Resident Continuity Clinic Research Articles

Implementing Standardized Screening for Adverse Childhood Experiences in a Pediatric Resident Continuity Clinic

Introduction:Exposure to adversity in childhood has been shown to impact the development of children and increase their risk of poor early childhood mental health and chronic medical conditions in young children, and developing chronic diseases, mental health disorders, and substance abuse disorders as adults. The recognition of adverse childhood experiences (ACEs) and provision of behavioral-based interventions can help children build resilience. We implemented a screening method to help providers better assess patients’ exposure to adversity. Our goal was to increase the screening for ACEs utilizing a standardized ACEs screening tool from 0% to 80% of children presenting for annual well-child visits within 1 year.Methods:We implemented a screening tool to determine a child’s exposure to ACEs within our general pediatrics clinic. A variety of interventions, including resident, faculty, and staff-focused educational lectures, simulation, and process changes were performed to increase screening. Also, we surveyed resident physicians and faculty about their experiences with ACEs screening.Results:Over 1 year, we screened 1,206 patients for exposure to ACEs and increased screening from 0% to 60%. Provider comfort with discussing abuse with patients and familiarity with resources for children exposed to ACEs did not change significantly.Conclusions:Patients can successfully be screened in a resident-led, general pediatric clinic using a standardized ACEs screening tool. Such an approach can successfully identify patients with high-risk ACE scores. Additionally, education on and implementation of the tool may improve provider comfort with screening for ACEs.

Signed, Sealed, Delivered: Increasing Patient Notification of Test Results in an Internal Medicine Resident Continuity Clinic.

Informing patients of their test results is an important patient safety issue, yet many physicians perform dismally in this regard. Residents often face additional barriers to communicating test results to patients. We wanted to determine whether streamlining the notification process, communicating expectations, and having residents audit their performance would increase result notification rates. We used a quasi-experimental design, and a single-group before-and-after intervention. Our multifold intervention consisted of development and standardization of a notification process in the electronic medical record, an education component, and a self-audit component. During a 15-minute session, we educated residents on the use of the new process. We also restated expectations regarding notifying patients of their results. Residents audited their own charts for a period before the intervention and during a second, postintervention period. An independent review of notification rates took place simultaneously as well as during an additional period several months later. In total, 87 residents were eligible for participation. All 87 completed the project, giving a 100% participation rate. Resident-reported laboratory test notification rates increased from 16% to 91%; other test result rates increased from 33% to 84%. The three independent reviews showed laboratory test notification rates increased from 18.5% to 71.7% to 87.1%, and notification of other test results increased from 23.5% to 66.7% to 91.7%. Baseline rates of notification for diagnostic tests results were low, but streamlining the notification process, clearly stating expectations for using it, and using resident self-audit can improve notification rates.

Engagement in Psychotherapy Improves Outcomes for Veterans.

The longstanding partnership between the Birmingham Veterans Affairs Medical Center (BVAMC) and the University of Alabama at Birmingham School of Nursing inspired the establishment of one of the country's first psychiatric-mental health nurse practitioner (PMHNP) residencies and subsequent formation of a Resident Continuity Clinic (RCC). Within the RCC, PMHNP residents deliver evidence-based care that is informed by measurement-based care (MBC) to improve patient outcomes and reduce time to recovery. Determined by the BVAMC Institutional Review Board to be a quality improvement project, PMHNP residents administered the Patient Stress Questionnaire (PSQ), a MBC tool that uses four independently validated screening tools to measure the behavioral health symptoms of depression, anxiety, trauma, and alcohol use. Additional clinical variables of interest included patient use of illicit substances, participation in psychotherapy, and use of psychotropic medications. PSQ scores were reviewed retrospectively via descriptive statistics and nonparametric tests. Analysis demonstrated statistically significant improvements in depression and anxiety. Data also revealed that patients engaged in psychotherapy demonstrated greater improvements on all PSQ screening tools compared to patients not involved in psychotherapy. The results reinforce the value of MBC in psychiatric care and highlight the importance of engaging Veterans in psychotherapy to improve outcomes. [Journal of Psychosocial Nursing and Mental Health Services, 57(6), 30-38.].

The Influence of Care Coordination on Patients With Special Health Care Needs in a Pediatric Residency Continuity Clinic.

This study evaluates the influence of comprehensive health care coordination for children with special health care needs (CSHCN) in a resident continuity clinic. CSHCN patients were identified from 2 resident continuity panels. Patients were eligible with a score of 2 or greater on the CSHCN screener. Interventions included extended appointment times, a binder, and direct phone access to the social worker who facilitated follow-up appointment scheduling. Data measured included completed and no-show visits for primary care and subspecialty appointments, hospitalization and emergency department visits, use of binders, and parent satisfaction surveys. Patients with a baseline CSHCN screener score ≥4 were 15.6 times more likely to keep their appointment after enrollment (P = .0035). Mental health no-show visits decreased significantly (P < .0001). The utilization of components of comprehensive team-based care coordination, even with limited resources, can improve the delivery of health care for children with complex medical needs and mental health disorders in a resident-based clinic.

3.34 Psychiatric Consultation in Pediatric Residency Continuity Clinic Training

3.34 Psychiatric Consultation in Pediatric Residency Continuity Clinic Training

Continuity of Infant Well Care in a Community Health Center Resident Clinic.

Achieving patient continuity in resident continuity clinic is challenging. Patients, residents and primary care providers (PCP) benefit from this ongoing relationship. We examined rates of continuity of infant well care for first year pediatric residents (PL1) and associated factors in three clinics (W, E and K) in a community health center system. We collected the number of infants who had PL1 PCPs for academic years 2010, 2011 and 2012 and patient demographic data. We measured continuity using the usual provider of care method. We assessed rates of continuity, total numbers of infants and factors associated with continuity and medical home by Chi Square, ANOVA, Student's t test and multivariate linear regression (SPSS version 21). 115 patients had a PL1 PCP and attended 408 visits with 19 residents. The mean number of infants seen per PL1 in each clinic was W 7.8 ± 2.2, E 3.8 ± 1.5 and K 3.7 ± 2.9 (p < .01). PL1 continuity percentage was 66% at W, 47% at E and 54% at K (p < .01). Total continuity of care for all providers at W was 70%, E 65% and K 60% (p < .01 W vs. K only). In multivariate linear regression, only continuity of care for all providers was associated with mean PL1 continuity with β of 2.24 (95% CI 1.13-3.34), p < .001. PL1 continuity differed significantly between clinic sites. The only predictor of PL1 well care continuity was total clinic continuity of care. Maximizing continuity through the Medical Home practice was significantly associated with increased resident continuity of care.

Integrated Behavioral Health Care in Family Medicine Residencies A CERA Survey.

Behavioral health integration (BHI) in primary care settings is critical to mental health care in the United States. Family medicine resident experience in BHI in family medicine residency (FMR) continuity clinics is essential preparation for practice. We surveyed FMR program directors to characterize the status of BHI in FMR training. Using the Council of Academic Family Medicine Educational Research Alliance (CERA) 2017 survey, FMR program directors (n=478, 261 respondents, 54.6% response rate) were queried regarding the stage of BHI within the residency family medicine center (FMC), integration activities at the FMC, and the professions of the BH faculty. BHI was characterized by Substance Abuse and Mental Health Services Agency (SAMHSA) designations within FMRs, and chi-square or ANOVA with Tukey honest significant difference (HSD) post hoc testing was used to assess differences in reported BHI attributes. Program directors reported a high level of BHI in their FMCs (44.1% full integration, 33.7% colocated). Higher levels of BHI were associated with increased use of warm handoffs, same day consultation, shared health records, and the use of behavioral health (BH) professionals for both mental health and medical issues. Family physicians, psychiatrists, and psychologists were most likely to be training residents in BHI. Almost half of FMR programs have colocated BH care or fully integrated BH as defined by SAMHSA. Highly integrated FMRs use a diversity of behavioral professionals and activities. Residencies currently at the collaboration stage could increase BH provider types and BHI practices to better prepare residents for practice. Residencies with full BHI may consider focusing on supporting BHI-trained residents transitioning into practice, or disseminating the model in the general primary care community.

Motivational Interviewing to Improve Quitline Referrals – a Resident Education Initiative

OBJECTIVES To improve referral rates to the New York State Smoker’s Quitline (NYSSQL) in resident continuity clinics; to educate residents on motivational interviewing techniques to address tobacco smoke exposure with their patients/patients’ families. METHODS In 2012, our Children’s Hospital partnered with the New York State Smokers Quitline (NYSSQL) to implement a policy-driven Quitline program, Opt-to-Quit™ in all inpatient units and the Emergency Department. Smokers are referred to the NYSSQL, primarily by nursing staff, via direct data …

Patient Views on the USPSTF Statement Regarding the Annual Screening Pelvic Exam [23M

INTRODUCTION: The screening pelvic exam has been an integral part of the gynecologic annual well-woman visit. A recent US Preventative Services Task Force (USPSTF) statement states that there is insufficient evidence to support or refute the performance of annual screening pelvic exams in asymptomatic, non-pregnant adult women. METHODS: Patients in an outpatient gynecologic resident continuity clinic were asked to complete a 14-question survey inquiring about their views on annual screening pelvic exams, as well as demographic information. Statistical analysis was performed using the Student’s t-test. RESULTS: 100 female patients, ranging from 15 to 64 years of age, completed the survey. 81% identified as African American or Hispanic/Latino. 63% were insured by either Medicaid or Medicare. 94% reported an annual household income &lt; $50,000. 69% were unaware of the recent statement regarding annual screening pelvic exams made by the USPSTF. 66% believed that the annual screening pelvic exam was necessary, even in asymptomatic women. 33% were concerned that something would be overlooked or missed if they did not receive a pelvic exam. Of the patients with an annual household income &lt; $50,000, 67% believed that the annual screening pelvic exam was necessary versus 100% with an annual household income &gt; $50,000 (p &lt; 0.05). CONCLUSION: The majority of women disagreed with the recent USPSTF statement that the annual screening pelvic exam may be unnecessary.

Implementation of “Brush, Book, Bed” Program in USF Resident Continuity Clinics

Implementation of “Brush, Book, Bed” Program in USF Resident Continuity Clinics

Implementation of “Brush, Book, Bed” Program in USF Resident Continuity Clinics

Objectives: Dental caries are the most common chronic childhood disease, yet most are preventable. Pediatricians play an important role in children’s oral health since many do not regularly visit a dentist. Less than 30% of patients with Medicaid insurance received at least one preventative dental visit in the past year. “Brush, Book, Bed (BBB)” is an American Academy of Pediatrics program aimed at improving children’s health by creating a nighttime routine of brushing the child’s teeth, reading together and setting a bedtime. Our resident clinics primarily care for minority children …

Overcoming missed opportunities in diabetes management to improve outcomes for hospitalized patients with diabetes

AimsThe purpose of this study is to assess the impact of hospitalization on 6–12 month medication adjustment and glycemic control. MethodsWe conducted a retrospective cohort study of hospitalized and non-hospitalized patients with diabetes of an internal medicine residency continuity clinic. Patients had baseline and outcome HbA1c taken 6–12 months apart. Multivariate linear regression was used to model predictors of HbA1c change from baseline to outcome. Multivariate logistic regression was used to model predictors of medication adjustment between baseline and outcome clinic visits. ResultsHospitalization was not a significant predictor of HbA1c change. Hospitalized patients with baseline HbA1c < 7% were more likely to have therapy adjusted (OR 3.05, p = .004), but this trend did not extend to adjustment in patients with baseline HbA1c ≥ 7% (OR 0.98, p = .249). A significant predictor of medication adjustment was having a specialized Chronic Care Model-based outpatient diabetic planned visit (DPV) (OR 1.63, p = .020). Depression was not a significant predictor for medication therapy change in well-controlled patients with diabetes, but was associated with a lower likelihood for medication adjustment in poorly-controlled patients with diabetes (OR 0.47, p = .004). DiscussionOur study supports previous research in that hospitalization may be seen as a “missed opportunity” to intensify treatment when indicated. Based on our findings, hospitalized patients may benefit from enhanced focus on outpatient follow-up. A next step for research is to assess efficacy of scheduling a DPV proximate to discharge for HbA1c reduction when diabetes is poorly controlled.

Addressing Orthostatic Hypotension in Parkinson Disease Patients in a Neurology Resident Continuity Clinic (P2.126)

Addressing Orthostatic Hypotension in Parkinson Disease Patients in a Neurology Resident Continuity Clinic (P2.126)

Provider Communication, Prompts, and Feedback to Improve HPV Vaccination Rates in Resident Clinics.

Human papillomavirus (HPV) vaccination rates lag behind vaccination rates for other adolescent vaccines; a bundled intervention may improve HPV vaccination rates. Our objective is to evaluate the impact of quality improvement (QI) training plus a bundled practice-based intervention (provider prompts plus communication skills training plus performance feedback) on improving HPV vaccinations in pediatric resident continuity clinics. Staff and providers in 8 resident clinics participated in a 12-month QI study. The intervention included training to strengthen provider communication about the HPV vaccine. Clinics also implemented provider prompts, received monthly performance feedback, and participated in learning collaborative calls. The primary outcome measure was eligible visits with vaccination divided by vaccine-eligible visits (captured HPV vaccination opportunities). Practices performed chart audits that were fed into monthly performance feedback on captured HPV vaccination opportunities. We used conditional logistic regression (conditioning on practice) to assess captured vaccination opportunities, with the time period of the study (before and after the QI intervention) as the independent variable. Overall, captured opportunities for HPV vaccination increased by 16.4 percentage points, from 46.9% to 63.3%. Special cause was demonstrated by centerline shift, with 8 consecutive points above the preintervention mean. On adjusted analyses, patients were more likely to receive a vaccine during, versus before, the intervention (odds ratio: 1.87; 95% confidence interval: 1.54-2.28). Captured HPV vaccination rates improved at both well-child and other visits (by 11.7 and 13.0 percentage points, respectively). A bundled intervention of provider prompts and training in communication skills plus performance feedback increased captured opportunities for HPV vaccination.

Immunization education for internal medicine residents: A cluster-randomized controlled trial

PurposeThe aims of this study are to evaluate the impact of a novel immunization curriculum based on the Preferred Cognitive Styles and Decision Making Model (PCSDM) on internal medicine (IM) resident continuity clinic patient panel immunization rates, as well as resident immunization knowledge, attitudes, and practices (KAP). MethodsA cluster-randomized controlled trial was performed among 143 IM residents at Mayo Clinic to evaluate the PCSDM curriculum plus fact-based immunization curriculum (intervention) compared to fact-based immunization curriculum alone (control) on the outcomes of resident continuity clinic patient panel immunization rates for influenza, pneumococcal, tetanus, pertussis, and zoster vaccines. Pre-study and post-study immunization KAP surveys were administered to IM residents. ResultsNinety-nine residents participated in the study. Eighty-two residents completed pre-study and post-study surveys. Influenza and pertussis immunization rates improved for both intervention and control groups. There was no significant difference in immunization rate improvement between the groups. Influenza immunization rates improved significantly by 33.4% and 32.3% in the intervention and control groups, respectively. The odds of receiving influenza immunization at the end of the study relative to pre-study for the entire study cohort was 4.6 (p < 0.0001). The odds of having received pertussis immunization at the end of the study relative to pre-study for the entire study cohort was 1.2 (p = 0.0002). Both groups had significant improvements in immunization knowledge. The intervention group had significant improvements in multiple domains that assessed confidence in counseling patients on immunizations. ConclusionsFact-based immunization education was useful in improving IM resident immunization rates for influenza and pertussis. The PCSDM immunization curriculum did not lead to increases in immunization rates compared with the fact-based curriculum, but it did significantly increase resident confidence in communicating with patients about vaccines.

Management of chronic nonmalignant pain: A needs assessment in an Internal Medicine Resident Continuity Clinic

The authors hypothesized that Internal Medicine (IM) residents experience a lack of preparation, confidence, and reward when managing patients with chronic nonmalignant pain (CNMP) in their continuity clinic and that they exhibit deficiencies in CNMP management practices, particularly when opioids are prescribed. As part of a quality improvement project in the IM resident continuity clinic, the authors performed a needs assessment through a self-administered resident questionnaire and a retrospective chart review. Fifty-seven percent of respondents rated their CNMP preparation as "fair" or "poor," 89 percent reported that their experience was "much less" or "somewhat less" rewarding than managing patients with other chronic conditions, and 58 percent reported that CNMP management "negatively" or "very negatively" affected their view of primary care as a career. Twenty-eight charts of patients receiving opioids during a 1-year study period were reviewed. Although residents were likely to document pain diagnoses (93 percent) and pain scores (82 percent) as well as utilize medication agreements (82 percent), they were less likely to document illicit substance use (39 percent), document legal history (32 percent), or obtain prior medical records (39 percent). Few urine drug screens were ordered (18 percent) and 25 percent of patients had fewer than four face-to-face visits during the year. The questionnaire indicated that IM residents lack preparation in managing CNMP, which results in lack of confidence and reward. The chart review revealed management practice deficiencies in risk assessment and prescription drug misuse monitoring. As a result, the authors have implemented curricular interventions, integrated a pain clinic within the continuity clinic, optimized residency program clinic scheduling, and developed tools for consistency in management practices.

Continuity of Care in Resident Outpatient Clinics: A Scoping Review of the Literature.

Continuity between patients and physicians is a core principle of primary care and an accreditation requirement. Resident continuity clinics face challenges in nurturing continuity for their patients and trainees. We undertook a scoping review of the literature to better understand published benchmarks for resident continuity; the effectiveness of interventions to improve continuity; and the impact of continuity on resident and patient satisfaction, patient outcomes, and resident career choice. We developed a MEDLINE search strategy to identify articles that defined continuity in residency programs in internal medicine, family medicine, and pediatrics published prior to December 31, 2015, and used a quality evaluation tool to assess included studies. The review includes 34 articles describing 12 different measures of continuity. The usual provider of care and continuity for physician formulas were most commonly utilized, and mean baseline continuity was 56 and 55, respectively (out of a total possible score of 100). Clinic and residency program redesign innovations (eg, advanced access scheduling, team-based care, and block scheduling) were studied and had mixed impact on continuity. Continuity in resident clinics is lower than published continuity rates for independently practicing physicians. Interventions to enhance continuity in resident clinics have mixed effects. More research is needed to understand how changes in continuity affect resident and patient satisfaction, patient outcomes, and resident career choice. A major challenge to research in this area is the lack of empanelment of residents' patients, creating difficulties in scheduling and measuring continuity visits.

Improving Rates of Hpv Vaccination Among Female Patients in a Pediatric Resident Continuity Clinic

Improving Rates of Hpv Vaccination Among Female Patients in a Pediatric Resident Continuity Clinic

Enhancing Resident Education and Optimizing Care for Children With Special Health Care Needs in Resident Continuity Clinics

Enhancing Resident Education and Optimizing Care for Children With Special Health Care Needs in Resident Continuity Clinics

Milestones-based direct observation tools in internal medicine resident continuity clinic

BackgroundWith milestones-based assessment, there is an increased need for tools to facilitate direct observation of clinical trainees. This study was designed to compare a Mini-CEX tool to new direct observation tools (DOTs) linked to internal medicine milestones.MethodsA web based survey was used to examine satisfaction and usefulness of DOTs compared to the Mini-CEX. Residents and preceptors were surveyed three times over 6 months with half serving as control (using mini-CEX) compared to those using the DOTs. Likert scale quantitative answers and qualitative comments were analyzed using generalized estimating equations.ResultsOut of 94 residents and 32 faculty 81 and 90% completed the survey for at least one time point. In adjusted models, there was no significant change in resident evaluation comparing the tools on a number of questions including overall satisfaction and resident perception of receiving high quality feedback. By contrast, faculty preceptors reported increased ratings on many of the questions evaluating their use of the new tools including ability to provide higher quality feedback and overall satisfaction.A number of challenges and benefits of the new tools were identified in qualitative feedback by both residents and preceptors.ConclusionsAll parties recognized the value and limitations of direct observation. Overall these new office based DOTs were perceived similarly to the mini-CEX by residents while faculty reported higher satisfaction. The DOTs are a useful addition to the tool box available for the assessment of clinical skills of medical trainees, especially from the viewpoint of faculty preceptors.