Taking the LEAD: Developing a Pipeline to Care for Wisconsin’s Medically Underserved Patients John Brill, MD, MPH; Byron Crouse, MD; Marge Stearns, MPH; Jeffrey Stearns, MD; Cindy Haq, MD, & Alison Klein, MPA University of Wisconsin School of Medicine and Public Health Handouts: Copy of TRIO Poster in black and white on legal size paper TRIUMPH Framework handout (same as in Jacksonville) Post on FMDRL: slides: TRIUMPH brochure, WARM brochure, TRIO poster

Session Goals & Format Rationale/Background Mission Methods Pipeline Programs RUSCH WARM TRIUMPH Small Group Discussions--Rural, Urban, Pre-med Programs Share Insights/Feedback

Rationale Shortage of physicians in rural WI and Milwaukee’s urban core, with demand expected to exceed supply during next 20 years—who will staff medical homes? 83% of WI counties are underserved 77% of those counties are rural Access barriers in Milwaukee include income, insurance status, ethnicity & 133 Health Professional Shortage Areas Health disparities in rural and urban WI

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. Health Factors are what influence the Health outcomes—physical environment (10%); SES factors (40%); Clinical care (20%); and health behaviors (30%) Health behaviors include measures of smoking, diet and exercise, alcohol use, and risky sex behavior. Clinical care includes measures of access to care and quality of care. Social and economic factors include measures of education, employment, income, family and social support and community safety. Physical environment includes measures of environmental quality and the built environment. Snapshot of City of Milwaukee: Higher premature mortality & morbidity rates than WI Low birthweight and high teen birth rates High STI rates Adult smoking rates high Low HS graduation rates 34% children live in poverty High unemployment rates 2 x #children with lead poisoning as rest of state

Promoting health careers in rural and urban medicine Mission: Increase access to healthcare and health for Wisconsin’s medically underserved populations by… Promoting health careers in rural and urban medicine Developing a pipeline of medical education programs Integrating training in clinical medicine and public health Producing physician leaders and advocates

Method: Create A Trio of Programs Select students with interests and backgrounds conducive to future practice in Wisconsin’s rural and urban underserved areas Integrate medicine and public health to develop required competencies Weave together existing resources and curricula with new partnerships and innovative programming

Pipeline to Increase Access to Healthcare and Improve Health in WI Pre-med WI AHEC & rural and urban school systems RUSCH—Rural and Urban Scholars in Community Health @ UW-Milwaukee & UW-Platteville Med School TRIUMPH—Training in Urban Medicine and Public Health WARM—Wisconsin Academy of Rural Medicine Post-med GME with focus on rural and urban underserved Alumni practice in rural and urban WI HPSAs CME to support practicing clinicians

Comprehensive Evaluation for Trio of Programs 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 Tracking outcomes/impact over time will be facilitated by building sustainability into projects/long term commitment TRIUMPH and WARM required changes in LCME reporting process—new campuses added due to longitudinal nature of experience

Partnership with UW-Milwaukee & UW-Platteville Aim: The University of Wisconsin Rural and Urban Scholars in Community Health Partnership with UW-Milwaukee & UW-Platteville Aim: Attract pre-med students who plan to practice in rural or urban WI Recruit students from diverse and disadvantaged backgrounds Provide 2 years of programming to prepare them for medical school and future practice

Rural and Urban Scholars in Community Health RUSCH 2 summer internships—community health project and clinical research Academic year seminars MCAT Preparation support Service Learning Shadowing

RUSCH Student Selection Qualifications Predictors of working with the medically underserved Rural or urban background/experience Community service and leadership GPA 3.0 or higher Prerequisite courses Application Process Letters of Recommendation Interview

RUSCH 2009-Now Students Curricula under development UWM RUSCH—12 students (4 r/8 u) UWP RUSCH—6 students (4 r/2 u) Curricula under development Each site has autonomy for local offerings Clinical research experience in Madison Funding from UW SMPH Positive student and partner feedback

The University of Wisconsin Training in Urban Medicine and Public Health

Training in Urban Medicine and Public Health TRIUMPH TRIUMPH is a 15-month experience for 8 students beginning in January of M3 yr Combines existing Milwaukee-based M4 electives & M3 Primary Care, OB/GYNE, and IM clerkships Adds a Community And Public Health ENrichment Experience (CAPHENE) X 2 Integrates the Longitudinal Preceptorship Experience with sites being added at three Milwaukee CHCs Longitudinal Community Project

TRIUMPH Student Selection M2 Recruitment TRIUMPH summer experience Urban Med Interest Group Information sessions Premed Pipeline under construction 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

Curricular Activities Longitudinal Community Projects TRIUMPH Framework (adapted from Strelnick et al. Acad Med 2008;83:378-379) Clinical Patient Care Community Health Medical Student/ MD As Person Curricular Activities Longitudinal Community Projects Abbreviated version—see handout. Acknowledge contribution of the Residency in Social Medicine at Montefiore. Core Competencies: Cultural humility and sensitivity Knowledge of community health resources Experience working with interdisciplinary teams Skills to engage urban communities and reduce health disparities

TRIUMPH Student Assessment Traditional UW SMPH measures Exams OSCE Tangible product for Primary Care Clerkship Personal/Professional Development Urban Learning Portfolio Reflection Log and discussions (NING) Community Projects Milestones outlined in manual—timeline, logic model, workplan, outputs, outcomes, presentations, final report and self-evaluation Activity Log—weekly record of time and effort Community mentor & faculty advisor feedback Activity log is on NING website—required weekly recording and the data will go into a database. Every six months a record will be generated for the student and community advisor to sign attesting to project activity. Reflection log—required to provide reflection on activities at least once a month—also on NING

TRIUMPH 2008—Now Students: 6 in Pilot & 8 in current cohort Expanding community partnerships Service Learning—clinical and community health projects Positive feedback from students and mentors Pilot group—Urban-based residency selections and 1 MPH degree “Medical school focuses a lot of attention on providing us with the knowledge we need to treat patients. But it doesn’t take long to realize that in order to truly help patients find health, you need to spend time learning about their culture andlifestyle as well. This is more difficult and not something that can be found in a textbook.” 2009 M3 TRIUMPH student

TRIUMPH in Action These photos show the three components of TRIUMPH—learning about the community and community health improvement; clinical skill development in an urban clinic; humanism round—learning how to care for yourself as a physician Hannah at South Division HS CAPHENE at Wisconsin Black Historical Society and Museum with the Queens of Harmony Hannah with Dr. Liz Bade at Sinai Family Care clinic on PCC Humanism rounds with Drs. Haq and McBride

The University of Wisconsin Wisconsin Academy of Rural Medicine

Wisconsin Academy for Rural Medicine WARM Expanding 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 Focus on primary care (esp. FM) Retention of rural physicians associated with community engagement (Pathman)

Curricular Innovations Content Context Continuity of patients and community Classroom Experiences Medical education through a “rural lens” Rural elective Content Timing Rural Health Interest Group Educational Context Continuity – patient and community Another option to review curricular innovation is more chronologically: Years one and two Rural experiences Classroom experiences Rural Interest Groups Summer Clerkship Years Three and Four Clerkship location Electives

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 Byron – 20 minutes on curriculum Educational Content Context Continuity

Specialty Interests 2007 (5) 2008 (13) 2009 (18) Fam Med FM/Psych 4 5 12 1 Int Med Med/Peds 2 Peds Surg Ortho Ob Gyn Undecided 3 Talk with this slide about admissions challenges – While too early to clearly define outcomes, concern about number of applicants and quality – both academic and rural For academically weak – interest in Health Sciences Post Bac For rural - refer to traditional program

WARM in Action

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

Acknowledgement Predecessors in rural and urban medical education—rich literature to guide us! Community Partners WARM and TRIUMPH Advisory Committees and RUSCH Development Team Adventurous students Students at Lao Buddhist Center at 19th and National

Challenges and Opportunities Student recruitment and admissions Curriculum development Faculty support Community engagement Retention Evaluation Funding Maybe each of should have some challenges and opportunities to lay for each program to set the stage for the small group discussions?

Small Group Discussions— How to grow the Pipeline? 3 Groups—Urban and Rural Tracks & Premed Programs Discussion—30 minutes What is your experience/interest in this pipeline component? Discussion focused on program details… challenges…problem-solving. Group Reports—15 minutes Lili with one of the Queens of Harmony and Clay Dean at home on the farm Common Questions—have groups serve as “focus groups” Introductions—experience/interests of participants Questions about the program component of interest—what do you want to know about in more detail? Challenges that we have identified—what other challenges do you see? What are barriers to success? What are promoter of success? Other components of the pipelines—ideas on how to further develop pre-college , GME, CME programs. Replication issues—could you do this in your institution/state?

For more information: RUSCH: http://med.wisc.edu/RUSCH WARM: http://med.wisc.edu/WARM TRIUMPH: http://med.wisc.edu/TRIUMPH Materials on FMDRL