Montefiore’s Department of Family and Social Medicine received a $2 million training grant from the Health Resources and Services Administration (HRSA) to develop an Advanced Primary Care (APC) co- training program that will prepare Family Medicine residents and post-graduate primary care psychology fellows to address living conditions that negatively affect people’s health, known as social determinants of health.

The program, which will focus on respiratory illnesses, aims to demonstrate that co-training family medicine residents and psychologists to practice APC and address patients’ needs outside of the clinic can translate to better clinical outcomes. The five year goal is to reduce emergency department (ED) visits by 20 percent and hospitalizations by 15 percent for patients with asthma and chronic obstructive pulmonary disease (COPD), diseases that cause 1.8 million ED visits and contribute to more than 14 million missed days of work every year, nationwide.

“This program will address the need for psychologists to be trained to work in primary care practices, something that now only happens after they have been hired to work in these environments,” said Mary Duggan M.D., the program’s project leader and program director of the Family Medicine residency program. “We believe that if we teach the next generation of medical doctors how to work with psychologists to positively impact health behaviors of the people in our neighborhoods, we can transform their quality of life.”

Montefiore’s Family Health Center and Williamsbridge Family Practice Center, located at One Fordham Plaza and 3011 Boston Road in the Bronx respectively, will be home to the first program that certifies residents and psychology trainees in APC with an emphasis on addressing the complex needs of underserved patients by integrating social determinants of health into their care plan. Both family medicine teaching clinics are Federally Qualified Health Centers, whose patients represent the most complex and vulnerable populations in the Bronx. 

Residents and psychologists will pilot new models of APC delivery including:

• Practicing risk stratified care management, a model of care in which patients are evaluated on complexity and multiple risk factors and resources are delegated appropriately to meet their needs, including mental health services, social work, health educators and community health worker support.
• Emphasizing planned care with patients, such as group visits, where patients with similar conditions meet with a doctor at the same time. This method often allows patients greater scheduling options at a reduced cost.
• Encouraging the use of services meant to prevent emergencies and maintain health through an enhanced interdisciplinary team-care approach that will include motivational interviewing, telephone management, smoking cessation programs and appointments with health educators.
• Data driven population health management using electronic medical records to analyze ED visits, hospitalizations and quality of life scores.

The program will be evaluated by measuring clinical and patient care outcomes, a step forward in holding educational programs accountable for real world results.