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CHCI Nurse Practitioner Residency Training Program:
Training to Complexity; Training to a Model, Training for the Future
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05/01/2023
CHC’s Family Nurse Practitioner Residency Training Program –est. 2007
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2007-2008 Residency Class2009-2010 Residency Class
2008-2009 Residency Class
2010-2011 Residency Class 2011-2012 Residency Class 2012-2013 Residency Class
2013-2014 Residency Class started on September 3, 2013
05/01/2023
Our Vision: Since 1972, Community Health Center, Inc. has been building a world-class primary health care system committed to caring for underserved and uninsured populations and focused on improving health outcomes, as well as building healthy communities.
CHC Inc. Profile:• Founding Year - 1972
• Primary Care Hubs – 13 • No. of Service Locations -
218• Licensed SBHC locations –
24• Organization Staff – 500+
• Providers- (all)- 170
Three Foundational Pillars Clinical Excellence
Research & Development Training the Next Generation
Innovations• Integrated primary care disciplines• Fully integrated EHR• Patient portal and HIE• Extensive school-based care
system• “Wherever You Are” Health Care• Centering Pregnancy model• Residency training for nurse
practitioners• New residency training for
psychologists
Community Health Center, Inc.
305/01/2023
FQHCs and our patients need expert primary care providers prepared to manage social and clinical complexity in the primary care setting.
Literature supports perceived and desire for post-graduate residency training.
Majority of NPs choose primary care, but are deterred from FQHC setting by mismatch between preparation, patient complexity, and available support.
We can provide new nurse practitioners with a depth, breadth, volume, and intensity of clinical and model training that prime them for FQHC success.
Train new nurse practitioners to a model of primary care consistent with the IOM principles of health care and the needs of vulnerable populations
Create a nationally replicable model of FQHC-based Residency training for nurse practitioners
Prepare new NPs for practice in any setting—rural, urban, large or small, with confidence
Develop a sustainable funding methodology
CHC’s Drivers in Creating NP Residency Training
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• Prior to 2007, there was no model for primary care nurse practitioner residency training
• No organized funding opportunity; no organized accreditation model though several specialty residency training programs exisit
• GME Legislation is not inclusive of nurse practitioner residency training
• Teaching Health Center Legislation under the Affordable Care Act also not inclusive of nurse practitioner residency training
Barriers to NP Residency Training
5Community Health Center, Inc © 2011
CHC Model Patient Care Model• PCMH (NCQA Level 3)• Advanced access scheduling• “Planned Care” and the Chronic
Care Model• Integrated behavioral health
services• Comprehensive dentistry/oral
health• Clinical dashboards• Expanded hours and 24/7 coverage• Comprehensive HIV /AIDS & Hep C
care• Formal research program • Residency training for nurse
practitioners• Neighborhood outreach, screening,
enrollment
Care DeliveryMedical Care & Ancillary
ServicesDental CareBehavioral Health CarePrenatal Services
Top Chronic Diseases
Cardiovascular Disease
Obesity/Overweight
Diabetes Chronic PainAsthma Depression
• Patients who consider CHC their health care home: 130,000
• Health care visits: 410,000 per year
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0%
25%
50%
75%
100%90.80%
22%
64.8%
42%
6%
65%
CHC Patient Demographics
CHC Patient Profile
What Does Primary Care Look Like In FQHC?
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Core Elements of NP Residency Training
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12 months, full time employment at CHC, Inc. Participate in on-call and weekend rotations Clinical committees and task force involvement Core elements:
• Precepted “continuity clinics” (4 sessions/week); expert CHC NPs and physicians as preceptors
• Specialty rotations (2 sessions/wk x 1 month) in orthopedics, women’s health/prenatal care, adult/ child psychiatry, geriatrics, HIV care, Hep C care, derm etc.
• “Independent clinics”: seeing patients as part of a CHC “team” (3 sessions/week);
• Didactic education sessions on high volume/ risk/burden topics(1 session/week)
• Continuous training to CHC model of high performance health system: access, continuity, planned care, team-based, prevention focused, use of electronic technology
• Strong evaluation component: personal, clinical, organizational throughout
• *Immersion of performance improvement training, and leadership development
Structure of NP Residency Training
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Initial weeks devoted to a deep dive into CHCI and Community Oriented Primary Care—model of care, technology, services, sites, data and their assigned community: health data, population data, walking tours, meeting with community leaders.
Throughout the residency, Residents engage in service and community events: Veterans Stand-down, Health Fairs, Missions of Mercy.
Intensive review of current expertise with essential primary care skills and advancement if needed; training to electronic health record and team based care
Community Orientation, CHC Orientation, Community Engagement
13Community Health Center, Inc © 201305/01/2023
• Vaccines and Immunizations of Children and Adults
• EKG Interpretation
• Lab Values
• Managing Diabetes
• Pain Management
• ADHD
• Managing Anxiety and Depression
• Self Management Goal Setting
• Orthopedics, upper and lower extremities and back
• Managing Menstrual Issues and Contraception
• Tobacco Cessation and Motivational Interviewing
• Pediatric Development
• Mindfulness Based Meditation and Stress Reduction
• HIV/AIDS- treatment and medications
• Chronic Liver, Kidney and Heart Failure
2013-2014 Didactic Schedule (partial list)
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Sample Schedule
Groton, CT
Old Saybrook, CT
Meriden, CT
Clinton, CT
New London, CT
Stamford, CT
Norwalk, CT
Enfield, CT
Danbury, CT
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Middletown, CT
New Britain, CT
Bristol, CT
Waterbury, CT
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Buildings in transformatio
n
PERSONAL&PATIENT CENTERED
COMPREHENSIVE
COORDINATED
TECHNOLOGY AND DATA-DRIVEN
RESEARCH AND QI INFORMED
COMMUNITY CENTERED
TEAM BASED
INTERDISCIPLINARY COMPASSIONATE
AFFORDABLE
SUSTAINABLE
JOYFUL!
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The Architecture of Our Care Model
• Dedicated primary care provider• Care is provided in the patient’s language
– Bilingual staff– Language line– Cultural competency
• Access when patient’s need it– Advanced access scheduling– Extended hours– 24 hour on call coverage
• Patient portal access – Lab results– Care team secure messaging– Patient care record
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PERSONAL
COMPREHENSIVE
COORDINATEDTECHNOLOGY
AND DATA-DRIVEN
RESEARCH AND QI INFORMED
COMMUNITY CENTERED
Care that is Personal
• Clinical integration – Medical– Dental– Behavioral health– Prenatal– Primary care nursing– Pharmacy
• Additional on-site specialties– Nutrition– Diabetes education– Chiropractic– Podiatry– Retinal screening
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PERSONAL
COMPREHENSIVE
COORDINATEDTECHNOLOGY
AND DATA-DRIVEN
RESEARCH AND QI INFORMED
COMMUNITY CENTERED
Care that is Comprehensive
• Morning huddles– Primary care team meets and reviews
clinical needs for each patients in advance
– Emphasis on prevention and screening, chronic disease management
• Panel management– Weekly meetings focused on
managing patients with poorly controlled chronic illness
• Teamwork– Each clinical teams divided into pods:
RN, MA, PCP, integrated behavioral health provider
– Mutually identify patients requiring additional care needs05/01/2023 20
PERSONAL
COMPREHENSIVE
COORDINATEDTECHNOLOGY AND
DATA-DRIVEN
RESEARCH AND QI INFORMED
COMMUNITY CENTERED
Comprehensive Care Through Being Proactive
• Clinical Dashboards to drive improvement– Outcome and performance data to
the level of the individual provider and patient
– Cancer screening – Pain management– Diabetes– Hypertension
• Clinical decision support at the point of care
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PERSONAL
COMPREHENSIVE
COORDINATEDTECHNOLOGY
AND DATA-DRIVEN
RESEARCH AND QI INFORMED
COMMUNITY CENTERED
Care that is Technology and Data-driven
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Project ECHO
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Residents are part of Project Echo-CT: Weekly, case-based, distance learning with team of experts in care of patients withHIV, Hepatitis C, and chronic pain
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MyEvaluations.com
25Community Health Center, Inc © 2011
Outcome Data
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Each NP Resident develops a panel of approximately 450-550 patients
Each NP Resident delivers 700-900 visits Peer review, frequent performance appraisals, and monthly precepted session
with clinical advisor document on-going progress Weekly reflective journals provide insights into the nature of practice, of
learning, and of the transition process Research study using Meleis’ transition theory confirms successful completion of
transition: mastery, a sense of confidence, and personal well being More data from more residency training programs needed!
Resident Average Competency self-assessment- beginning of year
Competency self-assessment- end of year
2007-2008 3.4 (3.6) 4.4 (4.5)2008-2009 3.5 (3.25) 4.0 (4.0)
2009-2010 3 .5 (3.4) 4 .25 (4.3)2010-2011 3.1 (3.0) 4.56 (4.3)2011-2012 3.6 (4.0) 3.6 (4.0)2012-2013 3.0 (3.4) 4.2 (4.3)2013-2014
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The Institute of Medicine Report-The Future of Nursing: Leading Change, Advancing Health
The 2010 report includes recommendation #3: Implement nurse residency programs for pre-licensure or advanced practice degree program or whentransitioning into new clinical practice areas. The report references CHCI’s testimony on the need for residency training for new nurse practitioners
The Patient Protection and Affordable Care Act
Section 5316 of the Patient Protection and Affordable Care Act: This amendment introduced by Senator Daniel Inouye of Hawaii authorizes the establishment of a 3 year demonstration project that will replicate CHC's residency training program for family nurse practitioners in federally qualified health centers (FQHCs) and in nurse managed health centers (NMHCs).
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Support for Residency
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Cost per resident/program is a combination of both fixed costs (salaries and overhead) and diminished revenue of preceptors during sessions.
Residency Cost Overview in FQHC setting2011-2012 NP Residency Budget
Personnel Base Salary FTE Amount Fringe Total
Residency CoordinatorResidents
Subtotal PersonnelPreceptors Lost of Revenue from Preceptors Subtotal Lost of Revenue $Total Costs $Patient Revenue- generated by residents $
Grants and other revenue(Loss) $
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Next Steps
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• National Consortium made up of current and future nurse practitioner residency programs formed June 2013. ( NPRTPC)
• Continued dialogue with leaders in nursing, primary care, health policy, education
• Book in progress: “Guide to Establishing a Successful NP Residency Program”
• Consideration of model expansion to include other APRN specialties, e.g. psychiatric APRN residency
• Continued collaboration and work towards a sustainable funding model:• Medicare GME change? Medicaid GME utilization? HRSA workforce
development? Veterans Administration continued support?
• Accreditation: Groundwork being laid—key focus for 2013-2014
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05/01/2023 30Transforming Primary Care
If you want to do something, do it. Just get started
31Community Health Center, Inc © 2011
Dr. Jack Geiger
Loretta C. Ford, EdD, PNP, FAAN
Comments or Questions ? Please Contact:
Margaret Flinter, APRN, PhD, Senior VP and Clinical Director, CHC, Inc. & Director, Weitzman Center for InnovationCommunity Health Center, Inc.
Community Health Center, Inc.675 Main StreetMiddletown, CT 06457
Email: [email protected] Tel: 860.852.0899
Kerry Bamrick, Sr. Program Manager, Weitzman CenterEmail: [email protected]: 860-852-0834
Website: www.npresidency.com
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