PROJECT IDENTIFIER INFORMATION
Grant Number:
T91HP21546
Project Title:
Teaching Health Center Highway to Keep Primary Care GME Services Relevant to
Community Health
Organization Name:
The Wright Center for Graduate Medical Education
Mailing Address:
501 Madison Avenue (Note: Moved from 746 Jefferson Avenue)
Scranton, PA 18510
Primary Contact:
Linda Thomas-Hemak, M.D.
President & CEO
Internal Medicine Program Director
Contact Phone
570-343-2383 Extension: 2141
E-mail Address:
thomasl@thewrightcenter.org
WORK PLAN PROGRESS SUMMARY
Brief Project Description
The Wright Center for Graduate Medical Education (WCGME) is a fully accredited Accreditation
Council for Graduate Medical Education/American Osteopathic Association (ACGME/AOA) GME
Sponsoring Institution of a 35 year old Primary Care Internal Medicine Residency Program in Northeast
Pennsylvania (NEPA). The Wright Center Medical Group, the faculty practice plan of the GME corporation,
operates three ambulatory community health centers: The Wright Centers for Primary Care, Scranton
(WCPC-S), Mid-Valley (WCPC-M), and the newly 2010 established Clark Summit (WCPC-CS) practices.
All WCGME training sites are highly responsive, non-discriminatory safety net providers for the
communities they serve, having care process and clinical outcomes of recognized significance. The former
two ambulatory care centers are both engaged in the Pennsylvania Department of Health’s Practice
Transformation/Chronic Care Initiative and are established inter-professional workforce training
environments. Both of these clinics have evolved authentic patient-centered medical home delivery services,
with successful Level-3 NCQA PCMH recognition earned since the original grant submission on December
30, 2010. All eligible WCPC providers have qualified for and received Electronic Medical Record (EMR)
Meaningful Use funding for Stage 1 and are finishing up Stage 2. WCPC takes great pride in role modeling
authentic medical home, chronic care and EMR Meaningful Use principles as an exemplary educational care
delivery system committed to the transformative evolution of health care delivery systems to high reliability
and performance. WCPC practices’ performance in the PA Initiative is testimonial to this commitment.
The mission of WCGME is to provide excellence in GME in an innovative and collaborative spirit in order
to deliver high quality, evidence based and patient centered care to the citizens of NEPA. The HRSA
Teaching Health Center (THC) funding has provided resources to empower WCGME to build upon its
historical success training internal medicine physicians in order to replenish the physician manpower in
NEPA. In the second year of THC funding, FY 2012, WCGME’s primary care Internal Medicine residency
program has expanded by 16 THC Full Time Equivalents (FTEs), as proposed in the initial and expansion
applications (see visual depiction of the resident distribution in Document A1). Consistent with the
organization’s mission and the expressed intent of the THC development to address physician workforce
shortages, mal-distribution and escalating health disparities, the most notable accomplishment of WCGME’s
GME THC development is the expansion and development of new educational learning venues for THC
track residents within a network of distributed community health centers, including 3 FQHCs of which 2 are
remote and rural, our regional VA’s Medical Home ambulatory clinic, a Title X funded Maternal and Family
Health Services center and an FQHC based dental clinic. This strategic development consistent with the
ACA eligibility THC intent has validated and strengthened WCGME’s community governed, organizational
position as a Primary Care THCGME Consortium model. Our THCGME Consortium development aim was
to inextricably link GME training with community relevant, highest quality patient care delivery ignited by
the catalyzing development of relevant, academically excellent training venues, fueled by Milestones
Competency based curriculum overhaul and modeling within transformed and “wired” medical home
learning venues. The Consortium has been very effective at this aim and clearly unifying for our healthcare
and medical education community. The Consortium was formed upon notification of HRSA THC funding
designation in the first quarter of 2011 and has formally met quarterly since. We now have established and
growing learning environments in three partnering Federally Qualified Health Centers (FQHCs); Scranton
Primary Health Care Center (SPHCC) in Scranton, Lackawanna County, PA, Wayne Memorial Community
Health Center (WMCHC) in Lords Valley, Pike County, PA, and North East Pennsylvania Community
Health Care (NEPA CHC) in Hallstead, Susquehanna County, PA. In addition to the FQHCs, new
partnerships with Maternal and Family Health Services (MFHS), the public health dentist and dental clinic at
SPHCC, and the Wilkes University Psychiatric Nurse Practitioner program through WCPC-M have created
enhanced curriculum and training opportunities for women’s health, primary care dental and psychiatric
services training for the residents respectively. In addition, WCGME has expanded the collaborative
partnership with the VA facility in Wilkes Barre to create a resident medical home continuity clinic as part of
their Patient Aligned Care Team (PACT) initiative as a focused VA investment of part of their total 5 FTE
GME funded training positions. The successful engagement of primary care residents has facilitated
expanded access to a nondiscriminatory medical home for patients at all THC Consortium sites since July 1,
2011. A visual depiction of the THC partners, FTE distribution by site and shared learning environments can
be found in Document A1.
The THC-supported faculty funding provides partial salaries for the Primary Care Associate Program
Director (APD) and the 9 clinical supervising faculty at the depicted ambulatory care training rotation sites.
The THCGME induced training program growth mandated a second APD position be developed and
credentials for the newly appointed Ambulatory APD, who actively practices at WCPC-S. Dr. Deepa
Gopavaram is a medical graduate from India. She did her preliminary internal medicine residency at
University of Buffalo/Catholic Health System, Buffalo, NY and then transferred to the Wright Center for
Graduate Medical Education to pursue 2nd and 3rd years of internal medicine residency. She finished her
internal medicine residency in June 2011 and then started working as a full time clinical faculty at WCGME.
She is the associate program director for the WCGME primary care track residency program and also the
clinical director for Student Health Center. Her clinical interests include teaching, supervision of medical
residents; preventive health services; chronic disease management; and quality improvement.
In addition, a portion of the THC funds are used to support the Education and Community Relevance
Leader (ECRL), the Clinical Quality Improvement Leader (CQIL) and an Administrative Assistant for the
initiative, all previously described within the grant and expansion grant application.
The WCGME Consortium CHC sites are active participants in the Pennsylvania Improving
Performance in Practice (IPIP) Residency/CHC Collaborative—year two (IPIP:RPC-2). The collaborative
“walks” participants through the steps to become a patient-centered medical home model (PCMH)
recognized by the NCQA, promoting principles of team-based care, population management, Quality and
Safety, Medical Home and Chronic Care delivery models and EMR Meaningful Use. The THC track
residents and the consortium clinics are committed to the pursuit of NCQA Medical Home certification and
the synergistic PCMH 2011 alignment with measures for EMR Meaningful Use. Monthly team webinars are
conducted to transfer knowledge from IPIP faculty and staff on the standards for NCQA recognition, process
of care delivery and clinical outcomes improvement, and population management. The leadership of the
WCGME and the Consortium are required to attend 100% of these teleconferences along with quarterly faceto-face learning sessions. WCGME's Program Director Dr Linda Thomas-Hemak has been designated as one
of four IPIP faculty leads for this collaborative. The THC residents must meet a70% participation rate in
collaborative activities. The Consortium partners reported on diabetic care delivery and clinical outcomes
measures via IPIP's online data registry management system in their first year, and have transitioned to
Ischemic Vascular Disease (IVD) in the second year. Knowing that demonstrable consistency between the
taught curriculum and care delivery modeled is crucial, the Wright Center is also providing altruistic sharing
of available resources, expertise, experience and practice coaching to ignite and enable authentic PCMH
transformation and EMR MU development at our partnering FQHC and M&FHS training sites. THC
residents are actively engaged in practice transformation efforts through active participation in reflective
practice and systems of care CQI in all THC ambulatory learning venues focused on providing safe,
compassionate, comprehensive, accessible, continuous and coordinated, right venue care in sustainable,
“wired” team based medical home delivery systems with a culture of continuous quality improvement. .
The FQHC clinical exposure has enhanced the demographics of patients served and the
understanding of consumer/patient engagement at the highest level of governance. The focus on resident
presence in the FQHCs and ambulatory venues promotes the relevance of becoming servant physician
leaders who lead multi-disciplinary care delivery teams responsive to needs of individual patients and our
community. Recent assessment of THC curriculum effectiveness at one year show exciting and validating
comparison outcomes assessment of Traditional and THC track WCGME residents in knowledge and
attitudes in strategic THC curriculum focused arenas of Team, IT system supports, Use of EBM guidelines,
QI processes, population management, care coordination, patient centered care and mental health issues (See
Attached Comparisons Nov-May 2012 in Document A4). These strategic curriculum foci defined in our
original THC application were extracted from the well recognized Kaiser Permanente published data on
deficient skill sets of new physician hires, which are consistent with the necessary skill sets of physician
leadership for authentic primary care medical home and EMR Meaningful Use transformation.
Current THC Residents
As a testimonial to its community-driven mission governance, WCGME is proudly recognized as the most
significant primary care manpower renewal force in NEPA and has graduated 152 actively practicing
primary care physicians, with several graduates being recognized as regional and national physician leaders.
As a well-established community-based residency program with a stellar academic accreditation history,
WCGME has, over decades, proudly evolved a sophisticated recruiting system to enlist exceptional clinicians
from a global candidate pool. WCGME is proud of its mission-related investment in the development of our
effective recruiting process, which has been a lifeline to academic excellence as a community-based training
program. With the initiation and expansion of the THC funding, recruitment was strategically enhanced to
include more applicants than prior years and also an intentional selection bias toward applicants with a
Masters in Public Health (MPH) and/or an interest/experience in community and population health
management. Supplementing this rigorous recruitment process, WCGME also utilizes a well-structured and
tightly supervised voluntary observership/mentorship initiative, a viable channel to our recruitment pipeline
which did notably engage seven (7) of our current THC residents and several of our current and past
traditional track residents. Our established observership program afforded us welcomed recruiting flexibility
we deemed crucial in the first year of THCGMNE application for funding because of the timing within the
academic calendar year.
For both FY 2011 and 2012, all THC slots were successfully filled with no anticipated fall
out/training cessation. The original pioneering THC class successful completed the first year of training in
June 2012. Our greatest recruitment challenge has been with timely immigration/Visa processing issues
which delayed two THC residents’ start date in FY2011 and one THC resident’s arrival for formal training.
We did reconcile these late start THC residents financially in our 2011 HRSA payments, but were able to
pull a traditional track resident into the one month delayed THC block rotation at WCPC-M to avoid
financial reduction. This traditional resident was pulled from a hospital funded GME FTE slot above that
hospital’s CMS funded CAP. Hospital payment for the resident FTE were not reduced as our FTE
reimbursement from each of our community hospitals is above their CMS Cap, numerically driven by the
number of individual residents mandated for 24/7 service call given our current program size of 60 total
funded FTEs (See Document A1). Our partnering community based, CMS funded hospitals are definitely
aware of the beneficial ROI of our Consortium THCGME governance and financing model as it has
diversified our GME funding streams and expanded our training program size. Our community hospital
affiliates have benefitted from our THCGME expansion effort as they have not been required to fund even
more residency FTEs as notably driven in many academic medical centers by the new ACGME 2011 duty
hours, which WCGME holds sacred. As a result of complex, meticulous tracking of FTE distribution across
GME funding cost centers for HRSA’s THC, VA and CMS and clearly defined appropriately categorized
community hospital, VA, community based health center and non-hospital/non-community health center
training venues necessary for comprehensive, accredited primary care training, WCGME is intentionally
evolving a transparent financial/value accounting model demonstrating the synergy of multi-source federal
investment in GME through effective reconciliation of CMS, VA and HRSA THC cost centers. Our
curriculum, completely consistent with RRC-IM requirements, is split equally between ambulatory and
inpatient hospital training venues. Fifty percent (50%) of the individual resident’s FTE is covered in the THC
cost center and 50% of each individual resident's FTE is covered within combined hospital based (CMS and
above the cap) and VA cost centers. As seen in the reconciliation tool and color coded FTE cost center based
schedule (Attachment 2), THC and non-THC FTEs are clearly defined and calculated. As the sponsoring
institution, we transparently continue to share and evolve the related Program Letters of Agreement and
assignment of clinical rotation FTE allocations with our clinical partners to promote understanding of
Consortium value and also to facilitate team based federal cost center reporting, inclusive of hospital CMS
based IRIS reports. This healthy alignment of the GME sponsoring institution and our hospital partners has
not always been an honored community priority as demonstrated in one of our community hospital partner’s
discouraging 2011 CMS notification of an ACA Section 5503 FTE Reduction (Document A2) Unfortunately,
this decision was based on prior year fill rates before this hospital was engaged in partnership with WCGME,
and upon notification by CMC, the previous hospital administration failed to timely respond or share that
information with WCGME. WCGME immediately drove a comprehensive CMS response, even explaining
our approved pioneering HRSA THCGME 2011 expansion, but the CMS reduction was irreversible. All of
this was communicated previously to HRSA to explain the FTE commitment reduction from Community
Medical Center in 2012 from the originally projected 16 to 12 FTEs previously funded. (CMC CMS Cap 8.5,
See Document A2)
The WCGME Consortium has written confirmation to ensure the number of new resident FTEs over
the first three years of the grant is consistent with the number proposed in the initial and expansion
applications other than the isolated change driven by an ACA Section 5503 CMS reduction noted above.
Training program expansion occurred anyway as that hospital simply stabilized rather than increased the
FTE already funded above their CMS Cap. Two late start THC residents were financially reconciled within
the HRSA FY2011 and hospital beyond CMS Cap funding sources and the single late start resident in 2012
was reconciled within the community hospital funding source beyond its CMS Cap only. There are no
resident current or anticipated leaves of absence. WCGME maintains accreditation through ACGME and
AOA and recently completed a successful transition of our ACGME approved DIO, with documentation of
this encompassed by Document A3. This change was ignited by retirement of our founder, Dr Robert Wright,
prior DIO. Marlene Karam, with 25 + years of GME leadership, administration, operations and accreditation
experience at WCGME, was appointed as DIO with unanimous approval by the Graduate Medical Education
Committee, WCGME governing board and ACGME. There has been no other change in WCGME status
with the ACGME, AOA or Bureau of Primary Care.
As noted, 50% of WCGME THC individual residents are funded by other GME cost center through
affiliation agreements with Regional Hospital of Scranton (Mercy at the time of original application
purchased by Community Health Systems and renamed), Geisinger Community Medical Center (GCMC),
Moses Taylor Hospital ( now also owned by Community Health Systems), and the Wilkes-Barre Veterans
Affairs (VA) Medical Center. All WCGME affiliated CMS funded hospitals fund residency slots above their
CMS caps at a negotiated per resident rate based on minimal instructional and program-specific academic
costs (MIPSAC) related mathematical calculations taking inflation into account. Our affiliated hospitals
have traditionally funded resident numbers beyond their cap as necessary for 24/7 safety net teaching service
governed by strict compliance with ACGME duty hour standards. Up-to-date Program Letters of Agreement
with all non-hospital based teaching venues include details of appropriate rotation cost center allocation and
hospital based versus nonhospital based training activities consistent with federal/CMS regulations.
WCGME Consortium has a complex, transparent, and full programmatic schedule which is color coded by
rotational cost center funding allocation to validate synergy of and avoidance of any "double dipping" or
overlap between federal cost centers. Attachment 2 illustrates the funding scenario between WCGME and its
affiliates through a detailed block rotation schedule color coded by cost center allocation.
Barriers/Problems to Implementation with Strategies/Steps and Plans for Resolution
We previously noted the late arrivals of 2 FY 2011 and 1 FY2012 THC residents which causes us to
re-examine and learn best practice for THCGME Consortium collaborative functioning from the resident
FTE cost centers distribution documented in detail as part of the mandatory HRSA THCGME Reconciliation
Tool. This encountered challenge, reflective solution oriented assessment and mitigation plans provided
opportunity for transparent engagement of our affiliated community hospitals’ new owners to discuss ROI
for our Consortium GME model and to promote their understanding of service and educational benefits of
their engagement as an educational partner. This also notably opened up opportunity for collaborative
discussion of our shared organizational accountability to better assess the quality and safety of patient care
enhancement as a result of GME endeavors within the delivery system consistent with the evolving ACGME
New Accreditation System. Extremely productive, value driven discussions unfolded with our hospital
partners about their CMO participation on our GMEC committee, their CNO and pharmacy lead on our
GMEC Quality/Safety subcommittee and our faculty and residents’ increased participation on hospital
Quality and Safety, Credentialing, Education, Medical Executive and other committees. WCGME also
revamped our didactic conference schedule to promote minimal disruption of residents’ participation in the
delivery of patient care in all clinical venues. Significant changes reduced travel were creating block
conference schedule times outside of high volume patient care in various delivery systems that optimized
resident presence during clinic operations, early hospital discharge transitions and in the teaching didactic
conferences themselves. WCGME is absolutely committed to remote IT technology investment to enhance
distance learning accessible in distributed and even the most rural and remote of our learning environments.
The residents who participated in the pioneering FY 2011 THC track during the first 4 months of
implementation experienced an expected time of transitional anxiety about our non-traditional training
developments in our THC track, wasted travel time and lost inpatient educational experience. Many
transparent, reassuring conversations about WCGME’s commitment to academic excellence were invested to
promote their professional and personal development and anxiety resolution. Intense, repetitive education
was done about our Milestones Based curriculum evolution, commitment to Direct Observation Competency
tools and reconciliation of their “readiness” to lead and supervise inpatient floor and ICU teams with
Milestones and Competency Based driven scheduling. Consistent management of GME resources invested in
curriculum, faculty development, resident and program evaluations was strategic. Despite the pioneering
THC residents early collective nervousness surrounding the amount of inpatient experience available to
them, transportation obstacles to get to the FQHC training sites that were not within walking distance of the
hospitals and on-going concerns about suitable overnight accommodations in the case of inclement weather,
the accomplishments in their first year have been outstanding and their competency based performance
impressive. They have driven creative discussions about appropriate FTE cost center assignments of
rotational experiences in terms of % out and inpatient time to enhance the value of each inpatient and
outpatient clinical experiences. These THC residents’ engagement and outcomes in scholarly work have been
published in national journals, provided poster presentations at regional and national scientific conferences,
and both demonstrated and promoted the reflective Practice Based Learning and Improvement culture of
ACGME Competency Based Education and the PCMH Care Delivery Model. This scholarly work has also
developed and demonstrated resident skill sets development in key focus areas of our THC curriculum
development in arenas of Population Management, Quality and Safety, Team Based Care delivery and Care
Coordination. As part of a comparative evaluation between traditional and THC track residents, the PCMH
Clinician Assessment was conducted in November 2011 and May 2012 and the results showed significant
improvement in the knowledge and skills of the THC residents in each of the THC curriculum focus areas.
(The full comparison summary is provided in Document A4) THC residents’ academic activities have driven
care delivery enhancements in established WCMG CHCs and partnering FQHCs, most noticeably in these
arenas and the patient centered arena of Empanelment to promote continuous, longitudinal, healing patient
and provider relationships. A comprehensive listing of the THC track resident scholarly activities is provided
as Document A5. The progress of these young physicians has been especially evident in their recent
transition to PGY2. The arrival of the incoming FY2012 new THC residents starting July 1, 2012 offered an
opportunity for demonstrated leadership in both the clinical and teaching settings, which was remarkably and
tangibly demonstrated by the transitioning THC second years. Those who had been the most tentative
initially became very present, though informal, mentors to the new THC residents, allaying the trepidation of
the new recruits. Programmatic leadership certainly believes this shepherding effect of the residents for each
other, as well as the new and established FQHC and M&FHS learning environments, tangibly lessened the
“change” and transitional stress in the first 2 months of FY2012. The programmatic expansion and decision
this year to assign all new interns to the THC track, which has successfully evolved our Milestones and
Competency Based curriculum to inclusively promote the new skill sets necessary within high performing
delivery systems, has also lessened incoming resident anxieties by avoiding the sensationalizing effect of
even having different tracks.
Another problem to implementation was a decision by FQHC WMHCC to not provide the learning
environment for 1/3 FTE in their behavioral health clinic as proposed as part of the curriculum expansion for
the FY2012. In response, WCPC-M quickly engaged a Psychiatric Nurse Practitioner (Psych NP) Faculty
member from Wilkes University, supervised by FT WCPC Internal Medicine teaching faculty, to begin to
integrate behavioral and mental health services and to offer a 1/3 FTE time rotational inter-professional
experience in primary care psychiatry. The Psych NP is a paid contractor of the WCPC and works in close
collaboration with the medical care team to engage the residents in the assessment, engagement and
counseling of the patients for Behavioral Risk Assessment and Reduction efforts, Mental Health Screening
Assessments, Cognitive, as well as medical interventions, and Motivational Interviewing for Self
Management Support.
WCGME also leveraged presented opportunities to enhance patient population and demographic
exposure for our new THC residents by developing continuity learning environments within the WCPC-CS
and also the VA ambulatory clinic, which were both coincidentally in the early committed stages of medical
home developments. These new learning environments were ripe for teaching and resident presence with full
leadership and practicing physician engagement and commitment to education. The opportunity particularly
enabling a THC resident group to share WCPC-M and VA ambulatory learning environments offers
incredible opportunity to bi-directionally share best practices from these educational care delivery
environments which are collaterally evolving according to medical home, chronic care delivery and EMR
meaningful use principles
The PD and key residency program staff have participated in every conference call with the Health
Resources and Services Administration (HRSA), and also the separate THC conference calls facilitated by
Candice Chen and Fitzhugh Mullen from George Washington University. They also participated in the THC
Group meeting organized by Candice Chen at GW during the 2012 Beyond Flexner conference in Oklahoma.
The program director presented WCGME's Consortium project sketch as a model for replication at the
APDIM PA/Delaware Breakout and was a panelist/presenter at the Tri Board Initiative Roundtable organized
by HRSA and participated in the Education Subcommittee 2012 Spring meeting of NACHC. Memorandums
of Understanding with the FQHCs and community partners have been honored and the positions of the
Education and Community Relevance Leader (ECRL), Clinical Quality Improvement Leader (CQIL) and the
newly appointed Primary Care/Ambulatory Associate Program Director (APD) have been filled, as FT
positions with salary subsidies from the larger GME Consortium educational and faculty practice plan
revenues funding streams.
WCGME remains extremely grateful for the ACA driven federal funding investment in the THC and
is an active participant committed to GME value driven funding solutions. Initial and continued success can
be attributed to the regular and proactive partnership interaction with HRSA to ensure our understanding of
the project guidelines and expectations and to the intense Consortium strategic planning of how best to
actualize plans. There is no doubt that implementation continues according to plan with learning driven
improvements as our THCGME Consortium evolves. Planned Consortium milestones are being met, and
successful program implementation and expansion has measurably enhanced residents’ knowledge and
attitudes, as well as directly observed skill sets and scholarly work in the crucial curriculum arenas.
Initial challenges to working with FQHC practice sites were operational in nature, frequently space
and training program scheduling interface related. Operational challenges were augmented by coincidental
implementation of new electronic medical records at engaged FQHC sites. Clinical care delivery volumes at
the FQHCs were intentionally reduced because of the EMR implementation and initiation of THC GME
training. Training and teaching of the THC residents were positively impacted because of these challenges,
despite initial visit volume reduction, by resident, faculty and FQHC staff reported feedback. Volumes
continue to increase, and are near or just beyond pre-implementation values by FQHC report. These
challenges have been openly discussed at Consortium meetings with the residents, teaching faculty and all
Consortium site representatives. The “Evaluation/Impact” section of this report will discuss postimplementation issues in more detail.
Transformation requires continuous self-reflection and evaluation of skill sets of both faculty and
learners. An intensive and authentic commitment to faculty development is occurring focused on individual
interest and strengths as well as collective program enhancement. Faculty has participated in ABIM, AHRQ,
and on-site learning opportunities. Visiting Professors providing faculty development includes Dr. William
Iobst, Milestones in Internal Medicine Training; Dr. Perry Dickinson, PCMH related to ACGME
Competencies; Dr. Paul Haidet, Team Based Learning; Dr. Roger Bush, Incorporating LEAN Principles into
Residency Training; and Dr. Lauren Mead, teamwork and milestone development.
Specific training attended by the APD includes Developmental Milestones for Internal Medicine
Residency Training at the ABIM, basic and master TeamSTEPPS, and Navigating and Resolving Conflict at
APDIM. The Clinical Coordinator has provided extensive development of the portfolio system as a
professional development and resident evaluation tools. Her pioneering work has been accepted and
presented at the MedBiquitous Annual Conference in May 2012 and also presented onsite at the Wright
Center for faculty. She is also a super-user for the online evaluation system, Myevaluations, attends user
conferences, and provides regular faculty updates. Faculty training also has included Physicians Orders for
Life-Sustaining Treatment Paradigm, which is supportive of current clinical enhancements to document end
of life wishes for primary care patients. The CQIL is currently attending Caritas Coach Education, a six
month program based on Human Caring Theory focused on authentic institutional and organizational
transformation.
Faculty attends weekly internal conferences with an educational component, which contain an
educational component, presented by faculty members within their area of expertise. Presentations were
developed and scheduled to address current knowledge and teaching of the ACGME competencies, as well
as further development of the mentorship program.
Plans for Upcoming Budget Year
Personnel and budget allocations for this project are expected to change for the upcoming budget
year as noted in the reconciliation tool for residents. As mentioned there was one individual FY 2012 intern
who had a six week late start so that individual gap was moved into the hospital beyond CMS Cap funds
transparently. Full 16 FTE presence in THC HRSA cost center presence was implemented July 1, 2012 and
can be appreciated in the color coded FTE schedule provided (Attachment 2). Change to support personnel
included the departure of the Education and Services Quality Improvement Leader (ESQUIL). Strategically,
redundancy with the ECRL was reduced by replacing this position with a Clinical Quality Improvement
Leader with a clinical back-round to enhance demonstration/modeling of the expected curriculum within
WCPC training environments and to bring practice coaching for medical home and EMR meaningful use
transformation enabled by academic activities and learner presence. Organizational Changes within the
WCGME included the retirement of the president and CEO, who was replaced by the current PD. These
organizational changes are being managed by transparent and frequent communication as restructuring
occurs, prohibiting any negative impact to the THC program and actually increasing organizational and
governance wide recognition of its value and significance.
The Consortium footprint has expanded continuity clinic partners to include a new FQHC in
Susquehanna County (NEPA CHC) and within our regional VA ambulatory clinic currently in the early
phase of implementing the well recognized VA Medical Home policies and procedures. Curriculum
enhancements were successfully implemented for oral hygiene in Scranton Primary Health Care FQHC’s
dental center, women's health in our local Title X funded MFHS, and primary care psychiatry at WCPC-M in
partnership with Wilkes University’s Psychiatric Nurse Practitioner program. First quarter resident and
faculty evaluations of these new primary care continuity and curriculum expansion rotations have been
amazingly positive. WCGME’s 2013 THC Expansion development plans include additional regional and
national FQHC partnerships with the THCGME Consortium model expanding into the discipline of Family
Medicine ACGME/AOA accredited training. This future vision and partnership opportunities to further the
mission of WCGME as well as the intention and success of the national THCGME efforts has triggered
WCGME to proactively request an ACGME Institutional Review Committee formal site review to be
designated as a Multi-Program/Discipline GME Sponsoring Institution. WCGME is eagerly preparing for
this IRC site visit opportunity as is guiding that preparation with the expectations of the ACGME’s New
Accreditation System and particularly with the relevant focus on Patient and Safety enhancements in
educational learning environments. This relevance of GME operations and both educational and patient care
delivery outcomes is very aligned with the delivery of WCGME’s mission and also its steadfast commitment
to the “Teaching Health Center Highway to Keep Primary Care GME Services Relevant to Community
Health” as recognized by HRSA.
WCGME will continue to review, assess and enhance its programmatic and educational IT
infrastructure to optimize the ROI of the federal THCGME investment and is committed to transparently
report the appropriate cost center allocations and funds distribution on a quarterly basis to ensure that the
educational and supervisory needs of the resident are being met consistent with the highest standards of
academic ACGME/AOA accreditation and Patient Safety/Quality. A focus for the Consortium is the
transparent reporting and documentation of specific direct and indirect medical costs which will provide a
platform for ongoing discussions with the affiliated hospitals about the use of GME funds and the true
identified cost to train and supervise a resident. At this time there are no anticipated leaves of absence
planned or discussed for the current THC funded residents, faculty, residency program leadership or staff.
Any future modifications to the THC schedule or application status will be reported in keeping with the
Federal Funding Accountability and Transparency Act (FFATA), and also transparently shared within the
THCGME Consortium.
Evaluation/Impact
Through the leadership of the program director and associate program directors, key administrative
THC and overall residency program staff, THC residents, as well as the active participation of our partnering
FQHCs, M&FHS, VA and patients, the WCGME THC has evolved quickly into an effective THCGME
Consortium. Regular contact, including mandatory face-to-face quarterly consortium meetings and
participation in the PA IPIP Residency/CHC Collaborative has greatly facilitated Consortium team building,
while broadening the knowledge-base about and experiential learning as teaching health centers about
patient-centered medical home delivery, development and NCQA certification requirements, as well as
principles of EMR MU, Patient Safety and Quality, Team based delivery and CQI. Continuous shared
consortium member self-critique, program and individual level evaluation, resident feedback, monitoring of
milestones and competencies, and the engagement of Penn State University in enhancing the evaluation
framework and methods of analysis have provided the necessary fuel to implement continuous quality
improvement PDSAs within and throughout the Consortium. The Consortium has cemented a comprehensive
framework of inextricably linked high quality primary care education and service delivery in community
based academic centers and FQHCs that is relevant and responsive to community health needs using an
intelligent, emotionally sensitive and flexible approach melding practice transformation coaching and
learning collaborative engagement in the PA IPIP Residency/CHC Collaborative honoring the duality of
WCGME’s education and patient care mission. FQHC and safety net participation, along with innovative,
established inter-professional Wright Center for Primary Care academic training centers offers diverse
clinical teaching settings which all share the dual Consortium GME mission of excellence in education and
patient care delivery/service. We firmly believe that Lackawanna, Pike, and Susquehanna counties will
become healthier communities with healthier people over the next five years because of the WCGME THC
Consortium initiative.
Consortium connectivity through the implementation of a regional Health Information Exchange
(HIE) has proved disappointing and problematic mirroring turtle paced interoperability efforts at the state
and national level. The project manager of NEPA HIE left the area and the contracted software company
disbanded. A partnership has been established with Misericordia University’s Executive Master's degree in
Health Informatics to develop and implement a plan for a regional HIE in the coming year. Students will be
engaged beginning in Fall 2013. Discussions are ongoing with regional hospitals and providers to enhance
the intuition of this project.
Recent externally facilitated THC resident focus groups have revealed continued moderate interest in
pursuing primary care safety net service for our pioneering first class of THC residents, now in their second
year. One THC resident previously interested in Rheumatology has a new vested interest in a primary care
career that has been consistently expressed since month four of her intern year. In FY2011 recruits, a handful
are committed to subspecialty careers primarily in Cardiology or Hematology/Oncology, but note that this
interest predated engagement at WCGME. These residents have mentioned in more than one venue and on
many occasions that the THC curriculum enhancements previously highlighted will better prepare them as
future Cardiologists and Hematologists/Oncologists. One THC resident originally interested and who
practiced this specialty in China has recently expressed an interest in specializing as a primary care medical
home advocate for Hematology/Oncology patients. The new class of THC residents was strategically
recruited to increase primary care and public health interest. Career choice and practice patterns are longterm outcomes to track persistence or encouragement of this intent. Overall programmatic evaluation has
been further refined through the guidance of the Penn State Center for Survey Research and Dr. Perry
Dickinson, a Medical Home Primary Care Residency expert from the University of Colorado . An annual
survey schedule has been implemented for all THC residents and the practices they learn in, focus groups,
and qualitative patient surveys provide impact evaluation on knowledge, skills, and attitudes related to
patient safety, curriculum, PCMH competencies, and qualitative measures of the program. Recently an
electronic centralized databank has been created linked to resident demographics extracted from ERAS,
survey results and trackable identity as labeled in the HRSA Reconciliation tool and FTE Cost Center Color
Coded Training Schedule. (Attachment 2) THC resident In-Training Exams scores, as well as program
surveys on PCMH knowledge related to ACGME Competencies currently exceed traditional track resident’s
scores. Initial focused interviews of patients reveal patient reception to satisfaction with the health care
provided by the residents in all continuity centers, although no clear evidence of a continuous relationship
has been yet documented. Empanelment efforts continue to be driven through the vested interest and
scholarly work of the THC residents, especially those interested in primary care. Recent assessment of 2012
focus groups of new and established THC residents presented similar significant interest in primary care
careers and service in safety net systems. Results of the Patient-Centered Medical Home Clinician
Assessment completed by both FY 2011 THC residents and traditional residents in November 2011 and May
2012 suggest the THC approach is significantly more effective in enhancing resident knowledge and
attitudes than traditional training, most notably in Team Approach, Information System Support, Population
Management, Quality Improvement, Patient Safety, Care Coordination, PCMH and Mental Health Issues.
The Overall Average of THC residents was 0.27 higher (on a 5-point scale) for THC residents. In addition,
scholarly papers and presentations, several of which reflect the above THC curriculum foci, have been
prepared, submitted, published in a range of health journals, and presented at various regional and national
conferences by our THC residents. (Document A5) The invested development of the rotation schedule and
FTE cost center methodology and inclusive Consortium dialogue has enabled the movement of residents
through their training sites to be fairly uneventful. These results and achievements demonstrate the
effectiveness of the implemented programs and partnerships that have been developed over the course of the
first year. The Consortium continues to focus on the goals, objectives, and activities set forward in the
original application’s work plan. The Consortium remains committed to significant primary care access
expansion in unduplicated patients served and annual visits provided at all four Consortium sites, as well as
significantly larger patient panel sizes for each THC resident than traditionally offered in GME programs in
order to more effectively teach skills of realistic and effective population management.
One of the greatest means of feedback is the regular online surveys which residents and faculty are
required to complete. Demographics/ informational, technology and other resource needs, patient
quality/safety and team attitude, and PCMH Skills correlated with the ACGME competencies are analyzed
through these surveys. All surveys utilized have been validated by Dr. Michael Behney of the Penn State
Center for Survey Research (CSR) and Dr. Perry Dickinson of the University of Colorado. The CSR has
created focus group templates and has conducted two focus groups, with PGY1 and PGY2 residents to
provide qualitative data related to the resident’s experience and expectations of the program. The results have
invigorated improvements in our mentorship program, enhancements to the WCGME website, and
improvements to the THC informational materials. Vital data from both PGY1 and PGY2 described a high
level of interest in careers in primary care serving safety net populations, even if specialty training was
intended. Focus groups are planned on an annual basis, with faculty and consortium partner focus groups
scheduled in the coming month. Logistically, patient focus groups were problematic to plan at distant partner
sites, so a 5-question, open-ended questionnaire was developed. A convenience sample will be collected
from ten patients at each consortium site, conducted by an observer trained to minimize bias. Follow up
results of Dr. Dickinson’s PCMH survey described above has demonstrated over all increased levels of selfassessed comprehension and knowledge for THC residents in the outlined Medical Home Competencies, as
they progressed through their first year, and also compared to the traditional track residents in May 2012.
Similar results in technology competency, population management, and teamwork were revealed in our
validated Quality/Safety/Teamwork survey baseline and follow up issued. Results demonstrate the
effectiveness of the Consortium training model in both didactic and clinical venues. WCGME continues to
improve learning opportunities, with new academic year focus on bringing for resident and faculty
development Visiting Professors with primary care expertise specifically in the principles of medical home,
chronic care, EMR Meaningful Use and Inter-professional care delivery. Often these VPs are engaged in
processes of external evaluation of THC programmatic developments. The consortium partners are invited to
attend or even often host VP presentations to further enhance the THC partnership and add value ROI to their
individual organizations. A comprehensive listing of the didactic sessions specifically targeted as a result of
the THC is included in Document A6.
SUMMARY
In keeping with any new initiative, the WCGME/Consortium has faced a number of anticipated and
unpredictable challenges, but even with limited human and capital resources, the program is flourishing and
attaining the objectives set forth in the application’s work plan which is powerful demonstration of
WCGME’s mission to deliver excellence in GME relevant fro excellent patient care. The Consortium is
strong and is a protective academic shell for clinical and point of care GME teaching endeavors taking place
in five counties in Northeast Pennsylvania, with multiple primary medical, mental and dental HPSAs and
MUAs. Engaged partners include rural and remotely located FQHCs consistent with this development’s
intent to address provider and workforce mal-distribution and related health disparities. Once barriers and
problems are detected, measured, analyzed, and transparently discussed with the relevant Consortium
partners, planned measures for improvement are expeditiously implemented and tracked. This lean quality
approach of swiftly addressing simple and moderate problems has already fostered broad programmatic
development and Consortium trust and team building in the process. The most complex issues/challenges
are due in part from external forces. Complex impediments beyond the immediate control of the WCGME
are dissected to understand where new approaches may be developed, resources deployed or new solution
oriented collaborative partnerships created to reach projected outcomes in a culture of CQI.
Since the THCGME Consortium is a new model for WCGME, all of us individually and collectively
are continuously learning. Aside from THC residents, there are approximately 30 to 40 other engaged
stakeholders and champions who have attended quarterly PA IPIP Residency/CHC training collaboratives,
and all engaged clinic continuity sites are engaged in the process of NCQA application guided medical home
evolution. The most critical indicators have been met or exceeded and the innovative energy of the
Consortium itself and the medical education community is incredibly positive. The amazing THC residents,
engaged patients, and provider staff, along with the steadfast commitment of WCGME and the Consortium
will accelerate successful implementation of activities committed by the original grant work plans.
Continued wholesome participation of the THC residents and leadership from all Consortium CHCs in the
PA IPIP Residency/CHC Collaborative will provide infrastructure for successful transformation and NCQA
Medical Home designation as well.
Reflectively, the infrastructure, guiding rails, and long-lasting pavement with lane-lines for the
WCGME “Teaching Health Center Highway to Keep Primary Care GME Services Relevant to Community
Health” are now securely in place with the THC residents now engaged in their dual established academic
and safety net learning environments as engineered in the initial THC application, implemented in FY2011
and expanded in FY2012. Patient traffic is flowing. The manner in which this “highway” has been planned,
built, and implemented with HRSA's inspiration and the engagement of incredible partnering FQHCs, our
regional VA and M&FHS partners meets and exceeds the expectations of the HRSA RFP and WCGME
GME Consortium's tactical and strategic planning process. Our THCGME Consortium partners are
confident that our much vested THC residents and patients will guide our way and keep all of our efforts
relevant and rooted in academic excellence.