1. WE HAVE THE RESIDENTS: NOW WHAT? How to integrate residents into a community health center. Karin Leschly, MD Medical Director, Department Family Medicine EBNHC Rachel Mott Keis, MD Assistant BUMC Residency Program Director

2. sive to population needs. BACKGROUND INFORMATION  Boston University Medical Center Family Medicine Residency  Urban, academic hospital with continuity sites in three federally qualified community health centers (Codman Square, South Boston and East Boston)  Serving urban underserved  Initially 6 residents per year, total: 18  Received grant to expand 10 residents, total: 30  Department of Family Medicine established: 1996  First residency class accepted: 1999

3. sive to population needs. BACKGROUND INFO  East Boston Neighborhood Health Center  Large, urban federally qualified community health center, established, 1970.  Over 300,000 visits /year  24/7 ED, Pediatrics, Adult Medicine, OB/Gyn, Specialties, Chronic Disease Program, Mental Health counseling, Pediatric Dental, Optometry, Senior Care and Elder Service Plan, 30b Pharmacy, Radiology  Family medicine established fall 2010  Over 30,000 visits/year  East Boston Demographics: (US Census 2010)  Insurance: >50% Medicaid/Medicare  Large Immigrant Population: 44% born outside USA  Ethnicity: 58.2% Hispanic/Latino (1990 17.6%)  Spanish is the primary language spoke by 37.3%, Portuguese 4.6% and Italian 5.9%

4. sive to population needs. TASK ON HAND  How to assign patients to residents ?  How many, how fast?  But first need to determine panel size  But first need to know their access  Important Facts: Residents are the PCP in the patient’s header  How to incorporate residents into practice?  How do residents fit into an established team based model?  How to schedule patients?  How many patients scheduled  How to make the finances of 1 Resident:1 Preceptor work  Important Facts: Rough goals  RRC visit requirements: PGY1 150 and overall 1650 patient visits  From this expect PGY2 to see 550-600 and PGY3 900-950  SR model

5. sive to population needs. HOW TO DETERMINE PANEL SIZE  How many hours is a resident seeing patients?  How much FTE is PGY1, PGY2, and PGY3?  How to determine their panel size.  Used this Industry Standard: 32 clinical hours per week x 44.8 weeks per year = 1434 clinical hours per year. Resident Estimated Yearly Clinic Hours Estimated Patients per Clinic Session Estimated Hourly Ratio = Patient per session/12 Estimated Patient Panel =Adjusted Yearly Hours= Estimated Yearly Hours x Estimated Hourly Ratio Estimated Adjusted FTE= Estimated Adjusted Yearly Hours/1434 PGY1 PGY2 PGY3

6. sive to population needs. ESTIMATING YEARLY HOURS  Estimated expected yearly clinic hours:  Used 44.8 (industry standard) weeks in clinic and multiplied by expected hours/week in clinic  PGY1: (1-2 sessions) 6 hours x 44.8= 269  PGY2: (2-3 sessions) 12 hours x 44.8= 538  PGY3: (4-5 sessions) 16 hours x 44.8= 717 Resident Estimated Yearly Clinic Hours Estimated Patients per Clinic Session Estimated Hourly Ratio = Patient per session/12 Estimated Patient Panel =Adjusted Yearly Hours= Estimated Yearly Hours x Estimated Hourly Ratio Estimated Adjusted FTE= Estimated Adjusted Yearly Hours/1434 PGY1269 PGY2538 PGY3717

7. sive to population needs. ESTIMATING HOURLY RATIO  Residents don’t see same number of patients as Attendings do.  Estimated allotted time in clinic- based on residency schedule already established over minimum 40 weeks per year  PGY1: 2 sessions/week, 4-6 visits/ session  PGY2: 3 sessions/week, 7-9 visits/session  PGY3: 5 sessions/week, 10-11 visits/session  Used estimated patient visits/session per each resident divided by average of attending patient visits/session (12)  PGY1 5/12= 0.42  PGY2 8/12= 0.67  PGY3 10/12= 0.83 Resident Estimated Yearly Clinic Hours Estimated Patients per Clinic Session Estimated Hourly Ratio = Patient per session/12 Estimated Patient Panel =Adjusted Yearly Hours= Estimated Yearly Hours x Estimated Hourly Ratio Estimated Adjusted FTE= Estimated Adjusted Yearly Hours/1434 PGY126950.42 PGY253880.67 PGY3717100.83

8. sive to population needs. ESTIMATING ADJUSTED PANEL SIZE FOR RESIDENT  Industry Standard Assumptions:  Full time MD: 1434 hours/year (32 hrs/week x 44.8)  MDs see 3 patients/hour  MDs panel size is yearly hours worked  For resident adjusted Annual Hours: used expected hours of each residents x Patient Ratio  PGY1: 0.42 x 269= 113  PGY2: 0.67 x 538= 360  PGY3: 0.83 x 717= 595 Resident Estimated Yearly Clinic Hours Estimated Patients per Clinic Session Estimated Hourly Ratio = Patient per session/12 Estimated Patient Panel =Adjusted Yearly Hours= Estimated Yearly Hours x Estimated Hourly Ratio Estimated Adjusted FTE= Estimated Adjusted Yearly Hours/1434 PGY126950.42113 PGY253880.67360 PGY3717100.83595

9. sive to population needs. CALCULATING THE RESIDENT ADJUSTED FTE  Used Residents Adjusted Estimated Hours Divided by Industry Standard (1434)  PGY1: 113/1434= 0.08  PGY2: 360/1434= 0.25  PGY3: 595/1434=0.42 Resident Estimated Yearly Clinic Hours Estimated Patients per Clinic Session Estimated Hourly Ratio = Patient per session/12 Estimated Patient Panel =Adjusted Yearly Hours= Estimated Yearly Hours x Estimated Hourly Ratio Estimated Adjusted FTE= Estimated Adjusted Yearly Hours/1434 PGY126950.421130.08 PGY253880.673600.25 PGY3717100.835950.42

10. sive to population needs. HOW MANY, HOW FAST  Important lessons learned  Interns have VERY limited access and patients will NOT meet their new PCP if they are assigned patients too fast  Have to “sell” patients to resident PCP  Foreign language knowledge really affects patient’s PCP choice  Frequently review reports and check in with staff and adjust real time

11. sive to population needs. HOW MANY, HOW FAST  New residents (interns):  July, 2013 thru Jan 2014: 10-11 slots per month  Goal for year end: 125 patients each  Second year residents (should be starting at 125)  July, 2013 thru December, 2013:- 19 slots per month (max out at 115 additional patients)  January, 2014 thru June, 2014:-10 slots per month (max out at 60 add'l patients)  Goal for year end: total of 300 (175 new)  Third year residents (should be starting at 300)  July 2013 thru Dec 2013:-33-34 slots per month (max out at 200 add'l patients)  January, 2014 thru MARCH, 2014= 16-17 per month (max out at 50)  CLOSE their panels at end of March.  Goal for year end: total of 550 (250 new)

12. sive to population needs. HOW TO INCORPORATE RESIDENTS INTO PRACTICE? Team 1 1.18 FTE PGY3 0.42 FTE MD 0.34 FTE MD 0.12 FTE RN 1 FTE NP 1 FTE PGY1.08 FTE PGY2 0.25 FTE Team 2 1.11 FTE PGY3 0.42 FTE MD 0.43 FTE LPN 0.9 FTE NP 1 FTE PGY1.08 FTE PGY2 0.25 FTE Team 5 1.17 FTE MD 0.58 FTE MD 0.59 FTE RN 1 FTE NP 1 FTE Team 3 1.11 MD 0.5 FTE MD 0.18 FTE RN 1 FTE NP 1 FTE Team 6 0.99 FTE MD 0.49 FTE MD 0.5 FTE RN 1 FTE PA 1 FTE 6.95 FTE MD 6.5 FTE NP/PA 6 Residents 6.8 FTE RN/LPN 11.5 FT MAs 4 FT Clerical 1 Administrative Director 1 Operations Supervisor 1 Care Coordinator Team 4 1.29 FTE MD 0.58 FTE MD 0.43 FTE LPN 1 FTE PA 0.5 FTE MD 0.28 FTE NP 0.5 FTE

13. sive to population needs. HOW TO SCHEDULE RESIDENT PATIENTS?

14. sive to population needs. HOW TO SCHEDULE PRECEPTOR PATIENTS WHEN ONLY ONE RESIDENT IN CLINIC? ?

15. sive to population needs. CONCLUSION  Hour, Visit and Access Data is coming in...  Our calculations seem to be slightly off...  we did not account sufficiently for all inpatient resident obligations and away rotations  Estimated hours seemed to be high and therefore we have assigned too many patients, however it works because...  patients no show  not every patient assigned to a PCP ends up coming to see their PCP  Residents are meeting annual visit goals  Residents are well integrated into team based care

16. sive to population needs. THE END  Contacts:  Karin.Leschly@bmc.org Karin.Leschly@bmc.org  Rachel.Mott@bmc.org Rachel.Mott@bmc.org