Guidelines for Medical Residents as Primary and Specialty Care Providers

Primary Care

MCOs may utilize Medical residents as participants (but not as designated 'primary care providers') in the care of enrollees as long as all of the following conditions are met:

  • Residents are a part of patient care teams headed by fully licensed and MCO credentialed attending physicians serving patients in one or more training sites in an "up weighted" or "designated priority" residency program. Residents in a training program which was disapproved as a designated priority program solely due to the outcome measurement requirement for graduates may be eligible to participate in such patient care teams.
  • Only the attending physicians and nurse practitioners on the training team, NOT RESIDENTS, may be credentialed to the MCO and may be empanelled with enrollees. Enrollees must be assigned an attending physician or nurse practitioner to act as their PCP, though residents on the team may perform all or many of the visits to the enrollee as long as the majority of these visits are under the direct supervision of the enrollee's designated PCP. Enrollees have the right to request care by their PCP in addition or instead of being seen by a resident.
  • Residents may work with attending physicians and nurse practitioners to provide continuity of care to patients under the supervision of the patient's PCP. Patients must be made aware of the resident/attending relationship and be informed of their rights to be cared for directly by their PCP.
  • Residents eligible to be involved in a continuity relationship with patients must be available at least 20% of the total training time in the continuity of care setting and no less than 10% of training time in any training year must be in the continuity setting and no fewer than 9 months a year must be spent in the continuity care setting.
  • Residents meeting these criteria provide increased capacity for enrollment to their team according to the following formula:

    PGY-1 300 per FTE
    PGY-2 750 per FTE
    PGY-3 1125 per FTE
    PGY-4 1500 per FTE

    Only hours spent routinely scheduled for patient care in the continuity training site may count as providing capacity and are based on 1.0 FTE=40 hours.

  • In order for a resident to provide continuity of care to an enrollee, both the resident and the attending PCP must have regular hours in the continuity site and must be scheduled to be in the site together the majority of the time.
  • A preceptor/attending is required to be present a minimum of 16 hours of combined precepting and direct patient care in the primary care setting to be counted as a team supervising PCP and accept an increased number of enrollees based upon the residents working on his/her team. Time spent in patient care activities at other clinical sites or in other activities off-site is not counted toward this requirement.
  • A 16-hour per week attending may have no more than 4 residents on their team. Attendings spending 24-hours per week in patient care/supervisory activity at the continuity site can have 6 residents per team. Attendings spending 32-hours per week can have 8 residents on their team. Two or more attendings may join together to form a larger team as long as the ratio of attending to residents does not exceed 1:4 and all attendings comply with the 16-hour minimum.
  • Specialty consults must be performed or directly supervised by the MCO credentialed specialist. The specialist may be assisted by a resident or fellow.
  • Responsibility for the care of the enrollee remains with the attending physician. All attending/resident teams must provide adequate continuity of care, 24-hour 7-day coverage and appointment and availability access which meets RFP standards.
  • Residents who do not qualify to act as continuity providers as part of an attending/resident team may still participate in the episodic care of enrollees as long as that care is under the supervision of an attending physician credentialed to the MCO. Such residents will not add to the capacity of that attending to empanel enrollees, however.
  • Nurse practitioners may not act as attending preceptors for resident physicians.

Specialty Care

Residents may participate in the specialty care of Medicaid managed care patients in all settings supervised by fully licensed and MCO credentialed specialty attending physicians.

  • Only the attending physicians, not residents or fellows, may be credentialed by the MCO. Each attending must be credentialed by each MCO with which they will participate. Residents may perform all or many of the clinical services for the enrollee as long as these clinical services are under the supervision of an appropriately credentialed specialty physician. Even when residents are credentialed by their program in particular procedures, certifying their competence to perform and teach those procedures, the overall care of each enrollee remains the responsibility of the supervising MCO credentialed attending.
  • It is understood that many enrollees will identify the resident as their specialty provider but the responsibility for all clinical decision-making remains with the attending physician of record.
  • Enrollees must be given the name of the responsible attending physician in writing and be told how they may contact their attending physician or covering physician, if needed. This allows enrollees to assist in the communication between their primary care provider and specialty attending and enables them to reach the specialty attending if an emergency arises in the course of their care. Enrollees must be made aware of the resident/attending relationship and must have a right to be cared for directly by the responsible attending physician, if requested.
  • Enrollees requiring ongoing specialty care must be cared for in a continuity setting. This requires the ability to make follow-up appointments with a particular resident/attending physician, or if that provider team is not available, with a member of the provider's coverage group in order to insure ongoing responsibility for the patient by his/her MCO credentialed specialist. The responsible specialist and his/her specialty coverage group must be identifiable to the patient as well as to the referring primary care provider.
  • Attending specialists must be available for emergency consultation and care during non clinic hours. Emergency coverage may be provided by residents under adequate supervision. The attending or a member of the attending's coverage group must be available for telephone and/or in-person consultation when necessary.
  • All training programs participating in Medicaid managed care must be accredited by the appropriate academic accrediting agency.
  • All sites in which residents train must produce legible (preferably typewritten) consultation reports. Reports must be transmitted so they are received in a time frame consistent with the clinical condition of the patient, the urgency of the problem and the need for follow-up by the primary care physician. At a minimum, reports should be transmitted so that they are received no later than two weeks from the date of the specialty visit.
  • Written reports are required at the time of initial consultation and again with the receipt of all major significant diagnostic information or changes in therapy. In addition, specialists must promptly report to the referring primary care physician any significant findings or urgent changes in therapy which result from the specialty consultation.
  • All training sites must deliver the same standard of care to all patients irrespective of payor. Training sites must integrate the care of Medicaid, uninsured and private patients in the same settings.