Assembling patient-centered medical homes-the Clerkship Initiative.

The field of family medicine has active national projects for premedical student recruitment (FutureFamilyDocs.org), residency education (P4 Project), and practice transformation (TransforMED). The purpose of these projects is to recruit and train family physicians who can provide care in patient-centered medical home (PCMH) practices. The missing link in this pipeline is a national project focused on the clinical experience of third-year family medicine clerkship students, which is a pivotal time for specialty selection. STFM is responding to this gap with a 2-year observational study of the development of medical home clinical experiences for family medicine clerkship students. The goal of the project is to understand efforts to spread the PCMH model to clerkship teaching practices. The rationale for the initiative is that the field of family medicine needs to know the current status of clerkship PCMH clinical experiences and to learn how predoctoral programs are attempting to remodel their clerkship clinical practice sites to expose students to the principles of the PCMH model. The STFM Research Committee has designed a baseline study that assesses the PCMH features of systematically selected clerkship teaching practices. This study will include approximately 100 clerkship teaching practices affiliated with coordinating medical schools in different regions. The clerkship sites will be selected to balance site characteristics, such as hospital/system owned vs private practice, residency site vs not, urban vs suburban vs rural, large vs small practice size, and large vs small number of medical students trained. The survey instrument will be the same as that used in the P4 Project and TransforMED, so comparison of clerkship teaching practices with the TransforMED and P4 practices will be possible. This study will be conducted under the supervision of the Research Committee by investigators at Oregon Health and Sciences University, who are also conducting the P4 evaluation. The STFM Board of Directors approved funding for this study when it met at the January 2008 Predoctoral Education Conference. While a one-time study of the status of diffusion of PCMH principles into family medicine clerkship teaching practices has value, it alone will not help predoctoral and clerkship directors learn how to build PMCH clinical experiences for their student programs. Accordingly, the Board of Directors approved in principle a 2-year observational project that will document and share information about strategies implemented by predoctoral and clerkship directors to achieve PCMH features in clerkship practices. Regional coordinators at the medical schools in the baseline study will monitor and record efforts to implement PCMH principles in selected practices. Information about these interventions will be coordinated and publicized in The STFM Messenger and at the STFM Predoctoral Education Conference, the STFM and American Academy of Family Physicians (AAFP) Conference on Practice Improvement, and the STFM Annual Spring Conference. For example, the STFM Special Task Force on the Future of Family Medicine has released competency-based curricula on advanced access, quality improvement, chronic care model, and group visits at http://www.fmdrl.org (search for advanced access, etc). It will be helpful to learn whether these curricula are used and are effective in students’ clinical site experiences. Now that the National Committee for Quality Assurance has released the elements and scoring for its Physician Practice Connections—Patient-Centered Medical Home Recognition Program, it will be very informative to learn about efforts of medical school departments to assist their community teaching practices with fulfilling the standards: “There are 9 PPC standards, including 10 must-pass elements, which can result in 1 of 3 levels of recognition. Practices seeking PPC-PCMH complete a Web-based data collection tool and provide documentation that validates responses” (http://web.ncqa.org/tabid/631/Default.aspx). Helping clerkship teaching practices attain this recognition would be a tangible way medical schools can contribute to volunteer practices and students can experience the PCMH elements. Learning about the methods predoctoral and clerkship directors use to help practices meet PPC-PCMH standards could be valuable to the field. This phase of the initiative will document other ways teaching practices and medical school faculty work together to provide clerkship students with PCMH clinical experiences. After this 2-year period of observation, documentation, and dissemination of lessons, the Research Committee will conduct another survey of the 100 practices to measure change in PCMH features. The STFM Clerkship Medical Home Initiative adds the critical missing element in the pipeline of active national projects for the future of family medicine: the STFM FutureFamilyDocs program for premedical student recruitment, the Association of Family Medicine Residency Directors and American Board of Family Medicine P4 Project for residency education, and the AAFP TransforMED project for practice transformation. The increasing sizes of US medical school classes is an opportunity to enhance recruitment to family medicine, but it is essential that family medicine clerkships provide students with clinical experiences in PCMHs so the students can appreciate this model of practice and make informed choices about specialty selection. This national clerkship initiative will provide important knowledge about effective interventions but also can be a catalyst to accelerate the change that is necessary. Other organizations in the family of family medicine have stepped up with their national projects; STFM is now doing the same.