Faculty putting their hands together as a team effort

Goal 1: Patient Care 

Facilitate transformation of primary care delivery into a patient-centered medical home model to promote compassionate, appropriate and effective patient careFellow ObjectivesInstructional Strategies

  1. Facilitate the implementation of team-based approaches to patient-care which improve patient outcomes and decrease cost.
    • Literature review/assigned readings/web-based instruction
    • Participate/lead WVU Healthcare and department PCMH meetings
    • Serve as team coordinator for care improvement teams
    • Participate in development and implementation of provider/staff training in PCMH care delivery
  1. Manage and coordinate care for patients at high risk for hospital admission/readmission, in collaboration with case managers and care improvement teams.
    • Participate in team case discussions
    • Participate in home visits for at-risk patients
    • Create and analyze population reports for high risk patients
    • Literature review/assigned readings
    • Participate in departmental PCMH meetings
  1. Analyze and develop strategies to optimize the patient experience of care.
    • Analyze patient satisfaction surveys, complaints/suggestions
    • Literature review/assigned readings
    • PCMH departmental meetings

Goal 2: Medical Knowledge

Demonstrate and disseminate knowledge of the established and evolving evidence for new models of primary care deliveryFellow ObjectivesInstructional Strategies

  1. Understand and articulate the knowledge framework for PCMH elements and inspire others to transform care delivery.
    • Literature review/assigned readings/web-based instruction
    • Deliver 3 didactic sessions on PCMH to residents/students
    • WVU Healthcare and departmental PCMH meetings
  1. Describe the process to successfully incorporate PCMH elements into a practice, including the policies and procedures to receive NCQA PCMH recognition.
    • Literature review/assigned readings/web-based instruction
    • Attend NCQA PCMH courses, "Facilitating PCMH Recognition" (1.5 day seminar) and "Advanced Topics in PCMH: Mastering NCQA's Medical Home Recognition" (1 day seminar)
    • Participate /lead WVU Healthcare and departmental PCMH meetings
    • Evaluate practices for implementation of PCMH elements into their practice
    • Participate in team training in PCMH elements
  1. Acquire applicable knowledge and experience regarding PCMH in an active PCMH environment.
    • Participate/lead WVU Healthcare and departmental PCMH meetings
    • Attend one PCMH oriented regional or national conference (STFM Conference on Practice Improvement or similar)
    • Participate in care improvement teams and facilitate practice improvement activities

Goal 3: Interpersonal and Communication Skills

Acquire leadership and patient-centered communication skills to work successfully with individual physicians, teams, practices and health related agenciesFellow ObjectivesInstructional Strategies

  1. Work effectively as a leader of the practice transformation team.
    • Participate/lead departmental PCMH meetings
    • Serve as a physician leader for home visits for high risk patients
    • Serve as team coordinator for care improvement teams
    • Role model collaborative team-based approach to patient care
  1. Develop skill in patient centered communication methods and self-management support.
    • Assigned readings/web-based training
    • Serve as role model for effective listening skills and motivational interviewing
    • Participate/lead the planning and implementation of team training in patient centered communication techniques and self-management support

Goal 4: Professionalism

Demonstrate respect, compassion and responsiveness toward patients and coworkers. Demonstrates commitment to ethical principles, including confidentiality, patient autonomy. Fellow ObjectivesInstructional Strategies

  1. Demonstrate effective, professional and respectful working relationships with multidisciplinary healthcare team members.
    • Serve as role model for collaborative respectful communication during all team meetings
    • Serve as team coordinator for care improvement teams
    • Participate/lead PCMH team meetings and team training
  1. Demonstrate sensitivity to diverse cultural and psychosocial backgrounds of patients and families.
    • Participate/lead team case discussions
    • Serve as role model for respectful, patient-centered communication
  1. Understand and explain appropriate steps to protect confidentiality when creating and utilizing patient reports for quality improvement.
    • Didactic sessions with faculty PCMH supervisor
    • Assigned readings

Goal 5: Practice Based Learning and Improvement

Evaluate the quality of care of practice population(s) based on best available scientific evidence and improve care through continuous quality improvement strategies.Fellow ObjectivesInstructional Strategies

  1. Demonstrate proficiency in creating and analyzing quality and utilization reports for practice populations.
    • Didactic sessions with faculty PCMH supervisor
    • Prepare and analyze PCMH quality reports; share and explain reports to providers and teams
    • Participate in WVU Healthcare PCMH and Quality meetings
  1. Develop and implement practice improvement plans to improve patient outcomes, quality measures, care gaps or excess utilization.
    • Facilitate quality improvement projects by care improvement teams and serve as resource for resident leaders
    • Plan and implement one practice-wide performance improvement project with measurable outcomes
    • Present one quality improvement project or research project at regional or national meeting

Goal 6: Systems Based Practice

Demonstrate and promote awareness of the larger healthcare "medical neighborhood." Promote coordination of local community resources to enhance patient self-management and improve outcomes.Fellow ObjectivesInstructional Strategies

  1. Evaluate practice communication and care coordination with outside providers, facilitates and healthcare agencies.
    • Participate/lead departmental PCMH meetings, including team case discussions and case manager conferences
  1. Promote effective patient-centered care coordination for high risk complex patients.
    • Participate/lead team case discussions to develop care plans for complex patients
    • Participate in patient/family conferences
    • Home visits
    • Formulate action plans using shared decision making with patients and family members
    • Identify community resources for complex patients to overcome barriers to effective healthcare.
    • Participate in and/or lead team training in patient-centered communication techniques.