Integrated Care
Preparing the Personal Physician for Practice (P4)
Rochester p4 Video: Training to Teams from Gina Lamanna on Vimeo.
In 2007, we were chosen as one of 14 residency programs to participate in the P4 project: a national demonstration program designed to encourage innovations in residency training to prepare graduates for family medicine in the future. In addition, in mid-2009, we were awarded a 3-year $600,000 Residency Training Grant from HRSA that we utilized in tandem with our P4 initiative. As a result of this longitudinal project we have experienced a transformative culture shift toward the aim of our P4 effort stated as: “…establish a learning lab and culture of team-based, practice-based experimentation and innovation that will result in improved quality of care and resident learning." The major areas of effort in our P4 project continue to be: 1) a fundamental, organic practice redesign with emphasis on learning about, achieving recognition and training residents in the NCQA Patient Centered Medical Home (PCMH) model and 2) the comparison of patient outcomes and healthcare disparities at our primary care practice with the new IMP-UP model.
Team-based Care
The continuity practices within our residency program continually strive to optimize team-based care. We currently have the following team-based features built into our practice, with other innovations and improvements in the planning and early-implementation stages:
- Dedicated time for team building and shared leadership
- Huddles
- Chronic Care Model teaching afternoons
- Collaboration with community-based organizations
- Group visits focusing on diabetes, pain mangement and depression
Behavioral Health Services (BHS)
The departmental practice hosts an on-site behavioral health satellite of the Department of Psychiatry. Residents refer patients to behavioral health practitioners and the psychiatrist. To enhance the experience for the residents, therapists, and patient families, joint meetings can be conducted on site with all providers. This collaborative experience develops the residents’ knowledge, skills, and attitude about how to work successfully with mental health practitioners. Trainees develop familiarity with Models of Collaboration in a healthcare setting.
“Recently one of my patients retired and decided that he could no longer afford his COBRA insurance coverage. Without telling his providers, he decided to discontinue his psychotropic and blood pressure medications in preparation for not being able to afford them. When the patient told me about his decision during what he said might be our "last session" (because he would no longer have coverage), I discussed Strong Memorial Hospital and Highland Hospital Charity Care and the $4 prescription list. He was meeting with Elder Source a week or so later to discuss his options and I called to check in after that meeting. At that time the patient said that he was shaky and sweaty without his medications. I tasked Dr. Lurie with an update and he called our patient within an hour and prescribed high blood pressure medication off the $4 list. The patient is able to continue seeing all of his providers as we processed his Charity Care application. I know that my patient felt cared about when his doctor called him at home concerned and willing to problem-solve.”
–Lacy Morgan-DeVelder, staff Marriage and Family Therapist for Behavioral Health Services (BHS) at Highland Family Medicine Center
