Sturm, Lynne A. PhD; Shultz, Janet MLS; Kirby, Rebecca MPA; Stelzner, Sarah M. MD
Primary care pediatric providers must frequently assess and manage psychosocial issues of the children and families they serve and coordinate services for children with special health care needs. Doing so successfully calls for linking families with community-based resources. One way to teach residents this skill set is to place them, during both their developmental–behavioral and community pediatrics rotations, in community agencies,1 where they can become familiar with available services and personally participate in service learning projects to improve the health of children in a community.
There are reasons, however, for supplementing agency visits with the opportunity to learn and apply these skills back in the clinical setting. For one, the families of pediatric patients are seen by pediatric providers at the clinic, not at a community agency, and so the links to community resources by pediatric providers typically originate there. Primary care settings are also the most effective sites for teaching residents to identify and address developmental and behavioral health concerns.2,3 Recent recommendations to improve training in developmental–behavioral pediatrics include expanding the longitudinal experience beyond a one-month rotation by infusing teaching into continuity clinic experiences.4 Adults are most motivated to learn when they need to immediately apply the learning to life situations,5 and, indeed, residents best acquire new skills and knowledge while providing actual patient care, “a time when the resident is most interested and best able to put the information into clinical practice immediately.”2 Teaching during clinical care also exposes residents to cross-disciplinary collaboration. Recent developmental–behavioral training guidelines recommend that faculty involve a multidisciplinary team in both teaching and patient care so that residents experience “a model for direct professional collaboration when in practice.”2 Residents can be expected to value the contributions of nonphysician professional colleagues only to the degree that such individuals are consulted and esteemed by their faculty physicians.
In light of these considerations, we developed a model in which residents learn about community-based resources and linkages while directly caring for patients in continuity clinics. A promising strategy for establishing a “medical home” in pediatric practices involves colocating providers and services.6,7 Our innovative training model builds on that well-regarded service delivery strategy by colocating representatives from community-based organizations (“community partners”) within pediatric continuity clinics. By serving as copreceptors with physician faculty during clinical care, the community partners teach residents (and faculty) about community-based resources and model how to work with multidisciplinary partners. The community partners' involvement also repeatedly focuses the residents' attention on psychosocial issues throughout their primary care continuity clinic. In this article, we describe the development of this teaching model, highlight the challenges that arose during implementation, discuss strategies that emerged to address barriers, and review the lessons learned by residents, academic faculty, community partners, and project staff.
Origins and Overview of Project
In 2001, the Department of Pediatrics at Indiana University School of Medicine became part of the second wave of community pediatrics training programs funded by the Anne E. Dyson Foundation. This collaborative of 10 programs served as the foundation for the Community Pediatrics Training Initiative, housed at the American Academy of Pediatrics.1 At Indiana University, our main focus has been to teach residents about community pediatrics through the development of medical homes for vulnerable children and youth and through partnerships with communities and the organizations that serve them. Over the past decade, we have established and grown strong partnerships with three community agencies: About Special Kids (ASK), the Julian Center, and La Plaza. Following the training initiative's partnership model, we reimburse the agencies for their staff members' time and efforts with residents, provide adjunct faculty status at the university level, and ensure consistent protected time.
ASK is a “parent-to-parent” organization whose mission is helping children with special needs by educating, empowering, and connecting families with other families.8 Using a Web-based resource directory, the agency assists both families and professionals throughout Indiana to understand the state's systems of care related to special needs. The Julian Center, established in 1975, is a nonprofit agency that counsels, shelters, and educates survivors of domestic violence and sexual assault. The innovative center has an on-site school, counseling center, health clinic, and detective unit, and the staff does outreach and consultation to educate the greater community about the issues of domestic violence. La Plaza serves the Hispanic/Latino community in Indianapolis through health and social services, youth and adult education programs, and arts and cultural celebrations. The community partners had masters degrees in social work or public affairs.
In 2007, feedback from residents indicated that many of them felt unfamiliar with the complexities that arise when families from different cultural backgrounds present with issues related to child development and family function. In response, pediatric faculty at Indiana University obtained an internal grant to continue the training initiative's work, with a focus on using primary care continuity clinics to teach about the psychosocial issues that affect pediatric health. The primary objective of the grant was to provide the multidisciplinary expertise and relevant clinical experience that pediatric residents need to address the psychosocial issues of children from diverse backgrounds in the context of their family and community. The second objective was to inform faculty preceptors about community resources and effective linkages by expanding their knowledge of the three community-based partner organizations and other community agencies they could access on their patients' behalf. In April 2011, following the project's completion, Indiana University's institutional review board granted the project exempt study status.
The Indiana University School of Medicine Pediatric Residency Program
There are 150 residents in the Department of Pediatrics residency program at Indiana University School of Medicine, including combined pediatric residents (e.g., medicine/pediatrics, emergency medicine/pediatrics, pediatrics/psychiatry/child psychiatry). The residents have experiences with primary care outpatients in 30 Indiana University Medical Group and private pediatric offices throughout the Indianapolis metropolitan area. Residents at the two largest Indiana University Medical Group clinics participated in our project. In those two continuity clinics, which were each held four afternoons per week, an average of two faculty physicians and six to eight residents participated in a given session; each resident was scheduled to see between six and nine patients.
The project's activities were directed by a faculty preceptor for a continuity clinic who is an expert on cultural effectiveness and local community resources and a pediatric psychologist with experience precepting residents about developmental and behavioral health issues in the continuity clinic setting. The program coordinator for the university's Community Pediatrics Training Initiative served as administrative liaison to the community partners and their organizations.
At the project's onset in 2007, we invited one individual from each of the three community-based organizations to participate, offering them adjunct faculty status. Their organizations signed business associate agreements for each practice setting, and the individual community partners signed confidentiality agreements. Funded for four hours per week, each of these community partners spent a two-hour block in two of each week's eight scheduled clinic sessions. They rotated the days on which they attended the two clinics with the goal of each community partner working with each resident on average once per month.
The staffing patterns for the community partners changed across the two-year project in response to both feedback from faculty and residents and changing needs of their home organizations. During 2008–2009, an unanticipated job change and a family illness resulted in two of the three community partners' inability to participate in the project. For the project's duration, a single community partner from the ASK program attended two clinic sessions each week at each of the two clinics. The decision to not replace the departing community partners from La Plaza and the Julian Center arose from two considerations. First, by all parties' report, the expertise of the departing community partners (Latino/Hispanic health and domestic violence) had been underused. Second, because so many families asked their pediatric providers about school-related problems (such as poor performance, possible ADHD, and disciplinary measures), it made better sense to increase the hours of the ASK community partner, who had expertise in those issues, than to replace the two others. This would allow the ASK community partner to be more available in the clinics to teach the residents about those frequently encountered family concerns. Under the revised schedule, each resident encountered the ASK community partner every other week (in contrast to once per month). Comments on the 2009 feedback surveys indicated an unexpected benefit of this reduced staffing: Residents and faculty appreciated interacting with a single community partner with a predictable schedule rather than having to adjust to three different community partners with less predictable schedules.
The roles of the community partners evolved across the two-year project in response to the residents' needs. From the beginning, the community partners coprecepted residents during case discussions with pediatric faculty and accompanied residents during well-child visits to talk to families about community resources. They taught both residents and faculty about accessing community resources, communicating with families, and working in multidisciplinary teams, and they provided expertise in their specific areas. At one of the clinics, they were invited by pediatric faculty to expand their role by participating in the pilot of group well-child care visits. They led discussions for families on such topics as how to ask your child's doctor for information using the “ASK Me 3” questions,9 the impact of family violence on young children, and community-based resources for young families. In response to feedback from residents in the winter of 2007, in which they requested additional presentations on psychosocial topics, the community partners gave two hourlong lectures each year for the larger group of pediatric residents on such topics as accessing the resource directory on the ASK Web site (using case examples drawn from clinic patients), immigration status and its impact on family access to community resources, and human trafficking.
Initial orientation to the project for the community partners, whose prior familiarity with medical settings varied, included several face-to-face meetings with project staff. We discussed the program's goals and explained clinic staffing, administrative organization, and clinic visit flow, using flow diagrams, schedules of resident assignment to clinics, and organizational charts. We also provided written materials, such as abbreviation lists and medical dictionaries, for deciphering unfamiliar medical lingo. A project staff member who had experience co-teaching as a pediatric psychologist in the clinics provided suggestions for co-teaching with physicians. Orientation activities continued at the community partners' first sessions in the clinics. We accompanied each community partner to each of their clinic sites to introduce them and explain their roles to faculty physicians, clinic staff, and residents. At the beginning of the project's second year (July 2008), we also incorporated the community partners into the residency's intern orientation. The community partners made presentations to the intern class and met individually with the interns assigned to their continuity clinics.
We also oriented the faculty physicians who would co-teach with the community partners by attending several clinic faculty meetings to describe the project's goals, the co-teaching model, and the roles that the community partners would play in their continuity clinics.
Following the model of continuous quality improvement, we regularly collected feedback from the program's participants and used the information to fine-tune procedures and address concerns. We held monthly meetings with the community partners and met quarterly with pediatric faculty in all-physician clinic meetings to address concerns and challenges that had arisen from co-teaching. To determine if we were on the right path to meeting the goals of the project, we sought written feedback from faculty and residents twice during the project (winter 2007 and summer 2008) and at the end of the project (summer 2009). The feedback surveys, which we developed with input from the community partners, consisted of a blend of quantitative and qualitative questions. For example, residents and faculty used Likert-type scales to rate the community partners' contribution to their learning, the community partners' value in providing services to patients and families, and how frequently they discussed community resources when the community partners were not present. They also wrote brief narratives about how they could apply what they had learned to future clinical care, what had surprised them, and suggestions for the community partners' role in the clinic. The community partners, too, completed surveys, which also mixed quantitative and qualitative formats, in the springs of 2008 and 2009. They gave feedback on the clarity of the program's goals, the degree to which they benefited, personally and professionally, from the partnership, and ways in which the program might be improved.
The community partners also completed a semistructured form for each clinic session they attended. In these forms, they indicated the number of contacts they had with residents, faculty, and families and described their clinical activities, the lessons they had learned, what they thought had worked well, and missed opportunities for involvement. Some of the descriptions were extensive; others were contained in brief notes.
Lessons Learned: Challenges and Strategies
The community partners' perspective
The community partners faced the initial challenges of developing relationships with a large number of residents and faculty and adjusting to the unfamiliar medical culture. List 1 summarizes the strategies that emerged during the project to address those challenges. In the first year, the three community partners, rotating across eight continuity clinic sessions, came face-to-face with a given resident only every five to six weeks. Such infrequent contact, which required that they repeatedly introduce themselves to clinic staff and reiterate their roles, hampered their ability to build rapport. In late 2008, when two of the community partners left and the remaining one increased her hours in the clinics, relationship building improved. Future co-teaching arrangements might avoid this challenge by securing enough funding to maximize the frequency with which community partners can attend clinic sessions (e.g., every one to two weeks rather than every five to six weeks).
The community partners also faced a process of acculturation when stepping into the medical world from that of nonprofit organizations. Perhaps the most important new skill they had to develop was how to assert themselves as copreceptors with the physicians in the quick-paced, jargon-filled, and often stressful clinic environment. They needed to become competent in their sense of timing—to know when it was most efficacious to ask questions and offer expertise. Comfort with this skill emerged at different rates for the different community partners, depending on personality style and degree of prior experience with the cultures of primary care and medical education. In the end, though, they all learned to join the case discussion, even when not directly invited.
Although the community partners were initially given a general overview of goals for the project, in their 2008 end-of-year evaluation, they requested more clearly articulated goals to better help them explain their role and function to residents and staff. Using suggestions from the residents' and faculty's 2008 end-of-year evaluations, we worked with the community partners to clarify their responsibilities and goals (List 2). In addition to teaching responsibilities during clinic sessions and at noon conferences, the community partners also aimed to encourage the faculty physicians' use of cross-agency communication forms, to find teaching moments or tools during downtime between patients, and to participate in group well-child visits at one of the clinics.
During 2008–2009, the community partners voiced interest in having feedback from residents and faculty more frequently than twice each year. They suggested that, in future co-teaching projects, residents' perspectives be routinely gathered by inviting a resident to attend the monthly face-to-face meetings between project staff and community partners. They also suggested that their long-term impact be evaluated by surveying residents 6 months and 12 months after graduation to examine their attitudes toward and referral practices with community agencies.
The community partners appreciated their status as equals in the project. We encouraged them to present themselves as “experts in community resources” and as true partners with the health care providers in the clinics, and we formalized their equal status by making them adjunct faculty in the Department of Pediatrics. We considered equal partnership between faculty physicians and community partners a key to residents learning how to partner with non-MD colleagues, so we encouraged faculty, during their quarterly clinic meetings, to relate to the community partners as equals. Most did engage in positive interactions with and readily used the community partners, thereby modeling for residents a deep appreciation of how multidisciplinary teams enhance patient care. The community partners appreciated this respectful relationship. As one of them stated in an end-of-year evaluation:
Having staffing pediatricians model positive interactions and use of community partner representatives makes a difference ... I feel much more comfortable and useful entering the clinic on days with the preceptors who will ask, “What do you have for us today?” or when they consult with me on a patient or even introduce me to a patient needing a service.
Faculty and resident perspectives
In addition to learning about available community resources and how to incorporate community resource linkages into pediatric outpatient visits, faculty and residents became aware of how frequently patients who should have been referred to a community organization had not been prior to the community partners' presence in clinic. Faculty also reported increased awareness of the psychosocial issues related to the particular populations served by the individual, community-based partner organizations. For example, when discussing the needs of patients with ADHD, they learned from the ASK community partner about summer activities and camps available for children with special needs. Both faculty and residents learned how to use the computerized ASK community resource directory to provide referrals for their patients.
Residents found the community partners' presence helpful to achieving their goal of developing a medical home. In evaluation survey narratives, they reported that the community partners gave “immediate insight to providing resources for families regarding a patient's medical problems, which ultimately improves patient care” and that it was important “to continue learning about community resources to provide a better quality of patient care.” As one resident reported:
I will be a fellow in ... next summer but I know the importance of continuing a medical home in my subspecialty. I believe a well-rounded subspecialist knows the importance of ... partnerships with community-based resources to provide support and comprehensive care to families.
A number of faculty physicians commented on the importance of the community partners' communication skills. They appreciated one community partner's assertive communication style whereby she listened carefully to the resident–faculty discussions and proactively offered resources relevant to the patients and their families.
Faculty physicians also commented on the team skills that they modeled for residents through their partnering with the community partners. One physician described proactively introducing families, even those without current needs, to the community partners “just because”; this introduction acquainted families with a resource that they could use if future needs arose. Another physician remarked that she included the community partner in precepting discussions so that residents could appreciate how much she respected and valued the community partner's expertise.
In the spring of 2008, faculty and residents identified difficulties with referring families to the community-based organizations when the community partners were not present in the clinic. In response, we and the community partners developed a communication form whereby faculty and residents could fax referrals directly from the clinic to the community-based organization. Thus, providers could quickly refer families rather than waiting for the relevant community partner's next session in clinic. On the form, the physician provided brief information about the issue affecting the patient, steps taken in clinic to address the issue, a focused request for the community partner, and the family's signed consent to be contacted. Following contact with the family, the community-based organization provided feedback to the physician about the referral's disposition.
Program staff perspectives
Feedback from community partners and faculty physicians helped us appreciate the importance of comprehensive orientation activities for the co-teachers. The community partners agreed that it took them about six months to feel comfortable “taking their place at the clinic conference table,” literally as well as figuratively. As noted in List 1, to address the challenge of developing self-assertive co-teaching skills, the community partners recommended that the initial orientation include role-playing of situations that commonly arose during the project's early months, such as when faculty or residents appeared reluctant to involve the community partners in precepting discussions or consultations with families. Thus, we recommend that future co-teaching projects structure the orientation so that it continues through the first six months of the community partners' involvement. Thereafter, regularly scheduled (e.g., monthly) face-to-face meetings between project staff and community partners can provide additional mentoring and coaching. Faculty physicians also suggested that they could improve their own collaborative skills by incorporating “team-partnering skills” into the orientations they receive in preparation for the arrival of their community partner co-teachers at the continuity clinics.
As stewards of the project, we came to appreciate the challenges that accompany “casting too wide a net” when assembling a team of community partner co-teachers. We had anticipated that teaching by three different community partners would enrich the residents' and faculty's learning. In actuality, they underused the partners from two of the three community-based agencies—the domestic violence shelter and the Latino center. This may have reflected a mismatch between the families served by the clinics and the community partners' expertise. For example, during the project, relatively few Latino families used one of the clinics, negating the need for the community partner from La Plaza. In future projects, the socioeconomic and cultural composition of the clinic's population should be carefully considered when planning community partner staffing. The underuse may have also arisen from a failure by pediatric staff and residents to uncover real family needs. Future projects should provide targeted teaching to residents and faculty about prevalent issues, such as domestic violence, that may go unidentified because of provider discomfort with interviewing families about these topics. For all such projects, a needs assessment of the clinic's population could improve the fit between the community partners' expertise and the families' priorities for community resources. Of note, the one need consistently identified by both families and medical providers throughout the two-year project was for a community partner skilled in addressing school-related difficulties.
Reviewing the community partners' postclinic narratives opened unexpected windows into the learning needs of residents regarding the linkages between the patient, the provider, and community-based organizations. These narratives detailed interactions between community partners, residents, faculty, and families.
In one narrative, the community partner described asking whether the mother of a 15-month-old boy with Williams syndrome might benefit from a discussion of potential community/national resources. The resident stated she did not feel the mom would be “very receptive to information like this.” The community partner met with the family, and the mother voiced a need for information about day care for her child. At the end of the conversation, the community partner spoke with both the resident and preceptor to share the mother's receptiveness, the nature of the information that was provided, and the mother's appreciation for the offer of resources. This follow-through with the physicians served as a “teachable moment” about the importance of asking all families about their needs rather than anticipating a parent's reaction to the topic.
The community partner joined a precepting discussion about a child with behavioral challenges. She suggested that the mother might benefit from a discussion of local resources available to her and her family such as support groups and respite care. When the community partner asked the resident whether this conversation might be beneficial, the resident replied that she did not think it was “needed” because the mother was an employee of the hospital and “well connected.” The reflexive assumption that families from certain socioeconomic backgrounds have lesser needs for community resources was clear and was addressed. Such assumptions are known to delay linking families to services such as health care financing and can compound feelings of social isolation and being overwhelmed by a child's special needs.
Although we did not routinely collect data regarding referrals from clinic to community-based organizations throughout the project, we did collect data on the number of referrals to ASK from the two clinic sites across five months during the project's second year. This was the period when the number of community partners had been reduced from three to one and the ASK community partner was present in clinic two days a week at each pediatric clinic site. Prior to the ASK community partner's presence in the clinics, referrals of families from a physician at either of the two pediatric clinic sites averaged one to two every three months (∼0.33/month). Within the surveyed five months, 24 referrals were received (∼4.9/month), a marked increase, which we feel reflects the impact of the ASK community partner's co-teaching in the clinic. Of note, these referrals were initiated by residents or faculty, not by the ASK community partner herself.
During this project, we regularly obtained participants' feedback regarding their co-teaching experiences so that we could quickly fine-tune the procedures and troubleshoot concerns. Future applications of our co-teacher model should include both pre- and postproject assessments of residents' and faculty's attitudes and referral patterns. Changes in physicians' sensitivity to family needs, knowledge about available resources, and perceived competency in achieving family–agency linkages should be assessed. Data that document changes in the frequency of referrals to community-based agencies due to colocation of community partners would also be useful. Assessments of family needs and community assets will help ensure an appropriate choice of community partners.
Funding limitations meant that our co-teaching project lasted only two years. Fortunately, staff from the three original community-based organizations remain involved in other teaching activities within the residency program's community pediatrics training curricula (e.g., community-based participatory research, seminars with residents during off-site visits to the community partners). Nonetheless, more sustainable iterations of the co-teaching model would require fundraising efforts, such as the variety of proposals, related to our medical home initiative, that we have submitted to private foundations and pediatric organizations. Public funding may be another resource. The Medical Home Learning Collaborative, a joint project of the Indiana University School of Medicine and the Indiana State Department of Health, is exploring the funding of case manager positions in community health centers. These case managers, who would have expertise in linking families with community-based organizations, might also be called on to co-teach. Another funding mechanism is “using what you already have” in innovative ways. For example, since our project was completed, some of the primary care continuity clinics have colocated with providers from a community mental health center. Buying portions of those providers' time to have them co-teach about family psychosocial and child behavioral health issues could be “win–win” for both the pediatric residency training program and the mental health center.
Rotations on community-based pediatrics and developmental–behavioral pediatrics are typically organized around residents' off-site visits to community-based agencies. Although these visits undoubtedly benefit the residents, they do not routinely involve pediatric faculty working in collaboration with the partner organizations and, so, do not model the skills important to interdisciplinary teamwork. Nor do they give the trainees the opportunity to solidify their knowledge through immediate application. Learning about community resources does not hone such skills as (1) recognizing when a family may want or need a community-based resource, (2) introducing the resource to the family, (3) linking the family with the community-based agency, and (4) tracking the referral or performing a “facilitated referral.” And off-site visits cannot completely rectify the inadequate attention, documented in recent surveys, that training programs give to both culturally competent care and developmental–behavioral pediatric issues,10–12 an oversight that leaves many trainees unable to effectively communicate with parents about psychosocial concerns and the social and cultural determinants of health.
All of these skills—interdisciplinary communication, community resource know-how, and cultural competence—are increasingly important as primary care providers change the way they coordinate care and delivery services, changes such as colocating community resources and mental health services in the medical home.7,13,14 The novel model we have described in this article, which uses colocated providers as co-teachers, extending their value beyond the delivery of services to include the training of the next generation of physicians, has the potential to address the deficits mentioned above. In contrast to time-limited rotations, our model exposes residents across their residency training in continuity clinic to examples of interdisciplinary communication skills for teamwork and facilitated referrals, which are considered a core component of the medical home14 and of the Residency Review Committee's15 competency-based curriculum. Learners see their faculty collaborating with community partners in real time at point of service during primary care. Our model also helps residents—and faculty, for that matter—internalize the importance of links to community-based resources by bringing community partners into the clinic and treating them as equal members of the team. And, finally, community partner co-teachers, who generally work with varied populations, can help residents become culturally competent communicators around issues of developmental–behavioral pediatric health.
To our knowledge, no one has yet conducted a research-based comparison of the effectiveness of traditional off-site visits versus co-teaching models like ours with respect to teaching residents. Clinical descriptions of colocating community partners in primary care settings to address family psychosocial needs are plentiful,3,6,7 but they all have focused on colocation as a way to improve service delivery to families. Such research may be helpful to future resident curriculum training in developmental–behavioral and community pediatrics.
The authors thank their community partners—Wendy Cervantes, Elaine Cuevas, Laura Dandelet, Nathan Ferreira, Jaime Maroney, Mary O'Brien, Janice Parks, Angie Price, and Jane Scott—for generously sharing their expertise with residents, faculty physicians, and project staff. The authors also would like to acknowledge Nancy Swigonski, MD, MPH, for her helpful review of this manuscript.
The Community-Based Partners as Co-Teachers Project was supported by a grant from the Clarian Values Grant program of Clarian Health.
The project was granted exempt study status by the Indiana University institutional review board in April 2011.
Information from this article has been presented at the Pre-Meeting Education Workshop, Annual Meeting of the Society for Developmental and Behavioral Pediatrics, Cincinnati, Ohio, October 17, 2008; a workshop at the Regional Faculty and Educator Development Symposium, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, September 24–25, 2010; and the American Academy of Pediatrics National Conference and Exhibition, San Francisco, California, October 4, 2010.