Improving Continuity of Care at Naval Hospital Pensacola Family Medicine Residency Program

By Lt. Kevin M. Bernstein, MC, USN, Family Medicine Resident, Naval Hospital Pensacola Family Medicine Residency Program

Bernstein for webThe ability to learn and practice within the Medical Home Port model of primary care delivery was a top priority for me when going through the residency selection process.  At Naval Hospital Pensacola, Med Home Port was quickly introduced providing dramatic changes to the delivery of primary care services.  Their transformation intrigued me because of how much they had already accomplished within such a short period of time.  Many questions surrounding the potential success of Med Home Port left unsettling feelings with some.  However, after learning of my selection to Naval Hospital Pensacola, I was eager to begin my journey into the unknown. 

After a year and a half as a Family Medicine resident at Naval Hospital Pensacola, I have had the ability to appreciate the wide variety of obstacles and barriers to Medical Home Port implementation at a residency program.  Given the multiple demands that a residency program provides, many question the ability to meet the challenging metrics that are tracked. Furthermore, many still question the ability to successfully carry out Med Home Port’s mission with so many moving parts and other responsibilities that residents have throughout our training.  Although residency is quite vigorous given the multitude of learning we need to accomplish and the various places we are expected to be, it is possible to carry out Navy Medicine’s mission and priorities: providing world-class care anytime, anywhere while emphasizing readiness, value and jointness.

Increasing Primary Care Manager (PCM) continuity (the percentage of encounters that patients see their assigned PCM) within the Medical Home Port is a top priority for Navy Medicine as well as the Military Health System. Many studies have shown that sustained continuity of care between provider and patient directly decreases: rates of hospitalization, emergency room utilization, duplicative ancillary testing, delays in diagnosis, and medical errors. Furthermore it has been shown to increase patient satisfaction and delivery of preventive services. 

Naval Hospital Pensacola’s PCM continuity goal, based on a Pilot Business Plan initiative by the TRICARE Management Activity (TMA), is set at 60%.  This past year, our Commanding Officer, Captain Maureen O. Padden, challenged the Command as well as our residency program to go above and beyond this goal.  This challenge resonated down our chain of command to our Department Head who set higher standards for our Family Medicine Providers as well as to our Program Director who set higher expectations for our residents. 

Achieving increases in PCM Continuity within a residency program is a unique situation given the fact that many of our Family Medicine residents have many responsibilities within and outside the hospital while rotating through different specialties and covering overnight hours.  The situation created puts many of our residents at a disadvantage when trying to improve continuity with our patient panels.

Due to these barriers, the Naval Hospital Pensacola Family Medicine Residency did not see this as an excuse for poor PCM continuity but an opportunity to improve PCM continuity and prove that Medical Home Port implementation and accomplishment is not only possible, but also a successful model for delivery of primary care within a residency program. 

Increasing our PCM continuity within the program was not an easy task. This required a teamwork approach to coordinate and communicate between appointment clerks, nursing staff, paraprofessionals, providers, and patients as well as working within the work hour restrictions of a Family Medicine Residency Program set forth by the Accreditation Council of Graduate Medical Education (ACGME). 

Each member of the ancillary staff instituted a number of additional measures to help our residents achieve these new goals for PCM continuity. Staff and residents began to “scrub” the appointment list the day before the patient’s appointment and move patients to see their PCM. They would place them in the same time slot if possible or call the patient and request that they schedule a different time if possible. The staff and residents stepped up efforts to educate patients to the importance and benefits of PCM continuity. Additionally, providers and residents were encouraged to see their patients even when they were not scheduled in clinic. This concerted team effort between ancillary staff, providers, residents and patients necessitated a balance of professionalism, a change in culture, and appropriate patient-centered clinical judgment in the best interest of patient safety.

Since implementation of the initiative, each team has exceeded the command goal, with PCM continuity constantly ranging between 68 and 72 percent. Our residency also improved in PCM continuity.  A little over a year ago, our residency average for PCM continuity was 45 percent.  After elevating expectations and goals, our residency has improved steadily over the past year and now achieving over 65 percent. 

Our improved PCM continuity directly correlated with improved metrics and outcomes including: improved Patient Safety Reporting (PSR), preventive screening, chronic disease management (as indicated by HEDIS measures), and decreased re-admission rates – all of which directly improved our beneficiaries overall health and patient safety. After two years of development, all three of our Family Medicine Teams went on to achieve the highest recognition level awarded by the National Committee for Quality Assurance (NCQA) for our work within the Medical Home Port. Our work was also recognized by the Department of Defense Patient Safety Program, winning a 2012 Department of Defense Patient Safety Award.

Learning how to deliver primary care within the Medical Home Port is not only a useful tool to learn during residency, but a necessity once we graduate from residency to carry out Navy Medicine’s mission of successful Medical Home Port execution.  Although implementation of Medical Home Port may be difficult with a residency setting, we have shown that it is possible to do this and perform at an extraordinary level.

As the Navy’s first and most successful Family Medicine Residency operating as a Medical Home Port, our beneficiaries can be confident that our graduating residents from Naval Hospital Pensacola will provide top-notch, high-quality care to improve readiness, population health, experience of care, and per capita cost.  In fulfilling this “Quadruple Aim” we are saving the Military Health System money, improving quality of life for our patients as well as improving the health of those in the fleet to operate effectively to support the Navy’s mission.  I am extremely proud to be part of this residency program and hope that we can lead by example to help our other residency programs in this very important initiative.