Criteria for Excellence | Chapter 9C: Models of care delivery
Explore care delivery models that strengthen patient care and resident training.
Use the patient-centered medical home model in family medicine residency
Models of primary care delivery continue to evolve, and the desire to deliver the Quadruple Aim will drive further pressure to accelerate change. The challenge faced by many programs is how to provide the best clinical and educational environment for all stakeholders and mitigate stressors that accompany change. The patient-centered medical home (PCMH) describes the core tenets of primary care with a team-based approach. A Program of Excellence focuses on using this framework for providing care that is accessible, comprehensive, coordinated, and patient centered.
Adopt a Clinic First approach to residency training
Residency teaching programs have two equally important missions: educating tomorrow’s physicians and caring for today’s patients. In the past decade, innovative family medicine teaching programs have begun a shift in the balance between inpatient teaching and ambulatory teaching, moving toward creating a more leading role for ambulatory care. In this framework—called Clinic First—the clinic is the curriculum. In the new paradigm, education and service to patients are inseparable, so this shift in paradigm may more aptly be termed “patient first.”
Use the Clinic First framework to transform teaching practices
The Clinic First framework was developed at the University of California San Francisco (UCSF) Center for Excellence in Primary Care based on their work on transforming primary care education using the 10+3 model. This model extends the 10 building blocks of high-performing primary care to include three elements unique to teaching clinics: resident scheduling, engagement, and work-life balance. Programs of Excellence engaged in transforming to a Clinic First model can use the Building Blocks of Primary Care Assessment for Transforming Teaching Practices (BBPCA-TTP) as a guide.
Residency Program Solutions (RPS) recommendations are based on research on Clinic First innovators conducted by the UCSF Center for Excellence in Primary Care and other recent studies. An increasing number of Clinic First residency programs have demonstrated that providing excellent ambulatory patient care is the foundation of excellent family medicine graduate medical education. However, RPS believes family medicine residencies are early in this transformation trajectory. While Clinic First residency programs are embracing a new balance between inpatient and ambulatory rotations, other residency programs are exploring earlier stages of the transformation of teaching practices.
Prepare residents for advanced primary care models
It is important for all residents to have a working understanding of the principles of advanced primary care practice and available models. A Program of Excellence will keep current with the range of primary care demonstration projects, as well as the outcomes of these projects as they become available. In addition, it will consider how advanced practice models can be implemented in the family medicine practice (FMP) as specific funding becomes available.
Teach value-based payment and the Quality Payment Program
The Medicare Access and CHIP Reauthorization Act (MACRA) became law on April 16, 2015. The most important aspect of MACRA is that its initiatives move away from fee-for-service (FFS) payment toward value-based payment models. MACRA created the Quality Payment Program (QPP) with two tracks of payment:
- Merit-based Incentive Payment System (MIPS), which adjusts FFS payment based on quality, cost, improvement activities, and promotion of interoperability.
- Advanced Alternative Payment Models (AAPMs), which provide a type of incentive, plus bonuses based on quality and utilization.
Integrate value-based payment into the residency curriculum
A Program of Excellence needs a curriculum component focused on non-FFS payment methodology with specific instruction regarding the QPP. The program also needs an experiential component wherein the clinical practice takes advantage of enhanced payment opportunities provided by MACRA as these opportunities become available in a service area.
Metrics for excellence in care delivery
The practice participates in an organized, comprehensive performance improvement process, such as PCMH recognition.
The program continuously enhances residents’ primary care experience, including adopting models such as Clinic First.
Residents participate in a curriculum that gives them a working knowledge of developing innovations in primary care.
Residents and faculty understand the principles of MACRA and how to successfully navigate in that system.