BHPR -

Minutes of May 1-3, 2005 Meeting

Attendance

Mary Amundson, MA
Hugh Bonner, PhD
Cheryl Cameron, PhD, JD
Thomas Cavalieri, DO
William Elder, PhD
Rosebud Foster, EdD
Robin Harvan, EdD
Teresa Hines, MPH
Anthony Iacopino, DMD, PhD
Karona Mason-Kemp, DPM
Richard Oliver, PhD
Cynthia Pan, MD
Rose Yuhos, BS

HRSA, Bureau of Health Professions (BHPr) Staff
Lynn Wegman, MPA
Ann Bell
Louisiana Jones

Format of Minutes

These minutes consist of two sections:

Advisory Committee Business; and
Allied Health Workforce (Recommendations, Findings and Testimony).

I. Advisory Committee Business

Review and Approval of January/February 2005 Meeting Minutes
Review and Approval of Fourth Report
Release of Third Report
New Members
Committee Leadership
Subcommittees
Future Meetings: Format and Topics

Review and Approval of January/February 2005 Meeting Minutes

The Committee voted unanimously to accept the January/February2005 meeting minutes with the corrections specified by the Committee members.

Review and Approval of Fourth Report

The Committee members discussed the Fourth Report. In addition to proposing some revisions to the text (see below), other issues relating to the report were discussed. In particular, concerns were raised regarding the length of the report and the number of recommendations. The final version of the report has 30 recommendations, down from an initial 47 recommendations. Having so many recommendations can dilute the impact of the report and could possibly deflect focus from the Committee’s priorities. Members of the writing subcommittee pointed out that the length of the report and the large number of recommendations was unavoidable. This report is unique from the Committee’s other reports since it covers five topic areas, each with its own set of recommendations.

To enhance the readability of the report it was suggested that the following format changes be made:

Include a list of all the recommendations in the executive summary or immediately following the executive summary; and
Renumber the recommendations to run from one to 30.

It was also suggested that in future reports the writing subcommittee explore the use of graphics and charts to more effectively communicate information. In addition, Committee members discussed the choice of words used in the report. Specifically, Committee members discussed the use of the words “encourage” and “require” in recommendations. Some members thought that requiring specific actions on the part of grantees might negatively impact applicants and grantees that are unable to meet the requirements due to their unique circumstances. For example, programs in rural areas might be challenged to meet specific cultural diversity requirements. However, Committee members agreed that there where many circumstances where requirements were appropriate, as with data collection and reporting. The discussion reinforced the importance of carefully wording Committee recommendations to ensure the Committee’s desired outcome.

The Committee voted, 10 to 1, to accept the current draft of the report with additional editing and consolidation.

Proposed Changes to the Fourth Report

Delete Health Workforce Recommendation 7 (Page 20)

The planning committee for the “BHPr All Grantee” meeting in June 2005 should consider creating a venue to explore strategies to share information, data, and resources among BHPr grantees.

The BHPr All Grantee meeting will take place in June 2005. Committee members considered omitting this recommendation since the meeting will have already taken place by the time the report is released. It was decided to leave the recommendation in, since it documents the Committee’s interest in the meeting. The Committee took a similar approach in the Third Report with the bioterrorism recommendations that HRSA had already acted on before the report was released.

Several other minor changes to the text were made to clarify points made in the report.

Release of Third Report

The Third Report is still in the clearance process.

New Members

Eight proposed members are going through the approval process and may be appointed to the Committee before the September 2005 meeting. If this occurs, the remaining five original members will rotate off the Committee.

Committee Leadership

At the May 2004 meeting, Tom Cavalieri, Hugh Bonner and Rosebud Foster were elected to serve as vice chairs. Due to other commitments, Rosebud Foster resigned as vice chair at the May 2005 meeting.

The Committee voted unanimously to elect Tom Cavalieri to serve as the chair of the Committee when Robin Harvan and Teresa Hines rotate off.

Hugh Bonner will serve as vice chair and an additional vice chair will be elected at the September 2005 meeting.

Note: BHPr will send out an email to Committee members to inform them that an additional Committee chair will be elected at the September 2005 meeting. This way, even members who are not present at the meeting can nominate candidates.

Terms of Office

No specific term of office for the Committee chairs has been established. In the past, the chair has stayed in the position until he or she rotated off the Committee.

The Committee voted unanimously for a two-year term of office for the chair.

The two-year term will facilitate the transition of leadership since it will limit the term of office. The chair elect will be able to observe the leadership process.

Subcommittees

Some of the subcommittees have been inactive. To more effectively utilize subcommittees, Committee members considered eliminating the Legislative Subcommittee and reorganizing the Data Subcommittee as the Best Practices and Data Subcommittee.

Committee members felt that much of the work of the Legislative Subcommittee is redundant with the overall work of the Committee and that it might not be the best use of members’ time to focus on legislative issues. In addition, it is not the role of the Committee to advocate on specific issues, beyond making recommendations.

The Committee voted, with one abstention, to disband the Legislative Subcommittee and rename the Data Subcommittee as the Best Practices and Data Subcommittee and expand its scope.

The Best Practices and Data Subcommittee must develop a statement of purpose, goals and objectives. It is most likely that this subcommittee will become more relevant following the All Grantee meeting. One focus for the subcommittee might be reviewing logic models for each Title VII program. In addition, the subcommittee can make recommendations on how barriers to the collection of data and the dissemination of best practices can be overcome. Bill Elder expressed an interest in possibly serving as chair of the subcommittee once the purpose has been defined.

It was also suggested that the Committee consider forming a subcommittee to address core competencies for interdisciplinary training. Several other organizations/efforts have addressed core competencies in the past and the Institute of Medicine (IOM) is currently working on developing core competencies for health professions education.

Committee members were reassigned to the three subcommittees and new chairs were selected. New members will be assigned to subcommittees at the September 2005 meeting.

Planning Subcommittee

Chair: Thomas Cavalieri

Members: Mary Amundson, Hugh Bonner, Susan Charette, Karona Mason-Kemp and Ron Reed

Writing Subcommittee

Chair: Cheryl Hawke

Members: Hugh Bonner, Cheryl Cameron, Rosebud Foster, Gordon Green, Anthony Iacopino, and Rose Yuhos

Best Practices and Data Subcommittee

Chair: Vacant

Members: Bill Elder and Tony Iacopino

Future Meetings: Format and Topics

Meeting Format

Scheduling

The May 2005 meeting returned to the Committee’s previous format of starting meetings on Sunday night, with the Sunday night session devoted to Committee business. Several years ago, the Committee opted to change this format to the Monday to Wednesday (half day) format because the Committee was unable to accomplish all of its work in two days. The Planning Subcommittee decided to return to the Sunday to Tuesday format since it was addressing the topic of allied health for the second time and less time would be needed for testimony. Committee members discussed the merits of permanently returning to the Sunday to Tuesday format.

Committee members pointed out that there is always insufficient time to conduct Committee business at meetings. The Committee favored the longer, Monday to Wednesday, format. With the Sunday night meeting, if too few Committee members are present, it can prevent the Committee from conducting business due to a lack of a quorum. While they favored the longer meeting format, Committee members liked conducting Committee business first at meetings since it provides a review of the previous meeting, resulting in a more logical flow of information.

Lynn Wegman mentioned that it is also possible for meetings to run all day on Wednesday. However, Committee members need to make a commitment to remain for the entire day. In the past, this was a problem. If some members leave early there is no quorum, which means Committee business cannot be conducted.

Limiting Presentation

Due to cost considerations, Lynn Wegman advised the members that out-of-town speakers at future meetings should be limited to no more than five. The planning subcommittee will have to take this into consideration when identifying and inviting speakers.

Future Meeting Topics

General

The Committee discussed topics to be addressed at future meetings. In addition to those already proposed at previous meetings, Teresa Hines stated that the Committee may be called upon by the Area Health Education Centers (AHECs) and Health Education Training Centers (HETCs) to provide input on reauthorization of Title VII and the role Title VII providers play in providing care to underserved communities.

It was also mentioned that the Committee has called for joint meetings with other advisory committees. If this is still a priority, the Committee should review the schedules of other committees and look for opportunities for scheduling joint meetings.

Selected Topics

Implications of Performance Measures for the Bureau/Grantees

(Selected as the September 2005 Meeting Topic)

Given that the All Grantee meeting will take place this summer, Committee members felt that it is important that they respond to the logic models and performance measures proposed by BHPr. Addressing the All Grantee meeting at the Committee’s September meeting allows the opportunity to respond to and summarize the All Grantee meeting outcomes. Lynn Wegman stated that development of the logic models will not be complete in September so BHPr will not be able to present final versions of the logic models. BHPr will also need input on how to collect and present program data.

Since there is a significant lag in the release of the Committee’s reports, members decided it was better to address this topic as soon as possible so that the information can be disseminated in a timely manner. It was noted that the Committee already has one report addressing performance measures.

Note: Since there may be eight new members at the September meeting, time will also need to be allotted for orientation activities.

Interdisciplinary Training and Practice

(Selected as the January 2006 Meeting Topic)

This topic will explore program models for interdisciplinary training and practice within Title VII, using examples provided by grantees. In addition, reimbursement practices (billable hours models) and outcomes of interdisciplinary training and practice will be addressed.

Several possible presentations were suggested. These include: Association of American Medical Colleges (AAMC), which is coordinating a study of collaborative models between AHECs and HETCs; the Association of Academic Health Centers, which is addressing interdisciplinary issues at a June meeting in Nashville; and a report on an international meeting addressing interprofessional education and practice taking place in Toronto this summer (Robin Harvan is attending).

Note: The identification of core competencies relating to interdisciplinary training and practice should be incorporated into this topic. To date, the Committee has heard no testimony on core competencies. A recommendation on core competencies was proposed at the May 2005 meeting.

Additional Proposed Topics

Leveraging and Linking Higher Education Financing

This topic would address the various sources of support for higher education (states, Federal agencies [not just HHS], private foundations, and faith-based organizations) and explore the relationships between these sources. It would focus on linkages, both across funders and between grantees and funders, as well as how to leverage funds. Possible presenters include provosts, since they are responsible for building linkages with foundations, and the Rural Assistance Center, which can provide information on foundations and their funding priorities.

Public Health

This topic would explore responsive public and community health programs. Public health is becoming an increasingly popular field for students. They see it as an opportunity to explore the field of health in general before committing to a specific career. At the same time, public health departments and programs are being cut at the state and local level. Preparedness and bioterrorism are two areas where public health programs are increasing.

II. Allied Health Workforce (Recommendations, Findings and Testimony)

Process

At the January/February 2005 meeting on allied health, the Committee approved three recommendations, tabled one recommendation, and left three recommendations for future consideration. Because the May 2005 meeting continued the topic of allied health, the Committee reconsidered the January/February 2005 recommendations, both those approved and those under consideration.

Approved Recommendations (May 2005)

1.) Congress should enact the Allied Health Reinvestment Act (AHRA) with the inclusion of Title VII, Section 755 with the revisions proposed by this Committee in this report.

2.) The Secretary and Congress should appropriate funding, no less then the previous level of $35 million, under Title VII, Section 755 specifically for allied health programs to support interdisciplinary, community-based education and training projects. With this additional funding, HRSA should consider funding traineeships as authorized under Section 755(b)(1)(i) and explore all the ramification associated with this funding.

3.) Congress should expand the legislative authorities in Title VII, Section 755(b)(1) to include:

Innovative projects designed to meet specifically defined and well justified local and regional allied health training needs (L);
Faculty development demonstration grants to address severe faculty shortages in allied health profession programs including interdisciplinary, community-based faculty fellowships in allied health (M);
Those that establish partnerships with existing HRSA workforce centers to collect, analyze and report data on the allied health workforce, access and diversity and provide reports on workforce issues to Congress (N);
Those that provide incentives for partnerships with local higher education institutions such as two-year community colleges, tribal colleges, historically black colleges and universities (HBCUs), and Asian/Pacific Islander and/or Hispanic-serving institutions (O);
Those that provide rapid transition training programs in allied health fields to individuals who have certificate, associate, and baccalaureate degrees in health-related sciences (B); and
Those that expand or establish demonstration centers to emphasize best practices and innovative models to link allied health clinical practice, education and research (H.)

4.) The Secretary and Congress should amend Section 755(b)(3) to read, “Carrying out demonstration projects in which chiropractors and physicians collaborate to identify and provide effective treatment for spinal and lower-back conditions or planning and implementing interdisciplinary projects for chiropractic students in programs collaborating with other health professions and at least one allied health profession.”

5.) The Committee supports its previous recommendation to move podiatry to Section 747. The Committee requests an additional $1 million to support program development for podiatric students and residents to participate in interdisciplinary education models as part of their education track.

6.) The Committee supports its previous recommendation in the Second Report that states, “Create a new Section 757 (through removal of Section 755(b)(1)(j)) to support behavioral mental health for graduate psychology education (Section 757a), geriatric psychology education (Section 757b), and graduate social work education (757c). The Committee also requests an increase in appropriations to $7.7 million.

7) The Committee recommends that the statutory authorization of the Advisory Committee on Interdisciplinary, Community-Based Linkages be reauthorized.

Discussion of the Recommendations

As they began to craft recommendations, Committee members made some general observations to provide context to and help focus the recommendation process. In addition to these new observations (listed below), based on the presentations provided at the May 2005 meeting, Committee members also reviewed observations from the January/February 2005 meeting.

Behavioral/mental health professions, in particular psychology, have benefited from the interdisciplinary approach of Title VII programs.
Training programs lack the capacity to meet current admission demands. The number of students interested in entering allied health is not necessarily declining, training program capacity is not adequate.
There are high-level disincentives for the disciplines to work together. Incentives for interdisciplinary training, practice and reimbursement are needed.
There is a lack of knowledge about AHECs and HETCs and how they can facilitate interdisciplinary training and services. Title VII programs and the role they can play in interdisciplinary training should be promoted.
Loan repayment programs for allied health are needed to offset the high cost of training.
Loan repayment could help with recruitment of providers by community and rural health centers.
Curricula need to be strengthened and infused with interdisciplinary team approaches and training.
Incentives for community health centers (CHCs) to work with existing Title VII programs are needed, especially for CHCs that are trying to “grow their own” staff. Both Title VII and Title III legislation should call for these linkages.
Every state is different and will require different approaches for training students in CHCs.

1.) Congress should enact the AHRA with the inclusion of Title VII, Section 755 with the revisions proposed by this Committee in this report.

The Committee voted, 12 to 1, to approve this recommendation.

Discussion

The Committee discussed whether it would endorse AHRA. The discussion centered on how interdisciplinary, community-based training and care would be incorporated into AHRA and whether Title VII would be subsumed by AHRA. Committee members believed that both the discipline-specific approach of AHRA and the community-based, interdisciplinary approach of Title VII were key in addressing the current crisis in health care training. However, it was also discussed that an interdisciplinary, community-based aspect should be incorporated into AHRA. Committee members felt it was important to continue to make recommendations related to Title VII since it could be a number of years before AHRA is passed.

This recommendation was drafted to replace the following recommendation that was approved at the January/February 2005 meeting.

The Secretary and Congress should appropriate additional funding, no less than the previous level of $35 million, under Title VII, Section 755 specifically for allied health disciplines to support interdisciplinary, community-based education and training projects that include:

Recruitment and career ladders;
Identification and dissemination of best practices;
Funding for partnerships with existing HRSA workforce centers to collect, analyze, and report data on the allied health workforce, access, and diversity and provide reports on workforce issues to Congress; and
Incentives for partnerships with local higher education institutions such as two-year community colleges, tribal colleges, historically black colleges and universities (HBCUs), and Asian/Pacific Islander and/or Hispanic-serving institutions.

The revised recommendation is a combination of two recommendations proposed at the May 2005 meeting. The first part of the recommendation, relating to funding, passed unanimously. The recommendation was then amended to include the funding for traineeships. The motion to amend passed unanimously.

Discussion

Committee members discussed what would be an appropriate level of funding for the allied health program, given that the program is currently funded at $4 million. Committee members concluded that the need to bolster training opportunities in allied health to avert shortages of workers calls for a return to the 1972 level of $35 million. In particular, Committee members discussed the issue of career ladders and considered developing a separate recommendation to specifically address career ladders. While some professions, such as physical therapy, are making an effort to establish better career ladders, there remain many professions that provide little opportunity for advancement.

In considering the issue of traineeships, the Committee asked BHPr to clarify why traineeships were not being funded. According to BHPr, it was a decision by the Secretary not to appropriate funds for traineeships. BHPr also pointed out that traineeships are more costly to oversee than grant programs. However, the Committee members felt that traineeships would be an effective way to get more people trained and to serve in underserved areas.

For rationale:

There is an increasing need and demand for allied health providers (e.g., President’s initiative to double capacity of CHCs).
There is an impending crisis if adequate workforce is not trained.
Allied health workers make up 60 percent of the health care workforce but do not receive proportionate levels of funding to support training.
There is a need for innovative programs that support recruitment, expand enrollment, promote career advancement, facilitate inter-institutional articulation (e.g., two-year community colleges, tribal colleges, historically black colleges and universities (HBCUs), and Asian/Pacific Islander and/or Hispanic-serving institutions).
Allied health projects support the identification and dissemination of best practices.

3.) Congress should expand the legislative authorities in Title VII, Section 755(b)(1) to include:

Innovative projects designed to meet specifically defined and well justified local and regional allied health training needs (L);
Faculty development demonstration grants to address severe faculty shortages in allied health profession programs including interdisciplinary, community-based faculty fellowships in allied health (M);
Those that establish partnerships with existing HRSA workforce centers to collect, analyze and report data on the allied health workforce, access and diversity and provide reports on workforce issues to Congress (N);
Those that provide incentives for partnerships with local higher education institutions such as two-year community colleges, tribal colleges, historically black colleges and universities (HBCUs), and Asian/Pacific Islander and/or Hispanic-serving institutions (O);
Those that provide rapid transition training programs in allied health fields to individuals who have certificate, associate, and baccalaureate degrees in health-related sciences (B); and
Those that expand or establish demonstration centers to emphasize best practices and innovative models to link allied health clinical practice, education and research (H).

This recommendation was drafted to replace the following recommendation that was approved at the January/February 2005 meeting.

Congress should provide increased funding under the Title VII Interdisciplinary Training Programs to implement Faculty Development Demonstration Grants to address the severe faculty shortages existing in allied health professions programs to ensure the adequate recruitment and retention of faculty in the future. The demonstration grants would support Interdisciplinary, Community-based Faculty Fellowship in Allied Health, an allied health faculty development training and education award similar to the GACA.

The Committee voted, 12 to 1, to approve this revised recommendation.

Discussion

Given that Title VII, Section 755(b)(1) is made up of a list of fundable activities, the Committee opted to expand this list in order to address some of the issues related to current allied health training efforts such as the need for improved career ladders, identification and dissemination of best practices, program flexibility to meet local needs, and faculty recruitment and retention.

For Rationale:

Provide flexibility for programs to address local and regional issues.
Allied health programs require assistance in recruiting and retaining faculty.
GACA has been a successful model for faculty development.

This recommendation was drafted to replace the following recommendation that was approved at the January/February 2005 meeting.

Congress should integrate chiropractic into other Title VII programs to emphasize use of funds for the integration of chiropractic into Title VII programs in underserved and rural communities and to enhance interdisciplinary training to include other health professions and at least one allied health profession.

The Committee voted unanimously to approve this revised recommendation.

This recommendation was drafted to replace the following recommendation that was tabled at the January/February 2005 meeting.

Regardless of whether it is retained in Section 755 or moved to another Section, the Committee recommends amend Section 755(b)(2) language to read, “Planning and implementing interdisciplinary projects in preventive and primary care training for podiatric physicians in an approved or provisionally approved residency program and in collaboration with other health professionals and at least one other allied health discipline that shall include program development and financial assistance in the form of traineeships to residents who participate in such projects.”

The Committee voted unanimously to approve this revised recommendation.

Discussion

Committee members were concerned that moving podiatric to Section 747 would eliminate the interdisciplinary aspect of the program. However, members agreed that given the level of training and the qualifications required of podiatrists, the discipline would fit better in Section 747. The interdisciplinary character of podiatric medicine and the move toward interdisciplinary training for podiatrists help to ensure that an interdisciplinary aspect will be present in the program. Members discussed the merits of funding both residency training and interdisciplinary program development. They decided that making too many requirements would dilute the impact of the funding.

For Rationale:

The rationale should recognizing that podiatric medicine is interdisciplinary by nature and recommend that funded programs continue to work with other disciplines, including allied health disciplines.

This recommendation was drafted to replace the following recommendation that was proposed at the January/February 2005 meeting.

The Committee reaffirms our previous recommendation that statutory authority for GPE programming be moved to a new Section 757 and:

Recommends increased appropriations for GPE for the year FY 05/06 to $7.7 million;
Discourages reductions in allied health programs to compensate for GPE increases;
Encourages inclusion of psychology training in other HRSA and PHS health professions projects;
Recommends that the Advisory Committee on Training in Primary Care Medicine and Dentistry be renamed to recognize the importance of behavioral health;
Advises that psychology have representation on the Advisory Committee on Training in Primary Care Medicine and Dentistry in the form of at least two members, a psychologist in the GPE program and a psychologist involved with primary care physician training (e.g., pre-doctoral and residency training projects for pediatrics, family medicine, and internal medicine); and
Endorses language changes from use of the term “clinical psychologist” to “health service psychologist.”

The Committee voted unanimously to approve this revised recommendation.

Discussion

Despite the position of the American Psychological Association, which has a discipline-specific focus, presenters representing GPE programs emphasized that the interdisciplinary aspect of the programs was key to success and that the inclusion of social workers in the programs was very valuable. Moving the GPE program to Section 757 would not eliminate this interdisciplinary aspect.

7) The Committee recommends that the statutory authorization of the Advisory Committee on Interdisciplinary, Community-Based Linkages be reauthorized.

The Committee voted unanimously to approve this revised recommendation.

Discussion

This recommendation has been included in the Committee’s previous reports.

Additional Recommendations Proposed or Under Consideration

National Summit on Health Workforce

At the January/February 2005 meeting, a recommendation calling for a national summit on the health workforce that would bring together a wide range of stakeholders and focus on such topics as rural areas, underrepresented minorities (URMs), and underserved communities was proposed. Since similar summits have already been held, and the Committee has already called for increased linkages across Federal agencies and programs, the Committee thought that this recommendation was not necessary.

Core Competencies in Interdisciplinary Training and Care

It was proposed that the Committee consider developing a recommendation at the January 2006 meeting on interdisciplinary training and practice that addresses the development of core competencies for interdisciplinary training and care. Since there is no single definition for allied health professions, a set of core competencies would create some commonality across professions. To date, the Committee has not heard any testimony relating to core competencies. This topic could be addressed at the January 2006 meeting.

Findings

The Committee identified the following findings, in addition to the findings identified at the January/February 2005 meeting.

Collaboration

The Bureau of Labor testified that health care, and allied health in particular, is part of the President’s High Growth Job Initiative. The Committee needs to reiterate its call for Federal agencies to leverage resources since allied health is a major focus of the High Growth Job Initiative, yet the grantees that made presentations lack resources. (This is discussed in the Fourth Report.)

Data/Evaluation

Moving to five-year grant cycles will allow programs to achieve measurable performance and impact. Sufficient funding is also necessary for programs to demonstrate impact.

Education

A very significant relationship exists between allied health education and Title VII programs (high level of dependency).
A list of shared competencies for all allied health programs is needed. Teaching of specific interdisciplinary core competencies and shared educational experiences are needed.
The definition of allied health programs could be inclusive and include both new and expanded programs.
The definition of interdisciplinary, in relation to allied health, could embrace the concept of “more than one profession.”

Interdisciplinary Training

Despite practitioners and educators advocating for interdisciplinary training, to effectively incorporate interdisciplinary training into practice it will be necessary to: make training satisfactory for all participants involved; get management buy-in for interdisciplinary teams in workplace settings; and address reimbursement issues.
Allied health professionals do not determine the model they will use in their work settings. How to ensure that providers with interdisciplinary training fit in their job settings needs to be addressed.
Professional organizations may not be on the front lines in promoting interdisciplinary approaches. The innovators are the grantees.
Based on the testimony at the May 2005 meeting, allied health professional organizations should not be funded to promote interdisciplinary training.

Local Needs

Statutory requirements do not always address the needs of the local community. Programs do not necessarily have to be innovative, they just need to address local needs.

Podiatric

Continue to fund the existing podiatric program but also allow podiatric programs to apply for allied health grants, as long as the project includes podiatry and other allied health students.
The practice of podiatry requires an interdisciplinary approach. Podiatry is a valuable addition to the interdisciplinary team model.
There has been a shift in the structure of providing podiatric education and the training is now integrated with other disciplines.

Testimony

HRSA Update

June Horner
Deputy Associate Administrator, HRSA/BHPr

June Horner provided an update on HRSA’s and BHPr’s recent activities.

HRSA’s goals for FY 2005-2010 are to:

Improve access to care;
Improve health outcomes;
Improve quality of care;
Eliminate health disparities;
Improve public health and health care systems;
Enhance the ability of the health care system to respond to public health emergencies; and
Achieve excellence in management practices.

Over the past few months there has been a reorganization in HRSA’s leadership. Listed below are the staff changes.

Bureau of Primary Health Care

Michelle Snyder, Associate Administrator
RADM Don Weaver, Deputy Associate Administrator
Neil Sampson, Chief of Staff
Amy Taylor, Acting Director for the Division of Clinical Quality

Healthcare Systems Bureau

Joyce Somsak, Acting Associate Administrator
Rick Smith, Acting Deputy Associate Administrator

HIV/AIDS Bureau, Center for Quality

RADM Sam Shekar, Director
Suzanne Feetham, Senior Program Manager

Office of Minority Health and Health Disparities (previously the Office of Minority)

Bill Robinson, Director

Office of International Health Affairs

CAPT David Rutstein, Director

Office of Administration and Financial Management

Caroline Lewis, Deputy Associate Administrator

BHPr has also been reorganization.

June Horner, Deputy Associate Administrator
Jennifer Burks, Acting Director, National Health Service Corps
Jim Nohelty, Branch Chief, Nurse Education Loan Repayment Branch (new branch in the Division of Nursing).

BHPr Priorities

Currently, BHPr is focusing on the activities detailed below.

Third BHPr Health Professions Partnership Forum

The Forum, which took place April 12-13, 2005, brought together 50 partners from health professions organizations. The Forum was designed to gain input on BHPr’s Performance Measurement System, which includes specific performance measures for grantees, and to share the draft agenda for the All Grantee meeting.

BHPr All Grantee Meeting

The meeting will take place June 1-3 in Washington, DC. It will include active grantees from all five divisions and expected attendance is over 2,000 participants. The meeting is designed to present and receive feedback on BHPr’s Outcome/Performance measurements. There will be over 150 breakout sessions and 200 roundtable groups. Grantees will be able to network with each other and program models and best practices will be presented.

BHPr Presidential Initiative

To complement the President’s initiative to expand CHCs, BHPr is reforming and expanding the National Health Service Corps (NHSC) to meet staffing needs at CHCs and in health professional shortage areas (HPSAs). In 2005, there were 4,000 NHSC providers, an increase of about 2,300 since 2001. The NHSC includes Ready Responders, who received two weeks of training in March. NHSC Ready Responders have recently responded to hurricanes in the United States and the tsunami in Asia.

Bioterrorism Training Curriculum Development Program

The goal of the Bioterrorism Training Curriculum Development Program is the development of a health care workforce with the knowledge, skills and abilities, and competencies to: recognize indications of a terrorist event; meet the acute care needs of patients, including pediatric and other vulnerable populations, in a safe and appropriate manner; participation in a coordinated multi-disciplinary response to terrorist events and other public health emergencies; and alert the public health system rapidly and effectively of such an event at the community, state and national level.

In FY 2004, $26.6 million in funding was provided, $22.3 for continuing education for practicing providers and $4.3 million in curriculum development for health professions schools. Thirty-two (32) awards were made (19 for continuing education and 13 for curriculum development) and an estimated 193,314 trainees will be reached.

Commissioned Corps Readiness

Currently, 53 percent of Commissioned Corps Officers meet readiness standards. In 2004, 1,273 officers were deployed to 47 events. Over 240 officers have been deployed to national events and disaster missions in 2005.

Allied Health

The remaining testimony addressed two questions, identified by the Committee, to help focus the discussion on the allied health workforce. These questions expand on the three questions explored at the January/February 2005 meeting.

What are effective allied health interdisciplinary training programs and how are they achieved?
Are allied health interdisciplinary training programs meeting the needs of employers and what do those employers seek in allied health professionals?

Question 1: What are effective allied health interdisciplinary training programs and how are they achieved?

To provide insight into this question, the Committee heard from various allied health grantees.

Kevin J. Lyons, PhD, FASAHP
Thomas Jefferson University
Allied Health Projects Program: Allied Health Center for Excellence in e-Health, Promotion Programs for Underserved Populations

The Allied Health Center for Excellence in e-Health Promotion Programs for Underserved Populations (CEEPs – UP), which is funded by BHPr, grew out of previous projects conducted by Thomas Jefferson University. E-health is an emerging, but not yet integrated, approach in the field of allied health.

The first project, the “Model to Train Interdisciplinary Health Teams for Underserved Populations,” ran from 1994 to 1997. The goals of this project were to develop new community-based health care programs in education, service and research for underserved populations and to implement and evaluate a community-based, interdisciplinary curriculum for graduate student in allied health professions. The project targeted homeless individuals and the services were based in homeless shelters in Philadelphia.

The project had class and field components and included the following disciplines: dental hygiene; medicine; nursing; occupational therapy; and physical therapy. Class work focused on: developing team building, which was a main focus; integrating discipline-specific knowledge into an interdisciplinary framework; and expanding the understanding of the biological, psychosocial, and social needs of the homeless population with chronic conditions. The field work involved total immersion into the shelters, which sometimes resulted in culture shock for the participants. Initially, participants spent one year in the field, which was later reduced to one semester.

This project was identified as one of nine innovative and interdisciplinary programs for professionals caring for persons with disabilities by the Department of Health and Human Services in 1996. The identified strengths of the project were that 1) team approaches seemed to work well and 2) most projects resulted in successful outcomes. Weakness included: the impact of the projects was short lived; high staff turnover in the hosting organization impacted continuity; and a lack of continuity in the project in terms of identifying problems that differed from year to year.

The second project was the Community Health Empowerment Model, which ran from 1998 to 2001. It was selected as “Community Partner of the Year” by the regional headquarters of the Salvation Army.

The goals of this project were to: 1) establish a community health empowerment model integrating education of students in the health care professions with direct service providers and research to advance a community-based, integrated health care approach for urban underserved populations; 2) develop a community health care coalition compromised of university faculty, community leaders, and members of community agencies; 3) design, implement and evaluate an urban community health interdisciplinary curriculum; and 4) develop a community health infrastructure using a community partnership primary care model and continuous quality improvement methods. The project worked with four shelters and a wide coalition of representatives from organizations, academic institutions, shelters, and service providers, as well as consumers and students.

The coalition developed three curricular tracks: basic; elective; and specialty. Included was a Capstone course on interdisciplinary, team-based health services for underserved populations made up of both class work and field work. The interdisciplinary teams were made up of nursing, medical, occupational therapy and physical therapy students. Each team conducted a needs assessment in shelters and the community and implemented a project based on the needs assessment.

The strengths of this project were that the team approach worked well and that most team projects resulted in successful outcomes. However, the coalition began to lose momentum without new goals. Additionally, long-term interventions are needed to truly address the problems associated with homelessness.

Lessons learned from the first and second projects lay the foundation for the e-health programs. These lessons included: the needs assessments indicated a need for computer training among homeless individuals; long-term involvement is needed at the sites; health promotion is important with the target population; and e-health, which hadn’t been used by allied health professionals, is a viable approach to service delivery.

The e-Health Promotion of Underserved Populations Project, with a project period of 2001 to 2005, involves the disciplines of occupational and physical therapy. The goal of the project is to develop, implement and evaluate an electronic health promotion program for an urban underserved population. Specific activities included: development of websites to help disabled homeless individuals; training of staff to improve skills in working with clients; providing students with the knowledge and skills required to work in an underserved community; and students and graduates serving as online health promotion consultants to clients and staff.

An advisory board with expertise in various health professions disciplines, content and website design, and evaluation helped design the curriculum. Classroom work focused on a Capstone course on designing client-centered health promotion websites. Course work included: website design; evaluation of websites; tailoring websites for cultural, health and computer literacy; concepts of self management; and teleconsulting. Field work for students consists of convening focus groups on issues of health promotion; interviews of residents for case studies; working with residents on computer skills; and focus groups on components of the websites. An example of the websites developed by students is “I Take Control.Org,” which will be online this summer. The website focuses on a ten-step process to improve health. Topics include change strategies, managing medications, and leisure activities.

The establishment of computer labs with Internet access in three housing sites has had other benefits for the target population. The computers are used for resume development and job searches, research on community resources, educational opportunities, disease management, communication with family and friends, recreational activities, and creative writing.

The challenges encountered with the project includes: lack of adequate infrastructure and access in most shelters; lack of commitment from shelters; staff turnover in shelters; and lack of health and computer literacy in the target population. For the students participating in the program, their skills in content development were not as advanced as expected. In addition, the activities were expensive and time consuming.

The most recent project, CEEPs – UP, is designed to bring e-health to the larger allied health community. This project runs from 2003 to 2006 and includes the disciplines of occupational and physical therapy and speech, language and hearing.

The statutory purposes of the project are to: establish community-based allied health training programs that link academic settings to rural clinical settings; provide career advancement training for practicing allied health professionals; develop curriculum that emphasize knowledge and practice in the areas of prevention, health promotion and ethics; and establish a demonstration center to emphasize innovative models to link allied health clinical practice, education and research.

The goal of the funded program is to develop a center for excellence in e-health promotion. Partners include: Center for Collaborative Research; Journey Home; American Speech-Language Hearing Association; and occupational and physical therapy. The objectives are to: conduct a yearly summer institute designed to teach allied health professionals how to develop e-health programs tailored specifically to underserved populations; train 60 allied health professionals to develop e-health websites; build and evaluate 20 e-health promotion websites tailored to underserved populations; and build an allied health CEEPs – UP website to serve as a clearing house for information.

The summer training institute brings together interdisciplinary teams to develop e-health websites for underserved populations. Teams are made up of three individuals working in urban, rural or Native American underserved communities. The teams include both faculty and clinicians. Preference is given to interdisciplinary teams.

The training is a five-day, hands-on experience that explores: collaboration with the community; development of an e-health infrastructure; computer and health literacy; principles of program development; and tailoring an e-health program to the community. Participants conduct a needs assessment, visit an urban underserved community; develop a website; learn about ethical and legal issues; and evaluate public websites. Graduates of the institute have targeted: Hispanics and African Americans with low literacy levels; Native Americans on reservations in Nebraska; frail elderly; Hispanics using a community center; and students and elderly community members.

The first institute was held in June 2004. The outcomes from that training include: two active websites, one preparing to go live, and two other planned for 2005; dissemination of information by teams at professional meetings; outside funding obtained by one team for website development; successful collaboration and participation by community members; and an active listserve for networking and communication with other teams.

Some of the challenges encountered with the project include: recruitment; lack of institutional cooperation; time commitment; dissemination problems; and lack of an information/technology infrastructure.

To address the recruitment issue the project did a considerable amount of marketing but there has been a significant drop in interest in the project. In the first year, 70 inquiries were received, which resulted in 20 proposals being submitted with seven of those funded. For the second year, only seven proposals were submitted.

Questions/Comments/Discussion

Committee members inquired about the possibility of determining whether the projects resulted in better health care or better access to care. Dr. Lyons responded that there is no evidence related to these types of outcomes. The type of evaluation necessary to determine these outcomes is expensive and requires long-term follow up. Dr. Lyons acknowledged that given that many in the target population lack access to health care, projects are limited in the impact that they can have on health outcomes.
Committee members asked about the barriers related to setting up computer networks. The program got help from a computer company and some computers were donated. They also partnered with libraries, which have received funding for computer access.
Committee members noted that over the course of the five projects, the interdisciplinary involvement seemed to decrease. Dr. Lyons stated that there were some problems relating to involvement across disciplines. These included the time commitment (for medical students) and institutional politics. The program has explored working with community colleges but time and expense prevents it.
To improve allied health interdisciplinary e-health training, Dr. Lyons recommended that the grant cycle should be longer (increase from three to five years) and funding should be increased. Because the program is trying to break new ground, the current three-year grants cycle makes it difficult to both develop and implement a concept.

Gladys Gonzalez-Ramos, PhD
Assistant Project Director, Associate Professor of Social Work, NYU
Allied Health Projects Program: Allied Team Training for Parkinson
Elaine V. Cohen, PhD
Program Evaluation Consultant, National Parkinson Foundation

The goal of the Allied Team Training for Parkinson (ATTP) Program is to develop a model interdisciplinary training program designed to prepare current and future allied health professionals to provide integrated specialized care to individuals with Parkinson’s disease (PD) and their caregivers in medically underserved and diverse areas. The objectives of the program are to: develop specialized curriculum in PD, beginning with five professions; develop cross-curriculum modules on cross-cultural and interdisciplinary care; train allied health teams and individual practitioners for certification in PD care; collaborate with minority serving universities to enroll allied health students; involve local community leaders and others in team teaching to represent the community; and evaluate the effectiveness of the training program.

The National Parkinson Foundation (NPF) is an important partner in the program. NPF has a network of 30 national centers of excellence, 38 chapters, and 13 outreach centers. These local partners help in recruitment of participants.

The targeted professions include occupational therapy, physical therapy, speech-language pathology, social work, and music therapy. The first three are traditional therapies associated with PD. Social work was included because it is frequently overlooked in the care of chronic diseases and music therapy adds a more holistic aspect for both the patients and their families. Participants have included independent practitioners, existing allied health care teams, and students.

The 4.5-day training is designed to appeal to professionals. The training runs from Wednesday to Sunday so that participants do not have to take too much time off work. The training is free of charge and CEU credits are provided. Participants also receive a certificate from NPF.

In the first year, trainings were provided at eight sites in medically underserved regions, in both urban and rural areas, with a total of 308 participants. The program had projected 124 participants. The majority of the participants were occupational and physical therapists. Thirty-one (31) percent had five or fewer years of professional experience and 23 percent had more than 20 years, which meant that the faculty had to teach participants with a wide range of professional experience. People of color made up 27 percent of the participants and 63 percent of participants worked in medically underserved areas.

Sites were selected based on whether they had the potential to reach diverse populations. All the sites had NPF centers in the community to serve as partners. Demand for the training was high, especially among physical and occupational therapists. Enrollment was limited to 50. By the final training in Washington, DC there was a waiting list for the training.

The curriculum, which was peer-reviewed by each profession, evolved over time. Initially it was more discipline specific with a focus on individual modules. Over the course of the eight trainings it became more interdisciplinary and problem focused, with more shared modules. The curriculum includes various panels that shared with participants about aspects of PD. These panels address care partners, young onset, health literacy, and end of life. There is also a cultural competence component.

An important aspect of the curriculum addressed how participants can implement what they learn in the work place. In these sessions, participants have discussed their frustration in trying to integrate team care and whether it would be supported by management in their place of work.

There is an extensive evaluation component to the program. It includes collection of data on basic trainee characteristics, knowledge gain, participant satisfaction, and faculty feedback. There is a follow-up survey three months after the training and the program is considering following one or two teams on a long-term basis. Evaluation findings indicate there was a statistically significant knowledge gain about PD, interdisciplinary care, and cultural competence among participants. The satisfaction survey reported high scores in relevance of content, format and overall training experience. Adopting a problem-based approach, ongoing faculty communication, and a feedback loop that allowed for continuous change were important to the success of the trainings.

Continued challenges for the program include: increasing the interactive component; increasing team-based learning; focusing on critical reasoning; teaching participants with a wide range of experiences; and recruitment of diverse students and faculty. In addition, universities need assistance in understanding how to integrate the training program. Professional organizations, who program organizers originally thought would be very helpful, did not provide a significant amount of assistance.

The greatest challenge remains the lack of support for the team approach in the health care system. This includes the issue of reimbursement, since some disciplines do not get reimbursed for team work. Language and definition differences across disciplines are also significant challenges.

Questions/Comments/Discussion

The program hopes to expand to include non-allied health professionals. Physicians will be included in the next round and neurologists, in particular, have shown an interest in the program. Some medical schools have also expressed an interest. Nursing, pharmacy and nutrition are other disciplines that might be included in the future.
If the program is expanded to other disciplines, the curriculum will probably include a core program with other flexible components. The program is also looking at how to modify the curriculum so that it can be integrated at the university level.
Dr. Cohen stated that the training model that was developed has been shown to be successful and could be applied to other diseases, such as Alzheimer’s.
The program has worked with AHECs to market the trainings.

Richard E. Oliver, PhD
University of Missouri-Columbia
Allied Health Projects Program: Certification in Interdisciplinary Geriatric Assessment Program

The Certification in Interdisciplinary Geriatric Assessment Program (CIGAP) is a BHPr-funded three-year program. The program is currently it its third year of the funding cycle. The aims of the program are to provide research assessment and treatment information for health professionals providing services in underserved or unserved areas of Missouri. The program also promotes the use of interdisciplinary teams with patients with complex medical issues. The following professions are targeted: health psychology; occupational therapy; physical therapy; respiratory therapy; and speech-language pathology. Participants who complete the 25 hours of training receive a certificate from the School of Health Professions.

The program provides several educational programs which are listed below.

Geriatric lecture series: These free lectures address issues in geriatric care.

Geriatric resource library: This self-service lending library includes journals, books, exercise videos, and Tai Chi instruction. The library is promoted through open houses and announcements in the program’s newsletter.

Newsletter: HORIZONS is a quarterly newsletter. It is primarily distributed electronically.

Virtual health care team <vhct.org>: This allows for a combination of face-to-face and online training. Participants can earn CEUs and their time may also count toward the 25 hours needed for the CIGAP certificate.

Website: The website <muciga.org > includes resources and promotes other components of the CIGAP.

Workshops: The workshops address various topics. For example, one workshop focuses on Tai Chi instruction and practice and interweaves instruction with problem-based learning (PBL) sessions for interdisciplinary teams of practitioners. In 2004, two workshops were held. In Columbia, CIGAP partnered with the Mid-Missouri AHEC. This workshop was attended by 70 participants. In Poplar Bluff, 54 participated in the workshop and the Southeastern Missouri AHEC was the partner.

Additional activities in the second year included two site visits. The first site visit was to the Acute Care for the Elderly (ACE) unit. Three-minute care meetings are held for each patient in the ACE unit and a guide sheet has been developed to facilitate these meetings. The guide sheet serves to cue the team on what disciplines should be involved in the care of the patient. The second site visit was to the Program of All Inclusive Care for the Elderly (PACE). PACE teams assess all aspects of care and the process is incentivized to keep the patients as healthy as possible.

A workshop, “Use of Person-Centered Care in Caring for Individuals with Dementia,” took place in May 2005 in Poplar Bluff. The program focuses on an interdisciplinary approach to person-centered care and has applications for individuals working with older adults in a variety of settings including day care, long-term care, assisted living, hospitals, outpatient clinics, and home care.

The CIGAP has proven effective at reaching its target audience and the CEUs have been a popular draw. An important success of the program is that rural practitioners receive information that they can apply in their own settings.

The challenges faced by the CIGAP are: program self sufficiency; limitations of a three-year funding cycle; few incentives for providers to work as a team; time constraints for providers; lack of technology; collecting required data (participant feedback) can be burdensome; reimbursement issues can limit team participation; being responsive to the needs of the community; and time constraints limit faculty involvement.

Questions/Comments/Discussion

The CIGAP has also worked with the GEC in St. Louis.
Dr. Oliver was asked to expand on his comment about the conflict that can occur between statutory purposes and local need. Programs are sometimes forced to carry out activities because they are required by the grant. These activities may or may not reflect the needs of the community. Discretionary funds would allow the use of innovative approaches and promote collaboration.

Hal C. Lewis, PhD
University of Colorado Health Sciences Center
Graduate Psychology Education Program: UCHSC Collaborative Health Services Psychology Internship Program

The University of Colorado Health Sciences Center’s (UCHSC) Collaborative Health Services Psychology Internship Program is currently in the second year of a four-year grant focusing on pre-doctoral internships. The program has many collaborative partners including the Department of Psychiatry and the Division of Clinical Psychology; Department of Family Medicine; Department of Pediatrics; Department of Physical Medicine and Rehabilitation; UCHSC School of Nursing; UCHSC American Indian/Native Alaskan Health Programs; JFK Partners (Center of Excellence); A.F. Williams Family Medicine Center; and University Hospital Center for Integrated Medicine. The program also has numerous community-based training sites. The program is designed to increase the number of mental health care providers in places where people with mental health needs present for care, which is most often with primary care providers.

The purpose of the program is to train psychologists to provide mental health services to underserved populations in a way that: prepares psychologists to provide a range of services that are integrated into primary care and other health care settings; prepares both psychology trainees and trainees in other health professions for interdisciplinary collaboration and teaming; and utilizes training methods that emphasize cultural competence and linkages with community-based sites.

There are significant barriers to mental health care. These include the stigma of mental illness and fragmentation of the health care system. Patients often go without care or demand it from the primary health care system. Psychologist need to become members of primary care teams.

Interdisciplinary health service training is vital for psychologists. There are multiple reasons for incorporating this training.

It improves access to mental health services for underserved populations. Many underserved individuals will refuse traditional mental health services but be more likely to initiate dialogue in primary care settings.
It improves screening (and preliminary intervention if necessary) for mental health issues and/or psychiatric disorders through consultation and provision of information/education to primary care physicians and other health care providers.
It improves skills in collaborative care and teaming, which translates into better integrated holistic care.
In interdisciplinary health services settings, psychologists have much to contribute regarding psychosocial, culturally-based, and systems-related contributors to health.
Early exposure to interdisciplinary care models at the pre-service level can protect against later development of “turf issues” and myopic, single-discipline viewpoints that are often misleading.
It promotes early professional identification of psychologists as providers of collaborative care and team members.
It provides exposure to the rewards of working with underserved populations in a collaborative health care setting.

There are six major specialization tracks in the UCHSC program and the program works with one of the partner organization in each of these areas:

American Indian;
Abused and neglected children;
Development disabilities;
Deafness;
Inmates/corrections; and
Primary care (includes uninsured/underinsured, refugee and migrant labor populations).

Each of the above mentioned tracks has a health services focus. In addition to providing screening, assessment, treatment, and consultation services, each intern develops a health services focus within their major. These focal areas are presented to their peers and faculty in a 45-minute presentation in the Health Services Psychology Seminar. For example, the Native American intern is exploring diabetes and co-morbid alcohol abuse in Native American communities and is training family medicine residents in Native American health issues. The intern working with developmental disabilities is teaming with pediatrics residents and development disabilities assessment teams to assess the benefits of interdisciplinary teaming to both trainees and families.

Each intern also does two elective rotations. Of their two elective minors, one has to have an interdisciplinary health services emphasis. Each elective minor rotation is ten hours per week for six months.

Another component of the training is learning about teaming, leadership, system change, and adult learning through seminars. Examples of seminars include the health services psychology seminar and the development disabilities seminar.

The GPE funding has allowed UCHSC to expand a unique training program on the Pine Ridge Reservation by increasing the number of participants and adding a second week to the training. Participants spend two weeks on the reservation, one in September and one in March. Participants include an interdisciplinary group of trainees and faculty, including all psychology interns. Between 80 to100 semi-structured mental health screenings of children and youth boarding at the Pine Ridge School area conducted in consultation with school staff. The work done by participants has allowed the school to identify students in need of mental health services and obtain funding to provide these services. Follow-up staff consultations via interactive televideo conference are conducted on a monthly basis. Additional training activities carried out as part of the Pine Ridge project include meetings with the Bureau of Indian Affairs Health Center, leaders of tradition-based health programs, and community and tribal leaders. Participants also visit important reservation sites and attend cultural exchange activities.

Various evaluation measures are used to assess the overall program. These include: system accountability checks for program objectives; process measures (counts); skills acquisition checklists; self assessments on a variety of topics such as cultural diversity; and trainee follow up. The program tracks services provided to the underserved populations. The goal is to provide 600 to 800 services each year.

The program experienced the following challenges.

How can faculty teach collaborative teaming skills in a program or department that emphasizes preparation within a single discipline?
What are “core” health services practicum experiences across disciplines and how should those experiences be provided and supervised?
How can collaborative teaming on campus among faculty from different disciplines be expanded to promote full faculty collaboration?
How can faculty prepare students/trainees to function as consultants with other professionals, families and agencies?
How can training programs be organized and experiences provided to impart the values and skills of interdisciplinary teaming to students/trainees?
How can faculty and departments evaluate the extent to which students/trainees are accruing interdisciplinary skills?

The following barriers were also identified: professional socialization; turf issues, protectionism, and power hierarchies; coordination of training schedules; discipline-specific certification and licensure; intensity of discipline-specific curricula; lack of academic reward for interdisciplinary communication; limited awareness of resources to support interdisciplinary teaching and supervision; and lack of interdisciplinary training sites.

Potential solutions to these challenges and barriers include: team-based training models in both courses and practica; development of inter-departmental courses; infusion of interdisciplinary content rather than course replacement; mechanisms for networking and collegial exchange among faculty from varying disciplines; greater utilization of non-traditional practicum locations; teaching methods that employ a systems-oriented approach; community-based training sites; and technical assistance for faculty (identification and provision of resources to support innovative interdisciplinary training).

The following were identified as key elements for program success:

Teaching/training at the pre-service level regarding key practices in collaborative care such as teaming, communication and consultation skills;
Training in cultural competence to strengthen links with underserved communities;
Training in collaborative care to extend more accessible, effective and efficient health care to underserved populations;
Public-sector, community-based sites to promote collaborative care training;
Technical assistance and identification of resources for programs and faculty that aspire to increase and improve training in interdisciplinary, collaborative care; and
Health care financing reforms so that mental health services can be increasingly embedded in the broader health care context.

Questions/Comments/Discussion

Committee members asked Dr. Lewis to comment on the importance of interdisciplinary care. He stated that he would like to see the program expanded in the future. The intent of the program is to stress interdisciplinary care for underserved populations. These priorities fit best with collaborative health care teams. Psychology is a discipline that, in the past, has been insulated and most graduate training programs have a discipline-specific viewpoint. The discipline is moving away from seeing itself as a “mental health profession” to a “health profession.”
Dr. Lewis thought that as mental health is integrated into primary care, the inclusion of social workers along with psychology would be beneficial.

Victor Molinari, PhD, ABPP
University of South Florida
Graduate Geropsychology Education Program: Post-Doctoral Public Sector Interdisciplinary Training

The University of South Florida’s (USF) Post-Doctoral Public Sector Interdisciplinary Training Program is a partnership between USF’s Department of Aging and Mental Health, USF’s School of Aging Studies and the psychology services of the James A. Haley Veterans Affairs (VA) Medical Center. The program trains three fellows a year who are exposed to a variety of academic and health disciplines, with an emphasis on rural and long-term care.

The program includes four training components: clinical (50%); research (20%); didactic (20%); and advocacy (10%). Clinical rotations take place in a variety of settings including: memory disorder clinic; traumatic brain injury clinic; nursing home care unit; spinal cord injury clinic; cancer clinic; assisted living facility; and a rural community health clinic.

Fellows also participate in research and advocacy projects. Examples of research projects include: demographic characteristics of wanders; effects of drama groups for assisted living facility residents; and the psychological effects of hurricanes on older adults. Advocacy projects include: establishing the Florida Coalition for Optimal Mental Health and Aging; improving the dining experience in nursing homes; and advocacy relating to the difficulties experience by deaf elderly.

Fellows also receive training in didactics. They are required to take: a course in multicultural gerontology or social issues: a program evaluation course; a module or course in geriatric team training, geriatric medicine, social work, gerontology, or aging students; and a seminar in public policy.

The program has experienced some challenges. These include:

How to present interdisciplinary didactics to make them relevant for all disciplines given varied expertise;
Exposure to multiple disciplines does not always involve clinical ‘team work’ and teams need models demonstrating how to change the team function;
Recruitment of diverse applicants with clinical, research and advocacy interests; and
The lack of positions serving underprivileged older adults.

The program’s successes include:

Cooperation across three partners;
Fellows’ interest in conducting research and advocacy (most fellows have a clinical background); and
Fellows develop an understanding of the need for teamwork when serving multi-problem frail adults.

Questions/Comments/Discussion

There is a lack of positions in geropsychology. Advocacy is needed to emphasize the importance of geropsychology and the need for positions.
Dr. Cavalieri commented that his program in New Jersey has added a psychology component within their aging programs, which are based on the primary care model. This has had an impact both clinically and academically and has also stimulated research.
Dr. Molinari stated that the program emphasizes the team approach. Students are taught that they have to earn the respect of a team. Student experience relating to team work varies significantly.
Teaching a multidisciplinary group is a challenge. Some students think they have already learned certain aspects of the curriculum. However, when taking an interdisciplinary approach, these topics are often approached in a different way.

Kathleen Satterfield, DPM, FAPWCA
FACFAOM
University of Texas Health Science Center of San Antonio
Podiatric Primary Care Residency Training Grant Program: University of Texas Health Science Center of San Antonio Podiatric Residency Program

The residency program was originally established in 1972, with one resident, funded at $5,000 by the Texas Podiatric Medical Association (not by the University). At the time, the Podiatric Section was a division under the Family Practice Department. The program is rooted in the volunteer efforts of Dr. Louis T. Bogy who, at the urging of former undergraduate classmates at Baylor University and other medical doctors, became an unpaid foot care provider to indigent inner city patients at the County Hospital. Over time the residency program was expanded to the County hospital system, the Lower Rio Grande Valley, and to VA facilities.

Podiatry can be seen as a “minority” profession. With small numbers of practitioners, the entire group is judged by the actions of the individual. The move toward interdisciplinary training has provided an opportunity for podiatrists. As part of interdisciplinary teams, podiatrists can educate the community, medical schools, states, and the nation about the discipline. Podiatry has also gained acceptance through participation in research, training in integrated traditional academic settings, and the expansion of services.

The Podiatric Primary Care Residency Training Grant Program has allowed for the training of increased numbers of residents. The program was expanded into the Lower Rio Grande Valley, greatly increasing access to care for needy populations. The funding also allowed for the establishment of the Diabetic Foot Research Fellows Program. This program has resulted in over 100 articles in peer-reviewed journals and the development of the University of Texas Wound Classification System, an internationally validated system.

A significant advantage of the program is that it is located in an academic health center. The academic health center provides interdisciplinary availability and dynamic mentors. Interdisciplinary education is provided to third and fourth year podiatric students. Interdisciplinary training opportunities include: interdisciplinary research; Diabetic Foot Fellows; post-graduate courses; and podogeriatric grant research outcomes.

The program’s significant impact is due to several factors. It is situated in an area of great need, it has focused on minority health issues, and the increasing prevalence of diabetes and foot complications have resulted in more demand for podiatric medicine. For example, expansion into the Lower Rio Grande Valley resulted in a variety of patients and vastly increased numbers of clinical experiences. At Su Clinica, more than 100,000 patients have been served.

The program uses various measures to determine success. These include: results of orthopedics and primary medicine boards; interdisciplinary training situations and placement after graduation; and graduates practicing in underserved areas.

The successful aspects of the program include: placing residents in underserved areas resulted in increased numbers settling in these areas upon completion of training; training residents in interdisciplinary settings resulted in large numbers entering multi-specialty practices; and training in primary care podiatric medicine resulted in residents sitting for the primary care boards. In addition, the program has received requests from allopathic specialties, including internal medicine, endocrinology, and family health, to do rotations with podiatry. Graduates and externs of the program have become faculty at academic health centers and noted health care facilities. The grant has increased the number of residents; created full-time faculty in an allopathic setting; improved immigrant care; trained non-podiatric residents; and changed protocols for diabetic foot conditions.

Some aspects of the program needed to be revised. For example, South Texas Area Transitions (STAT) had the goal of placing residents in smaller clinics in the Lower Rio Grande Valley so they could gain experience caring for patient with severe health problems. What the program found is that due to limited access to care, the target population usually goes to emergency rooms instead of clinics so the residents were unable to reach those targeted.

The program also has encountered some barriers. These included decreasing enrollment in health profession schools and decreased numbers of student externs. The program did not want to lower standards so it reduced the number of residents in the Lower Rio Grande Valley. An additional barrier is that podiatric services have been dropped from Medicaid in Texas.

The program is currently pursuing new opportunities. It has developed a new residency structure, PMS 36. This 36-month residency provides a more comprehensive medical and surgical training experience.

In the future, the program would like to expand its work in immigrant health issues. An ongoing need that must be addressed in the future is the lack of state-supported podiatry schools.

Questions/Comments/Discussion

Committee members expressed the concern that allied health disciplines are frequently overlooked in the formation of interdisciplinary teams. Dr. Satterfield stated that at the Texas Diabetes Institute, physical therapist and occupational therapists are co-located. Residents learn about the whole spectrum of care and there is day-to-day interaction with allied health professionals. The program has a regular rotation on the diabetic foot for nurses. The program also offers a post-graduate course (60 CME) that is offered four times a year. However, participants in this course are not eligible for financial assistance.
Committee members inquired about where the program should be located in the Title VII Interdisciplinary, Community-based Grant Program and whether the program should continue to focus on financial aid for trainees. Dr. Satterfield acknowledged the benefits of interdisciplinary, community-based training and care and stated that there is a need for funds to train residents.

Question 2: Are allied health interdisciplinary training programs meeting the needs of employers and what do those employers seek in allied health professionals?

Lisa Cox
Assistant Director for Public Health Policy
National Association of Community Health Centers

A wide variety of health professionals serve in CHCs. CHCs strongly believe that quality health care means having enough qualified doctors, nurses, and other health care professionals willing to work the long hours needed to care for individuals and families who need services. These professionals need to truly understand the unique needs of diverse racial and ethnic populations.

There are over 1,000 community, migrant and homeless health centers. They are equally distributed between urban and rural locations. CHCs serve over 3,600 urban and rural communities in every state and territory. The CHC model has been recognized by the IOM as highly effective in providing primary care, the Government Accountability Office recommends expanding the CHC program, and the Office of Management and Budget ranked the CHC program as first among all Department of Health and Human Services programs and among the top ten of all Federal government programs.

The number of patients served by CHCs is steadily growing. Currently, 1.5 million patients are served. CHCs are serving an increasing number of older Americans and early retirees (45-65 years old).

CHCs must meet five Federal requirements designed to improve access to care. CHCs must: 1) be located in high-need areas (elevated poverty, higher than average infant mortality, and few physicians); 2) be open to all residents regardless of insurance status (fees set by ability to pay); 3) provide comprehensive health and related services (both health care and enabling services); 4) be governed by community boards; and 5) follow rigorous performance and accountability requirements.

CHCs strive to provide high-quality care and use a variety of measures to demonstrate impact. These measures include: improved access to primary care; care provided by CHCs is comparable or better than care provided elsewhere; reduced infant mortality and low-birth weight; high patient satisfaction; reduction of health disparities; and effective management of chronic disease.

Cost effectiveness is also a priority for CHCs, which have an average cost per patient of $1.25 a day, or $455 a year. CHCs reduce the overall cost of health care by reducing unnecessary hospital admissions and specialty referrals. In addition, there are community benefits. For ever dollar the Federal government provides to CHCs, an additional $3 is attracted.

Currently, the CHC program is in the fifth year of an expansion initiative. The President’s initiative will allow CHCs to see an additional 6.1 million patients by 2006. In FY 2005, the CHC budget was increased by $218 million, which resulted in the addition of 332 sites and 1.6 million additional patients. The initiative both expands existing sites and establishes new sites in underserved communities.

The President’s initiative will require a doubling of the CHC workforce by adding 60,000 health center staff, including 6,000 clinicians and 48,000 administrative staff, by 2006. Because of the expansion, the number of patient encounters is rising. Allied health professionals, such as nurse midwifes, nurse practitioners, and physician assistants, are seeing an increasing number of patients.

CHCs benefit from several key Federal programs when recruiting health professionals. These programs include: NHSC; J1 visa program; AHECs; Title VII residency programs; Title VIII nursing loan repayment and scholarship programs; and geriatric programs.

In addition, several NAC initiatives are designed to address workforce needs. These include a career website to help in the placement of professionals that should be available later this year, and new training opportunities, such as the Arizona Dental School, which provides training in a community-based setting. If this community-based training model is successful, it could be applied to medical training.

To effectively address the health care workforce shortage, NAC recommends: continued work with existing Federal programs like the NHSC; increased collaboration with key Title VII and VIII programs; increased rotations through CHCs; and continued dialogue on how workforce shortages can be addressed.

NAC, along with HRSA and Washington University, is conducting a survey on health center workforce issues. The final report will be available in the near future. NAC would like to share the findings with the Advisory Committee when they become available.

Questions/Comments/Discussion

Committee members asked about the major recruitment challenges facing CHCs. While long-term pipeline issues are of concern to CHCs, they also experience other recruitment and workforce problems. CHCs usually have about 90 days to get up and running after they receive a grant so staffing is an ongoing concern from day one. The complex needs of the target populations require that CHCs use an interdisciplinary approach.
Committee members asked about what changes in Title VII would facilitate collaboration between grantees and CHCs. Ms. Cox stated that collaboration between CHCs and Title VII programs should be increased. A statutory requirement for collaboration between CHCs and Title VII programs would make sure that the collaboration takes places. If it is only encouraged, it may or may not take place.
Committee members suggested that CHC patients are an untapped source of potential employees and CHCs could be effective in developing an education ladder for children from underserved communities. Ms. Cox noted that Federal programs such as HCOP could be expanded and coordination with NAC increased. Many CHCs have partnerships with academic hospitals. Also, primary care associations often co-locate with AHECs and present an opportunity for collaboration with CHCs.
Committee members were concerned about access to mental health services for CHC patients. Some CHCs collaborate with community mental health centers and this could help address lack of access to mental health services, especially if CHCs are not able to fill their mental health positions. Since many CHCs refer patients to mental health services because they cannot provide them inhouse, shortages of allied health professionals in mental health may not be reflected in NAC’s upcoming survey. Reimbursement is also an issue with mental health services.

Public Comment

Dan Rode, MBA, FHFMA
Vice President, Policy and Government Relations
American Health Information Management Association

The American Health Information Management Association (AHIMA) is a professional association representing more than 50,000 members who manage patient medical and clinical information in the form of health records, databases and departments. Quality health information is essential to all aspects of today’s health care system. Health information management (HIM) is the body of knowledge and practice that ensures the availability of health information to facilitate real-time health care delivery and critical health-related decision making for multiple purposes across diverse organizations, settings and disciplines. Effective management of health data and medical records has always been the area of HIM expertise, and with the increasing adoption of health care information technology, that expertise is now needed more than ever.

Until recently, medical records has been a paper-based business. Now, working toward a fully electronic future, AHIMA is advancing the implementation of electronic health information management (e-HIM) by leading key industry initiatives and advocating high standards for its members.

HIM Education and Workforce Needs

Today’s graduates must have skills to work across all clinical and administrative functions of the health care organization. HIM programs at associate and baccalaureate degree levels are offered at more than 230 colleges and universities and accredited through the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM). AHIMA approves certificate programs for coding and medical transcription and masters-level HIM programs. AHIMA develops curricula and promotes research with leading educators with the goal of graduating professionals who are ready to take on the challenges of a paperless future.

The U.S. Department of Labor’s Bureau of Labor Statistics projects the need for a 49 percent increase in the number of HIM workers by 2010, making HIM one of this decade’s fastest-growing health occupations. Approximately 6,000 new HIM workers will be needed each year to fill new positions and replace HIM professionals who retire or leave the field.

Students in HIM academic programs are provided professional practice experience in a variety of health care settings as part of their course of study. However, access to current, state-of-the-art health information technology (HIT) systems is limited in both academic and practice environments. New graduates learn the theory of managing electronic health records but have little opportunity for hands on skills building. This is particularly true in community college programs serving rural communities. The need to stay current with technology changes is putting enormous stress on academic training programs, and on those HIM professionals already in practice, at a time that workforce demand is increasing.

e-HIM Virtual Laboratory

The concept of the e-HIM Virtual Laboratory is to provide colleges and universities with single site, virtual access to a full array of core HIM technologies and the supporting tools and resources to allow them to successfully and effectively integrate these technologies into individual courses and lessons. The Virtual Lab will allow students to actually work with the technology they will encounter in the workplace, in an environment that closely simulates real world application of those technologies.

The plans call for providing access to a representative sampling of HIM software, from multiple vendors, in an electronic environment hosted and technically supported at AHIMA. When fully operational, the Virtual Lab will have the ability to integrate multiple functionalities between and among systems, to effectively simulate the reality of HIM technology challenges and electronic health records (EHR) capabilities in various types of health care organizations, delivery levels, and services. These capabilities - to host multiple vendor systems in a variety of configurations, tailored to specific course, lesson, and competency requirements – while critical to effective training, would be beyond the scope of most individual educational institutions to obtain, financially support, and manage.

The Virtual Lab implementation plan is being developed with input from an advisory committee made up of representatives from corporate technology developers. This combination of educators, technology developers, employers, and AHIMA’s experienced education and training staff, will bring together expertise in technology, product installation and implementation, pedagogy, adult education, HIM curriculum, and HIM practice. The advisory committee will confirm the mapping of applications to skill sets defined by the HIM core curriculum at the associate and baccalaureate level by course and lesson. This mapping will define the specific technology applications required to support each concept.

The Virtual Lab will be developed and tested in phases. The goal at the end of the two-year pilot will be to have at least one lesson developed for each course in the associate and baccalaureate core curricula. Education programs will assist in the creation of initial tasks, lessons, and identification of data sources for Virtual Lab databases and practice medical records to provide realistic content for the software. In parallel with lesson and learning objective development, staff and technology partners will identify, select and install appropriate segments of their technology systems to support the lessons being developed.

When fully operational, the Virtual Lab will serve as an electronic environment for practicing the design, use, analysis, presentation, storage, and retrieval procedures of health care data in electronic form. It will facilitate teaching activities and satisfy college software expansion needs, as well as provide access to a data repository. In addition, the Virtual Lab will provide exercises that emphasize the acquisition of skills related to the use of electronic tools to solve problems and make decisions.

Industry and Academic Partners

Industry partners to date include Cerner Corporation, Dictaphone, McKesson Corporation, Nauvalis Healthcare Solutions, QuadraMed Corp., and Siemens Medical Solutions. Each industry partner will donate licenses of selected technology solutions, provide necessary technical assistance and staff and faculty training, and participate on the project’s advisory committee.

Education and training partners include the College of St. Catherine, Dyersburg State Community College, Kirkwood Community College, Macon State College, Santa Fe Community College, Shoreline Community College, Stephens College, Texas State University, United Tribes Technical College, University of Alabama-Birmingham, University of Washington-Seattle, and Vernon College. Each of these partners will actively participate in project planning, training, lesson development, and piloting of the Virtual Lab. One or more faculty from each of the institutions will serve on the project’s advisory committee. The project will access the Workforce Investment System through seven of these education and training partners. These partners also have strong clinical relationships with more than 80 health care employers who will contribute knowledge of current practice to the development of Virtual Lab lessons, tools and curriculum.

Replication, Impact and Sustainability

The outcomes of this project will have national impact as the e-HIM Virtual Lab and its learning tools are accessed by HIM programs across the country. Through integration with the required curriculum for approved or accredited certificate, associate, baccalaureate, and master’s programs, the lesson plan built through the Virtual Lab will become imbedded into the full HIM education system. Through participation in the ongoing development of lessons and exercises, individual faculty will develop their skills at integrating technology into lesson plans, a capability that will better equip them to teach to and integrate with other allied health programs.

Interdisciplinary Opportunities

Health information permeates all allied health and health-related academic disciplines, such that any allied health or health-related program could access and utilize the Virtual Lab applications for hands on learning using electronic health record applications related to the discipline. An example is the College of St. Scholastica’s Health Information Management/Health Informatics Program in Duluth, MN that led other allied health disciplines, nursing, computer technology and a medical school in development of a model electronic health record project.

AHIMA’s Role

Housed at AHIMA, the Virtual Lab will eventually be used to support advanced continuing education for those already in practice. This will allow the Virtual Lab to have a reach well beyond the scope of the initial pilot project and ensure that access to the latest technology will be available to all HIM professionals, regardless of the current state-of-the-art at their employer institutions. The Virtual Lab lessons and exercises will be incorporated into continuing education programs such as coding basics, cancer information registry, medical transcription, and clinical data analytics. When incorporated in these programs, the Virtual Lab will be available to an additional 2,000 to 3,000 users who seek training to improve their current skills or acquire new ones. This will help HIM professionals to serve as leaders in speeding the transition and enable the reality of an electronic health record for all levels of health care delivery, support the growth of the National Healthcare Information Network (NHII/NHIN), maintain employment, and advance professionally.