I. Introduction

Background

In 1998, the Congress of the United States, recognizing the beneficial impact that interdisciplinary, community-based linkages can have upon the quality and availability of health care services to populations that have traditionally been underserved or are otherwise especially medically vulnerable, adopted legislation authorizing grant funds to support the development of such linkages. The legislation, set forth in Title VII, Part D, of the Public Health Service Act ("the Act"), identified five sets of programs, all with the central mission of training and education, deemed to be particularly endowed with the potential for beneficial linkages of this nature. The programs were as follows:

Although these programs differ in detail, they share a common element: each has the potential for fostering the development and application of interdisciplinary, community-based linkages in (a) areas where such linkages are most urgently needed, on (b) health care delivery issues of greatest concern from a community standpoint, to (c) populations that are especially vulnerable or underserved.

The mission of Part D, Interdisciplinary, Community-Based Linkages of Title VII, Health Professions Education, is to assure that there is a workforce that can meet the health needs of State, local, and rural populations of the Nation, especially those with unserved, underserved, vulnerable, and disadvantaged populations; a workforce that can respond effectively to new and demanding health priorities. "Interdisciplinary" and "community-based" training are two educational strategies that help in the preparation of health professionals, who are both knowledgeable of and sensitive to the needs of these populations because they worked with and for them in the course of their education. These initiatives are effective ways to ensure that there will be an adequate health workforce to meet the needs of communities, particularly those with at-risk populations, as well as our communities as a whole.

Thus, an important component of Part D, Title VII is to integrate "interdisciplinary" and "community-based" concepts into the training of health professionals. Given the diversity of the health care workforce, incentives for these professionals to work together in teams have become imperative. Moreover, these incentives should target education in community-based settings to optimize the delivery of the public's health care and to minimize its needs based on the goals and priorities established by Healthy People 2010. Also, by using interdisciplinary educational strategies, the quality of interactions among the professionals, quality of communications with the patient, and quality of actual services delivered will improve.

The Need is Compelling for Interdisciplinary, Community-Based Linkages Programs (ICBLP)

Interdisciplinary, Community-Based Linkages Programs (ICBLP), by virtue of their mission, prepare the health professions workforce to meet the current and future health needs in our society. These programs provide unique education and clinical training for the future health care workforce. They target this country's growing vulnerable and underserved populations in community settings, such as: the poor, homeless, frail elderly, ethnically and racially diverse, migrant, immigrants, rural, and incarcerated groups. Using a preventive, primary care and population-based approach to health care, these programs educate future generations of health professionals to deliver culturally competent, clinically effective and public health-oriented services in underserved communities. The integration of interdisciplinary and community-based concepts into the training of health professionals through these programs, demonstrates its efficacy by preparing a diverse national health workforce to provide culturally competent, high quality care to these populations. The public's health is enhanced through the population-based services delivered by these health professions learners and faculty, ultimately expanding the capacity of the current health workforce.

Without the Title VII Part D programs, interdisciplinary health professions education would be severely restricted and access to care for underserved and vulnerable populations would be reduced. Furthermore, the anticipated growth in these populations is expected to stretch health professions education and training resources well-beyond current and future capacity. Health professions' schools, deluged by these demands, are limited by the lack of available institutional resources targeted at institutionalizing service to communities. In addition, the distribution and diversity of the health workforce in these community-based settings frequently is not well matched to the populations it serves further limiting access to care. This combination of factors mandates the critical need for Federal and State support for these interdisciplinary, community-based programs.

These looming projections have been exacerbated in the wake of September 11. The health care concerns associated with bioterrorism, emergent infections and epidemics require collaboration across public health and primary care as well as an interdisciplinary teamwork approach. As examples, the increased incidence of West Nile Virus, anthrax, and terrorist activities over the past year, require higher levels of collaboration across systems of public health and primary care. These real threats to human health could be addressed through the efficient integration of existing Interdisciplinary Community —Based Linkage Programs mobilizing academic/ community partners to use population-based approaches to health. Through teamwork among health care providers, partnerships with public health and communities, and innovative education and clinical training programs, we can expand new and existing programs in a cost-effective manner, avoiding duplication and fragmentation.

Community Benefits of Interdisciplinary, Community-Based Linkages Programs (ICBLP)

The ICBLP offer real world experiences of community-based primary care education and training for health professionals, students, faculty, and community health workers. The value and benefits of each of the ICBLP are described in Chapter 2. Community benefits and outcomes that exemplify the overall annual impact of these programs are described below:

• Interdisciplinary community-based linkages programs have a longstanding history (since 1972) of providing education and training to develop and expand the nations health workforce, thereby improving access to care for this country's most vulnerable populations.

• Federal investment in interdisciplinary community-based programs has developed more than 180 academic/community partnerships;

• Interdisciplinary community-based programs link naturally with 530 Community Health or Migrant Health Centers and 170 National Health Service Corps training sites;

• More than 40,305 health professions students educated and clinically trained through the interdisciplinary community-based linkages programs;

• More than 340,000 students from K-12 have participated in health professions career recruitment programs;

• More that 194,000 health professionals participated in Continuing Education Programs;

• More than 70,800 individuals benefited from the delivery of health promotion programs provided by trainees;

Formation of the Advisory Committee for Interdisciplinary, Community-Based Linkages

In addition to the programs identified in Sections 751 through 755 of the Act, Section 756 authorized establishment of a committee, termed the Advisory Committee on Interdisciplinary, Community-Based Linkages, to which it assigned the following duties and responsibilities:

• provide advice and recommendations to the Secretary concerning policy and program development and other matters of significance concerning the activities under this part; and

• not later than 3 years after the date of enactment of this section, and annually thereafter, prepare and submit to the Secretary, and the Committee on Labor and Human Resources of the Senate, and the Committee on Commerce of the House of Representatives, a report
  describing the activities of the Committee, including findings and recommendations made by the Committee concerning the activities under this part.

Section 756 further directed that:

• appointments to the committee be made from among individuals who are health professionals associated with schools of the types described in Sections 751 through 755,

• a fair balance be maintained among the health professions, with at least 75 percent of the appointees being health professionals,

• broad geographic representation and a balance between urban and rural members be maintained, and

• there be adequate representation of women and minorities.

A 21-member committee meeting these requirements was appointed by the Secretary and assigned a charter with an effective date of March 24, 1999. The charter was subsequently renewed on March 22, 2001.

Advisory Committee's Agenda Rationale and Progress in 2002

The Advisory Committee's First Annual Report is dated November 2001 but was not disseminated publicly until mid-2002. The work of the Advisory Committee that led to its initial report was largely aimed toward developing an understanding of the Federal intent for the grant programs, reviewing available information regarding the progress demonstrated by grantees, and identifying prospective issues for future study. However, the Advisory Committee was able to conclude that the interdisciplinary, community-based grant programs have met and continue to meet a relevant national priority for training health care workers that can meet critically important local needs. Consequently, the Advisory Committee issued a strong endorsement of continuing Federal appropriations and authorization of such efforts.

As has been noted elsewhere, the Advisory Committee was meeting in Washington, D.C. on September 11, 2001 when the terrorist attacks occurred only blocks away from the Committee's meeting site. Not unexpectedly, the Committee's work on the First Annual Report was not completed and required an additional meeting to critically review its initial report. In this meeting on February 3^rd — 6^th, the members performed a self-analysis of the First Report and solicited feedback on the report from HRSA representatives, including Mr. Neil Sampson and other Federal staffs that oversee the individual grant programs. The Advisory Committee also heard from a representative of State government, Mr. Tim Henderson, National Conference of State Legislatures, in recognition of the important role that States play with funding and molding the operation of these grant programs. While each reviewer generally expressed support for the findings and recommendations of the Advisory Committee, the presenters felt that recommendations lacked specificity to guide actions with regards to changes in policy and/or administrative procedures. This critical review set the stage for the scope of work for other meetings in 2002.

The Advisory Committee's findings in its first year suggested that there may be important ways in which Federal policy and administrative procedures might be revised to enhance the efficiency and effectiveness of the grant programs, even beyond the high quality of present performance. It also observed that the relevance of these grant programs to preparing an adequate and appropriate health care workforce could be further magnified through cooperative interaction with other Federal programs administered within and outside of HRSA. In the context of these major conclusions from the Advisory Committee's initial year, a scope of work was defined for the year, 2002.

The agendas for the meetings can be found in the Appendix. Other meetings took place on April 28^th — 30^th, June 23^rd — 25^th, August 4^th — 6^th, and October 2^nd — 4^th, 2002. This last meeting in October led to the final approval of the recommendations found in this report. Previous meetings included testimony and presentations addressing a wide variety of proposed changes in policy and administrative procedures. Representatives from Federal agencies, grantee constituency groups, professional associations, academia, and community interests provided testimony.

In several instances, recommendations suggested by representatives have yet to be acted upon by the Advisory Committee. Such actions may be included in the Advisory Committee's future activities (see Chapter VI). However, it should not be construed by the reader of this Report that concepts or ideas proposed to the Advisory Committee were found to be unacceptable or a "low priority" simply because they are not included in the Second Annual Report. The Advisory Committee had only limited time and resources to review the proposals and to discuss other findings, and necessarily had to limit its focus to what could be accomplished within its meeting cycle.