A Novel Curriculum for Internal Medicine Residents to Care for High-Need, High-Cost Patients

High-need, high-cost (HNHC) patients comprise a small proportion of the US population yet result in a disproportionate amount of healthcare cost and utilization. In 2019, approximately 50% of total healthcare expenditures was accrued by 5% of the US population, and inpatient hospital care accounted for approximately 37% of spending for persons in the top 5% of spenders.¹ The quality of care does not necessarily increase with higher cost; frequently, HNHC patients receive redundant or superfluous care in fragmented healthcare systems that are difficult to navigate.²

Healthcare systems across the US have been challenged to develop integrated systems of care, including patient-centered medical home (PCMH) models that optimize care for HNHC patients by reducing preventable healthcare utilization while also increasing quality and continuity of care. Many innovative interventions that provide wrap around services and integrated, comprehensive care for HNHC patients exist,³ some of which have demonstrated benefit in reducing emergency department (ED) utilization, hospital stays, and readmissions.⁴

There is an anticipated significant physician workforce shortage in the US,⁵ which further exacerbates the growing need for more physicians who are trained to care for HNHC patients. There is also an increased emphasis on the importance of primary care focused not only on the diagnosis and management of chronic illnesses, but also on the provision of complex care for individuals with disparities and poor engagement in healthcare.⁶ Training physicians to provide high quality care for HNHC patients within integrated systems is therefore critical. Internal medicine (IM) residents would benefit from curricula focusing on developing the skills associated with providing comprehensive and patient-centered care in an integrated system. Such curricula highlighting the delivery of patient-centered care have demonstrated increased resident satisfaction.⁷ One institution demonstrated that a patient-centered, transitions of care focused curriculum for IM residents resulted in a reduction in 30-day readmissions for patients admitted with heart failure exacerbations.⁸ In addition, an intensive 4-week curriculum that was developed in a Family Medicine residency program resulted in an increase in self-confidence and desire for residents to provide care for complex patients.⁹

The UCLA Extensivist Program was established in 2017 as an interdisciplinary PCMH for HNHC patients. The Extensivist interdisciplinary team is composed of IM physicians, comprehensive care coordinators, pharmacists, registered nurses, nurse practitioners, and social workers who together provide continuity across inpatient and ambulatory settings for patients meeting the following criteria: diagnosis of a high-risk condition(s) (eg, end stage renal disease, advanced congestive heart failure, cirrhosis) and high utilization, defined as frequent hospitalizations (>1 in one year) and/or ED presentations (>3 in 1 year). Additionally, the Extensivist Program seeks to reduce psychosocial barriers to care (eg, co-morbid mental health disorders, high medication cost) that are common within this patient population.

The Extensivist resident curriculum is a novel training program that was established to empower trainees to foster comfort and develop the skills necessary to care for HNHC patients in an integrated medical system. Leveraging the resources provided by the Extensivist Program, the curriculum trains residents to identify root causes of health care utilization, recognize the role of psychosocial barriers in limiting access to care, and effectively work within an interdisciplinary team. We predicted that the Extensivist Curriculum would increase IM resident (PGY-2 and PGY-3) self-rated skills and attitudes in caring for an HNHC patient population.

This study was a survey-based interventional trial that was reviewed and approved by the UCLA Institutional Review Board (IRB) in July 2020, IRB#19-001623.

This novel resident curriculum sought to improve resident attitudes and skills surrounding caring for HNHC patients. Despite nonstatistically significant findings associated with our hypotheses, there were trends toward improvement in various self-rated attitudes and skills regarding caring for a complex, HNHC patient population. Specifically, participants in the intervention group demonstrated trends toward feeling less overwhelmed when seeing patients on their schedules for posthospital discharge visits, increased comfort in self-reported skills associated with identifying and addressing SDOH, and more confidence in the ability to utilize an interdisciplinary team to address previously identified SDOH.

Postdischarge ambulatory visits are critical in preventing hospital readmissions,¹⁰ especially for HNHC patients.^11,12 Our curriculum included dedicated time to perform root cause analyses regarding the etiology for hospital readmissions and to review specific questions and goals associated with postdischarge visits under the guidance of attending physicians, which may have led to participants in the intervention group feeling less overwhelmed with posthospital discharge visits. The corresponding increase noted in the control group may have stemmed from increased resident awareness of the limitations in how they can care for HNHC patients over time and a lack of specific curricula addressing this topic. Comprehensive assessment of SDOH is a key skill necessary to develop patient-centered solutions surrounding psychosocial barriers to health care and should be a priority in order to achieve better health outcomes in the US.¹³ Our study intervention resulted in a trend toward an increase in the self-reported skills associated with identifying SDOH and more confidence in the ability to engage an interdisciplinary team to address SDOH for HNHC patients compared to decreases in the control group. Establishing and integrating interdisciplinary teams to provide support to HNHC patients is a critical need within our healthcare system.¹⁴ Working as a member of an interdisciplinary team was a highlighted and unique feature of our curriculum; the specific curricula highlighting SDOH analysis and applying it in both inpatient and ambulatory settings while also participating in interdisciplinary rounds may have led to the intervention group feeling more comfortable understanding the roles of various interdisciplinary team members and how they could be incorporated in addressing SDOH.

Many participants in both groups felt guilty that they could not provide optimal care for complex HNHC patient populations, and there was in increase in the proportion of participants in both groups who identified feeling guilty after the study intervention. Additionally, only a minority of participants felt they could successfully transition HNHC patients between inpatient and ambulatory settings both before and after our intervention. These findings indicate that improving higher-level attitudes and skills such as guilt and transitions of care, respectively, may require more advanced training beyond 6 half-day sessions, and addressing these topics as a woven thread throughout residency training may be beneficial. There may have been an increase in feelings of guilt in providing optimal care after residents were exposed to more HNHC patients over time given time and structural constraints related to IM resident ambulatory training and difficulties in providing close continuity of care to these patients who would likely benefit most from frequent care. Further, difficulties that residents may encounter in engaging robust interdisciplinary support likely impact optimal transitions of care. Future studies may consider targeted assessment of these findings and specific interventions (ie, providing residents with more longitudinal access to interdisciplinary support) to improve them.

Qualitative data collected based on responses from an open-ended question in our survey indicated that some participants felt they benefited from the curriculum, especially regarding developing an understanding of system-based resources for HNHC patients, acquiring skills to coordinate transitions of care, and developing comfort in the assessment of psychosocial barriers and social determinants of health. These responses indicate the value of our curriculum and the importance of reinforcing these topics in curricula for IM residents.

There were several limitations in our study; we had a limited sample size based on the number of PGY-2 and PGY-3 trainees and given the nature of resident training and existence of various ambulatory training sites, the residents we compared (intervention vs control) received variable outpatient training. For example, the PGY-2 and PGY-3 trainees in the intervention group trained in the UCLA-Westwood and Santa Monica clinics, respectively, while the PGY-2 residents in the control group trained at multiple other sites. Patient populations in these clinical sites are varied. The UCLA-Westwood and Santa Monica sites are hospital-based clinics associated with a quaternary care health system, while other clinical sites (West Los Angeles VA, VA Sepulveda Ambulatory Care Center, Simms/Mann Venice Family Clinic, UCLA-Santa Clarita, and Olive View Medical Center) vary in location and patient population and may have a variable proportion of HNHC patients. We thus could not control for the patient population and associated unique training received by each resident, which in addition to limited sample size, may have impacted both their baseline and post-intervention attitudes and skills in caring for HNHC patients. Future studies may include residents who all participate in the same continuity clinic site and randomly assigning them to control versus a curricular intervention. Our study included PGY-2 categorical and PGY-3 primary care residents based on ease of scheduling with these particular groups, and the advanced nature of the care required by HNHC patients was likely more suitable for senior residents. This did, however, limit our sample size to a fixed study population, which precluded the need for power analysis. It may be important for future studies addressing curricula regarding caring for HNHC patients to include a broader range of trainees, or specifically target curricula to those with lower baseline self-reported attitudes and skills.

The study survey was developed by study investigators and included questions to assess the unique elements related to the curricular intervention. These questions were categorized into attitudes and skills, which were self-reported, subjective measures that are susceptible to confounders; the survey was not validated nor pilot tested. The use of validated measures, such as resident burnout using the Maslach Burnout Inventory or Mini Z Resident (Mini ReZ) survey, may be considered in future studies.^15,16 Future studies may choose to assess resident skills using Accreditation Council for Graduate Medical Education (ACGME) milestones which include evaluations of patient care and systems-based practice.¹⁷

Further limitations include our low sample size in addition to low participant response rates, especially in post-intervention groups, which may be attributed to the challenges associated with obtaining high survey response rates from physicians and especially those in training¹⁸; given these low response rates post-intervention, we treated pre- and post-intervention groups as independent samples (unmatched). Thus, the conclusions we reached should be interpreted with caution. Future studies may consider strategies to improve response rates, including administering surveys in-person and/or reducing the time period between pre- and post-survey assessments. Finally, given constraints associated with IM residency training and limited available time for elective curricula, the intervention we provided was relatively short (6, 4h sessions) when compared to others⁹ and considering the challenging goals of improving attitudes and increasing skills in residents to care for a complex patient population, which likely require more intensive and long-term training.

Our study indicates that many IM residents do not feel that they have the optimal attitudes or skills to care for our most vulnerable and complex patients. There is a necessity for curricula that provide IM residents with the necessary training to improve attitudes and skills associated with caring for HNHC patients, especially as we expect the number of patients with chronic illnesses and thus increased complexity to rise over time.¹⁹

The UCLA Extensivist Program which provides comprehensive and patient-centered care to a population of HNHC patients, was leveraged to provide a novel curriculum highlighting key components of comprehensive care with the support of an interdisciplinary team to help patients thrive within a complex medical system. This curriculum is adaptable to other IM programs aiming to teach residents specific skills to provide comprehensive care to a vulnerable, complex patient population. Future studies that include a higher number of participants and improved response rates will be helpful to further elucidate the importance of integrating curricula focused on caring for HNHC patients.