SUZANNE ALLEN, MD, MPH JAY ERICKSON, MD TOM GREER, MD, MPH WILLIAM R. PHILLIPS, MD, MPH UNIVERSITY OF WASHINGTON SCHOOL OF MEDICINE APRIL 26, 2012 Engaging Communities and Practices in Education

Overview WWAMI TRUST RUOP WRITE TRUST Learning Collaborative Linked student projects in continuity community

U N I V E R S I T Y O F W A S H I N G T O N S C H O O L O F M E D I C I N E WAMI Region 1974 Psych IntMd Peds ObGyn Peds Great Falls Montana State University Bozeman Missoula Billings University of Alaska Fairbanks Anchorage Boise Pocatello University of Idaho Moscow Washington State University Pullman

Community Medical School Residency

TRUST in Washington Ellensburg Grand Coulee Spokane W Port Angeles Moses Lake Chelan W W Port Townsend Ferndale / Lynden W W Shelton Newport Washington WRITE Site WWAMI Regional Office W W W W W

TRUST in Montana Libby W Lewistown W W Whitefish Helena W Montana Shelby W W W W Miles City Dillon Butte WRITE/TRUST Site WWAMI Regional Office W

Rural/Underserved Opportunities Program RUOP is….. 4-week immersion experience in rural or urban- underserved WWAMI community between 1 st and 2 nd years. Started in 1989 Clinical and community experiences.

RUOP Curriculum Goals 1. Early exposure to the challenges & rewards of delivering primary care to underserved populations 2. Promote a positive attitude toward rural & urban underserved community medicine. 3. Opportunity to learn how community health care systems function.

647 Community Preceptors have donated their time to mentor 1,843 medical students

RUOP + iii SOM Independent Investigative Inquiry requirement III-3 Curriculum integrated with RUOP experience Experience Driven Inquiry

COPC Framework Community Oriented Primary Care -COPC is a systematic approach that requires collaboration with the community to: Determine the major strengths and health care needs in the community Prioritize those needs Design an appropriate intervention to address those needs

References Acton, K., Rogers, B., Campbell, G., Johnson, C., Gohdes, D. (1993) “ Prevalence of diagnosed diabetes and selected related conditions of six reservation in Montana and Wyoming ” Diabetes Care 16(1): Lombard, KA., Forster-Cox, S., Smeal, D., O ’ Neill, MK. (2006) “ Diabetes on the Navajo nation: what role can gardening and agriculture extension play to reduce it? ” Rural Remote Health 6(4): 640. Armstrong, DL. (2000) “ A community diabetes education and gardening project to improve diabetes care in a Northwest American Indian tribe. ” Diabetes Education 26(1): Devlin, H., Roberts, M., Okaya, A., Xiong YM. (2006) “ Our lives were healthier before: focus groups with African American, American Indian, Hispanic/Latino and Hmong people with diabetes. ” Health Promotion Practice 7(1): Boyette, M.D., Bilderback, T.E. (1996). A Small Backyard Greenhouse for the Home Gardener. Retrieved June 1, 2007 from Turrel, G., Hewitt, B., Patterson, C., Oldenburg, B., Gould, T. (2002) “ Socioeconomic differences in food purchasing behavior and suggested implication for diet-related health promotion. ” Journal of Human Nutrition and Dietetics 15(5): U.S. Department of Health and Human Services, HIS ( ) TRENDS in Indian Health. Retrieved on June 1, 2007 from Montana Climate Summary. (n.d.) Retrieved June 5, 2007 from Climate of Montana (n.d.) Retrieved June 5, 2007 from Discussion In a community where diabetes has become epidemic in its incidence and severity, community oriented medicine requires more than regular patient education and sensitization during visits to the clinic. Organizations targeting the disease have taken it upon themselves to go out into the community and support behaviors and encourage activities such as gardening. Health care providers outside of the clinic setting should support such proactive measures. Contributing new ideas that support the ongoing efforts of an organization increase its capacity. Physician involvement in that capacity building improves the legitimacy of the organization in the eyes of patients and attitudes of those outreach persons who are working outside the clinic. The Blackfeet people often come together as a community to build traditional structures such as teepees, medicine lodges at the Sun Dance festivals and sweat lodges. Studies have recommended that interventions in community health be culturally sensitive and incorporate traditional values. Greenhouse construction is an example of how tribal traditions of building small shelters that enhance spiritual, social and family life can be extended into the area of food security. Purpose This project seeks to offset the geographical and climatic features that challenge attempts to attain a healthy diet by integrating the concept of an inexpensive family greenhouse into home gardening programs implemented by local diabetes organizations and active gardeners already operating within Heart Butte. A greenhouse, correctly utilized will extend the growing season for plants that require more than ninety days to reach maturity and protect seedlings that would easily be damaged by late spring frosts thereby allowing citizens to supplement their diets with affordable vegetables. Methods Research was done to design the appropriate structure necessary for the extreme weather that Heart Butte experiences. The North Carolina Cooperative Extension Service a division of the North Carolina State University College of Agriculture and Life Sciences has engineered an inexpensive, stable greenhouse that can withstand high winds and up to four inches of snow. Contributions from local gardeners allowed for its construction in Heart Butte during which time four individuals were trained in its assembly. Materials were attained from local businesses with costs totaling $150. Community training and awareness of the greenhouse design was organized through the Blackfeet Special Diabetes Program titled the “ Healthy Heart Project. ” Already involved in community outreach and patient contact through a family gardening program and the diabetic clinic at the hospital this community-based organization was the ideal group with which to network. During a Diabetic Clinic held at the hospital staff of Healthy Heart and associated patients were trained on the greenhouse construction process. Results Number of people trained in greenhouse construction (directly): 4 Number of people trained in greenhouse construction (indirectly): 15 Number of community organization outreach workers trained: 5 Number of community organization with increased capacity: 1 Number of greenhouses constructed: 1 Members were very excited about the concept of a low cost greenhouse. Currently all the seedlings used in the outreach projects are from the Blackfeet Community College which is far from many of the communities around Browning in which Healthy Heart is trying to operate creating additional transport needs for all the plants. It was suggested that at least one greenhouse be built in town where they were operating that could be maintained by a single family or a group of families. Background In the town of Heart Butte, MT the high cost and distance to affordable food has a major impact on the diet of the local population. The nearest grocery store with vegetables is twenty miles away, but citizens often commute up to two hundred miles to purchase affordable groceries. Heart disease and diabetes, both chronic illnesses that require adherence to a specific diet high in vegetable content, are epidemic among the Native American Indian population. Diabetes mellitus in particular has an incidence among Native Americans three times that of the general U.S. population. Heart Butte is located at a latitude known for high winds, a short growing season and killing frosts. This challenges many attempts by the community to cultivate crops that would supplement their diet. Positive dietary decision making in Heart Butte is undermined by the geographic, financial, and environmental choices available to the community. Acknowledgements Special thanks to Dr. Mary DesRosier and her family, John Padget, the Staff of the Heart Butte Clinic, The Healthy Heart Project, The Southern Piegan Diabetes Program and Blackfeet Community Hospital. Affordable Greenhouse Construction: A Response to the Climatic and Geographic Impediments to a Diabetic Diet in Heart Butte, MT University of Washington School of Medicine, III Intervention, 2007 Megan Chandler,WWAMI, MS-II

WWAMI Rural Integrated Training Experience- WRITE 20 week immersion experience for 3 rd year students Started in 1996 Modeled after Minnesota’s RPAP program Help meet the need for rural physicians in the WWAMI region 103 students have participated

WRITE in 5 WWAMI States Note: Alaska not to scale W Sandpoint Libby McCall Hailey Powell Wasilla Ellensburg W Lewistown Grand Coulee Juneau Boise Anchorage Cheyenne Spokane Lander WRITE Site WWAMI Regional Office W W W W Whitefish W Port Angeles W Moses Lake Chelan Helena W W W W W W W W W W Port Townsend Ferndale / Lynden W W Shelton Newport W Washington Alaska Idaho Montana Wyoming Shelby W W W W Miles City Dillon Butte Douglas W

WRITE Student Objectives Become familiar with a rural community Become a member of the rural healthcare team 20 week continuity experience Social integration into a rural community Instill confidence and professionalism Become independent learners

WRITE Clerkship Credit Family Medicine-6 weeks Internal Medicine-4 weeks Pediatrics-3 weeks Psychiatry-3 weeks Elective-4 weeks  Usually Family Medicine

Community Project Allows the WRITE student to better understand and give back to the community Use COPC methodology learned in RUOP Required in order to pass WRITE experience

Community Projects Spanish Diabetic Education Booklet Creating a Free Clinic in Powell, WY Tobacco-use Prevention - Introducing Tar Wars Program to the Community Fluoride Varnish Protocol in Primary Care Clinics Trekking Through Nutrition: Childhood Obesity Treatment and Prevention in Lewistown, MT Home Safety Assessment Program Educate Community about Exercise in Pregnancy Methamphetamine Survey: Jr & Sr High School Communities Depression in the Elderly; Helping the Community Recognize the Signs Diabetic Self Health Care Survey

New Initiative 1. Build on the students’ longitudinal experience in their TRUST communities. 2. Start and end with needs of communities and the practices. 3. Prepare students for their future practices. 4. Rely on the expertise of the community practitioner teachers.

TRUST Continuity Community. Build TRUST Learning Collaborative. Link student TRUST Projects. Partner on shared educational theme: “Preparing for Practice Innovation”

TRUST Learning Collaborative Learn the needs of communities and practices. Design integrated learning experiences for our students. Facilitate adaptation, innovation and growth.

TRUST Learning Collaborative Survey of practices Inaugural TRUST clinical faculty meeting Annual faculty development meetings Expert consultants on practice transformation Regular WWAMI faculty visits

Link student TRUST projects TRUST Continuity Community 1. Community Orientation 2. Community Project 3. Continuity Practice Project

Orientation – 1 st Summer Observe the burden of chronic illness in seniors. Community Project – Summer Years 1-2 Develop DM foot care program at Senior Center. Practice Project – Year 3 Use EHR to build DM patient registry for chronic care monitoring and recall. Linkage from 1 st Summer to Year 3

Needs of community and practice Student observation and lived experience in TRUST Continuity Community. Work in the community to address population and community needs. Work in the practice to help improve systems of care that address related needs. Integrate over 4 year TRUST Continuum.

Prepare students for their future “Preparing for Practice Innovation ” PCMH - Patient-Centered Medical Home Inter-professional team care Quality improvement Health information technology Patient-centered care Care coordination Population care Community linkages Enhanced access Managing change

Challenges Teaching practices vary widely with different:  Visions of the future  Demands of current environment  Stages of transformation toward PCMH. University cannot fund practice change. Learn about the future by practicing in the present.

TRUST PPI Program “Preparing for Practice Innovation” Linked student projects Web-based learning modules Elective courses Underserved Pathway Mentoring

QUESTIONS? Thank you

Acknowledgements Local communities and preceptors UW School of Medicine Department of Family Medicine HRSA Grants  HRSA three year grant - TRUST  HRSA five year grant – TRUST and PPI Washington Academy of Family Physicians Foundation Montana AHECs Montana Blue Cross Blue Shield Washington AHECs

Suzanne Allen, MD, MPH  Jay Erickson, MD  Tom Greer, MD, MPH  William R. Phillips, MD, MPH  Contact Information