Online Program

Transforming patient care at a residency teaching site through population health redesign: A team-based approach

Tuesday, November 5, 2013

Randi Sokol, MD, MPH, Malden Family Medicine Residency, Cambridge Health Alliance, Malden, MA
Anjana Sharma, MD, Tufts Family Medicine Residency at CHA, malden, MA
Jacob Crothers, MD, Tufts Family Medicine Residency at CHA, malden, MA
Nicole Salg, MD, Tufts Family Medicine Residency at CHA, Malden, MA
Honor Macnaughton, MD, Tufts Family Medicine Residency at CHA, malden, MA
Laura Sullivan, MD, Tufts Family Medicine Residency at CHA, Malden, MA
Greg Sawin, MD, MPH, Tufts Family Medicine Residency at CHA, malden, MA
Judy Fleishman, PhD, Tufts Family Medicine Residency at CHA, malden, MA
Hilda Gutierrez, Tufts Family Medicine Residency at CHA, malden, MA
Stacey Sabbag, RN, Tufts Family Medicine Residency at CHA, Malden, MA
High functioning primary care clinics are known to engage in population based healthcare to improve patient outcomes. At Tufts Family Medicine Residency, we aimed to transform the way we care for our patients by extending our focus beyond individual patient visits. We thus restructured our workflow to provide preventive health care outreach at the population level. Here we describe our efforts while transforming to a patient-centered medical home at a multiple-provider, safety-net family medicine residency clinic in Malden Massachusetts. Our redesign process emphasized 3 points: 1) Data-driven prioritization of population-health outcomes in a clinical setting traditionally focused on day-to-day patient concerns. 2) The development of high-functioning, interdisciplinary clinical care teams with whole-staff engagement and empowerment to address population health needs. 3) The promotion of continuous, team-based relationships between patients and appropriately-sized care teams through the population-health workflow. We will describe how implementation of this new model has impacted staff satisfaction, volume of patient outreach, population-health quality metrics, and patient / care-team continuity. We will also describe how this model is used to train resident family physicians to lead team-based population health promotion efforts within their future practices. Our approach is unique because of the challenges to continuity and team-based care that a residency clinic presents. We are a Family Medicine training site with 39 MD providers accounting for approximately 10 FTE positions. Accordingly, our baseline patient-PCP continuity rate is low and we experience a significant amount of MD and patient turnover.

Learning Areas:

Administration, management, leadership
Chronic disease management and prevention
Clinical medicine applied in public health
Planning of health education strategies, interventions, and programs
Provision of health care to the public
Systems thinking models (conceptual and theoretical models), applications related to public health

Learning Objectives:
List the benefits of creating interdisciplinary care teams for population health management. Describe the steps in planning, implementing, and measuring team-based population outreach in order to improve your clinic’s population management efforts. Identify strategies to engage residents in population health leadership as part of their core primary care education.

Keyword(s): Primary Care, Outreach Programs

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am a Master Teaching Fellow at the Tufts Family Medicine Residency at Cambridge Health Alliance and was integral in the developement of the topics presented. I have prior experience presenting on topics in Family Medicine Education.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.

Back to: 4274.0: Primary care poster session