Advanced Primary Care Training Program Introduces New Concepts

The program, funded by the Health Resources Services Administration (HRSA), aims to transform clinical training environments in primary care settings by creating an advanced primary care curriculum that incorporates interprofessional education (IPE) across the training continuum and primary care disciplines.

“Traditionally in primary care, the doctor interacts with a patient in a 15-minute office encounter, and the doctor sees his or her role as managing the patient’s medical care in the context of that office visit,” says Andrew B. Symons, MD, clinical associate professor of family medicine and principal investigator on the grant.

“We know, however, especially for patients with chronic diseases or multiple chronic diseases, that much of the necessary care can and does take place outside the context of that office visit and not necessarily by the doctor,” he says.

Symons cites an example of a diabetic who needs to meet with diabetes educators and nutritionists or a patient with chronic musculoskeletal issues who needs physical therapy.

The patient-centered medical home model, a concept that originated decades ago, is now being implemented as the new standard of care.

“It is where a team of health care providers under the leadership of a primary care physician is engaged in taking care of the patient,” Symons says.

A unique aspect of UB’s new program is that it includes collaboration between the Jacobs School of Medicine and Biomedical Sciences, the School of Nursing’s nurse practitioner program, and D’Youville College’s physician assistant program.

“One of the reasons we were successful in obtaining this grant is because we have all three primary care disciplines involved,” Symons says.

The program contains an exposure component that aims to broadly educate students on concepts of advanced primary care, such as the patient-centered medical home, social determinants of health, longitudinal care of patients in a primary care setting and roles and responsibilities of allied health care professionals.

“Those elements are woven into the curriculum during the five years of the grant so that all of the students will gain exposure,” Symons says.

The training program also has an experiential component where students who have expressed an interest in working in the advanced primary care model will be selected to work in primary care practices of UBMD Family Medicine and UBMD Internal Medicine, as well as community practices such as Jericho Road Community Health Center.

The goal is to identify high-risk patients (those who are hospitalized frequently) and intervene to provide comprehensive care for the patients and to avoid frequent hospital readmissions.

The concept is modeled after the “hot spotting” program of the Association of American Medical Colleges where students help identify high-risk patients and learn about coordinating care for them.

“The idea is to have interprofessional teams assigned to different offices working with the physicians, nurses and staff in identifying these patients and reaching out to them,” Symons says. “They will assess their social determinants of health, their ability to access care and their understanding of any medicine changes that may have occurred when they were discharged from the hospital.”  

The resources of another collaborator, HEALTHeLINK, the region’s health information exchange, will play a vital role.

“If you sign up for HEALTHeLINK, theoretically, anyplace you go locally in the health care system, your medical information is uploaded and transmitted to all of the doctors participating in your care,” Symons says. “HEALTHeLINK is instrumental in that we are going to use its technology to identify high-risk patients.”

“We know this kind of outreach does reduce readmissions to the hospital and in turn, saves the system money because people aren’t getting rehospitalized,” he says.

Each initiative ties into the Triple Aim model of better care, better health and better value, says John S. Taylor, executive director of development for UB’s Primary Care Research Institute.

“The model involves traditional preventative care and traditional management of diseases for most patients,” he says. “But there is a small part of the population that is so complex because they have so many chronic conditions.”

Taylor says that segment represents 5 percent of the patient population, but is responsible for 80 percent of hospitalizations.

Many in this high-risk group have social determinants — illiteracy, language barriers, homelessness and low incomes — that act as non-medical complications in accessing health care.

“You can often save the system $250,000 if you prevent three hospitalizations a year,” Taylor says.

In the new national model of value-based reimbursement, health care providers need to establish risk stratification and implement a new workflow, he says.

“Achieving Triple Aim is not accomplished by a physician, but by an interprofessional team. That is why IPE is now mandated,” Taylor says.

“The forthcoming curriculum under this grant will move it forward,” he says. “We are creating a team that has never existed before in primary care.”

More than 1,000 health profession students will be trained, including medical, nursing and physician assistant students as well as medical residents and community providers.

Most of medical education is very episodic, where a trainee sees a patient in a clinic once then never sees them again, according to Symons.

“In longitudinal care and primary care, the relationship between the doctor and patient is so important,” he says. “We know continuity of care provides better outcomes at a lower cost to the system.”

Thus, implementing a simulation of longitudinal care where the students will meet with “standardized patients,” people who are trained to portray patients, is an essential part of the experiential portion of the training program.

Students will meet with the standardized patients over a period of time, such as once a week for a month, simulating a year of actual care.

Using observed structured clinical examinations, the students will learn about the value of continuity of care and how to manage multiple chronic conditions through coordination of care.

“We have been doing this in the family medicine clerkship, but we are now expanding it to include physician assistants and nurse practitioners,” Symons says.

Other interprofessional experiential components planned are: service learning training and a program on social determinants of health.

“Interprofessional education is where students from the different health care professions learn with each other, from each other and about each other,” Symons says.

Symons notes that part of his mission as an academic scientist is to disseminate the work so these projects will be represented at national conferences and published in medical literature.

“We’re not doing this educational program in an ivory tower out of context of what’s going on in medicine. This reflects exactly the reorganization of primary care,” he says.

“It is great to be able to bring in this kind of funding, not only for medical education, but more specifically to promote students’ understanding of primary care and to encourage them to consider careers in primary care,” Symons says.

Along with this grant, HRSA also recently funded the UB Primary Care Research Fellowship Training Program, another Department of Family Medicine initiative.

Taylor says the department’s recent grant successes are the result of an organized team effort.

“In order to compete nationally, we have always approached external funding as a collaborative approach across disciplines,” he says.

“We have to bring together everyone that has the recognition, passion and willingness to work on change and educational research,” Taylor says. “The nature of what we do is implementation science, taking the evidence already determined to be true and using methodology to translate it into practice.”

Denise McGuigan, MEd, associate director for medical education in the Department of Family Medicine, is co-principal investigator and project director of the grant.