Integrating Medicine, Public Health and Community Engagement: An Educational Transformation Marge Stearns, MA, MPH; John Brill, MD, MPH; Byron Crouse, MD; Cindy Haq, MD, and Alison Klein, MPA University of Wisconsin School of Medicine and Public Health

Session Goals & Format  Discuss rationale and process for integrating medicine and public health in general curriculum  Describe rural and urban underserved tracks that integrate community-based service learning and traditional clerkships  Discuss evaluation of components of this transformation  Discuss logistical and funding issues related to curricular change

Medical School Transformation  Integrated model of medicine and public health  Service Mission: Enhance community engagement  Educational Mission: Blend biomedical sciences, clinical medicine and population health  Research Mission: Increase amount of translational and community-based research

Educational Mission: Increase access to healthcare and health for Wisconsin’s medically underserved populations by…  Integrating training in clinical medicine and public and community health  Producing physician leaders and advocates  Promoting health careers in rural and urban medicine  Engaging with communities in health improvement initiatives through service- learning

Rationale  Improve the health of Wisconsin by producing physicians who: Understand community issues Value community assets Engage with community organizations Advance the health of diverse populations  Increase the number of physicians practicing in medically underserved rural and urban communities

WI County Health Rankings—2010 Report by UW Population Health Institute and RWJF Milwaukee County ranks at or near the bottom 71 or 72 of 72 counties on all indicators Three additional southern urban counties have very low rankings Many northern and central rural counties rank in the lower half of WI counties The summary health factors ranking is based on: health behaviors, clinical care, social and economic, and physical environment factors. Lighter colors indicate better performance.

The Curricular Transformation  Embed population health concepts throughout the general curriculum  Integrate medicine and community health experiential learning to develop required competencies  Weave together existing resources and curricula with new partnerships and innovative programming  Evaluate outcomes

UWSMPH Population Health Integration  Transformation Process--committees  Core Competencies determined  Resources--MERC

Population Health Integration  MS I—Population Health and Epi  MS I-MS II—Electives and MEDIC  MS III Core Days—Integrative Cases  MS IV Public Health Selectives  Public Health Honors  MPH program in SMPH

The University of Wisconsin Wisconsin Academy of Rural Medicine

Wisconsin Academy for Rural Medicine WARM  Expanded class size from 150 to 175 with 25 new positions for WARM Need for all specialties  Admissions Established subcommittee of the SMPH Admissions Committee to address WARM  Curriculum RHIG Rural Health Elective during year 2 Years three and four innovations  Rural/Regional educational development

Rural Admissions Evidence: Features of medical schools that produce rural physicians (Rabinowitz)  Strong institutional mission  Targeted selection of students Rural background Stated commitment to rural practice Stated interest in Family Medicine Retention of rural physicians associated with community engagement (Pathman)

Curricular Innovations  Rural Health Elective  Rural Clinical experiences MS I and MS II  Rural clinical experiences Summer experience between MS I and II  Externship  Community/Public Health projects  Research MS III and MS IV  Geographic innovations  Longitudinal experiences  Rural enrichment opportunities

Curricular Innovations  Community and Public Health activities

WARM in Action

Specialty Interests Grads2009 (18)2010(21)2011(25) Fam Med FM/Psych Int Med1232 Med/Ped21 Peds121 Primary Care 123 Surg122 Ortho112 Psych122 Other3535 Undecided17

WARM Outcomes  Successful institution of the WARM Admissions process  Successful establishment of three regional academic campuses  Academic success of WARM students equal to that of traditional students  WARM student ‘confidence’ in commitment to rural practice increasing

WARM Outcomes  13 graduates 2 in in 2012  9 matched in WI residencies  4 in nearby states (MN, IA and IL)  3 MPH degrees

Training in Urban Medicine and Public Health TRIUMPH TRIUMPH is a 15-month experience for 8 students beginning in January of MS III Combines existing Milwaukee-based MS IV electives & MS III Primary Care, OB/GYN IM Adds a Community And Public Health ENrichment Experience (CAPHENE) X 2 Integrates the Longitudinal Preceptorship Experience with clinical sites at CHCs Active Learning—Longitudinal Community Project Reflective Learning—Personal and social support

TRIUMPH Student Selection  MS II Recruitment, Application and Interview  Selection Criteria Based on predictors of working with the medically underserved Evidence of commitment demonstrated by background and past experiences Good academic standing  To Date: 6 Pilot, 24 regular and 8 students in abbreviated program

TRIUMPH Curriculum Framework Clinical Skills+ Personal Development+ Community and Public Health Skills Integrated & Applied in Core Curriculum and Community Health Improvement Projects Leads to the development of Community-Responsive Physicians

Community Projects Guidelines  Social Determinants of Health  Cultural Humility  Asset-Based Community Development  Principles for “community-centered” CBPR / COPC  Team Development / Coaching Activities  Define community and health issue  Develop team, roles and trust  Tailor evidence-based practices  Develop intervention  Implement, evaluate and report  Plan for sustainability

Community Projects & Healthy People 2020 categories  Access to Health Services  Adolescent Health  Diabetes  Family Planning  Health Related Quality & Well-being  Heart Disease/Stroke  Immunizations & ID  Injury & Violence Prevention  LGBT Health  Maternal, Infant & Child Health  Nutrition & Weight Status  Physical Activity  Sexually Transmitted Diseases  Substance Abuse  Tobacco Use

Outcomes  TRIUMPH increased urban health knowledge, community health and advocacy skills, and commitment to and confidence in working with urban underserved populations  77% selected PC specialties (7 in FM)  100% training in busy urban settings  4 MPH degrees

TRIUMPH in Action “I was interested in working with underserved populations, but TRIUMPH solidified this as my career goal and gave me the practical tools and confidence to be an effective community physician and advocate.”

Student Assessment  Traditional UW SMPH measures Exams OSCE Tangible product for Primary Care and Longitudinal Clerkships  Personal/Professional Development Learning Portfolio Discussions  Community Projects—WARM and TRIUMPH Milestones outlined in manual Activity Log—weekly record of time and effort Community mentor & faculty advisor feedback

Comprehensive Evaluation  Evaluation Consultant  Student, faculty and community input solicited Surveys Focus groups Key informant interviews Recruitment and retention / satisfaction  Reports to funders and accreditation organizations  Outcomes/Impact—Graduate Tracking Survey and community health improvement indicators  Project outcomes

Funding  SMPH Tuition Capture Wisconsin Partnership Program  State New allocation  Partners Aurora/BayCare, Green Bay, WI Gundersen Lutheran Health System, LaCrosse, WI Marshfield Clinic, Marshfield, WI

Challenges and Opportunities  Sustaining momentum of transformation  Logistical challenges  Selecting innovations from WARM and TRIUMPH to integrate into general curriculum  Faculty support beyond early adopters  Increasing community engagement  Evaluation over time  Funding and resources

Acknowledgement  Other pioneers in the medicine-public health initiative  Predecessors in rural and urban medical education—rich literature to guide us!  Community Partners  Transformation Task Force and the WARM and TRIUMPH Advisory Committees  Adventurous students

For more information:  General Transformation: John Brill  WARM:  TRIUMPH:  Materials on FMDRL