Family Medicine Residency - Medical Home Port

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Organization Type: 
Program Type: 
Education Level: 
Postgraduate (e.g., residency, fellowship)
Educational Elements: 
Independent Study
Self Reflection Activities
Experiential not including services to patients
Experiential including clinical contact with patients
Other Element(s): 
Business principles to run Med Home Port at any Navy clinic/MTF
Program Description: 

Naval Hospital Pensacola is a 67-bed capacity medical and surgical facility averaging about 3,300 admissions and 230,000 outpatient visits annually. The Family Medicine Residency program offers a full Military Health System curriculum that utilizes lectures/didactics, self-reflective activities, and experiential training in order to produce residents who are competent in all fields of health care. The program also features a medical home elective (Medical Home Port) wherein residents learn how the medical home works, as well as how the Military Health System functions.

During Post Graduate Year 1 (PGY1), students have a panel of 75 patients and are in the clinic for 1 half-day per week. Residents participate in four to eight-week rotations that include the fields of gynecology, dermatology, emergency medicine, adult medicine inpatient service, general surgery, intensive care unit (ICU), military medicine, night float, obstetrics, orthopedics, and pediatrics.

During PGY2, the residents’ panel size increases to 200 patients with 2 to 3 half-days per week spent in the clinic. Residents participate in two to eight-week rotations in the fields of ear, nose and throat (ENT), ICU, adult medicine inpatient service, neurology, neonatal intensive care unit (NICU), night float, obstetrics, ophthalmology, primary care sports medicine, pediatrics, research, and other electives.

During PGY3, the students will see 350 patients with clinics 3 to 4 half-days per week.  Rotations are two to eight-weeks in the fields of cardiology, community medicine, dermatology, electives, family medicine clinic, adult medicine inpatient service, night float, pediatrics, psychiatry/pediatrics psychology, radiology, research, sports medicine/physical therapy, surgery-outpatient, trauma surgery, and urology.

During clinic rotations, residents are expected to meet the following competencies: 1) PGY 1/2/3 - Exhibit outstanding professionalism, patient care, and interpersonal skills in the care of outpatients; 2) PGY3 - Understand the basic principles of clinic management and implementation of the medical home; and 3) PGY3 - Understand methods for evaluation of personal practice patterns.

In the Medical Home Elective Rotation, residents develop knowledge concerning the Navy Medical Home Port model.  Specifically, residents learn to: 1) Verbalize the Navy goals for primary care manager continuity, access to care, and emergency room utilization; 2) Understand the importance of clinic templates, appointment types and booking rules; 3) Implement asynchronous messaging into clinical practice; 4) Explain the benefits of embedded clinical support providers and list examples of such found in the family medicine clinic; and 5) Articulate full-time equivalent (FTE) reductions and how they relate to panel size.

Program Results: 

After 24 months of PCMH implementation, continuity of care by staff providers improved from 48 percent to 72 percent. Continuity of care by residents improved from 45 percent to 65 percent. Further analysis revealed that 30-day hospital readmission rates decreased from 11.2 percent to 3.8 percent, patient safety reporting (PSR) events decreased by 26.7 percent, and many HEDIS measures including cervical cancer screening, breast cancer screening, and chronic disease management improved drastically.

Targeted Professions
Family Medicine
Internal Medicine
Self-Reported Competencies
PCPCC’s Education and Training Task Force identified 16 interprofessional training competencies critical for preparing health professionals for practicing in team-based, coordinated care models such as patient-centered medical homes. Listed below are the self-reported competencies that this program has achieved, which have been organized by the five core features of a medical home as defined by the Agency for Healthcare Research and Quality
Patient-Centered Care Competencies: 
Advocacy for patient-centered integrated care
Cultural sensitivity and competence in culturally appropriate practice
Development of effective, caring relationships with patients
Patient-centered care planning, including collaborative decision-making and patient self-management
Comprehensive Care Competencies: 
Assessment of biopsychosocial needs across the lifespan
Population-based approaches to health care delivery
Risk identification
Coordinated Care Competencies: 
Care coordination for comprehensive care of patient & family in the community
Health information technology, including e-communications with patients & other providers
Interprofessionalism & interdisciplinary team collaboration
Team leadership
Quality Care & Safety Competencies: 
Assessment of patient outcomes
Business models for patient-centered integrated care
Evidence-based practice
Quality improvement methods, including assessment of patient-experience for use in practice-based improvement efforts
Accessible Care Competencies: 
Promotion of appropriate access to care (e.g., group appointments, open scheduling)
Last updated November 15, 2013

* Please note: Information contained in this database is self-reported by representatives from each program. It does not represent an exhaustive list of education and training programs and inclusion does not constitute an endorsement from the PCPCC.


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