Preceptor Expansion Initiative Action Plan
Update from STFM
To combat the difficulty that primary care clerkships have obtaining and retaining quality clinical training sites, the FMAHealth Workforce Tactic Team launched a project to address this challenge – the Preceptor Expansion Initiative – and the Society of Teachers of Family Medicine (STFM) stepped forward to take the lead on implementation. STFM and other primary care stakeholders are now in the midst of a multi-year initiative to address this threat to the sustainability of America’s medical education system.
Outlined below are the project’s initial goals, key tactics, and their completion status as of June 2018. Successfully expanding preceptors is one key piece to reaching the Workforce Tactic Team’s Shared Aim – endorsed by leading family medicine organizations – to increase the percentage of U.S. allopathic and osteopathic medical school graduates choosing family medicine to 25% by 2030.
- Decrease the percentage of primary care clerkship directors who report difficulty finding clinical preceptor sites.
- Increase the percentage of students completing clerkships at high-functioning sites.
An interdisciplinary, interprofessional oversight committee met in June 2016 to set the direction for the work and met again in April 2018 to provide input on the work of the teams and to discuss plans for communication and dissemination.
Status of Tactics:
Five work teams have developed implementation plans with specific steps, timelines, and budgets to achieve their goals.
Tactic 1: Work with the Centers for Medicare and Medicaid Services (CMS) to revise student documentation guidelines
The rules regarding the use of student notes for billing purposes have hampered medical education and increased the administrative burden on the teaching physician. This team’s task is to explore with CMS, and other federal bodies as needed, ways to revise student documentation guidelines to relieve unnecessary administrative burdens on preceptors and increase the active learning of students.
Status: The Tactic 1 team and others invested in the outcome created a one-page request that was vetted by several organizations. Members of the team then met with CMS in December 2017, providing arguments in favor of the change and proposing revised transmittal language. CMS requested data to quantify the amount of time this change would save in a preceptor’s clinical visit. The tactic team created a survey, which received 1,900 responses in 11 days, and sent the data to CMS on January 24, 2018.
On February 2, CMS released a revised transmittal, Pub 100-04 Medicare Claims Processing Manual (updated May 31), that “allows the teaching physician to verify in the medical record any student documentation of components of E/M services, rather than redocumenting the work.”
While widely celebrated, the new transmittal generated numerous compliance questions. To better clarify how the new guidelines should be operationalized, several organizations involved in the Preceptor Expansion Initiative drafted and submitted – on March 21 – a request to confirm the tactic team’s understanding of the new guidelines. The response from CMS left unanswered questions about the requirements for the teaching physician being “physically present” with students and also about the role of residents within the context of students and teaching physicians. The responses from CMS did clarify that the revised guidelines do not apply to nurse practitioner or physician assistant students.
The team is now working on proposed revised guideline wording – to submit to CMS – about the resident and physical presence issues. They’re also developing an argument in support of the inclusion of NP and PA students, based on CMS’s definition of a student as “an individual who participates in an accredited educational program (eg, a medical school) that is not an approved GME program.”
Tactic1for links and updates.
Tactic 2: Integrate interprofessional/interdisciplinary education into ambulatory primary care settings through integrated clinical clerkships
This tactic explores a means to increase the number of learners at a given site without putting more pressure on the clinician’s shoulders. This means transforming education, in conjunction with the practice, away from the preceptor/student model or a model favoring any one profession’s education requirements. The team will approach this by developing effective, simple workflow models that target everyone along the learning spectrum from students to preceptors. The workflow models will be distributed at national and regional levels in professional development settings with a train-the-trainer model, and the dissemination plan will develop champions that can teach it at the local level.
Status: Two workgroups have been formed:
- A site selection sub-group will interview ambulatory practices that have shared decision-making practice models and are somewhere along a spectrum between novice and exemplary in integrating interprofessional students in their practices. The goal is to identify ‘bright-spots’ that can give feedback on developing workflow models as well as pilot models in their practices.
- A case development sub-group is writing primary care patient cases or patient management problems to illustrate specific examples of how to implement interprofessional education. The cases will inform the workflow models.
This team will meet in August 2018.
Tactic 3: Develop standardized onboarding process for students and preceptors & integrate students into the work of ambulatory primary care settings in useful and authentic ways
This tactic seeks to reduce administrative inefficiencies and add value to the student role by standardizing – across primary care schools, specialties, and health professions – the onboarding of students and community faculty.
Status: As a first phase, the team is creating the following for onboarding of students:
- A student passport, which is a fillable document that captures a student’s training, screening, clerkship background, and objectives for the current clerkship, and basic information
- A “How to Be Awesome in an Ambulatory Clinic Rotation” document to give students tips and strategies to hit the ground running at their clerkship site
- Three online training modules: “How to Create a High-Quality, Billable Note,” “How to Perform Medication Reconciliations,” and “Motivational Interviewing”
For preceptor onboarding, the team is working on:
- A campaign to promote the standardized use of the AAMC Uniform Clinical Training Affiliation Agreement
- A template for school administrators to use to create CVs in the required institutional faculty style
- A collection of materials for onboarding preceptors
Tactic 4: Develop educational collaboratives across departments, specialties, professions, and institutions to improve administrative efficiencies for family medicine community preceptors
This tactic will offer funding for self-identified new collaboratives that will improve administrative efficiencies for preceptors through coordinated standardization of administrative requirements as well as the onboarding of students and preceptors. The goal is to identify new models that can be implemented across the United States. The selected collaborative will pilot the standardized onboarding being developed as part of Tactic 3.
Eligibility & Requirements: Grantees must involve a collaborative across at least three primary care academic departments, specialties, professions, institutions, and/or organizationsto include at least one family medicine department. They must agree to a) participate in learning community videoconference calls every 6 months to share/learn about intervention approaches; b) provide biannual status reports, c) disseminate the model broadly and agree to participate in multi-grantee synthesis report, d) conduct standardized pre/post measurement to include the impact of the intervention on preceptors’ administrative burden, learning experience for students, and other metrics specific to the intervention.
Selection criteria: Selection decisions will be based on feasibility, innovation, impact, sustainability, and extent to which the models are generalizable to other contexts.
Status: The team held its first in-person meeting in December to develop eligibility, evaluation, and dissemination requirements for the call for proposals. The team also developed communications plans to spread models that prove to be effective.
The team is waiting for a decision on grant funding.
Tactic 5: Promote productivity incentive plans that include teaching and develop a culture of teaching in clinical settings
The unifying theme of the tactics under this umbrella is creating the incentives and culture needed to expand the pool of preceptors. The target audience for these efforts is the practices and health systems that employ community preceptors.
Status: The Initiative chair and the project team leader asked the American Board of Family Medicine (ABFM) to consider giving performance improvement credit for precepting. This was approved by the ABFM and a pilot program was announced on February 1, 2018. The program allows academic units (Sponsors) to develop and oversee the completion of performance improvement projects that meet the ABFM Family Medicine Certification requirements. To receive credit, teaching physicians must complete at least 180 1:1 teaching hours and implement an intervention to improve the teaching process. The pilot launched on April 2, 2018 with 41 participating sites. The Precepting Performance Improvement Program—with modifications based on the results of the pilot—will be open to all interested sponsors in 2019.
The team is compiling information on incentive plans that include teaching for primary care community preceptors and academic faculty. This list will be made available to preceptors, health systems, and academic institutions.
The team has drafted criteria and benefits for a national recognition program for systems/
practices that meet quality teaching criteria. The team has begun working with the STFM Faculty Development Collaborative on developing competencies for faculty. Members of the team and the Collaborative will meet later this year to focus on developmental competencies for preceptors and resources that tie those to the ABFM Performance Improvement Program.
The team is identifying and working with other teams to give presentations and write articles, essays, blog posts, and reflective papers advocating for and delineating the benefits of creating cultures/systems that encourage and reward teaching. Targets are leaders of health systems, deans and education leaders, students and learners, physicians/clinicians and the public. A list of presentations and papers is at the end of this document.
Other Notable Progress:
The Oversight Committee discussed options for a place to house resources developed through the initiative. There appeared to be consensus that dedicated space was needed with a name that is inclusive of the specialties/professions represented in the project. Current thinking is that the resources will be housed on TeachingPhysician.org, which may be rebranded.
Communication About the Work We’re Doing:
- A Multiorganizational Plan to Address the Shortage of High Quality Community Preceptors. 2018 NAO Biennial Conference, July 8-11, 2018
- Helping to Make Students Important Members of the Team. HRSA Advisory Committee on Interdisciplinary, Community-Based Linkages Webinar. June 6, 2018.
- CMS Change in the Use of Medical Student Documentation. AAMC Webinar. June 6, 2018
- Addressing the Preceptor Crisis: Implementation of the Preceptor Expansion Action Plan and How You Can Help. STFM Annual Spring Conference. May 7, 2018
- An Update for Residency Programs from the American Board of Family Medicine. (talked about STFM/ABFM Performance Improvement Pilot). AAFP PDW/RPS. March 25, 2018.
- ABFM Performance Improvement Precepting Program: A Pilot. STFM Conference on Medical Student Education. February 3, 2018
- Multiorganizational Plan to Address the Shortage of High Quality Community Preceptors. STFM Conference on Medical Student Education. February 2, 2018
- Six Tactics to Solve the Crisis of Community Preceptor Retention & Recruitment. AAMC Annual Meeting: Learn, Serve, Lead. November 6, 2017
- HRSA Stakeholders’ Meeting. February 22, 2017
- Initiative Creates Efficiencies and Incentives for Preceptors. Illinois Family Physician.Summer 2018.
- Initiative Creates Efficiencies and Incentives for Preceptors. Michigan Family Physician.Summer 2018.
- Initiative Creates Efficiencies and Incentives for Preceptors. Georgia Academy of Family Physicians. June 5, 2018.
- CMS Clarifies Rule, Again Requires Preceptors to Redo Student Work. PAEA. May 9, 2018.
- Preceptor Expansion Oversight Committee Discusses Next Steps on CMS Guidelines and Creating Efficiencies and Incentives for Teaching. STFM Messenger. April 11, 2018
- Policy Change from the Centers for Medicare and Medicaid Services Provides an Opportunity to Improve Medical Student Education and Recruit Community Preceptors.Academic Medicine. April 10, 2018
- Preceptor Expansion Action Plan – Description and Progress Update. Family Medicine.April 2018
- CMS announces major change to rules on medical student documentation. Legacy Health. March 2018
- Updated E/M Documentation Rules Good for Preceptors. AAFP News Now.February 16, 2018
- Medicare eases burden for E/M documentation involving medical students. A blog from FPMJournal. February 9, 2018
- New CMS guidelines eliminate requirement to re-document student notes. Becker’s Hospital Review.February 7, 2018
- Revised CMS Rule Should Ease Preceptors’ Administrative Burden, Help with Recruitment.PAEA. February 7, 2018
- Committee Tackles Community Preceptor Shortage. Ann Fam Med.September/October 2017 vol. 15no. 5 484-486
- Committee Tackles Shortage of Community Preceptors. STFM Messenger. June 14, 2017
- STFM Responds to Community Preceptor Shortage. Ann Fam Med.November/
December 2016 vol. 14 no. 6 583-585
- Stakeholder Meeting Addresses Shortage of Clinical Training Sites. PAEA. March 1, 2017
- Summit Will Address the Shortage of High-Quality Family Medicine Community Preceptors. Ann Fam Med. May/June 2016vol. 14 no. 3 282-283
- STFM to Address the Shortage of High-Quality Community Preceptors. STFM Messenger.May 13, 2016