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 care. Further develop clinical skills as a primary care physician including team-based and interprofessional models of care delivery.

Fellow Objectives

Instructional Strategies

1.       Facilitate the implementation of team-based approaches to patient care which improve patient outcomes and decrease cost.

1. Literature review/ assigned readings/ web-based instruction

2. Participate/lead WVU Healthcare and department quality meetings

3. Participate in development and implementation of new team roles and new clinic workflows to improve care.

2.       Manage and coordinate care for patients at high risk for hospital admission/ readmission, in collaboration with case managers and care improvement teams.

1. Participate in population health team planning meetings

2. Participate in case conferences for at-risk patients

3. Create and analyze population reports to identify disparities or risk and propose appropriate interventions.

4. Literature review/ assigned readings

5. Participate in system and practice-site population health meetings

3.   Analyze and develop strategies to optimize                                      the patient experience of care

4. Continue to develop clinical skill as a primary care physician

1. Analyze patient feedback (surveys, comments)

2. Literature review/ assigned readings

3. Understand shared decision making and use of decision aids

4. Participate in patient advisory groups or focus groups, when available

1. Provide primary care services to patients in academic department under faculty within own discipline

2. Participate in new models of care delivery in ambulatory clinic with faculty supervision, including team based and interprofessional models of care

Goal 2: MEDICAL KNOWLEDGE Demonstrate and disseminate knowledge of the established and evolving evidence for population health approaches, new models of care delivery for enhanced healthcare value

Fellow Objectives

Instructional Strategies

1.       Understand and articulate knowledge about current healthcare landscape and need for population health management and re-design of primary care delivery.

1. Literature review/ assigned readings/ web-based instruction

2. Deliver two educations sessions on population health topics to residents/students/other learners

3. Participate in WVU Health System and practice site population health meetings

2.       Describe the process to successfully incorporate population health management into primary care practice, including the policies and procedures to receive NCQA PCMH recognition.  

1. Literature review/ assigned readings/ web-based instruction

2. Attend NCQA PCMH courses, “Facilitating Patient Centered Medical Home Recognition” (1.5 day seminar) and “Advanced Topics in PCMH: Mastering NCQA’s Medical Home Recognition” (1 day seminar)

3. Participate /lead WVU Health System and departmental PCMH meetings

4. Evaluate practices for implementation of PCMH elements into their practice.

3.       Learn to use data to analyze the healthcare needs of patient populations, including demographics, vulnerabilities, and indicators of risk.

1. Participate/lead WVU Medicine and departmental population health meetings

2. Individualized training in creation and use of data reports for population health management by fellowship directors

3. Assigned readings/ web-based learning modules

Goal 3. INTERPERSONAL AND COMMUNICATION SKILLS   Acquire leadership and patient-centered communication skills to work successfully with individual physicians, teams, practices and health related agencies.

Fellow Objectives

Instructional Strategies

1. Work effectively as a leader of the practice transformation team

1. Participate/ lead practice site PCMH meetings

2. Serve as physician leader for case conferences for high risk patients

3. Serve as team coordinator for performance improvement teams

4. Role model collaborative team-based approach to patient care

2. Develop skill in patient centered communication methods and self-management support.

1. Assigned readings/ web-based training

2. Serve as role model for effective listening skills and motivational interviewing

3. Participate/lead the planning and implementation of team training in patient centered communication techniques and self-management support.

4 .Understand/Teach concepts of patient centered communication techniques including shared decision making with patients and family, use of decision-aids, motivational interviewing.

Goal 4 PROFESSIONALISM   Demonstrate respect, compassion and responsiveness toward patients and coworkers.

Demonstrates commitment to ethical principles, including confidentiality, patient autonomy.

Fellow Objectives

Instructional Strategies

1. Demonstrate effective, professional and respectful working relationships with multidisciplinary healthcare team members.

1. Serve as role model for collaborative respectful communication during all team meetings.

2. Participate in team meetings to understand diverse team roles of the practice team

2. Demonstrate sensitivity to diverse cultural and psychosocial backgrounds of patients and families.

1. Participate/lead team case discussions.

2. Serve as role model for respectful, patient-centered communication

3. Understand and explain appropriate steps to protect confidentiality when creating and utilizing patient reports for quality improvement.

1. Individual training sessions with fellowship director

2. Assigned readings / web-based instruction

Goal 4. 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 Objectives

Instructional Strategies

1. Demonstrate proficiency in creating and analyzing quality and utilization reports for practice populations.

1. Didactic sessions with fellowship directors

2. Prepare and analyze population health reports; share and explain reports to providers and teams.

3. Participate in WVU Health system and departmental Quality meetings

2. Develop and implement practice improvement plans to improve patient outcomes, quality measures, care gaps or excess utilization.

1. Facilitate quality improvement projects by performance improvement teams (system level and practice sites)

2. Serve as resource for primary care resident quality improvement efforts

2. Plan and implement one practice-wide performance improvement project with measurable outcomes.

Goal 5. SYSTEMS BASED PRACTICE   Demonstrate and promote awareness of the system-based nature of health care quality and the relationship of the practice microsystem to the larger “medical neighborhood.”  

Fellow Objectives

Instructional Strategies

1. Learn to evaluate practice communication and care coordination with outside providers, facilities and healthcare agencies.

1. Participate/ lead system and practice site population health/quality meetings, including development of payer-provider collaborations, medical neighborhood initiatives with community or home-based care providers, and health system care coordination approaches.

2. Individual instruction by fellowship director

2. Promote effective patient-centered care coordination for high risk complex patients

1. Participate in system population health planning for innovative care coordination approaches.

2. Participate in system or departmental meetings with case managers to discuss strategies for high risk patients

3. Assigned readings/ literature search/ web-based learning about innovative models of care.