Advisory Committee on Interdisciplinary, Community-Based Linkages

Minutes of May 7 and 9, 2008 Meeting

ATTENDANCE

ACICBL Members

Stephen Wilson, Ph.D., Chairperson
Louis D. Coccodrilli, MPH, Designated Federal Official, ACICBL and Acting Director, Division of Diversity and Interdisciplinary Education
Alan Adams, DC
Robert J. Alpino, MIA
Heather Karr-Anderson, MPH
Jeremy Boal, MD
Brandy Bush, OTD, OTR, CLVT
Ann Bailey Bynum, EdD
Jane Hamel-Lambert, PhD, MBA
Beth D. Jarrett, DPM
Gail M. Jensen, PhD, PT
Linda J. Kanzleiter, MPsSc, DEd
Barbara N. Logan, PhD, MA, MSN
David H. Perrin, PhD, ATC
Elyse A. Perweiler, RN, MA, MPP
Ronald R. Rozensky, PhD, ABPP
Steven R. Shelton, MBA, PA-C
Andrea Sherman, PhD
Laurie Wylie, MA, RN, SNP

Health Resources and Services Administration (HRSA), Bureau of Health Professions (BHPr) Staff

David Hanny, PhD, Program Officer
Norma J. Hatot, CAPT/USPHS, Acting Chief, Area Health Education Centers Branch
Tahira Henderson, HRSA Scholar
Adriana Guerra, MPH, ASPH Fellow
Vanessa Saldanha, MPH, ASPH Fellow

HRSA Administration and Other Staff

Marcia K. Brand, Ph.D., Associate Administrator, Bureau of Health Professions
Rick Smith, Associate Administrator, Bureau of Clinician Recruitment Services
Erica Pearson, BHPr

Private Citizen Representation

Abigail Schopick, Association of American Medical Colleges
Bill Finerfrock, Capitol Associates
Margaret (Peggy) Opitz, University of North Carolina at Pembroke

FORMAT OF MINUTES

These minutes consist of five sections:

1. Opening Remarks
2. Testimony
3. New Member Orientation
4. Findings and Recommendations
5. Committee Business

SECTION I:  OPENING REMARKS

Dr. Stephen Wilson, Committee Chairperson and Mr. Lou Coccodrilli, Designated Federal Official welcomed committee members and public guests.  Dr. Wilson summarized the proceedings for the next few days, noting that May 7^th and May 9^th would be devoted to the ACICBL’s individual meeting where members will hear and discuss testimony on healthcare workforce issues in rural America.  For the first time, BHPr will host a meeting of one-day devoted to All Advisory Committees on May 8^th inclusive of the ACICBL; the Advisory Committee on Training in Primary Care Medicine and Dentistry; the Council on Graduate Medical Education and the National Advisory Committee on Nurse Education and Practice.  This meeting will provide an opportunity for all four committees to come together and align outcomes along common themes such as health professions workforce, health professions training, access to care, and workforce diversity.

SECTION II:  TESTIMONY

Contact the Division of Diversity and Interdisciplinary Education at (301) 443-6950 for a copy of any presentation discussed in this section.

Vision for an Ideal Rural Health Care Delivery System

Marcia K. Brand, PhD/Associate Administrator
Bureau of Health Professions
Health Resources and Services Administration
U.S. Department of Health and Human Services
Rockville, Maryland

Dr. Brand focused on a vision for an ideal rural health care delivery system from the policy, local, and personal perspectives. 

Discussion – Questions:

• Changes in rural trends have occurred.  Overall, the health of rural America is better than it was decades ago, although significant disparity remains.  It is promising because these health systems are fairly small and allow for innovative demonstrations around quality and performance improvement in ways that can not be done in urban settings.  Critical access hospital programs have stabilized the rural community’s access to care.  In the mid-eighties, hospitals moved from cost-based reimbursement to prospective payment.  This resulted in the closure of 300 to 400 small rural hospitals that could not average the cost of care across such a small number of patients. 
• Currently, critical access hospitals have cost-based reimbursement that assists in their stabilization and allows for improvement and expansion of services.  Similarly, many land grant institutions have acknowledged their responsibility to graduate individuals to serve the state and the need to make a concerted effort to provide programs and encourage health professions students to work in rural communities.  Many medical schools have incorporated a distinct rural track or other focused rural effort that will address rural in/rural out theory and provide training in rural communities.
• Disadvantaged populations in any setting will ultimately benefit from the areas that improve a provider system of care. 
• Rural communities have the opportunity to be more proactive in changing their local healthcare systems from acute care to prevention and wellness.  It is important for rural communities to develop wellness programs that address their geography and resources.
• Regarding the root causes of health disparities in rural communities, there is little scientific research being conducted resulting in policy and programming changes.
• Concern with programs, such as the Quentin N. Burdick Rural Interdisciplinary Training, that have been cut from the Administration’s budget and not supported with appropriations is that they lack evaluations to determine their impact.  Title VII programs are up for reauthorization.
• In academia, everyone remains in silos.  In the absence of funding, what can the Federal government do to in the area of accreditation to move health profession programs to consider interdisciplinary work?  States could provide resources so that interdisciplinary training could be included in the curriculum at an academic institution.  In the absence of significant resources, the Federal government can serve as a convener and provide opportunities for individuals to discuss the importance of teams and developing educational systems that promote team work.  One way to do this is through the advisory committees charged with providing the Secretary and the Congress with advice and recommendations.  Another opportunity will take place next fall.  The BHPr, the Bureau for Primary Healthcare, the Office of Rural Health Policy, and the Bureau of Clinician Recruitment Services are planning a workforce summit that will address the principal issues in improving care for the rural underserved populations.  The public can share their best counsel on effectiveness at that time.

Rural Issues and the Health Workforce

Wayne W. Myers, MD/Columnist
The Rural Monitor
Waldoboro, Maine

Dr. Myers focused on the issues that affect rural America and the implications for the healthcare workforce.   

Discussion – Questions:

• In Texas, there has been success in working with the sheriff’s department to identify and train deputies in behavioral health issues and prepare them to respond to mental health emergencies in a first responder situation.  The health science campus worked with the health authorities to develop mental health follow-up programs.  The mental health center is funded to provide transportation and follow-up for individuals who miss appointments, a critical issue in acute and chronic mental health services.
• Medical schools tend to be in the business of self-perpetuating their product, which may be considered important, but is not necessarily medical education.
• Some primary care residency directors in internal medicine, pediatrics, and family medicine are either insensitive to or unaware of the market dynamics in their disciplines.  There appears to be disconnection between what the residency directors are doing and the purpose for doing it.
• There are role model programs at health science centers preparing the workforce across the health professions by incorporating inter-professionalism training in their curriculum.  For example,
  • The work of the University of Minnesota is driven by the chancellor, infrastructure, and resources.
  • Rosalind Franklin University has an inter-departmental course for first year students from various programs such as physical therapy, podiatry, and medicine.  Students learn how to work together in problem solving situations.
• There are data on health outcomes of interdisciplinary training in British Columbia where the model demonstrates whether the inter-professional or interdisciplinary education makes a difference in healthcare outcomes. They argue for more money in educational research around health professions education to make that happen.
• The National Training and Consultation Collaborative, part of a contract with HRSA, examines interdisciplinary training in geriatrics.  The projects assist the geriatric education center (GEC) network and include evaluation methodologies at the primary, secondary, and tertiary outcome levels.  For the first time, GECs were asked to look at clinical outcomes. 
• We are dealing with rural misperceptions and need policy makers to dispel these myths through perceptual readjustments.
• Building on the issue of trying to attract people to rural shortage areas in general, there are several publications that document significant increases in enrollment.  These trends suggest that total increased enrollment is going to result in more providers.  Many times, these providers go to areas where incomes are higher.  When services are increased, the jobs will be there and the salaries will be higher.  Therefore, it may not address shortages in rural or urban areas.  We need to know where to target funds when considering Title VII programs.  Should the focus be all training in shortage areas regardless of the discipline or just interdisciplinary training?  Should there be a focus on requirements and outcomes rather than process?

Partnerships and Funding the Behavioral Healthcare Needs of Rural America

Claudia R. Baquet, MD, MPH
University of Maryland School of Medicine
Program Director, Maryland Area Health Education Center Programs
Baltimore, Maryland

Dr. Baquet presented an overview of Maryland’s efforts to foster partnerships based on mutual respect and benefits and sharing resources.  There was an emphasis on behavioral healthcare services inclusive of an associated systematic approach to reduce tobacco related behaviors, enhance health literacy, and promote wellness. 

Discussion-Questions:

• The University of Maryland, School of Medicine has Historically Black Colleges and Universities (HBCU) as partners that include the University of Maryland Eastern Shore and Bowie State University with growing partnerships with Coppin State College.
  • The University of Maryland Eastern Shore, the longest partnership of five years, is a planning grant for comprehensive cancer disparities research education and training. The Department of Natural Science is represented by scientists who examine the exposure to pesticides and chicken feed runoff as an influencer of health outcomes, notably cancer. A genomic facility is funded by the Federal government to perform gene environment studies.
  • The Bowie State University partnership targets the curriculum with a focus on cancer disparities, methodology, and research with the goal of assisting faculty with career development training to obtain independent grants.
  • Both investments have the goal of increasing the numbers of HBCU faculty and students in research careers.
• This discussion focused on moving to a culture rooted in tradition and community outreach, research as a shared responsibility, and recommendations to help academic health centers achieve this transformation,
  • Revisit those programs that are no longer funded like the Quentin N. Burdick Rural Interdisciplinary Training grant. 
  • Mandate in grant announcements a certain amount of investment by the academic institution beyond the basic requirements.  For instance, request documentation of community engagement or capacity development.
• To what extent should the work of the Committee focus on preventive strategies? 
• The power of partnerships is exciting and cross-cutting.  When building new partnerships, efforts to communicate the effectiveness of the programs might compare to leveraging funding since both are needed to move to the next level, a challenge of   an academic center and community-based organization collaboration.  The level of rigor with non-profits and community-based organizations is different and besieged by cash flow problems.
• When refocusing on home and community-based services, it is important to consider health promotion and disease prevention.
• The unanticipated benefits of the rural clinical cancer trial efforts in terms of general rural health networking and community building were numerous:
  • The program started small and has grown as a single oncology practice with nurses running the trials.  The nurses, trained as Clinical Research Associates, expressed interest in clinical nursing research careers.
  • The program started with the community receiving literacy appropriate education about the potential benefits and challenges of research participation, but shifted to the community wanting to participate and being mobilized by the physicians who were pressuring by the community for information.
• Community health workers were trained to conduct pilot educational interventions specific to breast and colorectal cancer screening and follow up with randomized participants. Patients with abnormal tests were assigned to nurse navigators for assistance with further diagnosis and treatment.
  • The Maryland Community Health Worker Association plans to reconvene with the goal of assisting with employment and obtaining benefits. 
• How are the partners engaged in the telemedicine process?  Does telemedicine play a role in prevention?
  • Clinical telemedicine is used to train physicians to counsel patients on smoking cessation and nutrition.  These systems exist for training the partners on advances in clinical guidelines and prevention and for cancer patients needing radiation oncology services or care at the county level.
  • The video conferencing equipment is used for in-service training for the clinical and federally qualified health center staff.
  • There are still barriers in terms of reimbursement and liability issues since the patient is being served from a distance.
  • The VA (Baltimore) provides telepsychiatry and dermatology to veterans in Dorchester County with proficiency results comparable to in-person visits. The VA has a different payment system and was the first in the country to use filmless radiology and nuclear medicine in the telehealth arena.
• The nurse case manager and the primary care provider, whether a physician or a nurse practitioner entered into specialty care, is a new model of care for special populations.  This model is increasingly being utilized and evaluated.
• Application is one component along with a broad understanding of the potential reimbursements and the issues impinging on access to telehealth.  There are many rural areas where the infrastructure cannot utilize telehealth because of funding issues.

Rural Health Disparities and Recruitment and Retention

Daniel S. Blumenthal, MD, MPH/Professor and Chair
Department of Community Health & Preventive Medicine
Morehouse School of Medicine
Atlanta, Georgia

Dr. Blumenthal provided a brief overview on general health disparities and the implications on recruitment and retention of a healthcare workforce. 

Discussion-Questions:

• What are the possibilities for disconnecting residency training funding from in-patient hospital-based care?
  • Morehouse has residencies in public health and preventive medicine.  No in-patient care and very little out-patient are done.   To decouple residency programs from Medicare reimbursement, there needs to be some other source of funding.  Meanwhile, the VA increased its number of residency slots.
• The number of physicians available to practice is not going to increase even though medical school enrollment is increasing.  Without considering the international medical graduate issue, or the influences of the VISA policy for immigration support, changes are necessary to increase the number of physicians available to practice.
  • In the mid-1970s, the Council on Graduate Medical Education (COGME) published a report that studied physician need.  The Committee used formulas to examine the numbers of Americans with heart disease being cared for by primary care physicians versus cardiologists.  The same study was done for surgeons, obstetricians and others, concluding that there are many physicians, but distribution based on need is an issue fitting the model of health planning.  During the Reagan years, the thinking returned to a market-based model of demand.  The number of cardiologists needed was not questioned, but the number of people with hypertension preferring a cardiologist.  Largely, cardiologists, gastroenterologists, and others create their demand, which can become expandable, allowing many physicians to stay in the same area.
  • The difference between COGME and the Association of American Medical Colleges is not a change in the situation, but a change in the model used to predict the supply that is needed.  Medical schools want to expand enrollment but the prospects for increasing residency slots are rather limited.
• At Morehouse, how closely does the rural medical school program work with the undergraduate recruiting program?
  • Morehouse College, an independent institution and Morehouse School of Medicine, a freestanding school of medicine, work together with other colleges/universities to recruit students into the medical program.
  • Strengthening the pipeline to include the rural school systems will be critical. Practicing physicians and other health professionals should not feel the need to return to the cities so that their children will get a decent education.
  • AHEC programs offer presentations to students from K – 12^th grade and expose those in college to health career opportunity programs.
  • Most of the Morehouse medical school graduates who practice in rural areas are originally from rural settings.
• Primary care is not viewed as the most preferred discipline for entry even in academic health centers.  What are some thoughts in reordering the reimbursement opportunities for primary care and elevating the discipline in the academic health centers?
  • Some states, like California, require their medical schools graduate a certain percentage of primary care physicians.  Managed care systems were going to be built around primary care, but that did not happen.
  • The reimbursement rates need to be re-evaluated (Medicare, Medicaid and other insurance companies), followed by a healthcare system with primary care as its center and specialists deployed where needed.
• How might interdisciplinary education and training impact health disparities?
  • Organizing interdisciplinary training can be difficult.  Previously, Morehouse offered a community health course that involved students in medicine, social work, nursing, and allied health, but now it only has medical students.  Every discipline has its own objectives, goals, and funding streams, making it difficult.  Interdisciplinary training is the better way to provide healthcare.
  • Medical care is not really the answer to health disparities.  Prevention is the key to reducing health disparities.  A team of health professionals working together makes a much greater impact than having a physician work alone.
• It was recommended that preceptors in rural areas be paid as a way to strengthen the workforce for rural training. 
  • Morehouse does not pay the preceptors in rural areas.  Consistent with the great tradition in medicine, the Hippocratic Oath reads that physicians will train the children of those trained for free.
  • The biggest challenge is accommodating the students from the 32 medical schools in the Caribbean, who must find clinical placements in the United States.  Companies that specialize in finding clinical placements charge the students and pay the preceptors.  With preceptors receiving payments from those companies, it is hard to appeal to their loyalty.
• Are any preceptors dropping out because of economic issues, being unable to carve the time out of their practice to train, or reimbursement?
  • Morehouse has experienced a few preceptors leaving their positions, but some elect to reduce the numbers of students because of the time and money. 
  • The challenge rests with having enough preceptors in rural settings to train students.  Earlier, the rural clerkship placed 25 or 30 students annually, but places 50 to 70 students now.  Another challenge is the expansion of medical colleges and universities without a comparable increase in the number of preceptors in rural areas.
• Health disparities are relevant to the disconnectedness of the health workforce from the communities that are served.  The Committee has an opportunity to put forth a plan for an integrated, interdisciplinary health workforce policy at the community level that defines the relevant workforce and systems delivery model with a set of characteristics.
• Noting that Morehouse experienced preceptors reducing their time, is this seen more often in the community health centers?
  • AHECs are mandated to place students in clinical rotations with community health centers being one of these entities.  Frequently, the preceptor is viewed as less than fully productive.  The Committee should address this as an internal HRSA issue.  It has tremendous impact on the ability for AHECs to provide these opportunities for students especially when creating a workforce that will serve underserved, rural populations.

Interdisciplinary Approach to Address the Geriatric Healthcare Workforce

Linda J. Redford, PhD, RN/Director
Central Plains Geriatric Education Centers
University of Kansas Medical Center
Morehouse School of Medicine
Kansas City, Kansas

Dr. Redford provided testimony on the geriatric healthcare workforce training issues. 

Discussion-Questions:

• Incentives need to be designed for schools to increase their geriatric and interdisciplinary education.
  • Geriatrics will largely impact the reimbursement issue.
  • Incentives are needed for re-training of mid-life learners. Senator Barbara Boxer introduced a loan repayment bill for health professionals to work in geriatrics for two, three or four years following school.
  • Corporations and industries can be very powerful in providing incentives.  For instance, one of the rehabilitation companies in Kansas provided funding to establish a chair in geriatrics within the physical therapy department at the university.  The chair is required to teach geriatrics and to serve as an advocate in Washington for geriatric rehabilitation.
  • Providing stipends to students as done with the Quentin N. Burdick program is a great incentive.
• A root cause of young people not entering geriatrics and gerontology practice relates to the effects of a socio-cultural change between generations.  Learning experiences are vital to the future of a geriatric workforce.
• The Committee should consider encouraging more research funding in interdisciplinary and community-based programming, and outcomes in an academic health center.
• The use of simulation in interdisciplinary learning needs to be encouraged.
• There are regulatory and bureaucratic barriers to consider with the re-entry of foreign trained professionals into the workforce.
• Interdisciplinary education provided to all rural health providers includes continuing education programs that consist of organizational management skills and conflict resolution strategies.
• Interdisciplinary training is difficult; success is more readily experienced with continuing education. The logistics and realities of the demands of the professional organizations in terms of accreditation contribute to the difficulty of educational programs.  Interdisciplinary research grants assist with getting people to work together.

A Healthy Economy and A Healthy Population:  Why We Need to Pay Attention to the Rising Demand for Allied Health Workers

Erin P. Fraher, ABD, MPP/Director
North Carolina Health Professions Data Systems
Cecil G. Sheps Center for Health Services Research
University of North Carolina at Chapel Hill
Chapel Hill, North Carolina

Ms. Fraher presented the efforts engaged by North Carolina in creating a healthy economy and population by correlating the growth of the allied health professionals in the state.

Discussion-Questions:

• There is a direct link between the shortages in the workforce and the faculty.
  • The numbers of nursing students who are rejected each year are staggering.
  • Issues include expanding the faculty at the four-year university and identifying funding to support continuing education.
  • Salaries at community colleges and four-year institutions are strained.
• There is a barrier with faculty support, even in the face of industry willingness to endorse and underwrite the cost of certain faculty.
• The allied health programs offered at the community college is a great example of their capability to respond to local market level workforce needs.
• It is important to bring employers together to share their workforce needs.
• Assistive personnel, physical therapy and medical assistants, are not going away.   Embedding interdisciplinary care in that curriculum should be considered.
• The health professional schools should partner with potential employers and workforce development boards to provide input on multi-disciplinary education and assist with building capacity to employ qualified health providers in rural communities.
  • You must engage employers in workforce development before starting programs.  Institutions benefit from obtaining student clinical placements and employers retain the right mix of health professionals in the community.
• With the high attrition rates, the health careers pipeline has a huge leak.
  • At the community college level, there should be an open door policy to pull from the community.  Retention is adversely influenced by rigorous admission criteria and the science curriculum.
  • Part of the solution rests with drawing from the community and identifying better ways to support the student through retention policies such as counseling, transportation, and childcare.
• Four-year institutions should work with the community colleges that can provide the pipeline for individuals who want to pursue a health career and move into faculty positions. Faculty shortages are abundant in four-year institutions and make the case for developing a pipeline from the community colleges so that faculty can be shared.
• Partner with high school counselors to identify students and the types of skills needed to enter into a health profession.
• Move beyond thinking of healthcare workforce planning to economic development.
• The student is one aspect of the pipeline.  Attrition rates may be attributed to the familial themes of economics and cultural, which may require parental education.
  • After adjusting for family and community characteristics, underrepresented minorities reduced their probability of graduation by 20 percent.
• Are there any community college programs that have tried to attract high school students while they are in high school? 
  • North Carolina’s governor created the Early College Program: high school students graduate with associate degrees (healthcare field) in five years.
• Multi-skilled, cross-trained individuals work to support the family physician or a group of clinicians.  Medical assistants are the epitome of cross-functioning and perform clinical and administrative duties.

SECTION III:  NEW MEMBER ORIENTATION

Dr. Stephen Wilson provided an orientation on the legislative mandate for ACICBL and specific expectations and responsibilities of members. 

SECTION IV:  FINDINGS AND RECOMMENDATIONS

The Committee spent considerable time identifying findings and draft recommendations that must be further clarified and refined for consideration moving forward.

SECTION V:  COMMITTEE BUSINESS

The ACICBL will convene via conference call on Wednesday, July 16 and Thursday, July 17 and have an opportunity to hear more testimony. 

The following recommendations for further testimony were discussed:

Telehealth

• What are the infrastructure needs in setting it up?
• How feasible is it to do in rural healthcare settings?

National Rural Mental Health Association - services, to include best practices that guide mental and behavioral health services, reimbursement issues

Dental health - affect on overall health
Prevention and wellness oriented systems of care

• Understanding success in a community and how a variety of players are involved in creating an environment that promotes wellness will be the focus.

Institute of Medicine’s report Retooling the Healthcare Workforce for Aging Population

Interdisciplinary group of psychologists, physical therapists, occupational therapists, speech pathologists, and other disciplines working on competency-based issues in interprofessionalism

• Jody Gandy, American Physical Therapy Association, is a co-leader of the group.

National Association for Community Health Centers regarding placements for health professionals in rural areas;

• Possibilities include Robert Mountjoy and Anita Manoyan

Medical home practice models;

• What is a medical home?
• How the ACICBL can work with this model?
• What training will be required?
• How models are implemented in urban or rural areas?
• Contact expert Tom Weida from the American Academy of Family Physicians
• Dr. John Gilbert – Interdisciplinary Education