NATIONAL PROJECT ON THE COMMUNITY IMPACT
OF FAMILY MEDICINE RESIDENCY PROGRAMS
Crozer Keystone Health System
Family Medicine Residency Program:
One of the most important policy issues facing the country as a whole and, locally, Delaware County and its neighboring counties that comprise the Metropolitan Philadelphia area, is the need to find better ways to assure that the area’s population has access to health care that is of high quality and is affordable.
A common complaint is that the health care system is fragmented, with many health care facilities and personnel offering very specialized services, often at high cost even to patients with medical insurance. However, educational systems – including the Crozer Keystone family medicine residency program –
exist for training physicians that can provide health care comprehensively and that can assure continuity in the care provided.
Forty years ago the nation, through a partnership of the medical professions and the federal and state governments, established the family physician medical specialty and created three-year accredited residency programs accredited to train them. Family physicians, with general internists and general pediatricians, are the physicians who provide primary health care in the United States. Most persons who have a personal physician are in one of these primary care specialties.
Of the various physician specialties, family physicians are the most proportionately distributed to where the country’s population lives. Family physicians, unlike referral specialists, practice in most neighborhoods and communities. Often the practices of one or more family physicians will be one of the major employers in a neighborhood.
The accredited entities that train family physicians are called family medicine residency programs. A physician who is training to become a board-certified family physician is called a family medicine resident.
The Crozer Keystone Health System Family Medicine Residency Program
The Crozer Keystone family medicine program was established in 1994, and has graduated 79 family physicians, 36 of whom are practicing in nearby communities. Sixteen of these graduates utilize the hospitals of the Crozer Keystone Health System whenever hospitalization of their patients is required, which contributes to the financial health of these important community institutions. Each year the program graduates seven new family physicians.
Although helping a patient maintain good health is a principal goal of all family physicians (and primary care physicians generally), possibly the majority of patients that seek care are concerned with acute or chronic illness. Family physicians are trained to diagnose and actively manage the range of medical problems that a person or family may encounter in their lifetime.
Unlike other primary care physician specialties, family physicians are trained to provide both pediatric care and women’s health, including prenatal and obstetrical services.
For example, Crozer Keystone family medicine residents provide obstetrical, gynecological and pediatric care, as well as adult and geriatric care. Additionally, all residents and faculty and all graduates of the Crozer Keystone family medicine residency program are trained to diagnose and treat congestive heart failure and coronary artery disease, hypertension and high cholesterol – when appropriate and necessary, working with referral cardiologists and surgeons.
Similarly, such chronic diseases as arthritis, diabetes, asthma, chronic obstructive pulmonary disease (COPD) and chronic renal failure are best treated when detected early, and family physicians are extensively trained in determining which of their patients either show signs of these problems or are at risk for them. A family medicine resident or board-certified family physician will be able to obtain the diagnostic tests and, whenever medically appropriate, specialty procedures that a patient needs.
With proper care, most persons whose medical problems have advanced to a stage needing surgery or a highly specialized medical intervention, can still achieve a satisfactory lifestyle after their surgery or specialized treatment. A family physician, working in collaboration with the surgeons or specialists to whom the patient has been referred, will provide ongoing care afterwards to maximize a person’s health and well-being.
The Crozer Keystone Family Medicine Centers
A distinctive feature of the training provided to Crozer Keystone family medicine residents is that, in addition to the hospital inpatient rotations that constitute the site of learning for most physician specialties, each family medicine resident trains in a family medicine center, which provides care in an outpatient setting like a family doctor’s office.
Crozer Keystone Health Systems operate two such family medicine centers. The principal one is the Crozer Keystone Center for Family Health, located at 1260 E Woodland Avenue in Springfield. The program’s new urban office, the Crozer Keystone Center for Family Health Middletown is located at 1 South State Road in Upper Darby.
Designed to give the family medicine resident a three-year experience in providing a full range of medical and health maintenance services to the same group of patients, the Crozer Keystone family medicine centers are staffed by residents, their supervising physicians, and other health professionals.
An important public policy objective is to encourage everyone to establish a “medical home”, in which all of a person’s medical information can be cared for by a single medical entity, including direct patient care, providing or obtaining diagnostic testing, referral to sub-specialists when needed, coordination of pharmaceutical prescriptions, and management of chronic conditions. The Crozer Keystone family medicine centers each are specifically designed to be such a medical home, and utilize a sophisticated electronic medical record system to provide a full range of medical services to all of its patients.
In its family medicine center, the women’s health services include pelvic exams, pre-pregnancy wellness programs, osteoporosis screening, and weight loss programs. The women’s health program arranges for mammography and other diagnostic services for its patients. The program routinely provides such services as PAP smears, colposcopy and endometrial biopsies within the family medicine center, and can arrange for mental health counseling. The residency program also maintains in-house consultation in obstetrics and gynecology.
The Crozer Keystone Inpatient Family Medicine Service
Beyond the ambulatory care provided in the Crozer Keystone family medicine centers, the family medicine residency program maintains inpatient services within the Crozer Chester Medical Center in Upland and the Delaware County Memorial Hospital in Drexel Hill. In these settings family medicine residents and faculty, in collaboration with colleagues in surgical and referral specialties, take care of family medicine center patients who have to be hospitalized.
Additionally, the program, through its participation in “unassigned call”, assumes responsibility for caring for many patients without a physician who are admitted to the hospital through the Crozer Keystone emergency rooms. Persons in this category will often be among the community’s most disadvantaged patients.
The hospital’s inpatient family medicine services provide internal medicine, gynecology, obstetrical and post-partum care, and post-surgical care. Additionally, they act as “hospitalists” for the practices of some community family doctors, caring for their patients who have been admitted to the hospitals.
Crozer Keystone Student Health Services
The Crozer Keystone family medicine program provides health care services to elementary, middle and high in the Chester Upland, Interboro and William Penn School Districts, as well as to Monsignor Bonner High School and Ridley High School in Folsom. One of the important interactions with the area schools is the participation of the Crozer Keystone resident and faculty physicians in smoking cessation lectures to school students.
Care for chronic diabetes, not only takes place in the family medicine center (or, in extreme situations, in the hospital), but in the community as well. The residency program participates in diabetic group model visits; and, at health fairs and other community settings, screens for persons with or at risk for diabetes.
The Crozer Keystone family medicine residency program is a center for sports medicine training, located at the Crozer Keystone Healthplex (at 196 W. Sproul Road in Springfield). There the program provides a full line of sports medicine services, including nutrition counseling, physical and occupational therapy, and care for sports injuries (muscle or soft tissue injuries, casting, splinting, taping, fracture management, evaluation of surgical needs).
As evidence of the national recognition of the quality of Crozer Keystone family medicine residency’s sports medicine activities, it is accredited to provide a sports medicine fellowship whose training leads to special skills and a certificate of a family physician’s added qualification in sports medicine.
Crozer Keystone Family Medicine Cares for a Community’s Most Vulnerable
The mission of the family medicine residency program is to “promote and restore the health of family members of all ages, as well as to teach the highest standards of family-oriented medical care”. Among its values is to “respond sensitively to the changing needs of our patients and community. . .”
The program has devoted considerable resources to community needs assessment, through its participation in the area-wide Community Outreach Committee. The most critical finding was determined to be the need for increased access to comprehensive health services for many of the community’s most vulnerable populations. The most important response to this community-based needs assessment initiative has been the creation of the Crozer Keystone Center for Family Health Middletown, the new satellite family medicine center in Upper Darby, described above.
Even insured patients may find it difficult to negotiate the health care system without such advocates for their health care as they might obtain in their medical home. Approximately half of the patients of the Crozer Keystone family medicine centers are working class families covered by the private sector health insurance plans. The program is also a point of access to the community’s most vulnerable populations – the elderly, the disabled and the indigent, with over 28% receiving public assistance through Pennsylvania’s Medicaid program.
Because the costs of health care have become increasingly difficult for many individuals and families to manage, persons in these vulnerable categories of patients often defer necessary health services until they become acutely ill.
The community at large benefits if such persons are encouraged to establish a medical home to assure quality health care on an ongoing basis. The family health centers have been re-tooled to present an attractive medical home, organized like a friendly neighborhood family doc’s office, rather than an impersonal clinic.
The Crozer Keystone family medicine centers provide care to all persons, regardless of whether or not they have health insurance. Many persons find the centers through word of mouth, but area emergency rooms and other hospitals refer the disenfranchised to the Crozer Keystone family medicine residency program.
The Crozer Keystone family medicine program, working with the Crozer Keystone billing coordinators, has processes for assisting patients in obtaining health care financial assistance for which they may be eligible.
Additionally, the program has a special initiative to enroll elderly Medicare patients.
Crozer Keystone’s Community-oriented Family Medicine
The Crozer Keystone family medicine residency program helps staff ChesPenn Health Services, a federally qualified health center for low-income persons, located adjacent to Community Hospital in Chester. ChesPenn provides high quality health and dental care, including behavioral health and substance abuse services, regardless of ability to pay. Each Crozer Keystone family medicine resident spends one or more month-long rotations at the health center. ChesPenn is linked to over 20 community agencies, which complement the center’s health services with the social service programs of its community partners.
The residency program has an extensive range of services for the community’s elderly. The program works with the Delaware County Office of Services for the Aging, to provide home visits for homebound seniors. The residency program faculty and residents provide health-related lectures in various community settings, including nursing homes and senior centers. In addition, the residency provides extensive clinical services to area nursing homes, both for skilled-nursing patients and those patients needing long-term custodial care.
The community’s mentally incapacitated are among the special populations for whom health care access is particularly difficult. The residency program, to meet the needs of the mentally incapaciated, provides health care services to five homes in the surrounding area.
Additionally, the program provides ongoing care to persons with such chronic conditions as diabetes, cardiovascular and neurological diseases, severe asthma and behavioral disorders. With ongoing, continuous care, most of these patients can be kept out of hospital emergency rooms, one of the most costly ways of providing health services. In the case of public assistance or uninsured patients, the financial impact of the community of avoidable emergency room use can be very high.
One of the functions of family medicine residency programs is to help patients determine when they need diagnostic tests or to be seen by sub-specialists. The Crozer Keystone family medicine residency program has mechanisms in place to help most patients obtain the services they need. In the case of public assistance patients, these mechanisms prove invaluable, since many sub-specialists often do not offer their services to persons who do not have private sector health insurance.
Because of the rapidly growing numbers of ethnic and linguistic minorities in the Greater Philadelphia area, the Crozer Keystone family medicine residency program has devoted resources to teach their residents competence in providing care to persons from diverse cultures, not only in the family medicine centers, but in the inpatient setting as well. There is a notable demand in Delaware County for multicultural obstetrical services. Through word of mouth the program has established a large and diverse obstetrical service that is addressing that demand.
The Crozer Keystone family medicine program is achieving its goal of promoting access to primary health care, and to comprehensive, continuous health care to the neighborhoods of Delaware County. It community-based initiatives complement the goals of neighborhood organizations promoting health, are consonant with the service missions of the Crozer Keystone Health Systems, and contribute to the improvement of the community’s health and well-being.