Overview of CARE assignment

 

The CARE assignment:
Introduction
This assignment helps student move beyond disease specific guidelines when caring for patients with complex chronic comorbidities. Students will apply the principles of minimally disruptive medicine, explore social determinants of health, incorporate motivational interviewing, and integrate population management to achieve the following SOM milestones:
• Patient Care and Clinical Skills: Succinctly list cost effective assessment strategies and management plan for core patient types.
• Interpersonal and Communication Skills: Improve oral communication skills with patients
• Medical Knowledge: Develop more sophisticated understanding of social, cultural, and behavioral factors that influence the health of patients
• Population Health: Describe and apply principles of population health improvement for specific populations with attention to access, cost and clinical outcomes including quality of care, morbidity and mortality, functional status and quality of life. Identify factors that place populations at risk for disease or injury, and select appropriate strategies for risk reduction.
• Professionalism: Develop strategies to deal with difficult situations through self-reflection and peer feedback
This assignment will use team based learning and narrative writing to teach these principles.
The final product of the assignment will be a written consultation for the preceptor that provides specific suggestions on how to improve the care for a selected patient using interventions that can be implemented during the one on one encounter with the patient and interventions that require systems changes in the practice or the community. The individual components of the CARE assignment and how the CARE assignment is evaluated are described in further detail below.
Individual Components of the CARE assignment:
1) The assignment will be introduced during the orientation session of the clerkship in Chapel Hill. This introductory session will use TBL format and thus will require student preparation. Preparatory material will be sent to the students 1 week prior to the clerkship. At the end of the session students will be able to:
• describe principles of minimally disruptive medicine
• describe important social determinants of health and relationship to the biopsychosocial approach.
• demonstrate techniques of motivational interviewing and patient centered goal setting
2) During the first two weeks of the clerkship, each student will select a patient with a complex chronic health challenges (multiple chronic illnesses, concurrent mental health illness, complicated psychosocial context). The preceptor should be enlisted to help select an appropriate patient. The student will interview the physician who has been taking care of patient and identify the challenges and or questions the preceptor has had managing this patient. At the same time, the student will identify all relevant evidence based guidelines that apply to patient and prioritize recommendations that would be most beneficial to patient (finding the balance strongest evidence from studies and the patient’s own goals).
The student will then interview the patient to explore the patient’s understanding of their chronic illnesses and the patient’s psychosocial context and works with patient to set realistic goals to improve their health. Interviews can take place in the office, the patient’s home, or the patient’s workplace.  The interview should be recorded (with patient consent).
In preparation for the “day back” seminar at the AHEC campus, each student should reflect on strength of available guidelines, the interview with the preceptor and the patient and the review of the Flip recording video. Based on these reflections, the student should develop management plan that answers preceptor’s questions, integrates most beneficial interventions and responds to patient’s context and goals.  This becomes the consultant note that the student turns in at the end of the rotation. Students will also read assigned material in preparation for TBL component of the “day back”.l
3) During the AHEC “day back” seminar, student will discuss and prioritize chronic illness guidelines relevant to their patients. Students will review each other’s video recordings, reflecting on the cultural, and behavioral factors that influence the health of patients and refining skills of motivational interviewing.  The TBL component of the “day back” will introduce students to population management concepts and techniques using a practice registry. At the end of the session, students will be able to:
• define core terms used in population health management
• demonstrate ability define populations within the practice and describe characteristics of those populations
• describe community resources available to practices to help in care for populations of patients in the
• describe systems interventions at the level of the practice to improve quality of care, cost, and patient satisfaction for defined populations of patients.
4) After the AHEC “day back”, each student will define a patient population that has characteristics similar to patient student selected at the beginning of the rotation. For example if patient has diabetes, depression,  COPD and HTN but patients diabetes is the condition most relevant to that patient and depression is the co-morbid condition that is making control of diabetes most difficult to achieve, the student might define the population as all patients in the practice with diabetes and depression. Using the skills learned during the TBL session, the student will define characteristics and outcomes of interest in that population and perform chart audit of at least 10 charts belonging to this population.  Each student should reflect on implications and limitations of this audit.
5) Each student will synthesize the assignment in a 3-5 page “consultation note” that will be turned in to the campus director and the community preceptor at the end of week 5. The paper should include reflections on lessons learned from the work with the patient and specific individual recommendations and population recommendations to the preceptor.  More details on the consultation note are provided in the attached template.

Introduction:
This assignment helps student move beyond disease specific guidelines when caring for patients with complex chronic comorbidities. A shorter summary is available for students to give to their preceptors. Students will apply the principles of minimally disruptive medicine, explore social determinants of health, incorporate motivational interviewing, and integrate population management to achieve the following SOM milestones:

• Patient Care and Clinical Skills: Succinctly list cost effective assessment strategies and management plan for core patient types.

• Interpersonal and Communication Skills: Improve oral communication skills with patients

• Medical Knowledge: Develop more sophisticated understanding of social, cultural, and behavioral factors that influence the health of patients

• Population Health: Describe and apply principles of population health improvement for specific populations with attention to access, cost and clinical outcomes including quality of care, morbidity and mortality, functional status and quality of life. Identify factors that place populations at risk for disease or injury, and select appropriate strategies for risk reduction.

• Professionalism: Develop strategies to deal with difficult situations through self-reflection and peer feedback

This assignment will use team based learning and narrative writing to teach these principles. The final product will be a written consultation for the preceptor. Students will submit this to the AHEC campus clerkship director during the fourth Day Back session. If the campus does not have a fourth day back, the campus clerkship director will announce the due date. The note should also be shared with the preceptor but the preceptor will not grade the note. The note will provide specific suggestions on how to improve the care for a selected patient using interventions that can be implemented during the office visit with a patient and interventions that require systems changes in the practice or the community. The individual components of the CARE assignment and how the CARE assignment is evaluated are described in further detail below. We have also prepared a checklist for you to easily track your progress on the assignment. Click here for the checklist.

Individual Components of the CARE assignment:

1) The assignment will be introduced during the orientation session of the clerkship in Chapel Hill. This introductory session will use TBL format and thus will require student preparation. All preparatory material is available on the website. At the end of the session students will be able to:• describe principles of minimally disruptive medicine• describe important social determinants of health and relationship to the biopsychosocial approach.• demonstrate techniques of motivational interviewing and patient centered goal setting

2) During the first two weeks of the clerkship, each student will select a patient with several complex chronic health challenges (multiple chronic illnesses, maybe with concurrent mental health illness and/or with complicated psychosocial context). It does not need to be the most complicated patient ever. The preceptor should be enlisted to help select an appropriate patient. The student will interview the physician who has been taking care of patient and identify the challenges and or questions the preceptor has had managing this patient. At the same time, the student will identify all relevant evidence based guidelines that apply to patient and prioritize recommendations that would be most beneficial to patient (finding the balance strongest evidence from studies and the patient’s own goals).  The student will then interview the patient to explore the patient’s understanding of their chronic illnesses and the patient’s psychosocial context and works with patient to set realistic goals to improve their health. Interviews can take place in the office, the patient’s home, or the patient’s workplace.  The interview should be recorded using the Flip recorder given out at orientation. It is important to carefully read instructions on getting patient consent and ensuring patient privacy. Follow this link to read these instructions. In preparation for the “day back” seminar at the AHEC campus, each student should reflect on the strength of available guidelines, the interview with the preceptor and the patient and the review of the Flip recording video. In reviewing the video, students should reflect on what sections will be most helpful to their peers. Segments in general should be limited to 4-5 minutes and can demonstrate things that went well or things that did not go well. Some of the best learning comes from things that did not go well!. Students should not spend excess amounts of time editing video. If editing does not work easily students should simply remember time marks for beginning and end of segments. In reviewing the guidelines, the guideline template provides a helpful structure. Also using high value resources will make preparation easier. We recommend first reviewing the FM text book, perhaps reading what UpToDate has to say. The AAFP topics and Guidelines.gov are also extremely helpful. Based on reflections from the video and review of the guidelines, the student should begin to develop a management plan that answers preceptor’s questions, integrates most beneficial interventions and responds to patient’s context and goals.  This will become part of the consultant note that the student turns in at the end of the rotation (described further below). Students will also read assigned material in preparation for TBL component of the “day back”.

3) During the AHEC “day back” seminars, student will discuss and prioritize chronic illness guidelines relevant to their patients. Students will review each other’s video recordings, reflecting on the cultural, and behavioral factors that influence the health of patients and refining skills of motivational interviewing.  The TBL component of the “day back” will introduce students to population management concepts and techniques using a practice registry. Campuses may vary in when individual components are covered. Since preparation is crucial for all components students should check with their AHEC clerkship director about when each components will be covered. Follow link to find prep material for TBL 2. At the end of the session, students will be able to:• define core terms used in population health management• demonstrate ability to define populations within the practice and describe characteristics of those populations• describe community resources available to practices to help care for populations of patients in the • describe systems interventions at the level of the practice to improve quality of care, cost, and patient satisfaction for defined populations of patients.

4) After the AHEC “day back”, each student will define a patient population that has characteristics similar to the patient the student selected at the beginning of the rotation. For example if patient has diabetes, depression,  COPD and HTN but the patient's diabetes is the condition most relevant to that patient and depression is the co-morbid condition that is making control of diabetes most difficult to achieve, the student might define the "population" as all patients in the practice with diabetes and depression. Using the skills learned during the TBL session, the student will define characteristics and outcomes of interest in that population and perform chart audit of at least 10 charts belonging to this population.  Each student should reflect on implications and limitations of this audit.

5) Each student will synthesize the assignment in a 3-5 page “consultation note” that students will submit to the AHEC campus clerkship director during the fourth Day Back session. If the campus does not have a fourth day back, the campus clerkship director will announce the due date. The note should also be shared with the preceptor but the preceptor will not grade the note. The note will provide 3 prioritized and specific suggestions on how to improve the care for a selected patient using interventions that can be implemented during the office visit with a patient and one fleshed out intervention that requires systems changes in the practice or the community. More details on the consultation note are provided in the template. You may also want to look at some consultation notes handed in by prior students (example 1, example 2)