Family Medicine Residencies Are Incorporating Medical Home Model

P4 Programs May Be Leading Off, But Others Not Far Behind

February 17, 2009 03:30 pm Barbara Bein

Although most family medicine residencies have begun adopting pieces of the patient-centered medical home, or PCMH, model, the 14 residencies taking part in the Preparing the Personal Physician for Practice(, or P4, initiative, are well down the road when it comes to educating future family physicians in this new environment. The P4 initiative is being coordinated by the AAFP's wholly owned practice redesign subsidiary, TransforMED LLC.

"We believe that many of the residencies in the P4 demonstration initiative already are among those furthest along in implementing this model of care," says Gerald "Jay" Fetter, EVP of the Association of Family Medicine Residency Directors and director of the P4 project. "The residencies in Middletown (Conn.), Hendersonville (N.C.), and the University of Colorado in Denver are examples that plan to share what they have learned at upcoming national meetings."

Middlesex Hospital Residency

Located next door to MHS Primary Care, a TransforMED LLC national demonstration project, the Middlesex Hospital Family Medicine Residency Program in Middletown, Conn., has been taking advantage of TransforMED's consulting services.

According to program director Michael Stehney, M.D., the residency has worked through numerous modules, or core competency sets, that are part of TransforMED's Medical Home Implementation Quotient( program. One major transition the program plans, he says, is moving from a three-year program training eight residents a year to a four-year program with six residents a year. The extra year will allow more core rotations in areas such as behavioral and developmental pediatrics, home health care, systems medicine, and practice management.

The program has had a well-established electronic health record, or EHR, system for some time, Stehney says, but it recently launched a Web portal that lets patients access their medical information, make their own appointments and communicate directly with their care team.

Stehney says he's most proud of the program's interdisciplinary quality improvement teams, which comprise physicians, nurses and other office staff. The teams identify and implement best practices for managing various health conditions, providing preventive services, and monitoring medication efficacy and safety.

"They've helped us look at education, they've taught teamwork and best practices, they've helped us improve our workflow and we've also used them to help our billing," Stehney says.

"We have our eyes on this goal of fully implementing the model of the PCMH," he adds. "We'll be there a year from now. But we already have a lot of elements in place. Our hypothesis is that our graduates will implement the features of the PCMH in their practices or choose a practice that has these features."

Hendersonville Residency

Located in western North Carolina, the Hendersonville Family Medicine Residency Program trains its residents in three rural practices linked by the same EHR system.

New residents soon learn that the program's shared EHR and other health information technology, or HIT, systems are the centerpiece of the practice environment and undergird all interactions between health care professionals and patients, says Geoff Jones, M.D., program director.

Patients can use a Web portal to book their own appointments, choose the care team member they want to see and enter information into their own charts.

At the main residency practice site, the front desk and the waiting room have been eliminated. Members of the health care team communicate with each other and with staff members via walkie-talkie. When a patient comes in, a staff person equipped with a computer and a walkie-talkie contacts the team.

Patients first go to a room outfitted with scales, a phone and a computer. There, care team members perform such tasks as recording their vital signs, ordering tests or drawing blood. Physicians and physicians-in-training access care guidelines online, where they also can get answers to an array of clinical questions.

"They get a lot done electronically," Jones says, adding that the care team has cut a typically hour-long visit to 30 minutes. That means physicians and physicians-in-training can spend more time interacting with patients, he says.

University of Colorado Residency

At the University of Colorado Family Medicine Residency in Denver, residents have a new curriculum that spotlights PCMH features, such as chronic disease management, health behavior change, information management and community integration, says program director Daniel Burke, M.D.

First-year residents learn about PCMH concepts in three discrete skill-building blocks that focus on various aspects of care for adults, infants and children, and older patients. Cardiovascular life support, life support in obstetrics and pediatrics, ICU care, and orthopedics are among topics covered.

To hone their skills, residents may tackle a case presentation on how to help a patient quit smoking or lose weight through stage-of-change analysis, motivational interviewing and other patient-centered techniques.

As part of the program's community integration emphasis, care teams might help create a community directory of resources tailored to patients' special needs and lifestyles, says Burke. For example, patients with diabetes need to exercise. If they are affluent, they can buy a gym membership. But for patients who aren't well off or who live in dangerous neighborhoods, the directory might list a church group that offers exercise in a safe environment.

It's all part of the whole-person orientation the program strives to instill in its residents, Burke says. "We don't look at a patient in the context of a 15-minute visit but in the context of where they are in their family and where the family is in the community. Knowledge of those areas allows us to have better leverage on getting people healthier."

Smoky Hill Residency

Perhaps propelled by the early successes of residencies participating in the national P4 project, programs that are not part of the P4 initiative now are jumping on the PCMH bandwagon, as well.

The latest is the University of Kansas School of Medicine-Wichita Family Medicine Residency Program at Smoky Hill-Salina, which focuses on training family physicians to practice in rural areas. Last month, the program announced plans to establish the PCMH model of care, with technical assistance from TransforMED, according to residency director Robert Freelove, M.D.

The transformation project will focus on more fully integrating the program's EHR and other HIT systems; increased patient self-support; scheduling innovations; and alternatives to the routine office visit, says Freelove. Residents will learn how to use the EHR to look at population-based health and care concepts; they'll also use it for point-of-care reminders and decision support. Another major goal is to expand patients' access to information by bringing them into the electronic system.

When the transformation is completed, Smoky Hill will be among the first residency programs in the nation to offer training in a comprehensive medical home environment.

"All family medicine residency programs are doing some of the things in the patient-centered medical home, but there aren't many places doing all of it. I want to be one of those places" doing it all, says Freelove.