Addendum A - Course Description

A four-week, in-depth experience of primary care in the midst of a multi-specialty practice with special emphasis on:

• Care Coordination
• Care Transitions
• The SETMA Model of Care with emphasis on provider transparency public reporting of provider performance by provider name.
• The Place and Power of Informatics in Primary Care with an introduction to HIPAA
• Healthcare Transformation and the Triple Aim
• A sustainable primary care business model with emphasis on cash management, cash flow and the balance between professionalism and mission, and economic realities.
• What it means to be part of a learning organization with collegial relationships with nurse practitioners, nurses, support staff and other colleagues.’
• Designing and sustaining quality improvement initiatives and Performance Improvement CME.
• Clinic Decision Support and disease management tools
• The distinction and origin of that distinction between electronic patient records and electronic patient management.  The place of “systems thinking” in primary care design.

Addendum B - Course Objectives

To identify, describe and define:

• The critical role of primary care in healthcare Transformation,
• Why the future of healthcare is dependent upon primary care,
• Why the only segment of medicine which can effect sustainable change is primary care, and
• Why the best and the brightest will find the greatest fulfillment in primary care.

Addendum C - Details

Sections

• Readings
• Lectures
• Disease Management Tools
• Preventive Health Tools
• Framingham Cardiovascular Risk Scores and “What If” Scenarios
• Clinic Experience
• The Business of Medicine

Students will have reading assignments prior to arrival to include

The SETMA Model of Care

More Than a Transcription Service: Reorganizing the Practice of Medicine With Computerized Patient Records (CPR) (1999)

The Contrast of Electronic Patient Records and Electronic Patient Management

Revolutionizing the Practice of Medicine With Electronic Medical Records (EMR) which Evolves into Electronic Patient Management

Beyond Electronic Medical Records: The Hope and Promise of Electronic Patient Management

The Following Lectures will be Delivered at Appropriate Times During the Four-week Course

Nextgen as a Tool for Redesigning Primary Care to Fulfill IHI’s Triple Aim

The Importance of Data Analytics in Physician Practice

Care Transitions: The Heart of Patient-Center Medical Home

Students will select from the following disease management tools (2 Major Conditions)

Disease Management Tools

Angina

Diabetes

Lipids

Lipid Quality Audit

Hypertension

Primary Pulmonary Hypertension

Congestive Heart Failure

Adult Weight Management

Acute Coronary Syndrome

Cardiometabolic Risk Syndrome

Chronic Renal Disease

Students will Select from three Preventive Tools (LESS Initiative is a required selection)

Preventive Health Tools

LESS Initiative

Smoking Cessation

Exercise Prescription

Diabetes Exercise Prescription

CHF Exercise Prescription

Preventing Diabetes

Preventing Hypertension

Weight Management

Framingham Cardiovascular Risk Assessment and SETMA’s “What If” Scenario (Required of all students)

Cardiometabolic Risk Assessment

LDL Level

Frederickson Classification of Dyslipidemia

Lipid Disease Management

Framingham Heart Study Risk Calculators

Clinic Experience

Students will follow at least one patient a week through a clinic to hospital admission or emergency department to hospital admission.  They will experience the preparation of the following elements of Care Coordination which begin on admission and conclude when the patient is seen in the clinic for follow-up after discharge:

• History & Physical Examination in the EMR
• Hospital Admission Order Set
• Hospital Admission Plan of Care
• Daily Progress Notes Created in EMR
• Hospital Care Summary and Post Hospital Plan of Care and Treatment Plan
• Care Coordination (Care Coaching Call)
• Follow-up visit of the same patient in the clinic

Students will be supervised in the evaluation and treatment of four patients a day from intake to discharge from the clinic; they will be responsible for:

• Preventive Health Issues
• Screening Issues including HIV screening
• Diagnoses
• Plan of Care and Treatment Plan
• Hierarchical Code Classification
• Evaluation and Management Coding
• Association if ICD-9 Codes and CPT Codes through EMR (introduction to SNOMED and ICD-10)
• Use of applicable disease management tools

The Business of Medicine - students will be introduced to cash flow and cash management

• Daily Cash Flow report
• Cash Management
• Creation and use of a budget