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Journal© 2014

ADVANCED PRACTICE NURSING

STUDENTS IN THE PATIENT-CENTERED

MEDICAL HOME: PREPARING FOR A

NEW REALITY

KATHRYN SWARTWOUT, PHD⁎, MARCIA PENCAK MURPHY, DNP†,MELANIE C. DREHER, PHD, RN‡, RAJ BEHAL, MD§, ALISON HAINES, BA‖,

MARY RYAN, MHPE¶, NORMAN RYAN, MD#, AND MARY SABA, MS⁎⁎

ant Prg, Chiciate Prg, ChicEmirituo, IL.iate Ch, Rushce Admsity Meant Visity Mer Medico, IL.ctor of Nl Centeress corsing, 60n_d_sw223/13

of ProElsevie

Driven by reimbursement incentives for increased access, improved quality and reduced cost,the patient-centered medical home model of health care delivery is being adopted in primarycare practices across the nation. The transition from traditional primary care models to patient-centered medical homes presents many challenges, including the assembly of a well-prepared,interprofessional provider team to achieve effective, well-coordinated care. In turn, advancedpractice nursing education programs are challenged to prepare graduates who are qualified forpractice in the new reality of health care reform. This article reviews the patient-centeredmedical home model and describes how one college of nursing joined 7 primary care physicianpractices to prepare advanced practice nursing students for the new realities of health carereform while supporting each practice in its transition to the patient-centered medical home.(Index words: Patient-centered medical home; Advanced practice nursing education; Health carereform) J Prof Nurs 30:139–148, 2014. © 2014 Elsevier Inc. All rights reserved.

ofessor, Rush University Medical Center College ofago, IL.ofessor, Rush University Medical Center College ofago, IL.s, Rush University Medical Center College of Nursing,

ief Medical Officer, Senior Quality & Patient SafetyUniversity Medical Center, Chicago, IL.inistrator, Medical Affairs, Ambulatory Operations, Rushdical Center, Chicago, IL.ce President, Rush University Medical Group, Rushdical Center, Chicago, IL.al Director, Rush Health, Rush University Medical Center,

ursing, Rush University Medical Group, Rush Universityr, Chicago, IL.respondence to Dr. Swartwout: Rush University College0 South Paulina, Office 1036B, Chicago, IL 60612. E-mail:artwout@rush.edu/$ - see front matter

fessional Nursing, Vol 30, No. 2 (March/April), 2014: pp 139–r Inc. All rights reserved.

THE NEED TO improve access and quality whilereducing cost is driving change in the delivery of

primary care. The Patient Protection and Affordable CareAct (2010) requires health care providers to create asystem that is more patient-centered and less costly.Many primary care practices are transitioning to thepatient-centered medical home (PCMH) model ofprimary health care delivery to meet these expectations.Practices that choose to seek recognition as a PCMHmustmeet high standards set by the National Committee forQuality Assurance (NCQA). In addition to conferring theprestigious PCMH designation, such practices may beeligible for financial incentives offered by health plans,employers, and federal- and state-sponsored pilot pro-grams (NCQA, 2011).

As effective coordinators of patient-centered care,nurses have an opportunity to play a central role intransforming the health care system to create a moreaccessible, high-quality, and value-driven environment

148 139http://dx.doi.org/10.1016/j.profnurs.2013.07.004

140 SWARTWOUT ET AL

for patients (Institute of Medicine [IOM], 2010). Thetransition to a PCMH model presents unique challengesto primary care practices, including the need for aninterprofessional provider team qualified to assume theresponsibilities of patient-centered, coordinated caremanagement. In 2011, the NCQA recognized nursepractitioner-led PCMH practices in states with allowablelicensure laws. Such practices also are eligible foraccreditation by the Joint Commission. In response tothe PCMH movement, schools and colleges of nursingthroughout the country are revisiting their programs ofstudy for advanced practice registered nurse (APRN)primary care specialties, including the selection oftraining sites in which students can prepare forleadership roles in the new realities of health care reform,particularly interprofessional team-based practice and theuse of information technology to increase access, improveoutcomes, and reduce cost.

This article reviews the PCMH movement and de-scribes how one college of nursing (CON) formed astrategic alliance with physician leadership in sevenaffiliated primary care practices to support their transi-tion to PCMHs. While meeting their usual NationalOrganization of Nurse Practitioner Faculties (NONPF)clinical learning objectives, advanced practice nursingstudents developed competencies essential to increaseaccess, improve quality, and reduce cost. These includedinterprofessional team building and leadership, advanceduse of electronic medical records, long-term carecoordination of complex patients, effective managementof patients with chronic illness, utilization of a registry ofhigh-risk patients, and sophisticated collaborative rela-tionship-building skills.

Primary Care“Primary care is the provision of integrated, accessiblehealth care services by clinicians who are accountablefor addressing a large majority of personal healthneeds, developing a sustained partnership with patients,and practicing in the context of family and commu-nity” (IOM, 1996). Abundant research has shown thathealth systems built on a solid foundation of primary caredeliver more effective, efficient, and equitable care thansystems that do not (Starfield, Shi, & Macinko, 2005).Furthermore, there are fewer disparities in health acrosspopulation subgroups in primary care-oriented healthsystems (Starfield, 2008).

Primary care in the United States is facing a confluenceof challenges including an increasingly chronically ill andelderly population, a more ethnically diverse societyrepresenting many language groups, and an escalation inhealth disparities in combination with a highly fragmen-ted health care delivery system (IOM, 2010). In addition,there is a projected shortage of primary care practitionersand a seriously uneven geographic distribution ofprimary care services (Bodenheimer & Phan, 2010).According to the IOM (2010), the solution to theseproblems is found in expanding access, improvingquality, and reducing cost. The PCMH is an innovative

practice model with the potential to meet thesechallenges (Rittenhouse & Shortell, 2009). The Congressand the President have supported this model byallocating funds in the Patient Protection and AffordableCare Act. This act requires that medical homes besupported by community-based, highly coordinatedinterprofessional teams (Patient Protection and Afford-able Care Act, 2010).

The PCMH MovementIn 1967, The American Academy of Pediatrics introducedthe concept of “medical home” as an effective structure tomeet the needs of children with special health care needs(Kilo & Wasson, 2010). This group established princi-ples for care provided by the medical home in 1992:accessible, continuous, comprehensive, family centered,coordinated, compassionate, and based on trustingrelationships (American Academy of Pediatrics, 1992).In 2000, the American Academy of Family Physiciansexpanded the medical home concept to include patientsof all ages, along with enhanced chronic diseasemanagement, a team approach, enhanced patient access,and the use of information technology to support optimalcare (Kilo & Wasson, 2010).

In 2007, the American College of Physicians, AmericanAcademy of Family Physicians, American Academy ofPediatrics, and American Osteopathic Associationadopted consensus principles of the “patient-centeredmedical home” (Kilo & Wasson, 2010). These principlesinclude access to a personal physician who directs a teamwho collectively assume the responsibility for theongoing care of the patient; patient care should have awhole-person orientation, be coordinated across thehealth care system, and be focused on quality and safety(Grumbach & Grundy, 2010). The movement towardPCMH models has grown steadily since then. In fact, ithas been endorsed by a broad coalition of health carestakeholders, including employers, all the major nationalhealth plans, consumer organizations, labor unions, and19 specialty health care organizations (Patient-CenteredPrimary Care Collaborative, The patient at the center,n.d.). The number of PCMH practices has grown steadilyto almost 3,000 (NCQA, 2011).

Evidence on Quality and CostsThe patient-centered primary care collaborative (Patient-Centered Primary Care Collaborative, Evidence ofquality, n.d.) recently released a report summarizingthe outcomes of implementing PCMH interventions,concluding that it results in improved quality of care andpatient experiences, as well as reductions in hospital andemergency department (ED) utilization. Fields, Leshen,and Patel (2010) compared seven of the most successfulPCMH demonstrations across the country to identifycommon features across the models. Their analysis alsofound reduced use of hospitalization and ED visit andoverall cost savings. The authors concluded that therewere four essential value-generating components ofsuccessful PCMH models: expanded access,

141PREPARING FOR A NEW REALITY

performance management tools, effective incentivepayments, and a dedicated nonphysician care coordi-nator. In fact, nearly all experts in the models reviewedidentified effective care coordination as essential todriving medical home success.

One model that integrated care coordination anddemonstrated positive financial and clinical outcomeswas that of the Group Health Cooperative of Puget Sound,WA (Reid et al., 2010). In 2006, group health cooperativepiloted a PCMH model at one of its Seattle area clinics.This site was selected because it had a stable workforce,strong leadership, and a history of successful qualityoutcomes. The redesign included significant workforceinvestments to reduce primary care physician panels froman average of 2,300 patients to 1,800 patients, expandvisits from 20 to 30minutes, and add telephone and e-mailcontacts. They shifted to a team approach, with the goalsof promoting stronger relationships with patients, addres-sing care needs more comprehensively, and providingtime for coordination of care. The team was composed ofmedical doctors, nurse practitioners, patient assistants,registered nurses, licensed practical nurses, pharmacists,and medical assistants. The project resulted in improvedquality of care across multiple health care effectivenessdata and information set measures, as well as improvedpatient and provider satisfaction. The project also resultedin a 29% reduction in ED visits and an 11% reduction inavoidable hospitalizations (Reid et al., 2010).

The Geisinger Health System, a large integrated deliverysystem in Pennsylvania, implemented a PCMH redesigncalled proven health navigator in one of its primary carepractices (Gilfillan et al., 2010). The goals of this redesignwere to improve the quality, efficiency, and patientexperience of care. This model emphasized primary care-based care coordination with team models featuring nursecare coordinators, electronic health record decisionsupport, and performance incentives. Nurse case managerswere established as an integral part of the practice careteam. They met with the highest risk patients and familiesto design specific plans of care. They also provided closefollow-up for patients transitioning from hospital to homeand formed partnerships with preferred home healthagencies and nursing homes. The results of this innovativemodel included significantly fewer hospital admissions(18%) and readmissions (36%) when measured across theentire population. There were also significant improve-ments in the quality of preventive care, coronary arterydisease, and diabetes care (Gilfillan et al., 2010).

Both the group health cooperative and GeisingerHealth System models highlight the benefits of a teamapproach and care coordination. Care coordination hasbeen identified as indispensible to improving the qualityof care in the United States (IOM, 2003). More recently,the National Priorities Partnership convened by theNational Quality Forum identified care coordinationas one of the priority national goals to help accel-erate fundamental change in the health care deliverysystem (National Quality Forum, 2011). Care coordina-tion is a core competency for the nursing profession in

both acute care and the community setting (Peikes,Chen, Schore, & Brown, 2009; Naylor et al., 2004).Furthermore, recent systematic reviews of the literatureconcluded that APRNs provide effective and high-qualitypatient care (Newhouse et al., 2011; Naylor & Kurtzman,2010) and, thus, well poised to participate in thedevelopment and implementation of innovative caredelivery models such as the PCMH.

The Rush University Medical HomeProject: An Intentional Alignment

In 2009, leaders in the Rush University Colleges ofNursing and Medicine began exploring the feasibility oftransforming physician-based primary care practices intoPCMHs while creating a venue for preparing primary careadvanced practice nurses for health care reform. In acontext of impending health reform, rising interest ininterprofessional education and practice, and a nationalmovement from master's to doctoral education foradvanced practice nursing, the CON was seeking newkinds of clinical learning opportunities. In the samecontext, the college of medicine faculty practice leaderswere investigating integrated models of care delivery thatwould improve the quality of care and reduce cost whileresonating with new performance criteria for reimburse-ment. In a brief but enthusiastic meeting between thedean of the CON and the associate chief medical officer,the idea of shifting existing primary care practices to amedical home model, facilitated by advanced practicenursing students and faculty, was conceived, and themajor players from both colleges were identified andconvened. After several months of planning, the projectbegan officially in June 2010 with three primary carepractices that quickly were joined by two others. Within6 months, two additional practices entered the initiative,expanding the project to include one pediatric practice,two internal medicine, three family practices, and onegeriatric practice. The initiative was completely consis-tent with Rush core values of creating clinical learningcommunities through the integration of health careimprovement and health care education.

Leadership and oversight for this important initiativewas originally provided by a steering committee com-posed of four representatives from the Rush UniversityMedical Center administration, three medical directorsfrom interested primary care practices, the dean and onefaculty member from the CON, and the director ofclinical informatics. Early in the deliberations, thesteering committee agreed to launch the initiative as aself-funded demonstration project. A project managerwith expertise in quality improvement was appointed tooversee implementation.

Six advanced practice nursing students were placedduring the first term and were followed by 41 morestudents, yielding 47 students placed in seven sites by theend of the second year of implementation. Although 47students participated, many of the students stayed in apractice site for more than one academic term resulting in

142 SWARTWOUT ET AL

70 rotation placements. Currently, the seven practicescontinue to have advanced practice nursing studentsparticipating.

In this strategic alliance, selected primary care advancedpractice nursing students (family nurse practitioner, adultgerontology primary care nurse practitioner, and pediatricnurse practitioner) were placed in the seven primary carepractices for training in the PCMH model of care. Tofacilitate the placement and learning of students, weestablished a workgroup composed of the project manager,managers from each of the affiliated primary care practices,and a member of the advanced practice nursing faculty(one of the authors). The workgroup began to identify thekey features that distinguished practice in a PCMH andcreated a structure for the assimilation and participation ofstudents including CON faculty members from each of thethree primary care specialties who were identified asliaisons to each of the seven practices. CON facultyidentified as practice liaisons were expected to communi-cate frequently with the manager of their assigned practiceand the advanced practice nursing students placed therevia site visits, telephone calls, and e-mail. A role descriptionfor the advanced practice nursing students was developedby the workgroup (see Figure 1).

From its inception, the pilot had two highly alignedpurposes: to migrate seven traditional primary carepractices to PCMHs and to prepare advanced practicenursing students for the new realities of health carereform. Advanced practice nursing faculty strived toequip advanced practice students to lead change in healthcare while meeting the established NONPF competen-cies. The initiative supported the seven practices inmeeting the NCQA medical home recognition criteria. Ineach aspect of the pilot, this intentional alignment ofstudent learning objectives with medical home expecta-tions was a consideration for ensuring overall success ofthis initiative, including (a) the selection and placementof students, (b) their orientation to the practice andrelationship with preceptors, (c) the identification oflearning activities and objectives to prepare them for thenew realities of health care, and (d) an assessment of theirperformance. By the end of the pilot, all seven primarycare practices were fully transitioned to the medical homemodel and had achieved the highest level of recognitionas Physician Practice Connections–PCMH Level 3(PPC®-PCMH™) from the NCQA. An ongoing evalua-tion of patient outcomes, including the frequency ofmedical home monitoring, hospitalizations, and ED visitnumbers, was put in place to measure the success of thepractices in expanding access, improving quality, andreducing cost. Based on the success of the pilot,additional practices are considering joining the RushPatient-Centered Medical Home Initiative.

Lessons LearnedSelection and Placement of Students

Given the dual importance of the initiative, students werecarefully selected by the faculty based on the criteria

ordinarily assumed to predict success—high grades andhigh performance reviews in previous clinical practica.Throughout the pilot, however, observations and com-ments from preceptors and practice managers suggestedthat these usual criteria, alone, do not predict effectiveadaptation to PCMH practices. We had underestimatedthe importance of communication and relationship-building skills. Advanced practice nursing students alsoneeded to be excellent communicators—not only withpatients but also with their colleagues—and willing andskilled to work as part of a team. They also needed tobe highly self-confident, flexible, and open to a newvision of coordination of care. We realized that theselection decisions should be shared with the practicesand offered them the opportunity to interview potentialstudents. In addition to refining the selection processand providing career interview experience for students,it invested the medical home practices in the studentswhom they selected.

At the outset of the pilot, concerns—and sometimesobjections—were raised by the physician communityabout the potential encumbrance of orienting newadvanced practice nursing students in each academicterm. In response, the CON offered each practice thechoice of having students join the practice early in theiryear-long clinical progression and stay for multipleacademic terms or restrict the affiliation to advancedpractice nursing students in their last clinical term. Sixof the seven practices elected to take the moreexperienced advanced practice nursing students whowere nearing graduation, even though it meant thecontinuous orientation of new students. One practice,however, agreed to take two students for a full year,providing a future opportunity to compare the experi-ences of the two strategies. To accommodate thepractices that opted for the frequent changes instudents, faculty members, in collaboration with thepractice administrators, developed a “hand off” proce-dure that became a responsibility of each student as heor she left the practice. This required the developmentof an orientation checklist to guide the studenttransition that included a shadowing experience, in-troductions to staff members, orientation to thephysical layout of the practice, and a full report onthe departing student's patients to assure continuity ofcare coordination.

OrientationUnlike the usual orientation to the practice settings, theintroduction to the PCMH practices included a compre-hensive exposition of the concepts of the medical homemodel. It began with a discussion of the need for healthcare reform to enhance access to care, improve quality,and reduce cost and included an overview anddiscussion of the Patient Protection and AffordableCare Act of 2010 as well as the significance of the PCMHas an integral part of the Rush mission, vision, andstrategic plan for quality and safety. Finally, the role ofthe advanced practice nurse in care coordination—

Figure 1. APRN Student Role Description.

143PREPARING FOR A NEW REALITY

although very much in the development stage—becameapparent as an essential component of team-based care.The principles and objectives of PCMHs—access,quality, and cost—became the foundation for under-standing the structure and processes of care andultimately the evaluation of performance in a PCMH.These included, for example, the emphasis on informa-

tion technology and the importance of interprofessionalteam-based care.

Faculty Supervision and Preceptor RelationshipsIn the course of the initiative, we learned that studentshad been conditioned to follow one preceptor exclusive-ly, rather than function as part of a team. In contrast,

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students in PCMH practices were expected to care for anidentified panel of patients that may or may not have thesame primary care provider. Thus, although studentscontinued to be assigned to a specific preceptor, theywere expected to work and collaborate with all theproviders in the practice in a team-based approach. Forsome students, this was a difficult transition and requiredboth preceptor and faculty intervention.

As team members, students attended routine “check-in” meetings, held every 4 weeks and attended by CONfaculty, social workers, physicians, and medical centeradministrators. The meetings, led by the project directorand a CON advanced practice nursing faculty member,served as a venue for ongoing evaluation of the students'successes and challenges in managing and coordinatingcare for complex patients with chronic disease. Thestudents were given the benefit of interprofessionalcollaboration at these meetings. The meeting agendaincluded logistical updates such as electronic healthrecord changes to capture important data at each visit,new programs to promote patient self-management,updates in the use of the registry, and procedures tomake referrals to social services and other disciplines. Theexperiences and opinions of the students were solicited atevery meeting. Students shared stories of managingcomplex patient cases. This discussion identified severalissues that were addressed along the way. For example,early on, students identified that several patients requiredthe consultation with a social worker to identify commu-nity resources and that the students needed follow-upfeedback. As a result, the PCMH project team built in amechanism in the electronic health record visit template toinitiate a social service referral at the time of the visit. Inaddition, students shared cases of the ongoing supportand education required for patients with diabetesstarting insulin therapy. As a result, an evidenced-based self-management program is offered on a moreregular basis for patients with diabetes. Over the courseof the check-in meetings, the students gained increasingself-confidence in managing complex patients in thisnew model.

Student EvaluationFaculty supervision, including site visits and follow-up withpreceptors, is an important factor in ensuring that the studentis meeting both clinical objectives and the practiceexpectation related to the PCMH model. Each advancedpractice nursing student has a faculty member assigned tooversee the student's clinical placements and progress. Thisfaculty member reads and gives feedback to the students ontheir chart notes, makes site visits, monitors midterm andfinal written self and preceptor evaluations, and providesgeneral support for the students as they progress throughtheir clinical rotations. This facultymember is responsible forassigning the student a pass/fail grade at the end of each term.

Faculty members providing clinical supervision wereexpected to attend the PCMH orientation and be aware ofthe new expectations of their students assigned to thesepractices. Even so, some unexpected situations in student

evaluation surfaced. A number of faculty membersbecame concerned that students in the PCMH placementswere not seeing the usual quantity of patients andchallenged the benefit of the experience. Subsequentconversations with the students revealed that the depthand breadth of learning was actually substantially greaterbecause students often saw less patients but spent moretime delving into complexities than they could intraditional clinical settings. The performance evaluationsof the students participating in the PCMH practices couldnot be distinguished from their peers in other practicesites using an established written self and preceptorclinical evaluation tool based on NONPF competencies.

Use of Electronic and Telephonic Capability inCare Coordination

Familiarity with and utilization of a practice registry is animportant part of care coordination and team-basedpractice. A registry consists of patient billing data compiledinto a sortable database to identify patients by diagnosis, lastvisit date, ED visits, hospitalizations, and specific laboratorytests. This provided an excellent database for enhancingaccess, improving quality, and reducing the costs. Incollaboration with their assigned preceptor and practicemanager, students consulted the database at least weekly toidentify high-risk patients who hadnot had not been seen inseveral months. In addition to assuring appropriate accessto care, students identified unnecessary costs (e.g., EDvisits) and opportunities to improve the quality of care (e.g.,greater continuity and better symptom management). Forexample, students identified and contacted patients withuncontrolled diabetes and coronary artery disease who hadnot been seen in over 6 months.

Although students had little difficulty in consulting thepractice registry to identify patients who had not been seenin the last 6 months, some were challenged and evenobjected to using telephonic communication to evaluateand educate patients whom they had not yet met in person.Several advanced practice nursing students expresseddiscomfort, resistance, and even avoidance in followingup with patients who had not been seen in more than 6months. Even though they were creating access, improvingthe quality of care, and reducing costs, they did not identifytheir telephonic contacts with patients as “clinical” and,therefore, “valuable.” Most of our APRN students hadpreviously practiced in inpatient environment, where theywere accustomed to face-to-face communication withpatients. With little real-world primary care experience,the advanced practice nursing students did not immediatelycomprehend using telephonic care management to providereal-time, continuous care for persons with one or morechronic illnesses. The need to expand the definition ofclinical management as not just face to face but including avariety of tactics including Internet and telephonicmanagement are important tools for accommodating theinflux of patients anticipated with health care reform. Thevalue of and skill required for telephonic management as acomponent of highly coordinated care has been added to themedical home orientation.

145PREPARING FOR A NEW REALITY

Coordinated care, which includes continuous moni-toring and technology-assisted outreach, is anotherexample of an activity that has challenged some of theadvanced practice nursing students. Population outreachinvolves a new understanding of quality beyond that ofjust serving the individual patient who shows up in theoffice. The primary care practices were extremely busyand were extremely grateful for the assistance from theadvanced practice nursing students with outreach, butthe volume and burden of the activity presentedchallenges. Many of the practices had a very highnumber of patients appearing on the registry as eligiblefor outreach. The advanced practice nursing studentsfound it difficult to prioritize which patients to call andfound it difficult to balance between making outreachtelephone calls and seeing patients in the office. Manytelephone calls went unanswered or reached an answer-ing machine. In order to achieve intentional alignmentwith student educational goals, orientation now includesa more thorough discussion of the value and role ofoutreach, as well as guidance on prioritization. As aguideline, it has been suggested that the students spendapproximately 25% of their clinical time in telephonecare activities and schedule dedicated time for theactivity rather than trying to squeeze outreach betweenpatient visits. In addition, the PCMH administrativeteam has hired additional staff registered nurses to assistthe practices with population outreach, which presentsthe advanced practice students with additional opportu-nities for leadership and team care.

The advanced practice nursing students in the PCMHpractices were also expected to use specific electronictemplates developed for consistent documentation ofpatient care. Using these templates was a major changeand challenge for all the providers in the practices, andthe students played a role in modeling their use andprompting the other providers to adopt them. Inaddition, all the students had access to the sameevidence-based guidelines, patient self-monitoring tools,and patient educational materials (all placed on a shareddrive for easy access).

EvaluationAt this time, all seven primary care practices involved inthe pilot have achieved the highest level of recognition asPPC®-PCMH™ from the NCQA. An ongoing evaluationof patient outcomes, including the frequency of medicalhome monitoring, hospitalizations, and ED visit numbersis in place to indicate the success of the PCMH practice inexpanding access, improving quality, and reducing cost.

Evaluating student performance, on the other hand,presented some interesting challenges. In comparisonwith the NCQA criteria for measuring success of themigration of seven traditional primary practices tomedical homes, evaluating the preparation of studentsfor the new realities of health care was elusive.Traditionally, advanced practice nursing students areevaluated by the extent to which they achieve theNONPF competencies. Those competencies are well

known to advanced practice nursing faculties as a meansfor measuring students' clinical knowledge. Not surpris-ingly, the quality of performance on the competencies forthe 47 medical home students could not be differentiatedfrom their colleagues in the traditional primary caresettings. Measuring their preparedness for the new realitiesof health care, however, was a more iterative process. Incontrast to NONPF criteria, PCMH variables emergedthroughout the course of the project from facultyobservations and student narratives about their experience.They then had to be categorized and articulated inobservable behaviors that signaled a commitment to andcompetency in expanding access, improving quality, andreducing costs. As with any new project, a process of trial,error, and continuous adjustment occurred in every aspectof the experience. Although it would be premature tolaunch highly formalized criteria and methods of evalua-tion,much can be learned froma description of the iterativeprocess that characterized this first exposure to a PCMH,which is likely repeating itself across the country.

While data will continue to be collected and analyzedwith subsequent groups of students, the PCMH studentcompetencies identified in the pilot that demonstratethat the student understands and applies the carecoordination goals of the PCMH model of care includethe following:

(1) Provides continuous care to a specific roster ofpatients.a. Provides and documents regular patient fol-

low-up.b. Performs a comprehensive hand-off to next

student.(2) Contributes knowledge about the patient to an

interprofessional team care plan.(3) Routinely consults interprofessional team members

(social workers, physical therapists, pharmacists,etc.) in the provision of coordinated patient care.

(4) Utilizes electronic and telephonic technologyeffectively, including an electronic registry, forongoing clinical management.

(5) Identifies more effective and efficient ways for thepractice to enhance access and reduce cost.

(6) Assesses patient outcomes and identifies qualityimprovements for the practice.

Given that the competencies were defined onlyconceptually, the evaluation process was iterative andgleaned from student narratives about their experience,expressing their commitment to the ultimate goals ofexpanding access, improving quality, and reducing costs.See Figure 2 for a patient case example. The studentswere evaluated by the extent to which they

(1) understood and applied the concepts and goalsunderlying the PCMH model of care. Forexample, students proactively identified patientcandidates for care coordination and completedprevisit planning and postvisit follow-up for thoseencounters;

Figure 2. Case Example.

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(2) contributed to team check-in meetings regardingthe practice and individual patients. Studentscited the value of these meetings in providingthem with a network of support as they navigatedthe PCMH. Modifications to the pilot initiativeevolved from these check-in meetings such asdeveloping a more targeted plan for registry use;

(3) learned and applied the use of technology in theclinical management of all patients in the practice.Some students expressed dissatisfaction with thechallenges of telephonic care, and faculty realizedthat telephonic care was not covered thoroughlyin the didactic curriculum;

(4) facilitated continuity of care through appropriatetransition to new care providers. Students exhib-ited leadership and skill mastery as they proudlyreported on the successes of their patient panelsto the incoming students;

(5) routinely consulted interprofessional team mem-bers (social workers, physical therapists, pharma-cists, etc.) in the provision of coordinated patientcare. For example, many students demonstratedunderstanding of the contribution of social workersas part of the interprofessional team initiativethrough coordinating direct patient referrals.

All 47 of the advanced practice nursing studentsreported satisfaction with the experience and appreciatedthe opportunity to participate in the pilot. They were

complimentary of the holistic and interprofessional team-based care provided in the practices and consideredthemselves as active team members. All of the advancedpractice nursing students who have participated plan toinclude their experience with PCMHs on their curricu-lum vitaes as they pursue their careers as nursepractitioners. One graduate already reported that shewas invited to join a practice because of her experienceand knowledge with the PCMH model.

Master's capstone projects completed in this experi-ence are revealing in their commitment to knowledge ofthe concept and commitment to the goals of the PCMH. Anumber of the participating students have chosen tocomplete their capstone projects in the participatingpractices. For example, one student developed anevidence-based smoking cessation protocol to be inte-grated into care coordination activities. A successivestudent followed up with analysis of the implementationof the protocol and recommendations for improvement.A future student may examine longer range outcomes ofthe original smoking cessation project. Ongoing capstoneprojects of this nature have value to PCMH practice,contribute to attainment of NCQA standards, and werepreviously not possible in clinical sites because there waslittle coordination between the rotating students.

Future DirectionsThe transformation of seven physician-based medicalpractices into PCMHs required leadership, vision,

147PREPARING FOR A NEW REALITY

strategic planning, and a commitment of resources fromboth the physician leadership and the CON. In additionto achieving the NCQA highest level of recognition for allseven practices, 47 APRN students successfully complet-ed educational goals that prepare them for the newrealities of health care reform. In the process of achievingboth practice and educational goals, patients are nowfamiliar with the team-based care and the value of havinga care coordinator when they call the office.

This project has also set the stage for future collaborationbetween the CON and Rush University primary carepractice. Future directions may include expansion of thePCMH model to other primary care sites, development oftransitional care models for vulnerable populations, andintegration of advanced practice nursing students into thenewly built patient care pavilion.

In 2012, the CON transitioned all advanced practicenursing programs to the doctor of nursing practicedegree. Students completing this program will beexpected to lead initiatives designed to translate currentbest evidence into practice while addressing quality,safety, and cost-effectiveness. The lessons learned in thePCMH pilot are critical for designing the practiceexperience of all students pursuing an advancedpractice career in primary care. Because of thecollaborative relationships established during this ini-tiative, our advanced practice nursing students willhave an opportunity to propose and implementcapstone projects within these settings.

In addition, the CON has had significant growth inthe number of advanced practice nursing studentsacross all population programs. This has created achallenge for the clinical placement of students.Typically, preceptors in primary care settings are facedwith many challenges such as high volumes of patientsthat make it difficult to have time to precept students.We expect that our experience with the PCMH initiativewill serve as an example of successful integration ofadvanced practice nursing students in a new patient caredelivery model aimed at improving access, quality, andcosts. It may serve as a valuable educational model andexperience for the students, as well as a tool forattracting new sites and preceptors to collaborate withthe CON.

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Fields, D., Leshen, E. & Patel, K. (2010). Driving qualitygains and cost savings through adoption of medical homes.Health Affairs, 29, 819–826, http://dx.doi.org/10.1377/hlthaff.2010.0009.

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