Field of Work: Aligning the training of physicians and nurse practitioners with the demands of 21st-century clinical practice.
Problem Synopsis: In the 1990s, managed care became one of the dominant forces in health care. Physicians and nurse practitioners (NP's) were expected to know how to manage patients' health, often within a fixed budget. Although care was increasingly taking place in outpatient settings, physicians continued to receive most of their training in hospitals rather than in ambulatory care centers. They also received little training in preventive care, or in interprofessional collaboration.
At the time of the project, the hospital complex that housed the University of California, Davis Family Practice Center of Sacramento, Calif., part of the University of California, Davis Health System, provided care through approximately 28,000 patient visits each year. The patient population was diverse: approximately 45 percent White, which included a very large number of non-English speaking Russian immigrants; 25 percent Hispanic; 20 percent African American; 5 percent southeast Asian; and 5 percent "other." Nearly 20 percent of its patients required the use of an interpreter for patient visits.
In this period, the highly competitive managed care market in which the medical complex operates created systemwide pressure to increase the cost-effectiveness of its care delivery.
Synopsis of the Work: Partnerships for Quality Education (PQE) (April 1999 through January 2009), was initially funded by the Pew Charitable Trusts (during which time it focused on physicians only) and then by RWJF (which expanded it to include NP's). The program sought to improve a core set of skills in physicians and nurse practitioners, including interprofessional collaboration, chronic illness management, systems-based care and practice-based quality.
The UC Davis Family Practice Center participated in the Take Care to Learn (TCTL) component of PQE. With the RWJF grant, the Center at UC Davis began to create a computerized clinical database and to develop locally appropriate evidence-based clinical practice guidelines. The team was introduced to and began to use the chronic care model.
- Include patient registries when implementing a chronic illness management project.
- Understand the chronic care model as a whole and not just pieces of it.
- Include patient self-management as a key to improving outcomes.
- Involve clinic administrators and support staff when developing changes in the care delivery system.
- Quickly test ideas that have the potential to yield large gains; this goes a long way in implementing change.
- Tailor educational interventions to the developmental level of your residents.
- Third-year residents respond most enthusiastically to the project; these residents are developmentally more open and willing to evaluate a new approach to care.
- Maintain project momentum by whatever organizational means.
While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
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