University of Hawaii Family Medicine Residency

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Many of our graduates go into hospitalist medicine for multifold reasons like quality of life and flexibility. One reason has been frustration with the clinic experience - high volume, multiple problems, 15-minute slots without time to precept, disorganized workflow, poor follow-up and conflicting demands from other rotations. With a physician shortage of 35%, we hoped Clinic First Collaborative would give us tools to address this.

There were some obstacles to changes implemented, like external rotations resenting need for more clinic and administrative time. However, we felt overall support was present and reflective of the concerns our larger medical community has around providing quality ambulatory care in Hawai’i.

We organized our plans/initiatives around the Building Blocks for High-Functioning Primary Care Residency Clinics:

 Block 1 - Engaged Leadership:

  • Regular meetings between leadership

 Block 2 - Data-Driven Improvement:

  • Dashboards
  • Weekly incomplete note reporting
  • Daily visits with no-show rates
  • Monthly and quarterly quality reporting

 Block 3 - Empanelment:

  • Interdisciplinary Care Teams.
  • Empanelment

 Block 4 - Team-based Care:

  • 3 care teams - each comprised of faculty, residents, an MA and a PSR
  • Physician identifying cards
  • Morning and afternoon team huddles
  • Behavioral health and pharmacy co-location
  • Re-organized tasks in clinic within teams

 Block 5 - Patient-team Partnership:

  • Multiple didactics - development of a “clinic curriculum” including:
    • Motivational interviewing
    • 15 minute visits
    • Agenda setting
    • Difficult patient encounters
    • Billing and coding
    • Medication management
  • Elective to support intern transition in the first 2 weeks

 Block 6 - Population Management:

  • Resident dashboard reviewed monthly with our QI representative
  • Dedicated ½ day of admin time per week on most rotations
  • Complex care management services
  • Community health navigator
  • Quality Improvement curriculum

 Block 7 - Continuity of Care:

  • Scheduling outpatient rotations around clinic instead of vice versa
  • Increased the number of required clinics per resident to 1-2 per week for first years, 3-4 for second years and 4-5 for third years
  • Resident clinic schedules available more than three months ahead
  • Follow-up appointments given at the same time as refill request
  • Researching implementation of 2+2 scheduling system for 2021

 Block 8 - Prompt Access to Care:

  • Same-day appointments.
  • Evening clinics
  • Saturday clinic
  • 24 hour Physician paging system

 Block 9 - Care Coordination:

  • EMR in-basket messaging, continuing to optimize workflow
  • Dedicated referral coordinator
  • Notification of ED/Hospital follow-up system

 Block 10 – Future Template:

  • Group visits
  • E-visits
  • 2+2 scheduling
  • Clinic curriculum with input from community family physicians

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