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There is an increasing need for physician trainees to learn management of chronic illness. Training in chronic illness management is complicated by the acute care orientation of most healthcare systems. Coming on top of the broadening range of competencies that reflect the changing needs of healthcare delivery is the shift in evaluation of physician trainees in several countries to competency-based methods.12 The Accreditation Council for Graduate Medical Education (ACGME) has defined six core competencies: systems-based practice, practice-based learning and improvement, patient care, medical knowledge, interpersonal and communication skills and professionalism.3 Explicitly included now are two competencies essential for effective patient care and quality improvement—Systems Based Practice (SBP) and Practice Based Learning and Improvement (PBLI). Although all six competencies apply to management of chronic illness, these two have been the most difficult for residency programmes to address in any comprehensive manner.4–6 Training venues that mesh a systems approach to high-quality outpatient care for chronic illness with effective teaching are needed.7–10 Among the models proposed for healthcare system redesign is the chronic-care model (CCM) of Wagner et al. We suggest that this model with its six major elements (delivery system design, information systems, healthcare system, self-management, decision support, and community, italicised below for clarity) provides a conceptual framework around which education about chronic disease management can be organised.1112 We describe how we use a CCM-inspired outpatient clinic redesign, the diabetes shared medical appointment (SMA), to address the six core competencies. We illustrate how management in this setting of a paradigmatic chronic illness involves all six competencies and emphasise its utility, especially in SBP. We will discuss the six components of the CCM by heading and their application in our setting.
CCM AS APPLIED TO SHARED MEDICAL APPOINTMENTS/GROUP VISITS
Delivery system design
SMAs, also called “cluster visits,” “group visits” or “chronic healthcare clinics,” have been gaining popularity, in part based on efficacy similar to or better than usual care.13–18 SMAs or group appointments are based on a redesign of the type of care from individuals to group and constitute a planned visit. In our setting, a multi-/interdisciplinary team sees a group of patients (eight to 20) with diabetes for approximately 90 min. The SMA is structured in four patient phases: (1) welcome and introduction to the diabetes related topics to be discussed (∼5–15 min); (2) interactive learning and group facilitation of topics (∼20–30 min); (3) patients and family members/care givers sharing experiences (45–55 min); and (4) individual visits with the physician, nurse practitioner or clinical pharmacist, depending on patient need (∼10–15 min). After each clinic session, the multi-/interdisciplinary team with trainees sits down to discuss clinic flow for process improvement and patient plan for care.
The organisational transformation of the Veterans Health Administration (VA) has been described previously.1920 Of particular relevance to VA are long-term outcomes because once a patient enters the system, they stay for life. Consequently, the VA has a special interest in chronic illness care and an extensive series of quality measures specifically targeting chronic disease. Among the methods that have been used to improve quality and access to care are SMAs, which have been mandated as part of this organisation-wide improvement effort. All of our work takes place in the Veterans Healthcare Administration, a healthcare system which prioritises demonstration of quality of care measures and has mandated group visits as a way to improve access.1920
Clinical information system
Our diabetes SMAs are conducted in the context of an academic primary care clinic that provides care for ∼10 000 patients in a tertiary care medical center. Potential participants are identified using a local clinical registry of patients with diabetes (who constitute ∼25% or the clinic population). Patients with poor control or intermediate outcome measures (A1c >9, and/or systolic blood pressure >160 and/or ldl-cholesterol >130) are targeted for participation. Many of these patients have been labelled “non-adherent” by their primary-care providers.
Issues related to patient self-management, management of hypoglycaemia, and long-term sequelae of diabetes along with each patient’s laboratory results are discussed in the group by the patients and a multi/interdisciplinary team (prepared proactive team) of general internist, diabetes nurse practitioner/certified diabetes educator, health psychologist, clinical pharmacist and registered nurse. Most of the SMA is devoted to sharing of experiences between patients. Necessary medication adjustments are done individually. Additional resources in and out of the VA are discussed.
The VA is unique in terms of its being a relatively self-contained system offering a wide variety of services so that additional resources from the community are less of an issue. However, thinking broadly about what constitutes community, patients participate in VA supported and community weight loss programmes, tobacco cessation counselling, and exercise facilities. Patients get referral to physical therapy for pool use, nutrition classes and further self-management classes. Patients are informed of community resources for healthy eating, exercise and family support.
Because an endocrinologist was not available to participate in the SMA, although readily available for consultation, we sought specialist expertise from an Endocrine NP who was also a certified diabetes educator. She assisted with the integration of evidence-based guidelines into a clinic note template in our electronic medical record and with the implementation of this note within the SMA.
SHARED MEDICAL APPOINTMENTS AND TRAINEES
The integration of trainees into SMAs has been accomplished within the month-long ambulatory block rotations that internal medicine trainees do annually. All internal medicine trainees have an experience in this or another of our chronic disease SMAs (eg, heart failure, hypertension) between two and six times during the ambulatory month. Our conceptual model integrating the CCM and ACGME competencies is shown in fig 1. The figure illustrates how the CCM in particular the system redesign is applied in a SMA with a multi-/interdisciplinary team. Potential outcomes are shown for trainee, patient and organisation. In addition to the trainee-focused outcomes that relate to the six core competencies (SBP, PBLI, medical knowledge, patient care, interpersonal/communication skills and professionalism), we also include self-efficacy in chronic disease management as well as outcomes that could be considered interprofessional (shared perspectives, teamwork, team self-efficacy and attitudes towards collaboration). These overlap to some degree with “uni-professional” outcomes. The interdisciplinary nature of the SMA provides an excellent setting to model and practice interdisciplinary care. The SMA provides an opportunity to demonstrate chronic illness care, quality improvement, patient self-management skills and patient self-efficacy. Resident physicians are exposed to the role of peer support and group facilitation as opposed to traditional lecturing. While providing new knowledge, skills and attitudes toward diabetes care, this model addresses many other aspects of the Internal Medicine core competencies. Table 1 outlines the six aspects of the CCM that we have utilised in developing this clinic and how they can be used to foster specific competencies. Although all core competencies relate to elements of the CCM, we emphasise here the competency of systems-based practice. We suggest that because SBP encompasses working with multiple professions, competence in SBP could be enhanced in the environment of an SMA. The CCM is a system redesign of the current outpatient system, and the SMA is a further redesign. Seeing patients in a group is a redesign of the traditional one-on-one medical appointment. Residents are encouraged to think not only about the individual clinician patient interaction, but about the patient in the context of the group clinic and how this interdigitates with the overall healthcare system. This model can be conducted efficiently, as 15 patients can be seen in 90 min. The multi-/interdisciplinary team approach fosters shared decision-making combined with deference to expertise not rank. Residents can develop an awareness of and responsiveness to the system of healthcare (the hospital and clinic) by interacting with pharmacy, nursing, nutrition and mental-health personnel. SMAs give residents the opportunity to practise patient care among other healthcare professionals and understand how their practice affects other professionals, the healthcare organisation and the larger society, and how these elements of the system affect their own practice.
ELEMENTS OF SYSTEMS-BASED PRACTICE AND SHARED MEDICAL APPOINTMENTS BASED ON THE CCM
According to the ACGME, the competency of systems-based practice is as follows: residents must demonstrate their knowledge of the environmental context and healthcare systems within which they function. The scope of systems-based practice includes four major elements: (1) familiarity with financing structures, the organisation and capacities of provider entities and delivery systems; (2) tools and techniques for controlling costs and allocating resources; (3) systems for improving the quality of care—shared medical appointments contribute to developing competency in all three of the elements; and (4) the roles and contributions of other professionals in caring for individual patients and populations. Residents must use their knowledge of system resources to provide care that is of optimal value. Our SMAs address all four elements. Although financing structures are considered elsewhere in our curriculum, issues of workload credit and coding for reimbursement are addressed during the orientation of the trainees prior to their participation in SMAs. Similarly, the history of the development of our SMAs which constitute a care system redesign cognizant of costs is also addressed. However, SMAs focus on the third and fourth elements.
SYSTEMS FOR IMPROVING THE QUALITY OF CARE
Among the key methods for improving care is the implementation of decision support, a strong feature of the VA’s electronic medical record. Though traditionally related to electronic notes, decision support also involves the team members and patients who provide additional information that allow success in individuals. For example, one patient described a restaurant close to the hospital established for patients with diabetes. Patient decision support can provide information regarding community resources. Similarly, clinical information systems underpin improvement efforts. In developing clinical venues for improving diabetes, we thought about disease-specific management. We utilised our diabetes registry to identify patients not meeting quality goals. This registry is used to track patients and is demonstrated to resident physicians who can then use it to identify patients in their own practices. With our electronic medical record, residents use a templated note and clinical reminders to guide clinical decision-making. In the future, patients will have access to their own medical information via MyHealthEVet, and this will not only facilitate communication between patient and team but also facilitate self-management.
ROLES AND CONTRIBUTIONS OF OTHER PROFESSIONALS IN CARING FOR INDIVIDUAL PATIENTS AND POPULATIONS
Residents are part of the multi-/interdisciplinary team which collaborates at the end of the patient session regarding observations and collaboratively develops a plan for each patient. Resident physicians participate in individualised appointments with patient and NP, or clinical pharmacist as preceptor to increase interprofessional communication and education regarding other disciplines’ perspectives. The SMA facilitator, usually a health psychologist, assists resident physicians in teaching patient self-management and developing patient self-management goals. Residents can observe how different patients have solved different problems in different ways that make the most sense for the individual patient. This also helps to identify the patient as an expert in addition to the provider team. Patient self-management goals are written on sheets which residents use in the SMA and in their continuity clinic. Residents recognise that other clinics and services exist to support patient self-management.
RELATIONSHIP OF SMAS TO OTHER COMPETENCIES
Residents in the SMA must communicate with patients and their families as a facilitator of patient to patient communication. This is a novel skill for residents which advocates a patient-centred approach as opposed to lecture format. A health psychologist watches and evaluates resident physicians demonstrating these skills and gives feedback. Residents must use their knowledge of system resources to provide care that is of optimal value. This involves not only competence in systems-based practice, but also practice-based learning and improvement. Information systems support practice-based learning and improvement by residents in their continuity clinics. It is from these clinics and other clinics that patients are identified to participate in the SMA. Many of the residents’ patients get referred and identified via registry and after participation residents can see how this type of clinic can improve their own patient’s A1c, blood pressure, cholesterol and self-management skills. This type of system redesign and the patient recruitment demonstrates a population-based approach to management. Sixty resident physicians (67%) have continuity clinic at the VA and thus have patients that may participate in the SMA. Some residents ask to have their patients seen in the SMA during the times that they are participating in the SMA so that skills learnt can be translated back to their own practice. Residents develop self-management skills that can then be applied systematically with patient-centred self-management materials to their own patient population in continuity clinic. Skills learnt in the SMA can translate into a resident physician’s continuity clinic practice. There, s/he can use the checkout sheets that patients take home newly revised to include a section on self-management goals. This checkout sheet revision was inspired by one of the residents participating in the SMAs.
INITIAL EXPERIENCES OF TRAINEES IN SMAS
Residency training, in particular the ambulatory component, requires reform in its structure site, content and timing with team-based models.9 Our model is a novel outpatient approach to diabetes that uses the CCM for resident training in chronic illness care while addressing the six competencies. It is the delivery system (SMA) specifically, designed in accord with the CCM, that allows us to meet the needs of patients with chronic illnesses and improve intermediate outcomes. Our experience in integrating residents into the SMA for the last 1½ years demonstrates the feasibility of this approach. Although this paper is primarily conceptual, we have obtained early feedback from trainees. Two focus groups were conducted by an individual not directly associated with the SMAs. Themes revealed in qualitative analyses of participants’ perceptions: (1) Patient Benefits (“shared expertise,” “gain insight from one another,” “discover universal issues,” “well suited to poorly controlled patients”); (2) learning from team members/patients (“ability to rely on shared experiences,” “multidisciplinary approach,” “responsibility is divided”); (3) SMA as a mode of healthcare delivery is well suited to chronic disease (“tackles all aspects of patient care,” “chronic care is a lot of work,” “must address all issues surrounding disease”); and (4) patient-centred approach (“patients learn differently,” “create solutions to achieve compliance,” “allow patients to identify areas of change”). There are many existing validated measures for patients and organisational outcomes that can be utilised as part of a broad assessment of SMAs and their impact. The situation for trainees, however, is somewhat different. We have pilot-tested an instrument in 16 trainees. Confidence when working with other provider types was assessed on a scale: 1 = very confident to 4 = very unconfident; lower numbers reflect greater confidence. Confidence in conveying the logic underlying your clinical recommendations to providers from other disciplines rose from 1.75 (SD 0.77) Pre to 1.64 (0.74) Post participation. Confidence in understanding the distinctive perspectives of providers from other healthcare disciplines rose from 1.88 (0.62) Pre to 1.79 (0.70) Post, but the differences were not statistically significant. However, the next critical steps involve the development and use of good assessment tools for trainees. In addition to qualitative assessment, we plan to use some existing instruments, for example, the Diabetes Attitude Scale, and adapt other instruments, eg Beliefs about Barriers to (Optimal) Self Care.2122 Other potential methods of assessment include resident portfolios, a self-management mini-CEX, 360 degree evaluation, and direct observation with checklist.6723 An assessment of competence and/or capability24 will come from measurement of quality of care provided by the trainees in their own primary-care panels.
We believe that the SMA represents a novel approach for residency training. However, the SMA also represents a potential venue for inter-professional training/collaborative practice, since it encompasses key components of team training: willingness to work together, trust in other’s abilities, good communication and negotiation skills, and mutual respect, which includes knowing what other health professionals contribute to patient care. The need for sites where chronic illness care can demonstrate high-quality care for patients and training residents is clear. Because sporadic experiences may be insufficient to meet training needs, we plan to integrate SMAs as part of routine care into the residents’ continuity clinics. In summary, the CCM is a system-based approach to management of chronic diseases that can serve as a model for linking high-quality care and high-quality training in systems-based practice.
We wish especially to thank the reviewers for their incisive and challenging comments which contributed to significant improvements in both our thinking about this subject as well as the manuscript. We thank Dr Katherine Thweatt for her assistance in conducting the pilot evaluation. We appreciate the opportunity to have participated in the Academic Chronic Care Collaborative sponsored by the Association of American Medical Colleges and the Robert Wood Johnson Foundation for assisting the team in clinical and professional development. These studies were supported in part by the Health Services Research and Development Service of the Department of Veterans Affairs.
Competing interests: None.
The views expressed are solely those of the authors and do not necessarily reflect the views of the Department of Veterans Affairs.
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