clinic, is in a school-turned-community center -- both in disadvantaged neighborhoods, said Yarnall. A third clinic will be in a renovated middle school, she said.

Residents are trained in still another setting: schools. They work in clinics, or wellness centers, at the Glenn, George Watts and E.K. Powe elementary schools and at the greater-volume, Southern High School in the Durham Public Schools district. They give talks on health topics to children and teens at these schools, participate in health fairs and do health screenings for children in kindergarten, Yarnall said.

During their three-year program, residents "will be introduced to all these models of care -- the school-based care, the senior care, the community clinic where you never know what (kind of patient) will walk through the door," she said.

Another unusual aspect of the program is that residents are educated to be clinical leaders in their communities. Third-year residents are required to take courses offered by the community and family medicine department that cover a wide scope of topics, such as health care finance, medical informatics, operational management, quality measurement and improvement, and strategy implementation in health care, to earn a certificate in health leadership.

If they stay for an optional fourth-year fellowship, they take additional coursework in financial management, health economics, and health law and policy in the Fuqua School of Business, the Terry Sanford Institute of Public Policy, the Duke University School of Nursing and the School of Law. Successful completion of the fellowship earns them a Master of Health Sciences in Clinical Leadership degree.

Halstater said, "Our focus is to teach residents how to not only work in the community but also to think more broadly in the context of the family and the community and what role providers can take to improve the health of the community."