Transforming patient care at a residency teaching site through population health redesign: A team-based approach

High functioning primary care clinics are known to engage in population based healthcare to improve patient outcomes. At Tufts Family Medicine Residency, we aimed to transform the way we care for our patients by extending our focus beyond individual patient visits. We thus restructured our workflow to provide preventive health care outreach at the population level. Here we describe our efforts while transforming to a patient-centered medical home at a multiple-provider, safety-net family medicine residency clinic in Malden Massachusetts. Our redesign process emphasized 3 points: 1) Data-driven prioritization of population-health outcomes in a clinical setting traditionally focused on day-to-day patient concerns. 2) The development of high-functioning, interdisciplinary clinical care teams with whole-staff engagement and empowerment to address population health needs. 3) The promotion of continuous, team-based relationships between patients and appropriately-sized care teams through the population-health workflow. We will describe how implementation of this new model has impacted staff satisfaction, volume of patient outreach, population-health quality metrics, and patient / care-team continuity. We will also describe how this model is used to train resident family physicians to lead team-based population health promotion efforts within their future practices. Our approach is unique because of the challenges to continuity and team-based care that a residency clinic presents. We are a Family Medicine training site with 39 MD providers accounting for approximately 10 FTE positions. Accordingly, our baseline patient-PCP continuity rate is low and we experience a significant amount of MD and patient turnover.