CARE Assignment Details

 

Observed Patient Encounter – Family Medicine
Goals of Observed Patient Encounter:
• Patient Care and Clinical Skills: Elicit focused histories and perform appropriate physical exams. Discuss the relevant diagnostic tests, differential and management plan, including health promotion and prevention.
• Interpersonal and Communication Skills: Deliver succinct oral presentations and comprehensive written notes. Improve communication skills with patients and family members
• Medical knowledge: Strengthen basic medical knowledge in real patient encounters including knowledge of psychosocial and family issues.
• Professionalism:  Demonstrate behaviors of integrity and compassion with patients. Give and receive relevant feedback with colleagues.
Details of Assignment:
- Students do not need to prepare prior to their patient encounter
- Students will complete one observed patient encounter (OPE) with their preceptor during the first 3 weeks of the clerkship.  This will be evaluated using the mini-CEX form, but will not be graded.
- Students with then complete a second OPE with their campus director.  Students will have the option of repeating the encounter only at the discretion of the campus director.
- The OPE with the campus director will be graded.
- Clinic patients are scheduled with acute complaints, one patient per hour per student
o For 6 students there will be 6 patients over 6 hours
- Students can be scheduled in groups of 3-4.  One student will see the patient with the faculty member and the other 2-3 students will watch on video and evaluate or engage in another group activity. Students can also be scheduled individually.
- Student interviewers are prepped with the patient’s past medical history and chief complaint prior to entering the room.  The faculty member will discuss with the student what to focus on for the visit.  Students are expected to make a plan for acute problem while taking the patient’s comorbid conditions into consideration.
- Student interviewers may write a clinic note at the discretion of the campus director.
- Students should be observed completing the entire patient visit, including discussing the assessment and plan with the patient.
Example Encounter and Timeline:
8:00- 8:05 Patient is ready to be seen.
Student and Faculty review the PMH and decide the appropriate focus for the visit
8:05- 8:25 Student interviews and examines patient (faculty also examines pt as necessary)
Group uses the mini-CEX to evaluate their peer as they watch on video
8:25-8:40 Student interviewer presents history, PE, assessment and plan to the entire group
Group discusses any adjustments to assessment and plan
8:40-8:50 Student delivers assessment and plan to patient
8:50-9:00 Group discusses the visit, gives feedback
Assessments:
Peer Assessment – Students will use the modified mini-CEX
This does not count toward grade
Faculty Assessment – modified mini-CEX

CARE Assignment

Each student will synthesize the CARE assignment in a 3-5 page "consultation note" that students will submit to their AHEC campus clerkship director during session #4. If the campus does not have a fourth session, the campus clerkship director will announce the due date. The note will provide 3 prioritized and specific suggestions on how to improve the care of the selected patient using interventions that can be implemented during the office visit. The note will also provide one detailed intervention that requires systems changes in the practice or the community.

HERE ARE THE DETAILS

Part I: Individual Patient Management

Prior to Session #1:

- With the help of your preceptor, select a complex patient with at least one chronic disease. Ideally please choose a chronic disease from the list of 13 common chronic diseases under the Clinical Log tab.

- Ask your preceptor what are the specific challenges/questions in caring for this patient. For example:

    • This patient comes to all her visits but is clearly not taking her insulin and I can’t figure out why.
    • He says he wants to quit smoking but every visit he’s still at 2 packs per day, is there anything we can do to help motivate him?
    • This patient has chronic pain which limits her mobility but she really wants to lose weight.  What options can we give her?

- Arrange a time (either during the office visit, at a later time in the office, or a home visit) to do a more in-depth VIDEO RECORDED interview with the patient about how they manage their health and struggles they may be having. Try to address your preceptor’s questions. Practice using motivational interviewing techniques with attention to minimally disruptive medicine principles. Note that you get written consent from patient using consent form provided and make sure low battery level on Flip is OK when you start interview.

- Select portions of your video that illustrate how you assessed patient’s social context and/or your motivational interviewing techniques. Clips should be relatively short (8-10 minutes total) and do not have to be perfect or edited.

- Familiarize yourself with the guidelines for the chronic diseases of your patient.

After Session #1:

- Write a summary of the guidelines that are relevant to your patient. This is the beginning of your CARE consultation note.

- Write a summary of your insight into the patient’s context, goals and motivation.

- Develop a management plan that answers preceptor’s questions, integrates the most beneficial interventions and responds to patient’s context and goals.  Write 3 specific suggestions for the care of this patient.  Good examples of CARE notes are included below.

Part II: Population Health Improvement (Systems of Care and Practice Improvement)

After Session #2:  Population management and registries

- Define a patient population that has characteristics similar to the patient you selected above for your video.

    • For example, your patient may have diabetes, depression, COPD and HTN.  However, the patient’s diabetes is most important to that patient and depression is the co-morbid condition that is making control of diabetes most difficult to achieve.  Therefore, you might define the "population" as all patients in the practice with diabetes and depression.

- With your preceptor’s help, identify 8-10 patients who have the conditions you have chosen (DM and depression). Review the charts and define characteristics and outcomes of interest for your population.  Is it A1C levels?  PHQ-9 scores? Co-management by psychiatry?

- Write a description of your chart audit

- Write your reflections on the implications and the limitations of your audit

- Using your knowledge of population management as well as the results of your chart audit, write one detailed intervention your practice could undertake to improve the care for this particular population.  The suggestion should be specific, detailed and require systems based changes in the practice or in the community.

 

You may find the consultation note template helpful. You may also want to look at some consultation notes handed in by prior students (example 1, example 2)