The Ambulatory Long Block: A University of Cincinnati Educational Innovations ProjectEric J. Warm M.D., Brian Revis M.D., Sara McCune M.D., Jennifer Ernst, M.D., Yvette Neirouz, M.D., Tiffiny Diers M.D., Bradley Mathis M.D., Gregory Rouan M.D.

BACKGROUND: Historical bias toward service-oriented inpatient graduate medical education experiences has hindered both resident education and care of patients in the ambulatory setting OBJECTIVE: Describe and evaluate a residency redesign intended to improve the ambulatory experience for residents and patients METHODS: We created the ambulatory long-block as part of the ACGME’s Educational Innovation Project. The long-block occurs from the 17th to the 29th month of residency, and is a year-long continuous ambulatory group-practice experience involving a close partnership between the residency and a hospital-based clinical practice. Long-block residents follow approximately 120-150 patients, have office hours 3 half-days per week, and are responsive to patient needs (by answering messages, refilling medications, etc.) daily. Otherwise, long-block residents rotate on electives and research experiences with minimal overnight call. Residents receive extensive instruction in chronic illness care, quality improvement, and inter-professional teams RESULTS: The long-block has resulted in significant improvement in multiple clinical process and outcome measures, as well as improved satisfaction among residents and patients. There has also been a trend towards decreased emergency department visit rates and no show rates. Additionally, the long-block resulted in a robust multi-source evaluation that identified high, intermediate, and low performing residents, and suggested specific formative feedback for each CONCLUSIONS: An ambulatory long-block can be associated with improvements in quality measures, resident and patient satisfaction, no-show rates, and evaluation NEXT STEPS: Future research should be done to determine which aspects of the long-block most contribute to clinical and educational improvement

ABSTRACT

BACKGROUND• Most internal medicine graduate medical education is inpatient-based

• This historical bias towards the inpatient setting has led to dysfunctional ambulatory training settings

• Many residents receive little support for ambulatory chronic illness management, improvement science, or interdisciplinary teamwork

• The end result of these combined deficiencies has been characterized as the “training/practice gap” – few internal medicine graduates leave residency with the skills needed to function effectively in the ambulatory setting

CONTEXT• The University of Cincinnati internal medicine residency program consists of 108 residents (69

categorical) based in a large academic health center

• The categorical resident ambulatory practice is an urban safety-net practice located next to the main teaching hospital

• Residents are responsible for approximately 19,000 ambulatory visits per year

• 58% of the patients have hypertension and 32% have diabetes; only 1% have private insurance

• Residents rated their ambulatory clinic experience low during exits interviews, reported little time for learning in the ambulatory setting due to difficulty balancing ward and ambulatory duties, and reported a lack of personal reward the ambulatory setting

• The practice also had poor patient-doctor continuity, poor clinical quality markers, poor patient satisfaction, and poor staff satisfaction

HYPOTHESIS• Improving resident physician continuity within a highly functional clinical micro-system would improve

care and education

INTERVENTION• Creation of an Ambulatory Long Block (now into the fourth year)

• Part of the RRC-IM/ACGME Educational Innovations Project (EIP)

NEW RESIDENCY STRUCTURE• PGY-1-2: Months 1-16

– traditional residency, mainly inpatient based, with fixed half-day in the ambulatory practice– small patient panels (15-30)– each PGY-1 is paired with a long-block resident who serves as cross cover and mentor– when the PGY-1 rises to the long-block, he/she inherits long-block partner’s patients

• PGY 2-3: Months 17-28 – The Long Block

– 1 year of electives, paired with ambulatory care; minimal inpatient call service time– patient panels expand (120-150)– residents have ambulatory office hours three half-days per week on average – residents are responsive to patient needs (by answering messages, refilling medications, EMR) daily– a portion of one morning is reserved for an ambulatory education curriculum (AME, figure below))– balance of time is spent on electives (ambulatory, inpatient, research)

• PGY 3: Months 29-36

– residents return to primarily inpatient care– no ambulatory continuity practice– selected residents may elect to continue a portion of their practice one half-day per week

LONG BLOCK MICROSYSTEM

• Prior to each clinic session, residents review the EMR, prepare a progress note, and make a list of things that must be done during the session

• Residents and nurses then have a pre-clinic “huddle” to review the patients that will be seen , and decide on an efficient plan for the day

• The large team is broken up into mini-teams

• Each mini-team consists of a nurse leader, and a group of residents, supported by many ancillary staff

• The entire team, including residents, nurses, and support staff learn improvement skills, motivational interviewing and shared decision making at a yearly retreat

• In 2007, the nursing staff transitioned from a mostly medical assistants to all RN and LPN level staff to provide case management

• A nurse practitioner was also added

• The practice uses an electronic medical record (Centricity) and a disease registry (MQIC)

• Residents receive extensive EMR training

• Data includes quality data (above), financial performance data, patient satisfaction data, visit volume data, and the results of ongoing Plan-Do-Study-Act cycles

CLINICAL QUALITY RESULTSAmbulatory Practice Report

Initial Long Block

Practice Goal %

Cohort 1

12.1.06

Cohort 1

10.31.07PercentChange

p value

Total Number of Patients 1907 2593 36%

Diabetes Measures (31% of patients)

HbA1c < 7.0% 60 43.8 47.7 9% 0.192

Blood Pressure < 130/80 40 37.9 47.1 24% 0.002

Comprehensive foot exam in 1 year 90 35.7 59.7 67% <0.001

On ACE inhibitors or ARB's 75 76.6 80.3 5% 0.130

On statins 60 64.7 70.6 9% 0.034

LDL < 100 mg/dl 70 65 66.6 2% 0.573

On aspirin 80 75.2 86.2 15% <0.001

Pneumonia vaccination in 10 years 90 70.9 78.5 11% 0.003

Influenza vaccination in 1 year 90 64.1 50.9 -21% <0.001

Hypertension (58% of patients)

Blood Pressure < 140/90 60 47.2 58 23% <0.001

LDL < 100 mg/dl 80 82.4 82.9 1% 0.770

Prevention (all patients)

Women > 42 with mammogram in 2 years 50 41.6 63.6 53% <0.001

Patients > 51 with colonoscopy in 10 years 30 36.4 48.6 34% <0.001

Women 18-50 with pap smear in 3 years 30 7.7 61.7 701% <0.001

Men 50-70 with PSA in 1 year 60 34.4 51.7 50% <0.001

Tetanus vaccination in 10 years 60 27.9 59.9 115% <0.001

Pneumonia vaccination in 10 years 90 64.6 83.3 29% <0.001

Influenza vaccination in 1 year 90 54.5 46.6 -14% <0.001

Women > 65 with DEXA in 5 years 60 10.1 54.2 437% <0.001

• The initial data from the first long-block showed significant improvement for many process measures and intermediate outcome measures of care

• The initial improvements have held, and the resident practice now has many measures of care that are better than the larger health system

No Show Rates

Academic Year Comment Resident Practice No-show rate

2002-03 Pre-Work-Hours Restrictions 33.8

2003-04 Work-Hours Restrictions Implemented 33.2

2004-05 Pre-Long Block 28.6

2005-06 Chronic Care Model Implemented 28.2

2006-07 First Long Block Implemented 26.1

Jun07-Oct 07 Second Year of Long Block 18.3

p-value for trend <0.0001

• No show rates during the first long-block improved, and have maintained this level over 4 years

Year 2003 2008 Resident Practice/Emergency Department Interface

Number of Individual Patients in Resident Practice 7593 4047 The total number of individual patients in the

practice dropped since 2003.

Total Number of Visits In Resident Practice 18118 19539 However, the visit volume has stayed stable, or

increased over this time.

Average Number of Visits In Resident Practice Per Patient 2.39 4.82 This has resulted in a 102% increase in visits

made per year per patient in the practice.

Percent of Patients Seen 1 Time Only 30.5 17.0 The number of patients visiting the practice

only once per year dropped 44%.

Percent of Patients Seen 3 or More Times 48.1 64.2 The number of patients visiting the practice

three or more times per year increased 34%.

Average Number of Visits in ED per Year Per Resident Patient

1.46 1.54The average number of ED visits per patient per year initially dropped, then rose to baseline.

Average Number of ED visits Made by Resident Patients Resulting in Discharge

1.15 1.09However, the average number of ED visits made by Resident patients that resulted in discharge home fell...

Average Number of ED visits Made by Resident Patients Resulting in Admission

0.31 0.44...and the average number of ED visits made by Resident patients that resulted in admission has increased.

Chance of Resident Patient Being Admitted if in the ED 21 28.5

The chance of a Resident patient being admitted if seen in the ED has increased 36%, and is 61% higher than the general average

Total Resident/ED Contact Points Per Patient 3.85 6.37

The total number of contact points for the two areas of care (Resident/ED) has increased 65%, with Resident visits comprising the largest share

Learner’s Perception Survey: ComparisonPre and Post Long Block

*Scale: 1 = very dissatisfied, 2 = somewhat dissatisfied, 3 = neither, 4 = somewhat satisfied, 5 = very satisfied

Prior to First Long Block

After First Long Block paired t-test

Time for learning 2.94 4.44 0.0004

Ability to focus in clinic without interruption 3.44 4.56 0.0057

Ability to balance ward/inpatient duties on clinic days 3.00 4.59 0.0018

Overall satisfaction with the learning environment 3.65 4.24 0.0075

Overall satisfaction with the clinical environment 3.44 4.33 0.0156

Personal reward from work 3.33 4.44 0.0042

Relationships with patients 4.06 4.72 0.0001

Sense of ownership and personal responsibility 3.72 4.78 0.0002

Rate the value of the continuity clinic experience 3.29 4.44 0.0006

Total experience (on scale of 0-100) 73.23 87.50 0.0016

EDUCATIONAL RESULTS

• The Learner’s Perception Survey demonstrated significant improvement after the long-block intervention

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A B C D E F G H I J K L M N O P Q R S T U V Patient Care

Team Work

Professionalism

Efficiency

Physician Explains

Physician Listens

Physician Gives Instructions

Physicians Knows History

Physician Respects Patient

Physician is On Time

Physician Calls Back

Overall Physician Rating

Patient Would Recommend

In-Training Exam

In-House Testing

Quality Process Measures

Quality Outcome Measures

Self Evaluation

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Peer, Staff, Attending Rank

Patient Evaluation Rank

In-Training Exam Rank

Process Quality Rank

Outcome Quality Rank

Self Evaluation Rank

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Peer, Staff, Attending Rank

Patient Evaluation Rank

In-Training Exam Rank

Process Quality Rank

Outcome Quality Rank

Self Evaluation Rank

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Peer, Staff, Attending Rank

Patient Evaluation Rank

In-Training Exam Rank

Process Quality Rank

Outcome Quality Rank

Self Evaluation Rank

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NCQA PCMH Standard University of Cincinnati Ambulatory Long Block Access and Communication Keeps written standards for patient access and communication

Reviews data weekly regarding access, visit volume and communication Patient Tracking and Registry

Functions Uses a disease registry (MQIC®) with searchable data fields Organizes clinical information and uses registry data to identify important diagnoses and conditions Generates lists of patients and creates reminders of services needed

Care Management Uses evidence based guidelines for multiple conditions (e.g. diabetes, depression, hypertension, hyperlipidemia) Uses electronic flow sheet to generate reminders to clinicians Uses non-physician staff to manage patient care (e.g. insulin titration, self management goal follow-up calls) Coordinates care for patients who receive care in inpatient facilities (e.g. shared medication reconciliation sheet)

Patient Self‐Management Support

Assesses language preference and other communication barriers (multiple translators, including for the deaf) Actively supports patient self-management (e.g. extensive inter-professional instruction of physicians and staff; use of ancillary staff including pharmacotherapy clinic; printed medication reconciliation and instruction sheet for every visit; follow-up phone calls for support)

Electronic Prescribing Uses an electronic system to write prescriptions (Centricity®), including automatic safety/interaction checks and cost checks

Test Tracking Tracks test and identifies abnormal results systematically Uses electronic system to order and retrieve tests

Referral Tracking Tracks referrals using electronic system Performance Reporting and

Improvement Measures and reports clinical performance by physician and across the practice (data reviewed monthly by care team, quarterly by hospital senior administration) Surveys patient experiences using Press-Ganey and homegrown satisfaction surveys Sets performance goals and takes action to improve performance Produces reports using standardized measures (e.g. Diabetes Physicians Recognition Program measures)

Advanced Electronic Communications

Uses electronic care management support Currently in process of obtaining electronic patient portal and e-prescribing

• The entire team meets weekly to review data and solve problems; an open agenda is set by all team members

• Every meeting starts with a patient story

• Residents receive individual reports monthly • Each report includes a ranking on each

measure compared with peers• Data is used as part of competency

evaluation

• Long Block residents receive comprehensive multisource feedback (MSF) that includes self, peer, staff, attending and patient evaluations, as well as concomitant clinical quality data and knowledge-based testing scores

• Residents are given a rank for each data point compared to peers in the class, and this data is reviewed with the chief resident and program director over the course of the long-block

• The table above shows that in a long-block class the MSF demonstrates residents who performed well on most measures compared with their peers (10%), residents who performed poorly on most measures compared with their peers (10%), and residents who performed well on some measures and poorly on others (80%)

• Each high, intermediate and low performing resident had a least one aspect of the MSF significantly lower than the other, and this serves as the basis of formative feedback during long-block

• Residents receive radar graphs (figures A-C, below) as part of their evaluation

• Focus is given to lower scored measures (furthest from the center of the radar graph)

• Figure A represents the top three residents, Figure B represents 3 residents in the middle of the class, Figure C represents the bottom three residents

A CB

PATIENT SATISFACTION

• Patient Satisfaction is at an all time high (at left)• Resident scores have improved the most• Satisfaction dips immediately after a long-block

ends but then rebounds (above)• This may represent breaking and reforming of

therapeutic relationships

Class of 2005 Class of 2006 Class of 2007 Class of 2008 Class of 2009 Class of 2010

PGY 2 ITE v PGY 1 ITE

-1.3 -5.5 -6.5 -2.7 -9.4 -5.9

PGY 3 ITE v PGY 2 ITE

-1.3 -3.3 -0.2 6.5 13.4 14.1

-12.5

-7.5

-2.5

2.5

7.5

12.5

17.5

Average Individual Change in ITE Percentile

Δ Pe

rcen

tile

• Residents participate in long-block board review course

• Each long- block class has shown significant increases in in-training exam scores from PGY-2 to PGY-3

• Our residency is in the upper quartile for passing the ABIM certification examination

CONCLUSIONS: An ambulatory long-block can be associated with improvements in quality measures, resident and patient satisfaction, no-show rates, and evaluation

NEXT STEPS: Future research should be done to determine which aspects of the long-block most contribute to clinical and educational improvement

EVALUATION

• The resident ambulatory practice now meets many of the criteria for the National Committee for Quality Assurance’s Patient-Centered Medical Home

PATIENT-CENTERED MEDICAL HOME