1. Preparing for Teaching Health Center Residency Programs: Migrant and Farm worker 4 th year Transition elective Adriana Padilla, MD Clinical Professor, Family and Community Medicine, UCSF Fresno Ron Yee, MD Assistant Clinical Professor, Family and Community Medicine, UCSF Fresno and Chief Medical Officer, United Health Centers of the San Joaquin Valley

2. Background Teaching Health Centers are expected to develop as directed by the Affordable Care Act 4 th year electives have been noted to need clarity and rigor (1) The Migrant and Farm Worker elective has been a traditional elective since 2006 and is in process of developing into a transition elective for a proposed teaching health center residency program in the San Joaquin Valley (1) Stevens C. Commentary: Taking Back Year 4: A call to action. AcadMed 2010; 85: 1663-1664

3. Elective Purpose Highlight Primary Care and Rural Health Focus on Systems Based Practice Develop expertise in Latino health care; especially with migrant and farm worker populations Enhance transition to developing Community Health Center Residency Program

4. Methods 4 week elective Clinical care responsibilities 3 days per week Field work 2 days per week with local perspectives of:  Definitions and function of community health centers  Financing health care  Housing  Education  Occupational health  Border health  Community health

5. Evaluation Clinical evaluation form (UCSF clinical standard form) Reflection summaries – 4 required

6. Results 13 student participants since 2006 Reflection learning themes: Health Overweight/obesity epidemic Fitness Teen pregnancy Health Access Specialty medical care Complexity of the local Safety Net options Politics Social/Economic Housing options Work options Education

7. Reflection Learning Themes-Housing …challenge my assumption that life for migrant farm workers was uninterruptedly bleak Housing is fundamental to health in so many ways and despite the work done at the Migrant Center, many workers and their families live n inhumane conditions

8. Reflection Learning Themes- Obesity …the longer various immigrant groups remain in and assimilate to the United States, the more of our lifestyle associated diseases they acquire …those with the fewest resources face the greatest challenges in resisting them …subtleties of place, context and culture can drive both the need and the response to these challenges

9. Reflection Learning Themes- Fitness I learned that the term “environmental health” has expanded to include neighborhood accessibility to nutritious food and methods of exercise as well …small towns and depressed economic areas of the Central valley often have less access to fresh, nutritious food, simply because grocery stores cannot sustain themselves economically City planning now includes input from public health regarding sidewalks, lighting, bike paths…

10. Reflection Learning Theme - Work …the importance of work in structuring a patient’s life beyond simply their health insurance or risk of injury Patients, particularly those with few resources, do not have free choice in these lifestyle-related health determinants; where they live, what they eat, how active they are ore where and when to work

11. Reflection Learning Theme - Specialists Access to specialiaties is very limited for Medi- Cal because reimbursement rates are so low FQHC’s cover everyone, and part of their charge is to provide care to all who seek it Unfortunately there is no FQHC or PPS reimbursement system for specialist

12. Reflection Learning Theme - Politics President Obama made a point of stating that the Affordable Care Act does not provide coverage for illegal immigrants The problem with immigration status and healthcare goes to the root question – is healthcare a right or a privilege? If one argues against coverage for illegal immigrants, then healthcare is considered a privilege If one argues for coverage of illegal immigrants, then health care is considered a right

13. Conclusions Designing 4 th year transition electives as a pre-requisite for residency in community health centers provides more than just an audition purpose Transition electives can advance education and efficiency skills to promote a successful transition into residency. Student participants gain systems based knowledge and critical review skills from their reflective summaries Community based teaching health centers should be encouraged to collaborate with medical schools to design and market transition electives such as the Migrant and Farm worker 4 th elective as a favorable pre-residency experience

14. Future Work Qualitative analysis design and application to reflection summaries will drive future elective quality improvement Collaboration with the National Health Service Core can assist in designing the marketing of this transition elective