Longitudinal Integrated Clerkship (CFM-LIC) Program Guide

Sharon Casapulla, EdD, MPH casapull@ohio.edu

Scott Rogers, MD srogers@ohio.edu

Robert Bales, MD balesr@ccf.org

Amy Zack, MD zacka@ccf.org

The Continuity in Family Medicine: Longitudinal Integrated Clerkship (CFM-LIC) program runs during the third year of medical school and is only available by special permission. The student is situated within a rural or urban underserved family medicine practice to ensure they are exposed to the continuity of family medicine across the continuum of the inpatient and outpatient settings.

The yearlong LIC program exposes students to the breadth of family medicine including medical care of all ages, as well as enhance their ability to provide continuity in care.  This program exposes students to the collaboration of health care entities in the community, practice, management, and practice quality improvement.  It will also provide exposure to the  role of the physician on the healthcare team, including working with nurse practitioners, physician assistants, medical assistants, nurses, and other health professionals in and outside of the clinic setting.

Overall, the goal of the CFM-LIC program is to allow students to develop rural or urban family medicine continuity practice of their own under the direction of their supervisory site director. With this knowledge and experience, a better understanding of the scope of rural and urban underserved family medicine will be achieved.

In the continuity model, the student can see diagnosis, treatment, and education occur over a continuum, observing how these either fail or succeed in a patient’s life. In order to provide better continuity between routine clerkships being performed during the CFM: LIC, the on-site preceptor will be instructed to select patients for the student corresponding with the given clerkship. (For example: if the student is on Pediatrics, then pediatric patients should be targeted for learning) This exercise will complement the assigned clerkship with application in the family medicine realm.  Integration and continuity between clerkships and the CFM-LIC will allow for a more mature understanding of the primary focus of study. In addition, any patients of the practice encountered during routine clerkships will be encouraged to follow up with the student in the Family Medicine practice, assuring appropriate discharge planning, reintegration into the care of the primary care practice and continuing care beyond what might otherwise be an episodic illness encounter. 

The purpose of this program is to:

1. Increase student awareness of the broad scope of a family medicine practice in a rural or urban underserved setting learning how adaptability and living with scarcity and limits can affect the care of patients
2. Participate in the care of a continuity panel of patients representing a typical family medicine practice
3. Introduce basic practice business management skills
4. Practice interactive collaboration with other community healthcare providers and community agencies, building team approach advocacy, benefitting the delivery of patient care in rural/urban settings.
5. Use reflective practice techniques that will lead to the development of improved research/information/gathering skills and a clear, summarized understanding of clerkship principles.
6. Use a quality improvement approach to practice improvement 

The student will spend one full month beginning in July of the third year of medical school completing the third year Primary Care rotation in the yearlong CFM-LIC practice. The student will end the year-long LIC experience with the Family Medicine rotation, with the same preceptor. This office will be in a rural or urban underserved area where they will spend ½ day each week or one full day every other week for the whole academic year.  During this time the student will assist in caring for the practice’s patients including inpatient (if applicable), outpatient, and procedures performed, observing the physician/patient relationship in a rural or urban underserved area both in and out of the office setting. They will also follow the practice’s patients in any inpatient setting during other clerkships (when applicable) being the eyes and ears of the practice providing continuity of care by following that patient when back in the outpatient office setting. Success will be evaluated by the site preceptor. 

The student will:

• Complete Family Medicine (OCOM 8005) Satisfactorily
• Complete Primary Care (OCOM 8300) Satisfactorily
• Spend at least ½ day weekly or 1 full day every other week in the practice for one full academic year
• Care for patients along with the site preceptor, both outpatient and inpatient (if applicapable), as indicated, following inpatients into the outpatient setting
• Demonstrate to the preceptor that they can be adaptable and provide alternative care options based on resource availability

Continuity Panel

One of the goals of this program is for students to develop a continuity practice of patients representing all age groups, scope of diagnoses, and procedures relevant to family medicine. Students should highlight examples of continuity in their final reflection paper.

Proper history taking, physical exam, differential diagnosis, treatment, proper documentation of care, professional presentation, and the student’s ability to provide continuity of care should show continuous improvement and will be evaluated by the on-site preceptor. 

The student will:

• Show improvement in their history taking, note production, and development of their differential diagnosis abilities.
• Show improved competency in any procedural skills that they are exposed to within the scope of the practice and their level of training.

Business Practices

Throughout this program, the student will learn how to use proper coding and documentation to properly receive payment for services in the given practice setting. They should spend time with the business manager (or equivalent office staff) learning how the physicians, front office personnel, and business managers collaborate on day-to-day operations of a successful office.  They will learn how delivery of care needs to be adapted based on the resources of the office and patients.  They will learn by observation, discussion, and participation in the collaboration/preauthorization processes with insurance companies and reflect on how this improves and inhibits the delivery of care in rural and urban settings. 

The student will:

• Show improved skills using electronic medical record (EMR), documentation of encounters and developing coding practice with each encounter
• Demonstrate to the preceptor through discussion and practice their understanding of the business model that the practice uses
• Demonstrate that they can be adaptable in care delivery under the restrictions placed by insurance coverage and available resources

Community Resources

Many barriers exist for patients in underserved communities. Awareness of the assets and resources within rural and urban underserved communities is key to supporting patients.  Given the scarcity of resources in most rural/urban underserved areas the student will learn how to use the referral process with other medical providers, mental health providers, counselors, and community agencies.   Over the course of the year, the students should be able to demonstrate they have been able to follow this process from diagnosis to the referral, and back to the follow-up post referral.  Demonstrating how completing the continuity cycle within family medicine can ensure the patient gets the best care possible even if faced with limited resources. The student will also learn, observe, and reflect on how rural/and urban underserved physicians may wear multiple hats within the office and community and how that is balanced. 

The student will:

• Demonstrate that they can make logical choices and develop alternative care options for patients working with in-house resources and community agencies

Quality Improvement

Generally, students enrolled in the LIC will choose between completing a Quality Improvement (QI) project or a community engagement project.

Students enrolled in the South Pointe cohort will be expected to complete a group QI project under the guidance of Dr. Zack and Dr. Bales.

Quality improvement (QI) is a systematic, formal approach to the analysis of practice performance and efforts to improve performance.  The American Academy of Family Physicians states that “understanding and properly implementing QI is essential to a well-functioning practice and is necessary for any practice interested in improving efficiency, patient safety, or clinical outcomes.”

The specific areas that practices choose to address through ongoing QI efforts, and the methods they use to address them, vary based on the practice's concerns, circumstances, and resources.

In the quality improvement project, students will work with their preceptor to identify an area of improvement and gather data showing before and after implementation of the practice improvement. 

Students interested in completing a QI project will have the opportunity to meet monthly (via Teams)  as a group with Dr Zack and Dr Bales to work on planning and implementing quality improvement projects.

Additionally, in preparation for undertaking a Quality Improvement project students should :

1. Watch this brief overview of QI  (11 min)
   1. https://www.youtube.com/watch?v=jq52ZjMzqyI      
2. Complete the IHI Quality Improvement Modules (102,102, 103 and 104 are recommended). Each are about 1 hour long.
   1. https://www.ihi.org/education/ihi-open-school/Pages/courses-quality-improvement.aspx
3. Watch the recorded video presentation about implementing a QI project:
   1. https://catmailohio-my.sharepoint.com/:v:/g/personal/casapull_ohio_edu/EQKi_MmuDf9GlnNiEH-ofkQBM733H0uiZfmR1jitwF9Tiw?e=GCumqq

Once the concept is developed and agreed upon between the student and the preceptor this should be presented to the CFM-LIC Instructors of Record for approval.

The student will:

• Plan and implement a Quality Improvement Project and attempt to implement changes
• Present a summary (via PowerPoint) of their QI project implementation and outcomes at the final CFM-LIC cohort meeting. Reflect on the relevance of Quality Improvement.

Community Engagement

Generally, students in the LIC course will choose between completing a community engagement project or a Quality Improvement (QI) project. 

Students enrolled in the South Pointe LIC cohort will be expected to participate in community engagement in the South Pointe community under the guidance of Dr. Zack and Dr. Bales.

It is of vital importance that primary care physicians are interactive with their respective community outside of the office setting. The community engagement project is meant to give the student a chance to interact with and better understand the health priorities in the community.

There is no set structure for the community engagement project because every community has unique needs.  Understanding and utilizing existing resources such as the Community Health Assessment (CHA), Community Health Needs Assessment (CHNA) and the Community Health Improvement Plan (CHIP) for your county will help you get a broad view of the health needs and priorities in your community.

Students should have a discussion with their LIC preceptor about these projects and decide on a project that the student and the preceptor believe will be impactful and beneficial to both the practice and the local community and address community needs.  Examples of this could be developing an educational program for a local senior center, going into the classroom and educating students on health-related topics, or meaningful participation in a community health fair.  This is left open-ended to allow for flexibility.

Once the concept is developed and agreed upon between the student and the preceptor then this should be presented to the CFM-LIC Instructors of Record for approval. 

The student will:

• Review community needs and health priorities as found in the CHA, CHNA and CHIP
• Plan and implement a health-related project that engages the community or community organization
• Present a summary of their community engagement project implementation and outcomes (PowerPoint presentation) at the final CFM-LIC cohort meeting. Includes a reflection on how primary care practices engage with their communities

Reflection

At the program’s completion, the student will be enrolled in OCOM 8202 for one week. During this time, the student will complete a reflection paper of at least 2 pages explaining how they met the objectives and the business model they worked under. The student will address positives, negatives, how the clerkship shaped their specialty choice decision, and what they may take into their practice of medicine from what they learned in this Continuity in Family Medicine: Longitudinal Integrated Clerkship.

They should explain how they applied the competencies for underserved practice: Adaptability, Agency and Courage, Collaboration and Community responsiveness, Comprehensiveness, Integrity, Living with scarcity and limits, Resilience, Reflective Practice:  https://journals.stfm.org/familymedicine/2018/january/longenecker-2017-0030/ )

The student will:

• Write a final reflection paper that demonstrates how the student applied the course objectives and how continuity of care is applied in a rural/underserved primary care practice.
• The final reflection paper (at least two pages) should respond to the following guiding questions:
  • What were the three primary things you learned about family medicine in rural or urban underserved communities
  • Regarding the experience overall, reflect on what surprised you and why it did
  • Reflect on how you demonstrated the following competencies in the CFM-LIC practice: Adaptability, Agency and Courage, Collaboration and Community responsiveness, Comprehensiveness, Integrity, Living with scarcity and limits, Resilience, Reflective Practice

There will be a general orientation to CFM-LIC program in July. Additionally, after the CFM-LIC program orientation, the student should communicate with their preceptor prior to the first day of the program. Clarifying the following details with the preceptor will help to ensure a rewarding and successful year:

• Student responsibilities on the service
• Faculty expectations of the student on the service
• Goals, objectives, and the structure of the rotation
• Required rotation assignments and responsibilities in the faculty’s practice (e.g., clinics, lectures, conferences, other didactics, journal clubs, rounds, office hours, morning report)
• Course expectations (QI project or community engagement project)
• Discuss the Evaluation of Student Clinical Performance form

The student is strongly encouraged to ask for feedback several times during the rotation, especially at mid-rotation. Students are asked to use the HCOM Feedback Card to initiate a conversation with their preceptor monthly. In addition, they should be prepared to share past clinical experiences and personal objectives for this rotation with the faculty.

1. Attend program orientation session (July)
2. Attend all quarterly cohort meetings via Teams
3. Attend monthly QI learning sessions via Teams if applicable
4. Present summary of QI project OR community project at final cohort meeting
5. Students are encouraged to participate in Rural Health Scholars Retreat https://www.ohio.edu/medicine/about/offices/rural-underserved-programs/rural-health-scholars  and other RUSP activities
6. Complete any assigned readings based on the diagnoses and treatments seen in the continuity panel
7. Complete the Quality Improvement (QI) training series offered by ORUP/RUSP
8. Complete a QI Project OR plan and implement a community project
   1. Students in the South Pointe cohort will be expected to complete BOTH a group QI project and participate in community engagement in the South Pointe community.
9. All local expectations in regard to the student/preceptor need to be discussed at the beginning of the clerkship by the student with his/preceptor and ongoing throughout the year
10. Any practice learning activities/lectures will be at the discretion of the on-site director-preceptor and be the student’s responsibility to be compliant with the learning activities assigned
11. Be prepared to see assigned patients. Read up on the problems/procedures stated for the visit and ready to care for such issues within their scope and ability in conjunction with their preceptor.
12. Practice integration – while on other rotations the student should make all attempts to socially round and take part in the care of all the practice’s inpatients, if applicable.

The student’s grade is based on the following requirements:

1. Completion of Family Medicine (OCOM 8005) and required Primary Care course (OCOM 8300) at the same continuity office.
2. Completion of one elective week at the end of the clerkship, OCOM 8202.
3. Summary presentation of the QI project showing good data collection of a quality indicator with before and after implementation data and/OR summary presentation on the Community Engagement project.
4. Reflection paper showing that the student has accomplished all the goals set out above and has demonstrated a grasp of providing continuity in primary care.

The final grade in this course will be assigned on the following basis:

Successful completion of the third year Family Medicine (OCOM 8005) and Primary Care (OCOM 8300) plus satisfactory completion of the following requirements:

• Summary reflection paper 25%
• Quality practice improvement or Community Engagement project (including final presentation) 25%
• Summary evaluation from the supervising preceptor 40%
• Participation (attendance at cohort meetings) 10%

Quality Improvement:

1. Participants should complete the IHI Module:   http://www.ihi.org/education/AudioVideo/Pages/default.aspx

   2.  Then watch the recorded video presentation  https://catmailohio-my.sharepoint.com/:v:/g/personal/casapull_ohio_edu/EQKi_MmuDf9GlnNiEH-ofkQBM733H0uiZfmR1jitwF9Tiw?e=GCumqq

Readings relevant to rural and urban underserved communities:

• Community Health Needs Assessment (CHNA) for their assigned county. See local hospital websites.
• Community Health Improvement Plan (CHIP) for their assigned county. See local County health department website.
• County Health Rankings https://www.countyhealthrankings.org   

Resources relevant to longitudinal integrated clerkships:

• Hirsh DA, Ogur B, Thibault GE, Cox M. “Continuity” as an Organizing Principle for Clinical Education Reform. NEJM 2007; 356;8:858-866.
• Rural longitudinal integrated clerkships: changing interests and demographics of medical students. Can J Rural Med 2015;20:83-91. https://www.srpc.ca/PDF/cjrm/vol20n3/pg83.pdf
• Latessa R, Schmitt A, Beaty N, Buie S, Ray L. Preceptor teaching tips in longitudinal clerkships. The Clinical Teacher 2015; 12: 1–6. http://onlinelibrary.wiley.com/doi/10.1111/tct.12416/epdf

Resources relevant to the concept of continuity in patient care:

• Andres C, Cook L, Spenceley S, Wedel R, Gelber T. Improving primary care: Continuity is about relationships. Can Fam Physician 2016;62:116-9.

  http://www.cfp.ca/content/62/2/116.full.pdf+html

• Longenecker RL, Wendling A, Hollander-Rodriguez J, Bowling J, Schmitz D. Competence Revisited in a Rural Context. Fam Med. 2018;50(1):28-36. https://doi.org/10.22454/FamMed.2018.712527.

• Saultz J, Lochner J. Interpersonal Continuity of Care and Care Outcomes: A Critical Review. Ann Fam Med 2005;3:159-166.

  http://www.annfammed.org/content/3/2/159.full

• Stewart M. Continuity, Care, and Commitment: The Course of Patient-Clinician Relationships. Ann Fam Med 2004;2:388-390.An editorial associated with a theme issue of the Annals of Family Medicine, September/October 2004:

  http://www.annfammed.org/content/2/5.toc

• Stokes T et al. Continuity of Care: Is the Personal Doctor Still Important? A Survey of General Practitioners and Family Physicians in England and Wales, the United States, and the Netherlands. Ann Fam Med 2005;3:353-359.

  http://www.annfammed.org/content/3/4/353.full

• Tandeter HB, Vinson DC. Transcient Discontinuity of Care: Others Seeing What We Have Missed.Howard B. Journal of Family Practice 1998;47:423.

• Weir SS, Page C, Newton WP. Continuity and Access in an Academic Family Medicine Center. Fam Med 2016;48(2):100-7.

  http://www.stfm.org/Portals/49/Documents/FMPDF/FamilyMedicineVol48Issue2Weir100.pdf

Contact the Office of Advanced Studies for more details regarding available resources. If the DLIC has a required resource, it will be listed in the table below.