Va presentation. residency training for primary care n ps. seattle, september 2013


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Va presentation. residency training for primary care n ps. seattle, september 2013

  1. 1. CHCI Nurse Practitioner Residency Training Program: Training to Complexity; Training to a Model, Training for the Future 19/6/2013
  2. 2. CHC’s Family Nurse Practitioner Residency Training Program –est. 2007 2 2007-2008 Residency Class 2009-2010 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 9/6/2013
  3. 3. 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. 39/6/2013
  4. 4.  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 49/6/2013
  5. 5. • 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
  6. 6. 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 Delivery Medical Care & Ancillary Services Dental Care Behavioral Health Care Prenatal Services Top Chronic Diseases Cardiovascular Disease Obesity/Overweight Diabetes Chronic Pain Asthma Depression • Patients who consider CHC their health care home: 130,000 • Health care visits: 410,000 per year 6 0% 25% 50% 75% 100% 90.80% 22% 64.8% 42% 6% 65% CHC Patient Demographics CHC Patient Profile
  7. 7. What Does Primary Care Look Like In FQHC? 7Community Health Center, Inc © 2011
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  11. 11. 11 Core Elements of NP Residency Training 9/6/2013
  12. 12.  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 129/6/2013
  13. 13. 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 © 20139/6/2013
  14. 14. • 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) 14Community Health Center, Inc © 20139/6/2013
  15. 15. 15 Sample Schedule
  16. 16. Groton, CT Old Saybrook, CT Meriden, CT Clinton, CT New London, CT Stamford, CT Norwalk, CT Enfield, CT Danbury, CT 16 Middletown, CT New Britain, CT Bristol, CT Waterbury, CT 9/6/2013 Buildings in transformation
  18. 18. • 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 9/6/2013 18 PERSONAL COMPREHENSIVE COORDINATED TECHNOLOGY AND DATA- DRIVEN RESEARCH AND QI INFORMED COMMUNITY CENTERED Care that is Personal
  19. 19. • Clinical integration – Medical – Dental – Behavioral health – Prenatal – Primary care nursing – Pharmacy • Additional on-site specialties – Nutrition – Diabetes education – Chiropractic – Podiatry – Retinal screening 9/6/2013 19 PERSONAL COMPREHENSIVE COORDINATED TECHNOLOGY AND DATA- DRIVEN RESEARCH AND QI INFORMED COMMUNITY CENTERED Care that is Comprehensive
  20. 20. • 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 needs 9/6/2013 20 PERSONAL COMPREHENSIVE COORDINATED TECHNOLOGY AND DATA-DRIVEN RESEARCH AND QI INFORMED COMMUNITY CENTERED Comprehensive Care Through Being Proactive
  21. 21. • 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 9/6/2013 21 PERSONAL COMPREHENSIVE COORDINATED TECHNOLOGY AND DATA- DRIVEN RESEARCH AND QI INFORMED COMMUNITY CENTERED Care that is Technology and Data-driven
  22. 22. 22 Project ECHO 9/6/2013 Residents are part of Project Echo-CT: Weekly, case- based, distance learning with team of experts in care of patients with HIV, Hepatitis C, and chronic pain
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  25. 25. 25Community Health Center, Inc © 2011
  26. 26. Outcome Data 26  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 9/6/2013
  27. 27. 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 when transitioning 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). 27 Support for Residency 9/6/2013
  28. 28. 28 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 setting 2011-2012 NP Residency Budget Personnel Base Salary FTE Amount Fringe Total Residency Coordinator Residents Subtotal Personnel Preceptors Lost of Revenue from Preceptors Subtotal Lost of Revenue $ Total Costs $ Patient Revenue- generated by residents $ Grants and other revenue(Lo ss) $ 9/6/2013
  29. 29. Next Steps 29 • 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 9/6/2013
  30. 30. 9/6/2013 30Transforming Primary Care If you want to do something, do it. Just get started
  31. 31. 31Community Health Center, Inc © 2011 Dr. Jack Geiger Loretta C. Ford, EdD, PNP, FAAN
  32. 32. Comments or Questions ? Please Contact: Margaret Flinter, APRN, PhD, Senior VP and Clinical Director, CHC, Inc. & Director, Weitzman Center for Innovation Community Health Center, Inc. Community Health Center, Inc. 675 Main Street Middletown, CT 06457 Email: Tel: 860.852.0899 Kerry Bamrick, Sr. Program Manager, Weitzman Center Email: Tel: 860-852-0834 Website: 329/6/2013