Internal Medicine Health Center

The Internal Medicine Health Center (IMHC) is situated at St Joseph’s Hospital & Medical Center (SJHMC), a quaternary care, and academic medical center in downtown Phoenix. It is the primary residency continuity site for the internal medicine residents at SJHMC. The Health Center also trains medical students from Creighton University and Nurse Practitioner students.

The IMHC is an NCQA certified level 3 patient centered medical home (PCMH). Internal medicine residents spend 1/3 of their training in ambulatory settings. During the three-year residency training, they spend 130 half-day sessions in the continuity clinic. The resident clinic provides primary care to Medicaid, Medicare and the bulk of adult uninsured patients that receive sponsored charity care through SJHMC. For uninsured patients, the Health Center runs specialty clinics in Nephrology and Podiatry, funded by a grant to provide consultative services for those who cannot afford to pay. In addition, the IMHC also runs Endocrine, Infectious Disease, HIV, Tuberculosis, Hepatology, and Rheumatology clinics.

The Society of General Internal Medicine awarded the Quality and Practice Innovation Award to the Internal Medicine Health Center (SJHMC) in 2013. The award recognizes general internists and their organization that have successfully developed and implemented innovative role model systems of practice improvement in ambulatory and/or inpatient clinical practice.

The PCMH transformation was phased as follows:

1. Enhanced access and continuity
2. Ambulatory Electronic Health record (AEHR) conversion
3. Development of patient – practice partnerships
4. Development of population health and quality improvement curriculum
5. Development of programs targeted to patient needs
6. Dissemination of an education curriculum for teaching the community

1. Enhanced access and continuity of care: The Internal Medicine residents have individual patient panels analogous to real practice. Residents are part of a team system comprised of the faculty, residents and nurse practitioner, to ensure easy access for urgent appointments and continuity of care. Resident schedules have been developed to allow open access and same day appointments. In addition, dedicated registered nurses, medical assistants and a care coordinator nurse support the team.

2. Ambulatory EHR conversion with development of work flows and registries laid the foundation for the population health curriculum. The residents and staff were instrumental in ensuring that the AEHR was not just a medical record but continuous process improvement leading to improvement in work flows. Educational conferences on improving work flows have greatly made an impact on PCMH education.  A simulation seminar was conducted to teach team roles and functions.

3. Development of patient-practice partnerships: The Internal Medicine Patient Advisory Council is a group of committed patients, caregivers, healthcare providers and staff who work together as active partners to improve the healthcare experience. Several residents are part of this council. The Council developed a quarterly newsletter for the Internal Medicine Health Center.

4. Development of population health and quality improvement curriculum: A Population Health Curriculum aligned with PCMH components has been incorporated into the redesigned curriculum for the residents and medical students. The objectives of the curriculum are to equip all residents and health care professionals to:

• Define population health and contrast it to the traditional biomedical model of understanding health and disease
• Describe the major social determinants of health
• Identify population-level disparities in health locally, nationally and globally
• Utilize Healthy People 2020 as a measure of population health
• Develop and lead teams in health care
• Use of health information technology in providing population based health:                       
  •  EHRs, HIEs
  • Use of registries in the care of populations
  • Use of innovation in health care technology
• Explain principles for effective collaboration with communities to address the social and economic determinants of health
• Principles of chronic disease management
• Health care utilization
• Engaging patients in their care - self management
• Care coordination
• Identifying risk in patient populations
• Define and discuss the health professional’s public roles and professional obligations with respect to advocating for health
• Describe strategies for advocacy to improve health at a population level

The Internal Medicine Health Center is undergoing a phased change in practice pattern to PCMH delivery and focus on chronic disease delivery systems. The residents perform a quarterly review of their diabetic patient panels and complete any outstanding quality metric measures.  The ambulatory quality improvement (QI) curriculum is a requirement for graduation of our residents. A faculty member runs the QI curriculum; residents and faculty are required to identify projects aimed at the improvement of patient health. The QI projects have led to improvement of chronic disease, have been accepted for publication at national meetings, and have provided funding for the educational program. Results from HCAHPS patient satisfaction surveys are shared with the residents. Residents are also required to participate in weekly article discussions pertaining to ambulatory care, to enhance their knowledge and practice of evidence based medicine.

5. Development of programs targeted to patient needs: The Clients Aligned to Community and Hospital (CATCH) project was developed in 2013 to enhance resident competency in Systems-Based Practice. The aim was to build relatively low cost community services around our existing Patient-Centered Medical Home model and resident physician training program.

The goals of the CATCH program are to:

• Link our vulnerable patients with resources available in the community
• Re-engineer health care by addressing the bio-psycho-social needs of the patients
• Re-design the primary care delivery by adding home visits and multi-disciplinary team rounds with social worker, volunteers in the community, clinic nurses and internal medicine residents, students and faculty
• Use technology to extend the reach of the primary care team by using tele-precepting and an electronic community for care for remote reminders for patients
• Teach leadership development for IM residents
• Teach a curriculum in Systems Based Practice and Practice Based learning.

Residents present their findings and reflections at monthly CATCH conferences, which are integrated into the program’s didactic curriculum. Residents also conduct monthly diabetes group visits.  The clinic routinely provides urgent care for its own patients including treatment of uncontrolled diabetes, acute exacerbations of COPD, asthma and heart failure, to reduce hospitalizations. Transitional care visits are performed within 7-14 days of hospital discharge to prevent readmissions. This is coordinated by an inpatient clinical nurse coordinator. Referral and test tracking is done prior to the patient’s upcoming appointment in order to close the loop in a timely manner. A clinic wide initiative improved medication reconciliation during transitions of care from 57% to 96% within a six-month time frame. Residents take after hour calls for the combined faculty and resident practice. As part of a PCMH initiative residents improved on returning calls within the stipulated time and increased documentation of calls in the electronic medical record. A summer coaching program has been developed for college premed and prenursing students who are matched with patients to teach them about their disease. Volunteers meet with patients either directly or by phone to educate them on their chronic disease.

6.  Dissemination of an education curriculum for teaching the community:  The practice recently conducted a half day CME activity “Roadmap to Practice Transformation”, with the audience being physicians, nurses, students, administrators, managers and office staff. The conference goals were to:

• Recognize the applicability of the PCMH and Medical Neighborhood model to an existing practice.
• Implement the PCMH Model in order to identify and manage high-risk chronic disease patients.
• Utilize EMR to document the identification and monitoring of patients with diseases that are at high risk for frequent ED visits or hospital admissions.
• Recognize the bio-psychosocial barriers to patient compliance and the benefits of utilizing the resources in the medical neighborhood to improve outcomes.
• List activities that can reduce ED and hospital admission in patients with chronic disease.