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A Collaborative Approach to Achieving NCQA PCMH Recognition Within Family Medicine Residency Practices Carina M. Brown; Peter F. Cronholm, MD, MCSE; Jessica Wright, MPAP; William J. Warning II, MD; Lee Radosh, MD; Robert Gabbay, MD, PhD BACKGROUND AND OBJECTIVES: The Pennsylvania Academy of Family Physicians (PAFP) developed a statewide Residency Program Collaborative (RPC) to facilitate family medicine residency practices in Pennsylvania becoming recognized patient-centered medical homes (PCMHs). This report outlines the methods and a brief evaluation of the RPC, which included 20 residency practices. Participants attended tri-annual learning sessions and monthly conference calls, received physician faculty mentorship, and reported clinical quality data monthly on diabetes and ischemic vascular disease. METHODS: Two years after the start of the RPC, surveys were sent to residents, staff, providers, and administrators at participating practices to measure attendance and usefulness of collaborative sessions, mentors, and monthly reports. Evaluators also mapped the RPC curriculum to the Accreditation Council of Graduate Medical Education (ACGME) Core Competencies. RESULTS: All 20 participating practices achieved National Committee for Quality Assurance (NCQA) PCMH recognition, with 17 attaining Level 3 recognition. A total of 295 surveys were collected (92 residents, 71 faculty, and 132 office staff/administrators). Survey data showed higher collaborative attendance for residents and faculty compared to office staff/administrators (~84% versus 45%). No differences were noted between resident and faculty respondents regarding perceived helpfulness of collaborative sessions (6.3 and 6.5, respectively), mentors (6.6 and 6.2) and monthly reports (6.4 and 6.5), with both groups rating these components more highly than staff/administrators (5.3, 5.3, and 5.4 for each category). CONCLUSIONS: Learning collaboratives can assist residency practices in achieving PCMH recognition while concurrently providing an educational framework aligned with residency program Core Competencies. The RPC intervention, including learning sessions, monthly conference calls, data reporting, and faculty mentors, also can effectively guide residency practices in the PCMH transformation process and can serve as a means to experientially imbue future family physicians with the attitudes and skills to create and effectively operate their practices under PCMH principles. (Fam Med 2014;46(1):19-27.)

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T

he patient-centered medical home (PCMH) has been proposed as a solution to improve the delivery of primary care.1 Practices implementing the PCMH model have shown improved measures of quality care compared to more traditional models of care, particularly for patients with chronic conditions.2,3 Currently, heart disease, diabetes, hypertension, and other chronic diseases account for 70% of all deaths in the United States and three of every four health care dollars spent.4 As PCMH initiatives and evaluations throughout the country increase, evidence supporting the effectiveness of the model in improving patient care continues to grow.5 Medical educators must keep pace with the changing paradigms of primary care health delivery models as they prepare the next generation of clinicians. Yet, current resident education provides limited training within systems designed to meet the needs of patients with chronic conditions.6,7 In 1998, the Accreditation Council of Graduate Medical Education (ACGME) initiated the Outcomes From the Penn State College of Medicine (Ms Brown); Department of Family Medicine and Community Health, University of Pennsylvania (Dr Cronholm); Penn State Hershey Diabetes Institute (Ms Wright); Crozer-Keystone Family Medicine Residency Program, Springfield, PA (Dr Warning); Family Medicine Residency, The Reading Hospital and Medical Center, West Reading, PA (Dr Radosh); and Joslin Diabetes Center, Harvard Medical School (Dr Gabbay)..

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Project, which outlined six Core Competencies. The goal of the competencies was to help ensure quality education and prepare physicians to enter the workforce environment.8 As implementation of the PCMH has been found to improve quality of care, the American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), and American Osteopathic Association (AOA) developed PCMH educational competencies and sub-principles for physicians. These educational competencies must be integrated into resident education, as many of the outlined goals significantly overlap with curricular elements also required by the ACGME.9 Changing practice paradigms requires residency programs to develop methods to prepare trainees to both work within practices functioning as a PCMH and help existing practices in the transformation process to a PCMH.9,10 The learning collaborative model, based on the Institute of Healthcare Improvement’s (IHI) Breakthrough Series, has been previously found to help traditional practices achieve improvement in patient outcomes.11,12 Learning collaboratives

bring together teams to facilitate communication about developing and implementing successful practice transformation processes. Over the course of 2 years, more than 150 primary care practices in Pennsylvania took part in a learning collaborative process through the Chronic Care Initiative (CCI) aimed at optimizing chronic care delivery and transforming primary care practices statewide into PCMHs. The Pennsylvania state government developed the initiative, while the Pennsylvania Academy of Family Physicians (PAFP) performed data analysis and provided assistance in the form of practice coaches. Through participation in quarterly face-to-face learning sessions, monthly conference calls, and monthly quality metric data reporting, all complemented by on-site coaching, the CCI participants demonstrated improved care for patients with chronic conditions and achieved high rates of National Committee for Quality Assurance (NCQA) PCMH recognition.13 Based on experience with the CCI, the PAFP joined forces with primary care residency faculty across Pennsylvania to establish a residency-specific intervention,

with similar goals of improved patient care through PCMH implementation. Increasing educational demands, combined with limited research to effectively guide residency practice improvement, present unique challenges to residency practices attempting to keep pace with the ever-changing health care system.14,15 This report describes the curriculum of the largest single-state family medicine residency-specific PCMH collaborative, its outcomes related to NCQA recognition and participant satisfaction, and its relationship to the ACGME Core Competencies.

Methods Overview

The PAFP, along with family medicine residency physician faculty, initiated the Residency Program Collaborative (RPC), which developed the structure to improve chronic disease outcomes and transform family medicine residency practices throughout Pennsylvania into NCQA-recognized PCMHs (Table 1). The Pennsylvania Department of Health (DOH) and unrestricted educational grants from the private industry provided monetary support

Table 1: Overview of the Pennsylvania Academy of Family Physicians (PAFP) Residency Program Collaborative (RPC) Initiative During the Evaluation Period, Which Included Years 1 and 2 of the Collaborative Essential Features of PAFP Residency Program Collaborative Tri-Annual In-Person Learning Sessions Teams from residency practices attended in-person learning sessions every 4 months throughout the 2 years, which included didactics, team meetings, small-group sessions, and panel discussions. Monthly Practice Team Conference Calls Practices received didactic training, usually in webinar format, in a select PCMH topic. An open discussion time followed these informative sessions. Physician Faculty Mentors Residency faculty with PCMH experience acted as key off-site contacts to provide advice and guidance for five to seven practices. Mentors reviewed monthly data reports and provided written feedback. Monthly Quality Data Reporting Practices submitted evidence-based process and outcome measures. Information Sharing Practices shared information via e-mail and over a secure extranet. This extranet provided resources regarding practice transformation, chronic disease management, and NCQA PCMH recognition. Achievement of NCQA PCMH Recognition Collaborative leaders set the expectation that each practice attain NCQA PCMH recognition. NCQA—National Commission for Quality Assurance PCMH—Patient-centered medical home

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for the collaborative. The funds were utilized to reimburse participants for travel costs incurred, provide a small stipend to physician faculty mentors based on the number of estimated hours dedicated to this project monthly, and offset PAFP administrative costs. During the evaluation period, from July 2010 through June 2012, practices participated in learning sessions and conference calls. These elements were augmented by an identified physician faculty mentor, each of whom acted as a key resource for a small set of practices. Physician faculty mentors were selected based on their own experience with PCMH transformation in the CCI. PAFP staff managed practice data and provided administrative support, all coordinated through the Quality Initiatives Collaborative director. Practices worked to improve specified chronic disease measures and concurrently sought to achieve NCQA PCMH recognition.

Participants

All Pennsylvania family medicine residency programs were invited to join the RPC. Participation in the collaborative required attendance at tri-annual learning sessions and monthly conference calls, as well as monthly data submission. A total of 16 of the 30 Pennsylvania family medicine residency programs joined the collaborative. Other programs did not join due to prior participation in the aforementioned CCI or inability to meet RPC attendance and electronic data submission requirements. The 16 programs consisted of 22 family medicine residency practice locations. For this report, we included those practices that attended the six learning sessions and submitted the required chronic disease measures over the 2-year evaluation period, which totaled 20 of the 22 participating practices (91%). The characterization of practices by affiliation, location, and size was defined based on the AAFP Residency Database.16 Electronic medical record

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(EMR) information was gathered via survey data. None of the participating practices had achieved NCQA certification prior to joining the collaborative. Classification for NCQA recognition was derived from the NCQA Recognition Directory as defined by the 2008 NCQA PCMH guidelines.17

Collaborative Program Goals and Objectives

During the first year, the collaborative aimed to help practices achieve NCQA PCMH recognition and improve type 2 diabetes measurements. The RPC leaders required monthly submission of 14 evidence-based diabetes process measures, along with six outcome measures. During the second year, the collaborative added the goal of improving ischemic vascular disease measures with the addition of seven evidence-based measures. Practices shared ideas and submitted chronic disease data through a secure, central, web-based repository. A third, implicit goal of the collaborative was to develop a curriculum that could successfully balance PCMH transformation work with residency education goals.

Collaborative Structure

Throughout the evaluation period, the RPC held six day-long learning sessions at various locations throughout Pennsylvania (Table 1). Teams from participating practices, which included at a minimum a physician faculty, a second-year resident, a lead clinical staff member and/or a lead non-clinical staff member, attended the in-person learning sessions. Most practices kept the second-year resident on the team the following year, while a rising secondyear joined the team. Attendance at each learning session was required for travel reimbursement during the second year. Learning sessions were generally composed of 2 to 3 hours of interactive lectures along with 2 hours of small-group sessions specific to residents, staff members, or faculty physicians. Lectures and

small-group sessions were supplemented with team presentations and networking opportunities. Along with the learning sessions, RPC leaders established 24 mandatory monthly conference calls. These calls usually included 15 minutes of collaborative administrative information followed by a 45-minute didactic webinar-style presentation. An open discussion, in the form of casual questions and answers, followed the didactic material (Table 1). All materials presented during learning sessions and monthly conference calls were available for later review through the secure, central, web-based repository of RPC materials and data. On average, each physician faculty mentor provided support for six assigned practices (Table 1). Mentors assisted practices through offsite support and provided feedback for submitted measures of chronic disease management. The physician faculty mentors were available to participants by phone, e-mail, and during monthly calls to answer questions.  

Collaborative Evaluation

Semi-structured interviews were conducted with the PAFP Quality Initiatives Collaborative director and four of the five physician faculty mentors. The research team developed a structured interview guide, which explored initial PCMH experience, role perception within the RPC, and essential components of learning sessions and monthly conference calls. Interviews were audiorecorded and transcribed to supplement field notes. Team members identified salient themes within the transcribed narratives. Disagreements in analyses were resolved by group consensus.

Evaluation Survey

Surveys were sent to all residents, faculty, and office staff at practices participating in the RPC collaborative. Surveys included measures of reported attendance and self-assessments of the usefulness of collaborative sessions, mentors and monthly

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reports. Attendance was measured as a categorical variable (Answers: yes, no, don’t know) and helpfulness of curricular components was measured on a scale from 1 to 10 with “10” being the most helpful, as reported in Table 3. Measures were compared across stakeholder groups and measures of association included chi-squared test of proportions for categorical variables and ANOVA for comparisons of means across stakeholder groups (Table 4). Between group comparisons were made using t testing for continuous variables (comparing percentages of reported attendance) and chi-squared for the categorical variable (comparing means of reported helpfulness). SAS software was used for all analyses.19

Development of PCMH Curricular Content and Educational Competencies

Content from learning session materials and monthly conference calls were summarized and analyzed for curricular content. Similarly, content from both direct and audiovisual observation of learning sessions

Table 2: An Overview of Participating Practice Characteristics Residency Program Characteristic

Percentage

Residency practice location (n=20) • Rural practice sites • Urban practice sites

35% 65%

Size of residency program (n=16) • Large (≥8 PGY1 entering) • Small

50% 50%

EMR utilized • EPIC • AllScripts • MedDent • Athena • Other

35% 10% 10% 10% 35%

NCQA PCMH recognition within 2 years (n=20) • Level 3 • Level 2 • Level 1

85% 5% 10%

EMR—electronic medical record NCQA—National Commission for Quality Assurance PCMH—Patient-centered medical home

and presentation materials were analyzed for curricular content. Conference call curriculum components, identified through itemized agendas, were tabulated. The identified

curricular elements were correlated with the ACGME Family Medicine Residency Core Competencies.18 This study was granted an exemption by

Table 3: Summary of Attendance and Helpfulness of RPC Collaborative Components Across Stakeholder Groups Residents (n=92) Did you attend a learning session during your time at this residency practice?

 

Faculty (n=71)  

Staff (n=132)  

Total (n=295  

P Value