Since the inception of the grant, the Core has identified the need for a cognitive evaluation tool to assess learners’ comprehension and retention with respect to Medicaid managed care curricula. Our search for such an instrument at other institutions revealed that relatively little has been developed or validated in this area. Consequently, during the past few months our efforts have culminated in the development of our own cognitive assessment tool to be administered centrally within each department. With input from local item-writing experts, the present format (primarily extending matching) was constructed to correspond with the preferred format of the National Board of Medical Examiners. Sections of the exam mirror the four managed care components mentioned above, including items relevant to Medicaid. Within the Core, a discussion continues pertaining to the use of the outcomes of the cognitive measures, and whether they will be for the purpose of research, program evaluation, or reports.

The teaching platform for delivering the materials, resources, and evaluation instrument associated with these four components will be central (rather than within rotations) within each of the departments. For example, the residency-wide educational venue for Internal Medicine residents will be in the Preparation for Practice seminars – a series of six seminars taking place in the third year of residency. Dr. Brent Williams conducts these lectures, and will be incorporating the Medicaid managed care learning objectives into the curriculum. Family Medicine is formalizing plans to implement these components into its Wednesday morning conferences, integrating the managed care learning objectives into lectures on related topics. Pediatrics is in the process of obtaining consensus on where and by whom the material will be presented, with expectations of securing some of the noon conference time slots. Ob/Gyne is still formulating plans, and is considering the Wednesday afternoon Department Core lecture series.

For other Medicaid managed care competencies such as Team-building, Use of Community Resources, and Physician-Patient Relationship, much of the learning is derived from residents’ experiences in the field. Consequently, each department continues to develop community-based learning experiences within specific rotations to enhance the learners’ acquisition of these competencies.

Geriatrics: To date, Geriatrics has trained 4 residents, as well as several pharmacy, nursing, and social work students, in its Managing High Risk Elderly People in Community-Based Settings sequence. On Wednesday afternoons, learners meet for a didactic interdisciplinary training session, with one of the following four topics presented each week: Health Systems - Medicaid Managed Care, Comprehensive Geriatric Assessment, Case Management, and Dementia – a Multidisciplinary Management Plan. On Monday afternoons, learners participate in the following community-based activities once each month: visiting a patient receiving home health services with a visiting nurse or social worker; presenting an educational session on a relevant geriatric topic to a group of older adults in a congregate living setting; conducting a functional assessment of an older adult with dementia living in a nursing home facility; and conducting a functional assessment of an adult living in an adult foster care home or assisted living facility to determine the appropriate level of care needed. Once a month, learners visit M-Care to meet with a clinical pharmacist to discuss management of drug benefits, and a physician to discuss cost utilization reports for Medicaid patients, as well as financial and ethical issues. Teaching materials for Monday and Wednesday afternoons are being compiled into a bound notebook for dissemination to learners.

Pediatrics: Pediatrics has made progress in crystallizing Medicaid managed care enhancements in four of its rotations. As part of the Newborn Care Rotation, residents will now assist a visiting nurse on an early-discharge neonatal home visit to gain experience in conducting environmental assessments, as well as educational assessments regarding parenting needs. During the Community Pediatrics Rotation, residents now split their time between patient care visits at a practice site committed to the care of children who are medically underserved (e.g. The Corner Health Center), and community agency visits to organizations providing health care and family support to underserved families (e.g. WIC, Washtenaw County Health Department). As part of the Intern Primary Care month, where first year residents spend a month assigned to a primary care practice site, two additional modules have been added to help residents focus on Medicaid and managed care issues. One module is an experience at The Corner Health Center, where residents spend time with personnel who support patient care activities and/or provide community outreach – including social workers, the Theater Troupe, and nurses helping patients with health insurance eligibility. The second module is a half-day experience at the Coagulation Clinic, a subspecialty hematology clinic that serves as an excellent example of managed care use of subspecialty expertise. During the Pulmonary Medicine, Allergy and Immunology Rotation, a new Asthma Management in the Community sequence is being developed, in which residents will participate in asthma primary prevention strategies, including community-based education projects.

Family Medicine: Family Medicine continues to develop its newly created Community Medicine Rotation, comprised of two sequences: Care of Young Families Headed by Low-Income Adolescents, and Care of the Elderly in a Community Setting. Dr. Lourdes Velez has replaced Dr. Toni Cutson as the faculty member training residents in the Geriatrics component of Medicaid managed care. The weekly schedule of the community-based rotation is designed as follows:

Obstetrics/Gynecology: Ob/Gyne plans to pilot its Managed Care and Community Medicine in Obstetrics sequence in April 1999. Home visits, community education activities, community agency service work, and M-Care visits will all be incorporated into the new sequence, as well as coordinating with Pediatrics on a breastfeeding education program.

Each of the departments will individually handle the administration of the Attitude Survey. Internal Medicine has temporarily postponed administering the Attitude Survey, due to the fact that another faculty member is conducting a research project involving the dissemination of a similar survey. Pediatrics has placed the Attitude Survey on its Website, and will begin requesting residents to submit answers as soon as administrative technicalities are resolved.

A limited number of faculty members with in-depth expertise in the organization and finance of health care delivery under managed care are available to develop and deliver key aspects of the curriculum. We are addressing this issue by centralizing the curriculum components which are strong in managed care principles and which lend themselves to a didactic delivery mechanism. Also, we are experiencing limitations due to the lack of some aspects of managed care practices being present at our rotation sites – namely, the distribution of HEDIS reports and the existence of ongoing quality improvement projects. We are addressing this barrier through the development of mock reports from M-Care, and the development of written exercises and site visits to selected M-Care administrative offices by residents in each of the departments.

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