Integrated care delivery at Rutgers Robert Wood Johnson Medical School

Each month, the AMA highlights institutions that are part of the AMA Accelerating Change in Medical Education Consortium to showcase their work with the consortium and innovations in medical education.

Carol A. Terregino, MD

Carol A. Terregino, MD

Senior associate dean for education and academic affairs

Rutgers Robert Wood Johnson Medical School

Number of years in the consortium: 5 years

The initial AMA funding of Rutgers Robert Wood Johnson Medical School focused on health systems science. The goal of the project was to maximize integrated care delivery through interprofessional learner teams (ILT). We deployed medical students and other health professions learners on care coordination teams of an accountable care organization (ACO) to augment patient care and maximize integrated care delivery at home.

Co-investigator Joyce Afran, MD, was instrumental in coordinating the program and continuing the home visit program with medical and pharmacy students. This early project prompted us to engage in teamwork and leadership training through the implementation of TeamSTEPPS (team strategies to enhance performance and patient safety). Richard Lang, MD, RWJMS 2019, naval veteran, then an M2 student, led the faculty on this project.

We subsequently received additional grant funding from the AMA for an innovation project: Implementation of teamwork and leadership training among the residents and interprofessionals working in a critical care unit. Co-investigators included Payal Parikh, MD, Sugeet Jagpal, MD, Archana Pradhan, MD, MPH, Paul Weber, MD, RPh, MBA and Marine veteran Jared Escobar M3.

The school is leveraging the expertise and opportunities afforded by the consortium to accelerate change in our medical education program with a focus on health equity and professional development through coaching. Beginning in the new five-week introductory course, Introduction to Physicianship, and continuing in Physician Development and Practice intersessions, we have added new experiential learning opportunities which will add value to community, educational and clinical settings.

Students are learning to work effectively in various delivery systems, use techniques which foster effective communication, and an appreciation of the influence of social determinants on health and disease. Co-investigators include Shilpa Pai, MD, Payal Parikh, MD, and Betsy Mathew, MD, along with medical student leaders of the Community Health Initiative of the Homeless and Indigent Population Health Outreach Project who have served as liaisons for multiple value-added roles: Transitions of care for the underserved patients who are hospitalized, longitudinal experiences in a community health clinic and longitudinal relationships with community organizations to help improve health education. Interprofessional collaboration occurs between students and social workers, care coordinators and community health workers; there has been increased communication between the M1 students, M3 clerks on the hospital services and residents during these handoffs.

Adoption of measurement of performance on the core entrustable professional activities for entering residents across the curriculum has led to execution of a coaching program led by co-investigator Archana Pradhan, MD, MPH.

We like to view our accomplishments through the lens of how our learners are adding value. In our interprofessional home visit program among the cohort of ACO patients visited by the interprofessional student teams there were reductions in the costs incurred during emergency department visits and inpatient hospitalizations in comparison to the previous year of this cohort in the ACO without home visits.

The training of all of our medical students and internal medicine residents in TeamSTEPPS has impacted the workplace environment with improved esprit d’ corps, improved interprofessional communication and respect, new handoff tools and the creation and empowerment of change agents. The launch of the value-added roles for the first-year students has led to increased community organization engagement and a tangible way for students to understand health care structure and process, population health and the social determinants of health.

The new curricular structure supports longitudinal experiential learning which fulfills schoolwide objectives and enhances our health equity curriculum.

In the midst of the COVID-19 pandemic, the faculty pivoted to online learning, created new learning experiences and continued in their work to reform and then launch a new curriculum with new experiential learning. I credit them with resilience and fortitude and am personally grateful to them, as well as to my consortium colleagues for inspiration during this challenging time. I think the firm commitment to create authentic experiences to teach leadership, teamwork, interprofessional care and social determinants of health allowed us to concurrently manage the current disruption and crises of the day and continue to look ahead toward our shared goals.

I see the evolution of medical education occurring over a longer period of time, though great strides have already been made. We are developing the common language around what it means to be health-systems prepared, how to transition from undergraduate to graduate medical education, what an inclusive learning environment really means and how to be well. I see the next five years as the time to establish the evidence base for effective educational modalities and solutions through multi-institutional collaborations and investigations. Time is critical. Transformative change is needed. I think the medical education community is looking to the consortium for answers.

Before the pandemic, we were fortunate to have an established education group that included faculty and administrators—we have always been a supportive team—but getting everyone together monthly was challenging. For all of the disruption imposed by the pandemic, the opportunity to gather incredibly busy clinicians, educators and staff on a regular basis has been enhanced by the virtual meeting format. Our almost daily huddles are now weekly but the time allows for sharing of different perspectives on key issues, consistent messaging and some good humor with themed virtual backgrounds.

Establishment of the crisis management team and new off-the-shelf procedures in the event of new disruptions has led to less worrying. Reminding all that evening and weekend email responses are not expected has been helpful. Finally, we acknowledged that everyone would nadir at some point. We all were committed to identifying our colleagues who were low and throwing them a life support. And we all knew someone would be there to support us when we needed it. That is still the case.