An evaluation of internal medicine residency continuity clinic redesign to a 50/50 outpatient-inpatient model

BACKGROUND: There have been recent calls for improved internal medicine outpatient training, yet assessment of clinical and educational variables within existing models is lacking. OBJECTIVE: To assess the impact of clinic redesign from a traditional weekly clinic model to a 50/50 outpatient-inpatient model on clinical and educational outcomes. DESIGN: Pre-intervention and post-intervention study intervals, comparing the 2009-2010 and 2010-2011 academic years. PARTICIPANTS: Ninety-six residents in a Primary Care Internal Medicine site of a large academic internal medicine residency program who provide care for > 13,000 patients. INTERVENTION: Continuity clinic redesign from a traditional weekly clinic model to a 50/50 model characterized by 50 % outpatient and 50 % inpatient experiences scheduled in alternating 1 month blocks, with twice weekly continuity clinic during outpatient months and no clinic during inpatient months. MAIN MEASURES: 1) Clinical outcomes (panel size, patient visits, adherence with chronic disease and preventive service guidelines, continuity of care, patient satisfaction, and perceived safety/teamwork in clinic); 2) Educational outcomes (attendance at teaching conference, resident and faculty satisfaction, faculty assessment of resident clinic performance, and residents' perceived preparedness for outpatient management). RESULTS: Redesign was associated with increased mean panel size (120 vs. 137.6; p ≤ 0.001), decreased continuity of care (63 % vs. 48 % from provider perspective; 61 % vs. 51 % from patient perspective; p ≤ 0.001 for both; team continuity was preserved), decreased missed appointments (12.5 % vs. 10.9 %; p ≤ 0.01), improved perceived safety and teamwork (3.6 vs. 4.1 on 5-point scale; p ≤ 0.001), improved mean teaching conference attendance (57.1 vs. 64.4; p ≤ 0.001), improved resident clinic performance (3.6 vs. 3.9 on 5-point scale; p ≤ 0.001), and little change in other outcomes. CONCLUSION: Although this model requires further study in other settings, these results suggest that a 50/50 model may allow residents to manage more patients while enhancing the climate of teamwork and safety in the continuity clinic, compared to traditional models. Future work should explore ways to preserve continuity of care within this model.