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Ambulatory Care Training Settings

A strength of the Internal Medicine Residency Program at Johns Hopkins Bayview is that each resident develops continuity practices in three different settings, each of which provides distinct educational opportunities, practice populations, and methods of practice management. The three settings are described below.

SitePractice TypePractice SizeTypical Patient ProfileLocation
Johns Hopkins Medical House Staff Practice (MHSP)Hospital-based housestaff group practiceAbout 2500 patients.
37-38 residents.
10 preceptors.
Middle-aged to elderly.
Medicare>Medicaid>third-party>self-pay
Lower income.
Ambulatory Care Center at JHBMC
Elder House Call ProgramHome care
 
130 patients.
10-12 residents.
1 geriatrician.
Homebound elderly.
Lower to middle income.
Based at the hospital, but all visits in patients' homes
Johns Hopkins Community Physicians at Greater Dundalk (GD)


 
Community-based7,300 patients.
3 residents.
4 internists.
1 nurse practictioner.
All ages,including elderly.
HMO and fee-for-service.
Middle income.
2.5 miles southeast of JHBMC
Johns Hopkins Community Physicians at Riverside (RS)
 
Community-based12,000 patients.
3 residents.
4 internists.
All ages, including elderly.
HMO and fee-for-service.
Middle income.
20 miles north of JHBMC
Johns Hopkins Community Physicians at White Marsh (WM)Community-based61,000 patients.
3 residents.
10 internists.
2 physician assistants.
1 nurse practitioner.
All ages, including elderly.
HMO and fee-for-service.
Middle income.
5 miles north of JHBMC
Comprehensive Care PracticeCommunity-based5 internists.
3 residents.
1 nurse practitioner.
1 nurse educator.
All ages.
All income levels.
Focus on patients with HIV and chemical dependency issues.
On JHBMC campus

All sites: 1) are staffed by full- or part-time faculty general internists; 2) provide first contact, comprehensive, longitudinal, and preventive medical care; 3) emphasize continuity of provider; and 4) have medical record systems that emphasize longitudinal care and facilitate confidential record review/audit (problem lists, medication lists, flow sheets, etc.). All sites admit patients to Johns Hopkins Bayview Medical Center.

The Medical House Staff Practice (MHSP)

In its location in the 301 building, a modern ambulatory care center, the MHSP has 18 exam rooms. One exam room is equipped for videotaping. A reading/conference room has a core library of references useful in general internal medicine, and computers with extensive medical software and educational tools. Interns are oriented to the MHSP and begin to build their patient panels in the context of the Foundations of Clinical Excellence month early in the year – described above.

About 1,600 patients are followed in MHSP.  The average patient makes about 3 visits per year. About 20% of the patients seen per year are referred as new continuity-care patients from the medical wards, from other services, or from the Emergency Department. Another 10% per year are self-referred. The majority of MHSP patients have been followed in MHSP in previous years and continue to return for care. Many live and work locally and can be classified in low to lower middle income level groups. The majority of these patients are covered by Medicare or Medical Assistance.  Some are uninsured. Most have one or more chronic conditions, and many have a history of one or more hospitalizations.

MHSP sessions begin with a focused learning activity, usually in the form of (1) a written case with several questions presented by a resident and based on a recent patient encounter (“Clinical Pearls”), and (2) a “Management Gem” that addresses a practical system issue related to MHSP.  Medical Assistants are assigned to each resident to facilitate patient care during and between MHSP sessions.

The clinic is supervised by core senior faculty general internists (Drs. Randy Barker, David Kern, Laura Hanyok, Darius Rastegar, David Martin and Leah Wolfe). General Internal Medicine Fellows, Geriatrics Fellows and Chief  Residents also attend in the MHSP, so that for every session there are two attendings including one of the senior preceptors. Faculty preceptors are chosen because of their knowledge of ambulatory medicine, their teaching ability, and their enthusiasm.

The preceptors are not scheduled to see patients and are fully available during each MHSP session for educational, consultative and administrative support. Visit notes are dictated and reviewed by the faculty preceptor, with written or verbal feedback provided as necessary. Real time and videotape observation of housestaff by faculty preceptors, and a system of chart self audits, are part of the MHSP training experience.

The MHSP has a dedicated Social Worker, Ms. Joan Zelinka, who is available to see patients as needed, and who actively participates in the education of housestaff on numerous financial and psychosocial aspects of primary care.

Information derived from the computerized appointment system provides each resident with a regularly updated roster of all patients in his/her panel. Junior and senior residents take night and weekend call for the MHSP. Intercurrent and urgent care is provided by the PGY-3 “Block Doctor” when the patient’s primary resident provider is unavailable.

Elder House Call Program

PGY-2 and PGY-3 GIM residents provide longitudinal, comprehensive, primary care to patients in the Elder House Call Program. The aim of this is to help frail homebound patients avoid unnecessary hospitalization.

The patient population consists of frail (20% annual mortality) mostly elderly, homebound persons who wish to remain at home and whose families are devoted to helping them. About 140 patients are in the program. Patient ages range from 21 to 95, with the mean about 75. They are referred from JHBMC, local physicians, families, social services agencies, and other hospitals in the area.

The Home Visiting Team includes a geriatrics faculty member, a first year geriatrics fellow, PGY-2 and PGY-3 general internal medicine residents (who provide continuity), and a patient care coordinator. In addition, the program frequently utilizes the services provided by Johns Hopkins Home Care such as skilled nursing, personal care, physical therapy, occupational therapy, speech therapy, social work and hospice care.

A faculty geriatrician or a geriatrics fellow supervises each house staff member.  Initial orientation and the first several house calls are done jointly by a house officer and a member of the faculty or a fellow. The attending and fellow review resident visits after their completion. The attending or fellow is available to the resident for phone consultation during the time of each visit and when addressing patient issues during non-CBP blocks.

Community-Based Practices: Resident Firms

PGY-2 and PGY-3 GIM residents develop a third longitudinal, comprehensive, primary care practice at one of the community-based sites (see Table). All sites are within a 30-minute drive from the hospital. These practices provide residents with some educational opportunities not available in their other practices due to differences in patient populations and practice site:

  • Patient Mix – In several of the sites, the patients tend to be younger, and of higher socioeconomic status than the MHSP and Home Care Patients. The Comprehensive Care Practice provides a continuity clinic for residents interested in providing primary care to underserved populations with a focus on patients with HIV and chemical dependency issues.
  • Health Problems – In many of the CBP sites, patients tend to have fewer active and complex medical problems.  More time can be spent on preventive care, risk factor reduction, and behavioral counseling.  There is a greater expectation that the primary care physician should manage common or minor dermatologic, musculoskeletal, podiatric, ophthalmologic, and otolaryngologic problems, do routine gynecologic care, and perform minor surgical procedures.
  • Practice Management – Most of the practices serve a predominantly, but not exclusively, managed care population of patients.  Emphasis is placed on cost-effectiveness, efficiency, patient flow, and patient satisfaction.
  • Faculty – Preceptors at each of the sites are community-based GIM faculty who trained in the JHU/JHBMC Faculty Development Program.  Residents work one-on-one with an assigned preceptor, whose own patient schedule is reduced for that session.
 
 
 
 

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