Resident Continuity Clinic Research Articles

Improving the Frequency and Documentation of Gun Safety Counseling in a Resident Primary Care Clinic.

Increase the frequency and documentation of gun safety discussions during well-child checks in the pediatric primary care resident clinic to 50% within 6 months. This is a quality improvement study in a pediatric resident continuity clinic. Before implementing any interventions, a survey was conducted to understand residents' attitudes and practices regarding gun safety screening and counseling. Interventions included a parent safety survey, Be SMART materials in clinic, and a prompt embedded into Electronic Health Record templates. Chart reviews were conducted to determine frequency of gun safety discussion. Resident self-reported comfort with gun safety counseling was also evaluated. A statistical process control chart was generated to track documentation and found the baseline mean rate of gun safety discussions during well-child checks was 3%. Rates increased following the addition of the Electronic Health Record prompt, with the mean further increased to 84% in July 2019. A sustained rate of over 75% was achieved through February 2020. Over 4 study months, the proportion of trainees reporting feeling very uncomfortable/uncomfortable with gun safety counseling decreased from 22% to 15%. The Be SMART program was identified as a key intervention increasing gun safety counseling. Our study identified an effective approach to improving the frequency and documentation of gun safety discussions in an academic primary care setting, providing a unique blueprint for firearm screening and safe storage counseling success. Ultimately, we believe this will increase safe storage behaviors in the home and reduce risks of child death from firearms.

Breastfeeding Education in Family Medicine Residencies: A 2019 CERA Program Directors Survey.

Breastfeeding counseling is an integral skill for all family physicians, regardless of whether they ultimately practice maternal child health (MCH). Evidence on time spent in breastfeeding education and resident competence is lacking. This study aimed to identify program characteristics associated with an increase the amount of breastfeeding education and program directors' (PDs) perceived competence of residents' breastfeeding counseling skills. A national survey of family medicine PDs including breastfeeding questions was conducted as part of the 2019 CERA survey. We specifically sought to identify variables that correlate with increased breastfeeding education time and perceived competence. Family medicine programs with greatest breastfeeding education time and perceived resident competence included lactation consultants, had more MCH visits in resident continuity clinic, more graduates that practice MCH, and included competency evaluations by faculty. There was more volume of breastfeeding education in programs with group prenatal care and an academic affiliation. There was greater perceived competence among programs with more hours of breastfeeding training overall. This study defines associations with curricular targets for improved breastfeeding counseling competence among family medicine residents. Inclusion of lactation consultants, regular faculty observation of counseling skills, and group prenatal care may be gradually introduced in programs to strengthen resident education and skills in breastfeeding counseling. The body of evidence in this field remains lacking, and further research is needed to characterize curricular interventions that increase resident competence in this important skill.

The Ambulatory Teaching Minute: Development of Brief, Case-Based, Evidence-Based Medicine Exercises for the Internal Medicine Resident Continuity Clinic

IntroductionThere are limited data on best approaches for evidence-based medicine (EBM) teaching to residents in busy continuity clinic practices. Ambulatory Teaching Minute (ATM) exercises were designed to deliver brief, case-based, faculty-facilitated teaching to residents on high-yield ambulatory EBM topics.MethodsI developed four ATM exercises, with each one-page handout containing a clinical case, a guided discussion of a research question and study design sparked by the case, a synopsis of a recent research article addressing this question, and a teaching guide for facilitation. Internal medicine residents received these ATM exercises over the course of their monthlong ambulatory block. Surveys that assessed resident engagement were obtained from faculty-facilitators (N = 4) and residents (N = 6) at the end of the ambulatory block.ResultsResidents were actively engaged in the exercise, with an average engagement score of 3.81 out of 5. Most respondents reported ATM exercises taking 6–10 minutes. The majority of respondents felt ATMs could be realistically completed once per week.DiscussionIn this preliminary assessment of a new tool for EBM teaching in clinic, positive engagement scores among preceptors and residents highlight the potential of ATMs to efficiently and effectively address EBM topics during limited teaching time in clinic.

Implementation of an interprofessional learner team-based medication reconciliation and review in an Internal Medicine-Pediatrics resident continuity clinic

Abstract Background Medication errors are a substantial health problem. There is limited data evaluating the implementation of an interprofessional medication reconciliation in the outpatient setting. Purpose To describe and evaluate the implementation of an interprofessional team-based medication reconciliation quality improvement project in a medical resident primary care clinic. Methods Quality improvement methods were utilized for the project from May 2017 to May 2019. Medication reconciliations were performed for high-risk patients prior to their meeting with a medical resident for a primary care visit. Medication Therapy Problems (MTPs) and medication discrepancies were documented and then evaluated. Results Over 2 years, 287 MTPs and 680 medication discrepancies were identified. The average MTP per patient was 1.8 and resolution of MTPs was 46%. Conclusions This quality improvement project yielded the identification of medication list discrepancies and the identification and resolution of medication therapy problems in an outpatient medical setting. Additional studies are needed to determine clinical impact.

Medical student and resident perceptions when working together in resident continuity clinics

Summary Background Resident continuity clinics (RCCs), where residents see patients largely independently, is a common requirement for residency programs in the USA. Students often participate in these clinics but it is unknown how this effects resident learning or student satisfaction. Objective This study aims to describe effects on the learning environment when students and residents work together in an RCC. Design Separate surveys were administered to residents and students working at St. Joseph Mercy Hospital (SJMH) in Ann Arbor, Michigan, from 2016–2018. Results Response rates were 79/116 (68.1%) for students and 21/24 (87.5%) for residents. A one-sample Wilcoxon signed rank test was used to test whether most five-level Likert-type scale responses were ‘agree’ or ‘strongly agree.’ Of medical students, 88.6% enjoyed working with residents (p < 0.001) with 60.8% indicating residents were effective teachers (p < 0.001). The majority of residents (85.7%) were neutral, agreed, or strongly agreed that they enjoyed working with students (p < 0.001). However, 61.9% of residents believed they were too busy to be effective teachers (p < 0.001). Conclusions Both residents and students positively viewed their interactions in RCCs. Although most students felt residents were effective teachers, most residents worried about their ability to balance clinical care and teaching responsibilities.

Early use of telepsychotherapy in resident continuity clinics-our experience and a review of literature.

Telepsychotherapy is an underutilized tool in training programs, and use of telepsychiatry often occurs in the later years of residency. This study evaluates the feasibility of early exposure to telepsychotherapy in residency continuity clinics and reviews the existing literature on the use of telemedicine in the training of psychiatrists. Feedback from the participating residents and patients was used to determine the benefit of such a training curriculum. The results of the feedback and evidence from the review of literature indicate that the early use of telepsychotherapy should be employed in psychiatric training.

Multiyear Outcomes of a Population-Oriented Care Redesign in an Internal Medicine Residency Continuity Clinic.

The cornerstone of ambulatory care training for internal medicine residents is the continuity clinic, which often serves medically and psychosocially complex patients. We conducted and evaluated a population-oriented redesign to improve care for "high-needs" patients and the resident experience at a hospital-based safety net primary care internal medicine practice in the Southeastern U.S. A Define, Measure, Analyze, Implement, Control (DMAIC) framework was adapted to identify and develop three main interventions to address major unmet needs of patients and trainees: (1) a behavioral health-focused team care model; (2) a formalized hospital discharge transitions workflow; and (3) the creation of larger "firms" of smaller resident practice partnerships. We constructed a financial model to justify investments, with metrics to track progress. Over three years, sustained reductions in hospitalizations and ED visits (mean annual changes of -11.6% and -16.9%, respectively) were achieved. Resident primary care provider (PCP)-to-patient continuity and satisfaction also improved.

Outcomes of a novel office-based opioid treatment program in an internal medicine resident continuity practice

BackgroundThe integration of opioid use disorder (OUD) care and competencies in graduate medical education training is needed. Previous research shows improvements in knowledge, attitudes, and practices after exposure to OUD care. Few studies report outcomes for patients with OUD in resident physician continuity practices.MethodsA novel internal office-based opioid treatment (OBOT) program was initiated in a resident continuity clinic. Surveys of resident and staff knowledge and attitudes of OBOT were administered at baseline and 4 months. A retrospective chart review of the 15-month OBOT clinic obtained patient characteristics and outcomes.ResultsTwelve patients with OUD were seen in the OBOT clinic. Seven patients (58%) were retained in care at the end of the study period for a range of 9–15 months. Eight patients demonstrated a good clinical response. Surveys of residents and staff at 4 months were unchanged from baseline showing persistent lack of comfort in caring for patients with OUD.ConclusionsOBOT can be successfully integrated into resident continuity practices with positive patient outcomes. Improvement in resident and staff attitudes toward OBOT were not observed and likely require direct and frequent exposure to OUD care to increase acceptance.

Too Many Learners? Do Students Belong in Resident Continuity Clinics?

PURPOSE: Determine the prevalence of medical students in OBGYN resident continuity clinics and describe effects on the learning environment when students and residents work together in this setting. BACKGROUND: Patient continuity is an ACGME requirement often fulfilled through a resident run continuity clinic. It’s unknown how frequently students rotate in these clinics, or how multiple levels of learners influence each other. METHODS: We surveyed OBGYN program managers using a national listserv. Resident and student surveys were based on a Likert scale and sent to all OBGYN residents and students that rotated at our institution from 2016-2018. RESULTS: Program managers responded from 45 programs and 75.6% scheduled students in resident continuity clinics. Our response rates were 79/116 (68.1%) for students and 21/24 (87.5%) for residents. A one-sample Wilcoxon signed rank test was used to test the hypothesis that the typical response on the five-level Likert scale was “Agree” or “Strongly Agree.” Of medical students, 88.6% stated that they agreed or strongly agreed they enjoyed working with residents (p<0.001) and 60.8% stated they agreed or strongly agreed residents were effective teachers (p<0.001). Among residents, 52.4% agreed or strongly agreed that they enjoyed working with students (p<0.001). However, 61.9% said they agreed or strongly agreed they were too busy to be effective teachers (p<0.001). DISCUSSION: Many institutions have students rotate in resident continuity clinics. Residents and students have positive views regarding their interactions. Although students were satisfied, residents expressed concerns about their ability to be effective teachers given clinical demands. Our results highlight the importance of developing resident teaching skills.

Implementation of Case Conferences to Improve Interprofessional Collaboration in Resident Continuity Clinic.

Residents must be trained in skills for interprofessional collaboration and team-based care in the outpatient setting, and successful models are needed to achieve this aim. A longitudinal curriculum was developed to enhance residents' knowledge of interprofessional team members' roles, residents' attitudes toward team-based care, and patient referrals to team members. Postgraduate year 1 through postgraduate year 3 internal medicine residents with continuity clinic at a large hospital-based practice received the curriculum. Residents with continuity clinic at another site did not receive the curriculum and served as controls. Intervention residents attended five small-group conferences during the course of 1 year, each dedicated to a specific interprofessional discipline: pharmacy, psychology, diabetes/nurse education, social work, and case management. Conferences involved interactive, case-based discussions of patients who benefit from an interprofessional approach. Control and intervention residents were surveyed with pre- and posttests. The rates of patient referrals to interprofessional team members were assessed. Seventy-one residents received the curriculum. Intervention residents' knowledge of team members' names and roles, indications for patient referral, and communication methods improved after curriculum implementation. Attitudes toward team-based care did not change but were positive at baseline. Following curriculum implementation, new patient referrals increased for the pharmacist (0.1-1/100 patient visits, P = 0.015) and psychologist (1.1-2.2/100 patient visits, P = 0.032). Case-based interprofessional conferences improved residents' knowledge regarding interprofessional care and increased referrals to team members. This curriculum addresses barriers to team-based care experienced by residents in continuity clinic and is adaptable to other clinic settings.

1071 Awareness and Barriers to Hepatitis C Screening for Baby Boomers in Internal Medicine Training: A Nationwide Survey

INTRODUCTION: World Health Organization has determined a goal of 65% reduction in Hepatitis C Virus (HCV) related mortality by 2030. Baby Boomers, born between 1945 to 1965, comprises two-thirds of patients with HCV in the United States (US). Despite one-time screening recommendation by CDC and USPTF, HCV screening remains low in this age group. There is no available data to determine the adherence and awareness of HCV screening in internal medicine (IM) training programs for this birth cohort. The objective of this study was to assess adherence, awareness, and barriers to hepatitis C screening among IM residents. METHODS: An electronic medical record query was made for HCV screening in patients, born between 1945 to 1965, and seen in IM resident continuity clinics from January 2018 to June 2019. Later, a national survey of the IM residents was conducted to assess the awareness and barriers to HCV screening. A convenience-based sampling method was adopted, and we created a 15-item survey instrument on REDCaP that was disseminated to residents by reaching out to their program directors/coordinators through email. RESULTS: A total of 1207 patients with mean age 62.2 years, and 49% of females met inclusion criteria; however, only 63 patients (4.9%) had their HCV status tested. In contrast to that, the results from 186 survey respondents showed that 73.7 % of residents are familiar with CDC recommendation to screen baby boomers for HCV. The respondents estimated to provide care to a mean of 54 ± 17 patients from this cohort per year in their continuity clinics. The participants also identified that patients who undergo screening; only 36% understands the purpose of the testing. Notably, survey respondents stated that 9.4% of patients associate HCV testing with IV drug use, suggesting potential stigmatization with testing. Most common barriers identified in the survey are knowledge gap (51.76%) at either patient or provider end, lack of EMR alerts (11.76%) and time constraints (9.4%) due to increased patient load, or complexity of the patients’ comorbidities. Nevertheless, 61% of the participants suggested that providers need more education and awareness about HCV screening in baby boomers. CONCLUSION: Adherence and awareness of HCV screening among Baby Boomers in IM residency training are low. There is a need to increase awareness and overcome these barriers to improve HCV testing in this vulnerable population.

2.45 MARCHING 99484-WARD INTO A FINANCIALLY SUSTAINABLE MODEL OF INTEGRATED CARE

AACAP and AAP recognize that integrating mental health (MH) services into pediatric primary care is a potential solution to improving access to MH treatment. Several RCTs and a recent review support the efficacy of these models compared with usual care, but many models rely on grant funding and little is published about sustainable models. Although one study notes that there may be system-level cost savings with integrated care over time, another study notes that integrated MH clinicians most often do not cover the cost of their own salaries with billing revenue. We present billing data from July 2018 through May 2019 after integrating a child psychiatrist one half-day per week for both direct and indirect consultations into a pediatric resident continuity clinic and compare the use of traditional psychiatry billing with the use of the new CPT 99484 code for general MH integration services.

105. ADVERSE CHILDHOOD EXPERIENCES SCREENING IN RESIDENT CONTINUITY CLINIC

Background Adverse Childhood Experiences (ACEs) are traumatic events that occur prior to age 18. Exposure to ACEs has been associated with negative health outcomes including developmental delay and mental health conditions. ACEs are common and there are ∼17,000 children in our county with exposure to 2+ ACEs. Studies show early resource utilization and promoting resilience can combat the effects of ACEs, however many individuals are not using resources. Aim Statement his project is aimed at improving screening and recognition of ACEs to allow for referrals to resources in order to decrease effects from ACEs. Our goal is to screen 75% of children ages 0-5 for ACEs during well visits. For those who screen positive (score of 4+), our goal is to refer to resources 75% of the time. The project also focuses on improving provider knowledge of ACEs with a goal of 75% of residents reporting feeling at least “somewhat comfortable” with ACEs screening. This project takes place at Myers Park Pediatrics in the Resident Continuity Clinic and involves children ages 0-5 years. The project was initiated in March 2018 and is ongoing. Interventions Visual prompts were placed on workstations to help registration staff and providers remember which visits the screening was scheduled to take place. Scoring instructions were placed on the form. After initial data showed many screens were left incomplete, scoring instructions were taken off the form to encourage more families to complete the form without fear of a SW consult which was originally listed on the form. Provider education including resilience screening and lectures were provided to increase knowledge about ACEs and allow providers to understand the importance of screening. A cover sheet was also placed on the screening form and was edited to provide families more information on why screening was being performed. Measures Outcome measures included % of children ages 0-5 that are screened for ACEs and % of children ages 0-5 with positive screens that are referred with the goal for both being 75%. Process measures included % of residents trained in ACEs screening, % of front desk staff trained in distributing ACEs forms, % of forms distributed to families, and % of forms completed by families. Balancing measures included 75% of front desk staff will report no change in work flow due to handing out screening and 75% of residents will report that ACEs screening is helping them learn about ACEs and how to manage them. Results The average % of screening for all patients in the targeted population was 57%. At times the percentage of screens was above the goal, however was not sustained. Results demonstrated random variation despite multiple interventions. Only 4 patients had ACEs scores of 4+, however all were referred to resources which was above our goal of 75%. Only 10% of residents initially reported feeling at least “somewhat comfortable” with ACEs screening, however after initiation of the project and further education, 85% of residents reported feeling at least “somewhat comfortable”, with a goal of 75%. Eighty-six percent of residents reported that they learned from ACEs screening. When assessing balancing measure, 88% of registration staff reported no change in overall work flow. Conclusions and Next Steps ACEs are common and can have many negative health outcomes. Early intervention with resources can promote resilience and prevent negative outcomes. We have been successful in implementing screening in a local clinic, but have not met sustainability. We have been able to educate providers and ensure that there is no negative impact on clinic work flow. We continue to make changes to improve screening and identification of those affected by ACEs to refer them to resources. We have also been chosen to participate in a Pediatric Integrated Care Collaborative which will provide improved education for our providers and more resources to our patients related to ACEs.

48. CONTINUITY CLINIC PRACTICE FEEDBACK: WHAT DO RESIDENTS WANT?

Background The Accreditation Council of Graduate Medical Education (ACGME) recommends that residents receive data on quality metrics and benchmarks related to patient care. Continuity clinic (CC) is an ideal setting to obtain practice habit data. Objective To determine which CC practice habit data residents would find beneficial to receive during feedback. Methods A multicenter qualitative study was conducted with pediatric continuity clinic residents at 3 academic medical centers in two different phases. During phase 1, small resident focus groups were conducted at each site. The focus groups explored preferred content feedback on CC practice habit data. The qualitative data were reviewed by all investigators to identify major themes. For the second phase of the study, the results obtained from the focus group were used to develop a survey in order to determine how strongly residents felt about the particular areas of feedback that were identified in phase one of the study. This survey, which utilized a 5-point Likert scale to determine the importance of each feedback item, was sent out electronically to all categorical residents at each academic center. Results were analyzed with the mean and standard deviation for each question calculated. Results Focus groups were held at 3 sites with 3-10 residents per focus group. Consistent major themes which arose from the focus groups at all sites as desired areas to receive feedback on CC practice included the following categories: patient panel characteristics, quality measures, measures of efficiency in patient care, population management and information on specific patients. For the second phase of the study, 277 residents received the survey with 92 responding (33% response rate). The mean value that residents placed on the importance of each content area is displayed (table 1) with 1 being not important at all and 5 being very important. Conclusion Residents are interested in receiving practice habit data from continuity clinic. Presentation of the feedback described may enhance the resident continuity clinic experience and improve overall performance and enhance patient care.

Internal Medicine Attendings' Perception of Barriers to Outpatient Exam Room Presentations in Resident Continuity Clinic.

Outpatient exam room presentations (OERPs) in resident continuity clinic (RCC) can operationalize competency-based medical education and enhance patient satisfaction. We aimed to assess current OERP use and OERP barriers by surveying internal medicine attendings prior to and following a 4-week pilot of OERPs in RCC. Twenty-six out of an eligible 35 attendings completed the pre-pilot survey. Twenty attendings participated in the pilot and completed the post-pilot surveys. On the pre-pilot survey, 65% (17/26) of participants reported never using OERPs. Attendings' perception of learner discomfort with OERPs as somewhat of or a significant barrier significantly decreased from pre-pilot to post-pilot (96% (25/26) v. 65% (13/20), p = 0.03). Time, feedback, and sensitive topics were frequently rated as barriers on both the pre-pilot and post-pilot surveys. On the post-pilot survey, most participants reported patient discomfort with OERPs, attending physician discomfort with OERPs, difficulty writing attestations during OERPs, and difficulty teaching during OERPs were not barriers. Additionally, 45% (9/20) reported planning to use OERPs in the future. Despite benefits of OERPs, there are several barriers to OERPs that need to be addressed prior to more routine implementation in resident continuity clinic. Further research should focus on strategies for overcoming barriers and maximizing benefits of OERPs as well as developing a set of OERP best practices to support routine implementation in RCC.

Multidisciplinary Team Meetings-a Venue to Improve Team Engagement and Quality in Resident Continuity Clinic.

Multidisciplinary Team Meetings-a Venue to Improve Team Engagement and Quality in Resident Continuity Clinic.

Training Pediatric Residents in Literacy Promotion: Residency Directors’ Perspectives

Phenomenon: The American Academy of Pediatrics and Canadian Pediatric Society recommend that pediatricians incorporate literacy promotion during well child care, but literacy promotion education during pediatric training remains understudied. We sought to understand how literacy promotion training is currently implemented in pediatric residency programs from the perspective of program directors. Approach: We conducted semistructured interviews with all 9 residency program directors in 1 state. We analyzed data iteratively coding transcripts using an immersion/crystallization approach to identify themes. Findings: We achieved saturation after 9 interviews with 11 participants. We identified 3 major themes: (a) Residency programs rely on an existing primary-care-based literacy promotion intervention (Reach Out and Read) and the resident continuity clinic for literacy promotion training; (b) program directors encourage early and repeated exposure to facilitate literacy promotion education; and (c) service obligations, content specifications, and pressure on faculty create competing time demands that function as key barriers to literacy promotion training. Insights: Residency program directors used an existing, widely used intervention and the infrastructure provided by continuity clinics to facilitate training on literacy promotion, a relatively new pediatric care standard. Additional work is needed to overcome the barriers identified by program directors.

Improving patient portal enrolment in an academic resident continuity clinic: quality improvement made simple

Electronic health record patient portal usage has been associated with improvement in chronic disease parameters, patient functional status and patient satisfaction. Our institution’s patient portal is a secure, online health...

Screening for Social Determinants of Health in Pediatric Resident Continuity Clinic

ObjectiveDescribe current practices in systematic screening for social determinants of health (SDH) in pediatric resident clinics enrolled in the Continuity Research Network (CORNET). MethodsCORNET clinic directors were surveyed on demographics, barriers to screening, and screening practices for 15 SDH, including the screen source, timing of screening, process of administering the screen, and personnel involved in screening. Incidence rate ratios were tabulated to investigate relationships among screening practices and clinic staff composition. ResultsClinic response rate was 41% (65/158). Clinics reported screening for between 0 and 15 SDH (median, 7). Maternal depression (86%), child educational problems (84%), and food insecurity (71%) were the items most commonly screened. Immigration status (17%), parental health literacy (19%), and parental incarceration (21%) were least commonly screened. Within 3 years, clinics plan to screen for 25% of SDH not currently being screened. Barriers to screening included lack of time (63%), resources (50%), and training (46%). ConclusionsScreening for SDH in our study population of CORNET clinics is common but has not been universally implemented. Screening practices are variable and reflect the complex nature of screening, including the heterogeneity of the patient populations, the clinic staff composition, and the SDH encountered.

Psychiatric Nurse Practitioner Residents Improve Quality and Mental Health Outcomes for Veterans Through Measurement-Based Care.

Measurement-based care (MBC) is commonly used to manage medical illness, whereas only about 20% of psychiatric care providers use MBC. One aim of the partnership between the Birmingham Veterans Affairs Medical Center (BVAMC) and the University of Alabama at Birmingham School of Nursing (UAB SON) is to provide MBC to Veterans. The goal is to describe the efficacy of MBC in the treatment of Veterans by psychiatric-mental health nurse practitioner (PMHNP) residents. By teaching PMHNP residents evidence-based assessment, they gain tools to shorten time to remission of depression, anxiety, and posttraumatic stress disorder. Residents administered the Patient Stress Questionnaire (PSQ), an MBC tool that assesses depression, anxiety, trauma-related symptoms, and alcohol use, to patients of the Residency Continuity Clinic (RCC). Patient Stress Questionnaire scores from March 2016 to May 2018 were analyzed using paired t tests. Analysis revealed a downward trend in PSQ scores over time, suggesting improvement in psychiatric symptoms. Depressive and anxiety symptoms decreased significantly. This quality project highlights the utility of MBC by PMHNP residents in an RCC. Measurement-based care tools can be quickly and easily administered with little impact on workflow. Use of validated screening tools can enhance care, engage patients, and improve patient outcomes.