The Practicum in Primary Care: A Scalable Solution for Primary Care Offices Looking for Patient-Centered Medical Home and Quality Improvement Support

Background: The Initial Work

The initial concept for the Practicum in Primary Care grew out of necessity in 2011 when AccessCare, one of 14 statewide networks that formed Community Care of North Carolina (CCNC), became part of the Multipayer Advanced Primary Care Demonstration Project (MAPCP) sponsored by the CMS. North Carolina was one of eight states chosen to participate in the project. In conjunction with Medicare, the North Carolina Division of Medical Assistance, Blue Cross Blue Shield of NC (BCBSNC), and the NC State Health Plan, CCNC led the implementation of the MAPCP in seven rural North Carolina counties in two regions. One of the goals of the MAPCP was to see whether by incentivizing and supporting practices to become Patient-Centered Medical Homes (PCMHs) through the National Committee for Quality Assurance (NCQA) that overall utilization and cost would go down.

A number of benchmarks had to be met for continuing participation in the multipayer initiative. One of the requirements of MAPCP was that participating practices agreed to finish their work for NCQA PCMH recognition within 12 months. In addition, the practices agreed to go through BCSBNC’s Blue Quality Physician Program (BQPP) by the end of the second year of the project, a requirement that added another set of quality metrics that practices had to navigate through. NCQA estimated that it would take between 100 and 200 hours of work for the practice to finish and upload the roughly 150 documents needed to fulfill the application and be recognized as a PCMH. In total, there were about 30 practices in our region in the three-county area in the mountains of northwestern North Carolina that would need support from the network.

The CCNC team proposed joining forces with the local university, Appalachian State University, to meet these goals. The team contacted the ASU School of Health Sciences (College of Health Care Management) and worked with the faculty to structure the program. Within about three weeks, the team developed a syllabus, a curriculum, and a website, and determined which students and practices would participate in the program’s first semester.(1) The program started with five students, but the student ranks swelled to double digits by the beginning of the second year (2012). This growth may have been due, in part, to the program’s ability to offer stipends to students through a grant from the BCBSNC Foundation, which funded the students for a total of $20,000 over two years. The grant allowed students to concentrate on their studies without the pressure of having to have a second job to pay expenses. In addition, benefits for students accrued as the success of the program became recognized by the University, which later offered credit for a 300-hour internship to students who agreed to spend two semesters in service to the program. Being part of the Practicum internship further removed financial barriers for the students, who were able to work at a paying job during the summer months between academic years instead of participating in a nonpaying internship.

The design and structure of the Practicum developed quickly from the beginning out of necessity, as noted earlier. Students met weekly on campus for didactic sessions taught by the CCNC PCMH facilitation team. In these sessions, the students learned about the NCQA PCMH process. They also learned how to write policies and procedures for the practices to which they were assigned to help these practices meet the standards. These didactic sessions evolved over time to include other types of instruction and learning labs about quality improvement (QI) concepts and processes such as: Plan-Do-Study-Act cycles, improving office workflows, recording and reporting metrics, and helping practices improve patient participation in things such as preventive health screens. One group of students helped their practice design and implement a plan to decrease emergency department (ED) utilization by their patients, a solution that reduced Medicaid spending in that area of the state.

All of the practices involved were rural primary care offices that saw Medicaid patients and thus were all part of the CCNC local network. The main practice liaison position, a position that was critical to the success of the program, was held by a local pediatric office manager who was familiar with both the local offices and their office managers and had been named North Carolina Office Manager of the Year in 2011. This overseeing office manager was allowed to share her time between her office manager job and the work she did with the Practicum. Practices were recruited by the PCMH facilitation team, which included a nurse care manager, a family physician consultant (employed by CCNC), an IT specialist consultant, and the pediatric office manager.

Several funding sources made this program more attractive for the participating practices. The practices were given an incentive through the MAPCP grant with monthly per member per month (PMPM) payments for Medicare patients, depending on the level of PCMH achieved ($2.50 for Level 1, $3.00 for Level 2, and $3.50 for Level 3), as well as a $2.50 PMPM for their Medicaid patients, plus increases in their BCBSNC reimbursements for completing their PCMH recognition process. Of course, an added benefit for practices in our area was that the student program helped them achieve their goals for PCMH recognition.

Students received a good deal of oversight both in and outside of the practice sites. Students spent an average of 8 to 10 hours a week at the practices or working outside the practice on the projects. Members of the PCMH team often would meet the students at the practice to help work through any barriers with practice staff and basically managed the program. The team also set up regular times to meet with students to gauge ongoing progress and to intervene when students ran into barriers or needed support. The students, however, were encouraged to take a leading role and meet with staff regularly. Many students felt they became members of the practice’s team as they took ownership and built management skills in the Practicum.

All practices that participated achieved at least some level of NCQA PCMH recognition.

The results of the first year were excellent. All practices that participated achieved at least some level of NCQA PCMH recognition. Four of the practices achieved Level 3, five reached Level 2, and three practices gained Level 1 recognition.(2) The Practicum started with five students in the fall of 2011 and added nine more in the spring of 2012. In 2012 we also obtained the BCBSNC grant, which added fuel to the fire and generated a lot of student interest in the program.

Interest in the program remained keen. In the summer of 2012, eight students continued to work with the program. A couple of “star students” rose to the top. These student leaders were asked to supervise a few students over the summer and were named student managers. The program resumed in the fall of 2012 with 14 students in the program. By the spring of 2013, 15 students worked in the program. The Practicum continued to attract students, and 16 were added in the fall of 2013. The spring of 2014 added 15 more students—even without the support of the BCBSNC grant. It appeared the program had found a sustaining wind, fostered by positive word-of-mouth. Commendations, particularly from the ASU student group Future Health Care Executives, were helpful,(l) and one or two of their officers usually worked with the program and the CCNC PCMH facilitation team.

The program’s success also was bolstered by the fact that the program appeared to be a win-win-win:

• The students got real-world experience and meaningful interactions with practice staff and providers.

• The practices got a significant amount of no-cost and much-needed technical support.

• The university and local primary care network got to add a new collaborative learning program that helped both achieve their goals.

In the third year, medical practices that had started with the Practicum were beginning to think about the need to renew their PCMH status, because PCMH status lasts for only three years. In addition, as word of the Practicum’s success got out into the community, other practices were calling in hopes that they could get a student to help them with their PCMH recognition or BQPP certification. As a result, the Practicum had more interest than it had students to meet demand. The greatest number of practices that the Practicum worked with at one time was 18, and the greatest number of students that worked with the Practicum during any given semester was 16. Although this was a lot for the leadership team to manage, the quality of students the program attracted and their commitment to the Practicum made it comparatively easier on the leadership team than it might otherwise have been.

National Award Winner, Grant Recipient, and Expansion of the Practicum

In February of 2014, the team was notified that it had become a finalist for the 2014 Innovations in Rural Health Award supported by the Kate B. Reynolds (KBR) Charitable Trust. In April, despite stiff competition, the team was announced as the National Award Winners. The award included a $25,000 first prize, money that went right back into supporting the Practicum project. The award also encouraged the team to continue the work with the students at Appalachian State University with renewed fervor and enthusiasm.

In June of 2014, a proposal was sent to KBR outlining a plan to scale up the program across the state of North Carolina. By this time, the ASU program had matured and was running well. Furthermore, because many practices were preparing to reapply for the NCQA PCMH and BQPP programs, the leadership team was ready to move the Practicum into more of a QI support program. Given the initial resistance to the program by some practices, it was surprising that now the team was fielding calls from practices asking, “What can we do next to improve the quality of our outcomes?” The team responded by sending Practicum students into practices to help them improve their Medicaid quality metrics and Healthcare Effectiveness Data and Information Set (HEDIS) quality measures. Some practices worked with the program to reduce their ED utilization, whereas other projects included helping practices reduce the number of care alerts for overdue health screenings. As a result of these changes, a subtitle was added to the program, so that it was now called “The Practicum in Primary Care—Keeping the Medical Home Fires Burning.”

The benefits of the Practicum became far-reaching in their impact. For example, one of the ASU students, in his final term paper for the Practicum in Primary Care, wrote about the disparity between the resources that small, rural independent practices have when compared with practices that are part of larger systems (i.e., hospitals and health systems). In his paper, he outlined the need to have a different set of standards for smaller practices as compared with the larger ones possessing access to greater resources. The leadership team encouraged him to send his ideas to NCQA. As a result, two of our practices were included in an NCQA pilot program designed specifically to look at the needs of smaller practices. The whole team felt that those ideas and feedback had an impact on the new NCQA PCMH program that debuted in 2017. In addition, the students developed a video about the BQPP program with BCBSNC, which BCBSNC then loaded to their website as a resource for practices across the state. One of the students also spoke to the North Carolina Pediatrics Society about the Practicum and its work with BQPP. Finally, members of the leadership team spoke at the North Carolina Community Health Center Association and the CCNC Innovations Forum. Members of the leadership team also presented at the Institute for Health Improvement (IHI) and NCQA several times over the course of the Practicum.

In the spring of 2015, the Practicum team leadership felt that the program could and should be expanded to other sites across the state and, therefore, submitted a formal grant proposal to KBR that would allow the program to expand. By then, the team had had several discussions with other CCNC networks across North Carolina that generated significant excitement and interest in the Practicum. The best fit seemed to be to work with East Carolina University (ECU) in Greenville to develop the program further. ECU had a willing and eager faculty and a Health Care Management and Health Information Technology program. The Practicum leadership also had a good relationship with the Eastern CCNC network, which also was located in Greenville.

Meetings with the faculty at ECU began, and a plan was designed to start the program in the fall of 2015. The team received approval for partial funding of the proposal in April of 2015 and final budget approval on June 27, 2015. Accordingly, the ECU Practicum program began on July 1, 2015. The total award for the three-year grant was $703,000.

The work at ECU was a very different experience from that at ASU. Practicum leadership was involved in many early discussions with ECU leadership with regard to the structure of their program, sharing with them many “lessons learned” from four years of administering the program at ASU. However, Practicum leadership essentially gave free rein to the ECU faculty and AccessEast team to develop their own program. Guidelines were provided and regular visits and communication took place, but only moderate oversight was provided by the Practicum leadership team. They believed that just because a successful program had been developed at ASU that did not mean that ECU faculty should necessarily copy ASU’s program exactly. As a result, the ECU team was able to accommodate local differences and needs—a part of the mission that Practicum leadership held as a priority. It also was believed that that attitude would increase buy-in and commitment, because the ECU faculty would be developing their own ideas and methods rather than trying to adopt and employ those used by their counterparts in the ASU program.

Other differences between the programs at the two universities were notable. For example, ECU chose to offer their didactic sessions in the fall and then to send students out to the practices in January each year. At ASU, the students went out into the practices first thing in the fall and had their didactic sessions all year. While allowing the ECU program to evolve naturally and build innovation that would grow out of their own “best practices,” the leadership team strongly encouraged ECU faculty and leaders to have students meet with practices monthly starting in mid-September. It seemed imperative to have students in the practices early in order to put some “real world skin on the bones” of the didactic sessions. Parenthetically, the ECU students strongly agreed with this. In addition, the Practicum leadership team wanted to see the program opened to juniors the following year. (The ECU program originally was open only to seniors.) The ASU team had found that having both juniors and seniors was beneficial for the program. As noted, several juniors stayed and supervised or at least volunteered in the summer or even a semester or two in their senior year in the ASU program. This enriched the program and gave the ASU students a much deeper experience in preparation for the working world.

There was quite a bit of “cross-pollination” of ideas between the programs as well. One of those ideas was to include the IHI Open School experience as a requirement for ECU, as it was at ASU. Conversely, there was a desire to build ASU’s IHI chapter to be as active as that at ECU. In addition, a SharePoint site was started for the two schools as a way to build camaraderie and esprit de corps. Students from both schools also benefited from a number of WebEx trainings where they participated together to share best practices and to learn from one another as they visited their practice sites. The SharePoint site was a resource for both teams as they shared experiences and documents they were working on.

The programs continued to grow and be successful. At the end of the first year of the combined ASU and ECU program (2015/2016) the Practicum was serving 14 practices in two different parts of the state. The ECU program started with five students and then added seven more in the second year. ASU that year worked with 7 students and had a banner year in the 2016/2017 cycle with 11 students. Students not only were working on 2014 PCMH recognition with practices but also were participating with a number of practices in the NCQA PCMH redesign pilot. In addition, a lot of interest was raised and quite a bit of training was done with the students around the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and how the program could support practices with all they needed to know about the changes that were coming. Furthermore, work on BQPP continued across the state with the students and practices as well. One of the most significant benefits that was seen in the second year with ECU was the hiring of a new ECU liaison, who was a graduate of the ECU Practicum program’s first year. A peer-reviewed article was published in 2017 about the work going on at ECU in the first year of the Practicum experience.(3)

Expanding The Practicum Model To Include Community Colleges

After two years of a successful combined program involving two state universities, leadership wanted to see whether the model could be expanded to and applied at the community college level. It was recognized that there would be challenges specific to the differing types of students enrolled at the community college level. For example, many of the community/technical college students are married with families and work full-time jobs, often attending classes in the evening. For a Practicum program such as this one, this could have placed them at a disadvantage in terms of the time they had available to work at a practice site. Also, community college students often differ from traditional four-year students in other ways as well. For example, many community/technical college students may be seeking skills to improve their current job performance rather than looking for a new career, whereas most of the undergraduate students who had worked with the Practicum were headed to the work marketplace for the first time in entry-level jobs. These differences left the leadership team unsure as to how well the model could be adapted to the needs of this student population.

The question of where to add another site for the Practicum then became paramount. The first author (RWW), who is Medical Director of Community Care of Western North Carolina (CCWNC), believed it seemed logical to pursue McDowell Community and Technical College (McDowell Tech) in Marion, North Carolina. CCWNC already had a relationship with the school and faculty because of an established shared grant that placed some of their students in a Health IT internship at CCWNC.

The faculty was approached and found to be agreeable to joining the work, which continued throughout the spring and summer of 2017 as they put together the curriculum and lesson plans. The students at McDowell Tech, like those at ECU, did most of their didactic work in the fall and then did the bulk of their in-office practical/internship work in the spring.

The program demonstrated considerable success in its first year. At the McDowell Tech program, the Practicum worked with three students in three practices. Two of those practices successfully submitted their applications for recognition as NCQA PCMHs. The students did excellent work, which included interesting projects with the practices. All built QI dashboards in Microsoft Excel and ran reports in the electronic health record (EHR) to populate the dashboards with at least three months of practice data to be used by the practice to monitor how well they were meeting immunization, care coordination, preventative services, and utilization of services requirements for PCMH. They also built innovative tools such as calendars and tracking tools for the practices’ Complex Care Management staff. Additionally, students generated registries of patients due for their Medicare Annual Wellness visits and helped the practice distribute letters to inform patients that they were eligible for that free service. They even created patient portal instructional brochures, patient satisfaction surveys, and many other tools that supported the practices’ work in population health. Once again, the experience with McDowell Community and Technical College showed that the students had a rich and meaningful experience and that the practices benefited on many levels. Practice managers told the leadership team that they could not have had success in their PCMH recognition were it not for the Practicum and the work that the students contributed.

Lessons Learned and Applying them to a New Program

• Buy-in of the practice and office staff is paramount. Students should prepare a presentation on PCMH or QI to give to the practice staff so everyone knows who this “new person” is and what their specific goals are. Having the support of a lead clinician also is critical. The importance the staff places on the work being done and even the student’s level of comfort in the practice are related directly to how much the lead clinician(s) believe in the importance and meaning of the work. In addition, having the students create a poster for the practices to place in their waiting rooms to communicate what they are doing in the practice and what PCMH and healthcare transformation mean can be helpful for both staff and patients. Again, this is important so the practice staff will have improved understanding about the program. In short, take time to meet with the lead clinician(s) to make very sure they are ready and willing to receive the help. If not, find another place to begin your work.

• Make feedback on the program part of your processes. The Practicum team developed an evaluation form for the students to fill out at the end of their experience. A lot of feedback was collected about what the Practicum meant to the students, how it has changed their lives, their goals, their aspirations, and in some cases their career direction. There was also a sit-down debriefing with university faculty and participants at the end of each semester. Those sessions were recorded. Doing this made the team and the program better as it evolved and changed over time.

• Be firm on principle but flexible on method. Don’t be afraid to let the program evolve to meet the needs of the practices you are working with in the interest of staying relevant. For example, when the first round of PCMH recognition with the practices was finishing up, the program morphed into more of a QI program for students and practices. Additionally, it was found that practices (particularly small and rural practices) need a tremendous amount of support in their transformation process; being flexible to meet these needs is vital. After the second round of PCMH recognition and while working on the BQPP (Blue Quality Physician Program) certification for practices, the program morphed again when MACRA came on the scene. The Practicum started training the students and then the practices on collecting data to fulfill MACRA requirements and performing tasks such as helping them read their Quality Resource and Utilization Reports (QRUR) from CMS reports. Gathering and reporting data is still new for some practices. Learning and applying value-based tenets while still running 110% with fee-for-service medicine continues to be a challenge for most smaller practices. Keep in mind that different areas of the state may (and will) have different needs.

• Don’t be afraid of getting “too involved” with the students. Many internships where the students work tend to hold them at arm’s length. That is, they have a specific (sometimes very specific) goal or task and that is really all they get out of that program. Students go in, do their work, and leave. The Practicum leadership team found the more real and transparent the team was with the students, the better students became invested and the harder they worked. Although it is not best practice to become “friends” with students, getting to know them on a personal level and taking a real interest in their lives, work, and backgrounds made a real difference in the students’ experience. Getting to know them better and getting involved with them also helped the team know how to place them better in the job market. Many students found jobs through contacts that the leadership team had.

• Trust your people—students can do a good job of leading one another. Providing for and allowing students to grow into leadership roles can make a large impact on the success of the program. Positions were provided in the summers for one or two students to be responsible to assist students in accomplishing their goals. It was a “middle management” position, and gave those students a taste of working through problems and challenges, and figuring out a path forward. It was gratifying to witness the growth in the students.

• Students, even great students, need to be managed. For instance, it was helpful to use an agenda and notes for each practice meeting. It was a “deliverable” and it also helped the PCMH leadership team stay on top of what was going on with the students and practices. It provided one more touchpoint.

• Give the students enough rope to “surprise” you but not hang themselves. This lesson is related to “trusting your people,” discussed earlier. If you really let this be the students’ project and let them own it, the results can be amazing. Perhaps it need not be stated that these “20-something” students are very comfortable with technology, but it was impressive to see them go into a clinic that had hired several consultants to improve their connectivity and signals throughout an old building without success, only to see the student come in and fix the problem in just a day. Several found web resources and built websites for these practices that, in many cases, were totally free. Also, students’ ability to learn how the practice’s EHR works and figure out how to run reports, for instance, can be startling. They showed tremendous initiative and creativity in solving problems when the team simply stepped back and let the students figure it out. Thus, one of the biggest lessons of the Practicum is that students may be more talented than anyone gives them credit for! Allow them room to impress by trusting their problem-solving and creative abilities.

• Spend time to plan thoroughly. Working with faculty, students, and practice managers in defining roles, expectations, and timelines is vital. Make sure that all are clear on the direction and desired outcomes of the program. In addition, make regular interaction with students and practice personnel a priority. This should help solidify the team and, again, makes expectations and therefore a “path to success” clearer for all involved.

• Getting students involved in the practices as soon as possible is important. Students from the ECU program told the team that having just didactic materials to learn was quite dry, and getting out to their practices early to understand workflows was important in “lighting a fire” within the students. The team had learned this lesson at ASU and wanted to implement it at ECU but experienced some early resistance from faculty. However, after the first year, all agreed that needed to change, and then allowed time in the students’ schedules to meet with practices early in the fall semester.

• Make being part of the Practicum as competitive as possible. Becoming part of the Practicum was a very competitive process. Students applied to the program and wrote a short essay indicating what they wanted to get out of the Practicum. A “job interview” process for prospective students also was instituted at the beginning of our second year. Students were asked to put together resumes and dress in business attire, and this made becoming a part of the program a real “value-added” for the students. As a secondary benefit, these things added prestige and value to the program itself.

• If the program grows or expands, face-to-face meetings with practices and staff are vital. Even as good as WebEx’s and SharePoint sites can be, nothing yields success like a personal touch through a higher level of involvement by leadership. The time and distance (and mileage reimbursement) can be high, but made a difference. This was particularly true early in the programs as they were just getting off the ground.

• Keep students curious and growing by scheduling compelling speakers and participating in interesting field trips. For instance, the ASU students visited and toured the free clinic (Community Care Clinic) in Boone and were introduced to the Executive Director, who spoke with them about the clinic’s work with the indigent in the community. A former practicum student who had become an Instructional Designer for Allscripts was asked to return to the group to give a lecture. Again, this put a “real world” feel and added value to the program.

• Hands-on activities bring didactic concepts to life. For example, there were “labs” for the students every semester. Two quality improvement labs were presented on using Plan-Do-Study-Act cycles and using Lean training in a pharmacy simulation lab. These labs tended to be very experiential and got the students involved in hands-on experiences that helped them gain a different perspective than those gained from typical classroom activities.

Other Notable Benefits of Participation in the Practicum

• Students who worked with the Practicum had a definite market advantage. Employers now are looking not only for good academic performance from new graduates but also for field experience. When the students interviewed for positions, they already had 6 to 18 months of field work experience. This was a definite plus when speaking with prospective employers.

• Practices benefited from their involvement with the Practicum as well. One of the most valuable things that came out of their experience that was almost universally noted was the development of a Policy and Procedure manual for the practice. Practices used them for cross-training and new hires. It was heard over and over that although the practices did a lot of the procedures and had policies in place, they had never written anything down. It was tremendously valuable for them to have all of their policies and procedures in one place, so they could be catalogued and updated when necessary.

• The cultural experience the students received from participation in the Practicum was one of their most important benefits. Feedback from numerous students regarding their experience in the field showed that being exposed to and becoming part of a small, rural primary care office left a lasting impression. Also, exposure to programs like CCNC and the Practicum will help the student take an understanding and experience of rural healthcare and the struggles they have seen there with them wherever their careers lead them. That is bound to color their “life lens” in positive ways.

Conclusion

Incentives in the marketplace for medical practices have not turned out to be what they could have been. A lot of lip service is given to quality and paying for improved outcomes. Payers, in general, seem reluctant to pay for quality, but that may be changing. The MAPCP incentives that got this program started, for instance, have gone away. But practices still need help in navigating the winds of change that MACRA and the Merit-Based Incentive Payment System (MIPS) are bringing, along with a variety of other pay-for-performance programs that various payers are putting into place. Programs like the Practicum in Primary Care can help build a practice’s foundation in quality improvement and reporting. That will hopefully result in better payments in the future.

This work will change anyone who does it. Not only did the Practicum change the students and have an impact on the practices, it affected the PCMH leadership team as well. Most of the team already had “the heart of a teacher,” and it takes that to be successful at this kind of venture. Seeing students come into the program very “green,” then work with the practices, come to understand the importance of the work they did, and then leave the program to enter the marketplace with new skills was the team’s most gratifying experience.

References

1. Watkins RW. Partnering with universities and colleges to facilitate the PCMH process. An innovative plan to place healthcare management students into practices to promote healthcare transformation. J Med Pract Manage. 2012;28(2):134-136.

2. Lane SJ, Watkins RW. Helping primary care practices attain patient-centered medical home (PCMH) recognition through collaboration with a university. J Am Board Fam Med. 2013;26:784-786.

3. Sasnett B, Watkins RW, Ferlazzo M. Health service management interns serve as practice facilitators for PCMH recognition: East Carolina University–Appalachian State University Initiative. Health Care Manager. 2017;36:80-89.