CONCLUSIONS Unless there are changes in the broader health care system and within the specialty, the position of family medicine in the United States will be untenable in a 10- to 20-year time frame. Even within the constraints of today’s flawed health care system, there are major opportunities for family physicians to realize improved results for patients and economic success. A period of aggressive experimentation and redevelopment of family medicine is needed now. The future success of the discipline and its impact on public well-being depends in large measure on family medicine’s ability to rearticulate its vision and competencies in a fashion that has greater resonance with the public while substantially revising the organization and processes by which care is delivered. When accomplished, family physicians will achieve more fully the aspirations articulated by the specialty’s core values and contribute to the solution of the nation’s serious health care problems.

“Unless there are changes in the broader health care system anwithin the specialty, the position of family medicine in the United

States will be untenable in a 10- to 20-year time frame.”

Where are we now? Where are we now? • A new clinical model—PCMH• ACA—Access via Medicaid

expansion, prior conditions, etc• System Consolidation + ACOs• …Demand for Primary Care!

3/12/2013 2

US MD Graduates US MD Graduates Choosing Generalist CareersChoosing Generalist Careers

Percent Family Medicine + General Internal Medicine + Percent Family Medicine + General Internal Medicine + General PediatricsGeneral Pediatrics

05

10152025303540

1997 2000 2003 2006 2009

Source: AAMC Graduation Questionnaire

Building Communities of Building Communities of Solution: The ISolution: The I33 Collaborative Collaborative and the Future of Residency and the Future of Residency

TrainingTraining

Warren P. Newton, MD, MPHDepartment of Family Medicine

University of North CarolinaMarch 15, 2013

Incomes and Incomes and Career Career PreferencesPreferences

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009

Relative Income FM vs Specialties  (MGMA) Preference  for PC (GQ)

2008 Incomes:FM     $180,000Spec  $340,000

FM preferences increase from 4.8% to 6.4% between 2008‐9 

The Ratio of Primary

Care Physician Income to

Mean Specialty Income

The Percent of

Graduating US Medical Students Who Plan Careers in

Primary Care

But how do we get there?But how do we get there?

Innovations in Curriculum vs

Innovations in Residency Practice

UNC Family Medicine Center

• >50K visits/50+ providers; on site PT, xray, lab, acupuncture, colpo/ETT, with sports and dermatology clinics

• 59% Caucasian, 29% African- American, 4 % each Hispanic and Asian

• No capitation; Managed Care 40%, Medicare 27%; Medicaid 17.5%; Self- pay 12%

• Residents see 40% of visits and practice with faculty in 4 teams

• 54 clinical hours a week

Our PracticeOur Practice

Patient Satisfaction Patient Satisfaction

FMC Access, 2000FMC Access, 2000--20092009

UNC Family Medicine Center - Time to third available appointment for a routine physical exam

9.5-

10.0

20.0

30.0

40.0

50.0

60.0

May-00

Sep-00

Jan-0

1May

-01Sep

-01Ja

n-02

May-02

Sep-02

Jan-0

3May

-03Sep

-03Ja

n-04

May-04

Sep-04

Jan-0

5May

-05Sep

-05Ja

n-06

May-06

Sep-06

Jan-0

7May

-07Sep

-07Ja

n-08

May-08

Sep-08

Jan-0

9May

-09

Day

s

Faculty Resident Overall FMC Goal Linear (Overall)

Singlelengthappts. Eliminate

same dayclinic

Workingdown backlog

Inadequate summer contingencyplanning

Loss of Facultyappt. supply New

Appt.System

IncreasedAppt.Supply

December

Note: Prior to May ’03 the measure is days to 1st available appointment

Trajectory of Quality Trajectory of Quality ImprovementImprovement

Qua

lity

Time

No Change

Transient

SustainedImprovement

II33 RationaleRationale

• Quality chasm across the continuum

• The challenges of QI in residencies

• Potential impact of collaboratives

IHI IHI ‘‘BreakthroughBreakthrough’’ CollaborativeCollaborative

Quality improvement work is "orders of magnitude" harder in academic systems than in other health care settings.•Complex missions (research, teaching, clinical)•Academic culture•Large organization size•Weakness of governance structure•Underdeveloped planning processes•Lack of reward & accountability for improvement

Improvements in teaching practices benefit:•Patients of the practice directly•Graduating residents’ patients•Community practices’ patients

3

II33 Chronic Illness CollaborativeChronic Illness CollaborativeDiabetesProcess measures•HbA1c testing•Foot exam•Self-management documentedOutcome measures•HbA1c ≤

7•BP ≤

130/80; ≥

140/90All met/exceeded NCQA goalsCHFProcess measures•LVEF•ACEI/ARB•β‐blocker•“Best practice” careOutcome measure•Hospitalization38% reduction in hospitalization

Charleston (MUSC)

Hendersonville

Asheville

Charlotte

Chapel Hill (UNC)

Greenville(ECU)

Anderson

Concord

Columbia (USC)

Spartanburg

CHF

Diabetes

Chronic Illness (Diabetes, CHF)May 2006 – September 2008

Newton W, Baxley E, Reid A, et al. Improving chronic illness care in teaching practices: learnings from the I3 collaborative. Fam Med. 2011;43(7):495-502.

CHF Outcomes of ICHF Outcomes of I33

Percentage of Patients with LVF Assessment

0%

20%

40%

60%

80%

100%

Baselin

e10-0611-0612-0601-0702-0703-0704-0705-0706-0707-0708-0709-0710-0711-0712-0701-0802-0803-0804-0805-0806-0807-0808-08

II33

CHF Outcomes of ICHF Outcomes of I33

Percentage of Patients with EF <=40% on ACEI/ARB Therapy

0%

20%

40%

60%

80%

100%

Baselin

e10-0611-0612-0601-0702-0703-0704-0705-0706-0707-0708-0709-0710-0711-0712-0701-0802-0803-0804-0805-0806-0807-0808-08

II33

CHF Outcomes of ICHF Outcomes of I33

Percentage of Patients with EF <=40% on Beta-blocker Therapy

0%

20%

40%

60%

80%

100%

Baselin

e10-0611-0612-0601-0702-0703-0704-0705-0706-0707-0708-0709-0710-0711-0712-0701-0802-0803-0804-0805-0806-0807-0808-08

II33

CHF Outcomes of ICHF Outcomes of I33

Percentage of Patients with Documented Self-management Goal at Last Visit

0%

20%

40%

60%

80%

100%

Baseli

ne10

-0611

-0612

-0601

-0702

-0703

-0704

-0705

-0706

-0707

-0708

-0709

-0710

-0711

-0712

-0701

-0802

-0803

-0804

-0805

-0806

-0807

-0808

-08

Learning Session I Learning Session IINurses' Meeting

II33

CHF Outcomes of ICHF Outcomes of I33

Percentage of Patients with Admission or Observation within Previous 12 Months

0%

20%

40%

60%

80%

100%

Baseli

ne10

-0611

-0612

-0601

-0702

-0703

-0704

-0705

-0706

-0707

-0708

-0709

-0710

-0711

-0712

-0701

-0802

-0803

-0804

-0805

-0806

-0807

-0808

-08

II33

II33 PCMH CollaborativePCMH Collaborative

Asheville

HendersonvilleSpartanburg

AndersonGreenville

Columbia (USC)Florence

Charleston (MUSC)

Greenville (ECU)Chapel Hill (UNC)

Charlotte

GreensboroWinston Salem

(WFU)

Concord

Roanoke

Fairfax

Charlottesville(UVA)

Norfolk/Portsmouth(EVMS)

Lynchburg

Fayetteville

Wilmington

Internal MedicinePediatricsFamily MedicineExecutive Committee

PCMH – NCQA RecognitionMay 2009 –Nov 2010

GoalsSpread•Topic: chronic illness →

PCMH•Geography: Va, more residencies (25)•Discipline: Peds, GIMPCMH•NCQA recognition•Practice improvement•Education

Reid A, Baxley E, Stanek M, Newton WP. Practice transformation in teaching settings: Lessons from the I3 PCMH Collaborative. Family Medicine. 2011;43(7):487-94.

Key OutcomesNCQA Recognition•22/25 programs committed to NCQA application•21/22 achieved recognition

Learnings from ILearnings from I33

• Residencies working together can improve care dramatically.

• A residency network takes care of lots of patients, many are vulnerable; impact can be huge.

• Regional collaboratives with blended methods—a combination of regular face to face meetings and ongoing data collection and discussion--are effective.

• Very valuable to include residents and other learners

22

I3 POP PCMHI3 POP PCMH Our AssumptionsOur Assumptions……

• Populations are fundamental• Many barriers to change—ignorance,

incentives, information systems, other priorities

• PCMH must become the foundation of the new health care system; we need to learn how to improve population health

• We must start somewhere—with the populations our practices take care of.

• If not us, then who?

23

Who are we? Who are we?

• 26 residencies from three states and all primary care disciplines

• Almost 400,000 patients and 1,000,000 visits/year

• Majority minority, with almost 60% uninsured or medicaid

• Almost all participants NCQA PCMH level 3; all take care of their own inpatients…

• Baseline data: TTA—13 days; UPC Continuity 50%; %Hba1c, LDL median at or better than NCQA standards

II33 PCMH POP PCMH POP Triple Aim TargetsTriple Aim Targets

• Dramatic improvement in patient experience• Dramatic improvement in measured quality of

care across multiple diseases and symptoms• Dramatic decrease in utilization: 25%

reduction of hospitalizations, 50% reduction of ED visits, referrals and high end radiology

Satisfaction vs. ExperienceSatisfaction vs. Experience

3/12/2013 25

Early Early LearningsLearnings Patient Experience ThreadPatient Experience Thread

• Patient satisfaction surveys are necessary, but not sufficient

• It is not just about visit - it is about totality of care - access via phone or electronically, follow-up after the visit, etc.

• Clinicians’ perspectives on what would improve experience and patients' perspectives are not the same - insufficient to read about patient experience or talk with other healthcare professionals.

3/12/2013 26

Early Early LearningsLearnings QI ThreadQI Thread

• Baseline quality very good—better than NCQA standard across most measures in many residencies

• Great difference in experience with QI work across residencies

• The North Carolina AHEC change package continues to be effective in improving measures.

3/12/2013 27

Early Early LearningsLearnings Cost ThreadCost Thread

3/12/2013 28

Program RankResidency RResidency P 0.07Residency Q 0.07Residency O 0.14Residency N 0.15Residency M 0.17Residency L 0.21Residency J 0.24Residency K 0.24Residency I 0.26Residency H 0.27Residency G 0.31Residency E 0.36Residency F 0.36Residency D 0.37Residency C 0.38Residency B 0.51Residency A 0.55

• Data, data, data…• Seven fold variation

in rates of referral• Rates not related to

age of patients• Partially related to

what is offered on site…

• What’s going on?

The Curriculum is the PracticeThe Curriculum is the Practice

The I3 Collaborative

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