By Lauren M. Simon, MD, MPH

Our residency program's faculty coined this one-line moniker that describes our goal in training residents: "Nurturing system - savvy servant leaders in whole-person care."

We use core family medicine values to provide continuous care within a family and community context, promote healing relationships and maintain a whole-person care focus. Whole-person care is patient centered and considers all domains of the individual: physical, physiological, social, emotional and spiritual.  Although we have been teaching whole-person care for many years, this description fits right in with the new model of care and the Patient Centered Medical Home (PCMH). Our clinic has achieved National Commission on Quality Assurance (NCQA) Level 1 PCMH designation.

Our Loma Linda University Family Medicine Residency Program (LLUFMR) is a designated P⁴, (Preparing the Personal Physician for Practice) program. As such, it is one of 14 family medicine training programs across the country being studied for innovations in family medicine residency training  to ensure that family physicians are prepared to embrace new technologies and provide superior patient care.

LLUFMR has 32 residents divided into three designations. The first designation includes the traditional three-year family medicine residents. The second is the combined family medicine-preventive medicine four-year residents (who complete a Master of Public Health degree during their training and choose either Lifestyle Medicine track, which prevents illness by healthy living, or the Global Health track that teaches physicians to work with underserved populations cross-culturally). The third designation is the rural residents who begin training at Loma Linda University for six months, then complete the remaining two-and-a-half years at our rural hospital affiliate (Hanford Hospital in Hanford, CA).

Similar to findings from the AAFP- and Commonwealth Fund-supported National Demonstration Project (NDP) to test PCMH; our clinic implemented many of the technical elements of the PCMH but had more difficulty trying to implement elements that require additional resources such as group visits and population management. (More detailed findings are available in several articles on the NDP and PCMH in the Annals of Family Medicine May 2010 supplement).

Implementing PCMH in our P⁴ program meant a lot of changes, starting with a paradigm shift navigating away from the "physician handles everything" mentality and more toward team-based care. Since the start of implementation, validated resident surveys show our family medicine residents are significantly more "engaged and satisfied" compared to their peers in other specialties. One of our chief residents in 2010, Dr. Sally Sartin, described our residents as "dynamic and innovative, unafraid of change and good problem solvers. The residents love each other and care for each other."

More specifically, when we discuss changes, we focused on training "system-savvy" residents. We redesigned the curriculum to focus around outpatient clinic rotations. The residents were divided into resident teams to promote patient access and continuity within the team so that patients have improved access to physicians familiar with them. The resident teams were then placed on broader care teams that include medical assistants and nursing staff. The residents huddle with their team members to prepare for clinic flow and work with the care team to manage electronic and paper test results, health maintenance and chronic disease management and asynchronous care. Performance evaluations come from both physician and non-physician members of the care team with the goal of continuously improving patient care and team function.

To promote development of "servant leaders," we recruit resident candidates who are mission-driven individuals willing to work with people most in need of care in the local area and around the globe. For example, four of our 2010 graduates will be working with underserved populations domestically as well as in Asia and Africa.

Team-based care has provided a place for shared vision and responsibility for quality of care for our patients. The residents received experience in quality measures for health maintenance, diabetes and hypertension, and are moving toward the use of chronic disease registries.

Through our combined family medicine program, preventive medicine residents get additional exposure at the Jerry L. Pettis Veterans Medical Center, an integrated system where they have increased appointment length with patients, improved access to  internal  specialty referrals (without the frustration of a multiple payer system) and are involved in group visits for smoking cessation and weight management.

Implementation of PCMH is associated with hidden costs that are not discussed in the PCMH components. They include developing registries, team meeting time, leadership training and team facilitation, staffing needs (such as staff who help and maintain information technology), e-prescribing and ordering, to name a few. Thus, as we strive teach the components of the PCMH to our residents, we see the need for an improved health care delivery system and payment reform.  

Lauren M. Simon, MD, MPH, FAAFP is Assistant Director of the Loma Linda University Family Medicine Residency Program, Associate Professor of Family Medicine, Loma Linda University and a member of the CAFP Board of Directors.