Proceedings of the 22nd National Conference: How Will it Work? A New Era for the Teaching Health Center (Part 1, McKennett)

We gratefully acknowledge the sponsorship of the University of Texas Health Science Center, Tyler,  for funding the transcription and editing of this section of the Proceedings of the Twenty-Second National Conference:

This presentation follows: Proceedings of the 22nd National Conference: Thought Provocateur #3: How Might it Work? The Career of the Primary Care Physician in the Age of Health Care Reform (Haughton).

 

Robert Ross, MD, Oregon Health Sciences University, Klamath Falls, Oregon [plenary session moderator]: The next panel, on the subject of the teaching health center, will be comprised of Doctors Peter Broderick, the program director  for the Valley Family Medicine Residency in Modesto, Marianne McKennett, the program director for the Scripps Family Medicine Residency Program in Chula Vista, California, and Kiki Nocella, who will begin the session.

Kiki Nocella, Ph.D., Chief Executive Officer, Believe Health. Good morning. I used to come hang with this group quite a bit when I was at the University of Southern California, but haven’t had the pleasure in a while so it’s nice to be back. My company, Believe Health, has been around for about three years.

The three of us are going to talk today and share with you stories about teaching health centers (. Two are  in the San Diego area in an environment that has been walking, talking, acting like a teaching health center (THC) for quite some time.

Then Dr Broderick will talk about the program in Modesto that’s gone through quite a story in the last three years, that resulted, a few months ago, in a teaching health center grant award that starts up July 1, 2011.

We’ will talk about models of THC operations, THC funding, how that funding integrates with community health clinics and what, at least in our opinion, lies ahead.

Dr McKennett will start us off.

Marianne McKennett, MD; Scripps Health Center, Chula Vista, California

Marianne McKennett, MD, Scripps Hospital, Chula Vista, California [Dr McKennett is a Fellow of the Coastal Research Group]:  Good morning! As Kiki mentioned, I will start with a little historical perspective on graduate medical education [GME] and community health centers, even though I know there’s a lot of expertise here in the room.

Officially, there are nine federally-funded teaching health centers, although there clearly many more residency programs with varying types of affiliations with community health centers and I think this is an area that will certainly grow.

My background presentation will lead into our discussion of new models with new funding streams.

Just as a little background (I know that Kevin Murray can add to this) Several people have mentioned the work of Frederick Chen, MD, MPH and Carl Morris, MD, both of whom are with the University of Washington in Seattle.

They took a structured approach to looking at the relationship between family medicine residency programs and community health centers. This led to the formation of the tool kit out there for education health center initiatives. So hopefully that will be a road map for many of us in the future.

Family medicine faculty at opening of community school-based clinic

Through a series of focus groups and key informant interviews, they identified four areas that can be either barriers to the relationship or facilitators of it. (That’s actually an interesting way of presenting these areas of focus.)

First, (something that comes up frequently) is mission: Community health centers are clearly service driven organizations. Residency programs have education as their primary focus. The tension came come when the mission needs to shift to service and education.

Second, money is always an issue. Both of these entities are chronically underfunded. The key here is how to align the  missions, so that the money will follow and support both programs.

Third, both entities are plagued with administrative regulations. Sometimes those regulations are not in tandem. Sometimes Accrediting Council on Graduate Medical Education (ACGME) requirements are versus those of the governing board of the health centers.

Fourth, quality is probably an area where the entities could come together much more quickly, looking at both potential quality and patient care outcomes as well as educational opportunities.

Similarly, in this focus group related research there was a recommended approach to overcoming the barriers, looking again at that shared mission of service and education.

The San Ysidro Health Center’s Maternal and Child Health Clinics, served by the Scripps family medicine residency.

The entities could look for reimbursement streams that would focus on facilitating that shared mission without a threat to any existing funding. For instance, at a community health center decreased productivity could affect their current funding streams. Both entities should seek a rational approach to reimbursement that accounts for the costs of education and outpatient training.

Clear communication is needed to minimize the misunderstandings that can occur from bringing these two different cultures together.

The WWAMI study of Teaching Health Centers looked at  at affiliations that had been in existence between  three and 20 years, including both those settings in which a couple of residents a year might be in a community health center, as opposed to a fully integrated THC model.

One of the positive outcomes is that residents who graduate from these settings are significantly more likely to work in community health centers and significantly more likely to work in underserved areas.

It’s hard to believe that it’s been this long, but in 1995 in San Diego we looked at forming a collaboration to provide family medicine education in the community health center. Up until that time all family medicine education in San Diego had been handled in the very traditional University of California, San Diego (UCSD) tertiary care teaching center.

Building on the background, at UCSD’s affiliated Scripps Mercy Hospital family medicine residency program in Chula Vista, we brought together universities, especially UCSD; Scripps Mercy Hospital (the local community hospital); a very large federally qualified health center, San Ysidro Health Center; and our California Area Health Education Center (AHEC), that was very facilitative in this project.

We took our first class in 1999 and are now about to graduate our tenth class in June of 2011.

Scripps Mercy Hospital; Chula Vista, California

This relationship was governed by a three way affiliation agreement between Scripps Mercy Hospital, Chula Vista, our sponsoring institution in a pretty traditional residency sponsorship model;  UCSD is our school of medicine, our academic affiliate; and then the San Ysidro Health Center (SYHC).

Initially, SYHC ‘s  role was to be the family medicine continuity site. That role has actually grown as we have become more and more integrated.

I should mention that Scripps all along has also been a “disproportionate share (DSH)” hospital and had already been taking most of the admissions from the community health center, as well as a significant and continually growing number of underfunded and unfunded admissions.

I’ll give a brief overview of our funding model without any particular dollars attached. I think we would be considered a traditional funding model in a somewhat nontraditional setting. Scripps Mercy Hospital, as the sponsoring institution, receives all of the Medicare IME and DME for training the residents. They pay all of the faculty salary and benefits as well as the resident salary and benefits and the general education costs.

Mural at San Ysidro Health Center entrance

San Ysidro Health Center receives all the outpatient clinical revenue and actually pays for all of the family practice center overhead, including rent, staff salaries, and the implementation of our electronic health record. They do pay a somewhat under-market rate for the time that the faculty spends seeing patients directly, although not for supervising.

UCSD as the affiliated school of medicine pays a small percent of program director’s salary. There are some shared faculty and teaching facilities.

Our San Diego Border AHEC has been very instrumental from the start in a lot of our community-based activities as well as collaboration and grant writing.

We now have grown to 21 residents. With some expansion funding, not from the teaching health center funds, but from the primary care residency expansion funds, we will be going to a 24 resident program.

Not only do we have the family practice center, but also specialty clinics and work throughout SYHC in the areas of pediatrics, OBGYN, HIV care and mental health. We’re very integrated with the health center and the inpatient side with adult medicine, newborn care, and maternity care.

We’ve developed some collaborative school-based health center activities. Along the way, we have collaborated with two other smaller community health centers in the area; particularly in the area of women’s health, prenatal care and maternity care.

Our outcomes are somewhat very similar to the WWAMI data and, I understand, to data from Boston as well. A significant number of residents that are working in federally defined underserved areas number. That figure could probably be higher if you used more inclusive criteria for defining underserved areas.

There are significant number of National Health Service Corps scholars. In our own program for medical student recruitment, it has been tremendous asset in the recruitment of residents. It seems like enthusiastic residents are looking for these kinds of settings for training. We’ve had a 100% fill rate in the matching program since 1999.

In the group of residents we recruited there are 51% underrepresented minorities, primarily Hispanic residents from LCME schools who really fit the face of our community. About a fourth of our residents actually are from the local area and have come back to Chula Vista to train.  I think these are excellent outcomes that I hope that we can continue and build upon.

From the health center side, for health center recruitment of physicians is a big issue, we’re clearly graduating residents who are staying locally and helping out our local environment.

In summary, the Scripps family medicine residency relationship with SYHC over time has resulted in the recruitment of medical students’ in providing excellent training opportunities in the full spectrum of family medicine; in community involvement; in successful physician recruitment by the community health centers; in improved primary care numbers; and an increase in the diversity of our workforce.

Challenges still remain in workforce diversity and in the balance of service and education. I wouldn’t want to minimize that.

Financially, I’ll just say that in my setting, Scripps Mercy Hospital, I think I’m very fortunate. They’ve been extremely transparent about what graduate medical education money from Medicare comes in and where it goes. I’m not 100% sure that the same transparency would be automatically there if money came directly to the health center.

There’s no doubt that this relationship takes, like any successful relationship, a lot of time and a lot of communication to keep it working. So this is our crew, I love them, they’re really a great group.

Now, I’m going to turn things over to Peter Broderick.

This presentation is followed by: Proceedings of the 22nd National Conference: How Will it Work? A New Era for the Teaching Health Center (Part 2, Broderick)