This document describes the Community Health Center Inc.'s Nurse Practitioner Residency Training Program, established in 2007. The program aims to prepare new NPs for primary care practice in community health centers through a 12-month residency with clinical training, rotations, and didactics. It addresses the need for post-graduate training of NPs for managing complex patient populations. The residency follows CHC Inc.'s patient-centered medical home model of comprehensive, coordinated, and technology-enabled care. The program has trained over 100 residents and demonstrated improved competency self-assessments. It serves as a model for sustainable NP residency programs.

1. CHCI Nurse Practitioner Residency Training Program:
Training to Complexity; Training to a Model, Training
for the Future
19/6/2013

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. 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.  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. • 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. 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. What Does Primary Care Look Like In FQHC?
7Community Health Center, Inc © 2011

8. 9/6/2013 8

9. 9/6/2013 9

10. 9/6/2013 10

11. 11
Core Elements of NP Residency Training
9/6/2013

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. 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. • 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
Sample Schedule

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

17. PERSONAL&PATIENT
CENTERED
COMPREHENSIVE
COORDINATED
TECHNOLOGY AND
DATA-DRIVEN
RESEARCH AND QI
INFORMED
COMMUNITY
CENTERED
TEAM BASED
INTERDISCIPLINARY COMPASSIONATE
AFFORDABLE
SUSTAINABLE
JOYFUL!
9/6/2013 17
The Architecture of Our Care Model

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. • 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. • 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. • 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
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

23. 239/6/2013

24. 249/6/2013

25. MyEvaluations.com
25Community Health Center, Inc © 2011

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. 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
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. 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. 9/6/2013 30Transforming Primary Care
If you want to do something, do it. Just get started

31. 31Community Health Center, Inc © 2011
Dr. Jack Geiger
Loretta C. Ford, EdD, PNP, FAAN

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: margaret@chc1.com
Tel: 860.852.0899
Kerry Bamrick, Sr. Program Manager, Weitzman Center
Email: kerry@chc1.com
Tel: 860-852-0834
Website: www.npresidency.com
329/6/2013