1. Deep in the Heart of Texas Development of An Integrated Rural Training Track Tricia C. Elliott, MD, FAAFP, Steve Shelton, Ph.D., * Jorge Duchicela, M.D., * Robert Youens, M.D., * Olga Duchicela, M.D., Juanita Caskey and Linda Hubbell UTMB, Family Medicine Department, Galveston and *Youens & Duchicela Clinic, Weimar

2. Educational Objectives Participants will be able: Outline the steps to create and establish an integrated Rural Training Track. Understand the challenges in establishing an integrated Rural Training Track. Learn strategies to collaborate with key stakeholders for an integrated Rural Training Track. Discuss approaches for recruiting and retaining residents for an integrated Rural Training Track.

3. Family Medicine Department established in 1971, first academic department in Texas Residency Program in Family Medicine accepted first trainees in 1972, over 270 graduates since University setting with community-based experiences Eight (8) positions per year for traditional family medicine program Two (2) positions per year for rural training track Current Program / Background

4. Vision To foster interest and enthusiasm for living and practicing in rural area To develop special knowledge and skills to be an effective rural physician

5. Facts <30 established FM rural tracks in the United States 77% of counties in Texas are rural Even more counties are designated whole or partial HPSA’s and/or MUA’s

6. Rural Texas Facts Texas has the largest rural population of all states in the U.S. The rural population totals more than 3.3 million residents, which is 13.8% of the state’s total population Rural Texas covers approximately 80% of the state’s total area 82% of the state’s incorporated cities have fewer than 10,000 residents

7. Primary Care Physicians in Rural Counties

8. Steps to Create & Establish an RTT (or IRTT) Identify rural FM group practice – Contact FM practice groups with whom you already have a teaching history – Works best with 3 or more FM physicians – All interested in teaching and with time to teach – Exam rooms, support staff adequate for continuity clinic – Space for residents’ office area in clinic – Space for on-site rural residency coordinator’s office and equipment – Adequate patient volume and breadth of problems and procedures – Willingness to dedicate administrative time to project

9. Steps to Create & Establish an RTT (or IRTT) Organize an RTT consortium – Subset of UTMB FM residency program faculty and staff – East Texas AHEC – The rural FM practice group Obtain approval/support from Institution GME/DIO and ACGME

10. Steps to Create & Establish an RTT (or IRTT) Establish the operational infrastructure to support the RTT – Funding sources – Program residency coordinator, medical educator for curriculum, project manager – Partner with rural practice physicians – Local, on-site RTT coordinator Meet hospital, nursing home, and appropriate healthcare administrators to ensure approval for residents to practice in institution

11. Steps to Create & Establish an RTT (or IRTT) Meet with CPA organization for healthcare reimbursement consulting services – Include rural group practice, hospital administrator(s), consortium members – Discuss and make decisions about financial issues with FM group and hospital administrator(s)

12. Steps to Create & Establish an RTT (or IRTT) Develop patient care practice opportunities to meet residency curriculum requirements – Rely on FM doctors in rural group to recommend and make initial contact with healthcare providers in area, e.g. Specialists who are willing to teach (without salary) Community hospitals and other healthcare agencies Healthcare promotion opportunities in the community Establish business relationships – Follow up with visits by RTT residency program personnel to specialists and administrators – Obtain Affiliation Agreements between program institution and physicians and healthcare agencies

13. Steps to Create & Establish an RTT (or IRTT) Develop strategies to recruit residents for the RTT – Include FM rural physician group in strategy sessions – Work in partnership with the FM rural group to interview and list applicants for Match Design and implement RTT curriculum – Work with rural physicians to determine what would work best while still being compliant with RRC and ACGME guidelines – Consider “Block” or “Longitudinal” format Purchase and install teleconference equipment for distance learning and education

14. Curriculum / Schedule

17. Steps to Create & Establish an RTT (or IRTT) Identify and develop community engagement opportunities for RTT residents Create press releases, announcements, to build community awareness and interest Regular meetings with all members of consortium in attendance Be flexible and creative

18. Steps to Create & Establish an RTT (or IRTT) Consult with Rural Assistance Center (supported by the Office of Rural Health Policy) – A RTT technical assistance program – Randy Longenecker, M.D. – http://www.raconline.org http://www.raconline.org

19. Challenges Identifying rural group practice – Developed site check list to assist – Not near existing residency programs – Not near metro area Keeping rural residents engaged with the home base program Building the curriculum in a block vs. longitudinal format while having to follow RRC and other requirements Long-distance training of RTT program coordinator Difficult to recruit residents to RTT in initial year

20. Collaboration with Key Stakeholders Rely on rural FM group to identify and explain program and its value to the community – Hospital board of directors – Medical staff – Community leaders – Heads of foundations/potential funding sources Sponsor luncheon or dinner for key stakeholders – Opportunity to meet individuals (all parties involved) – Discuss RTT program and plans and impact on community – Residents and Community Meet and Greet – Respond to questions

21. Collaboration with Key Stakeholders Meet individually with specialist physicians and healthcare administrators – Establish working relationships – Ensure they are clear about the program and specific teaching expectations – Ensure their willingness and ability to participate – In lieu of salary for teachers, offer academic clinical faculty appointments to the Department of Family Medicine on-line access to the medical library resources

22. Resident Recruiting Website – Develop one specifically for RTT/IRTT – Incorporate RTT/IRTT information in general FM residency program website Residency fairs Posters and brochures for residency fairs FMIG presentations Facilitate medical student rotations in our rural sites Focus on recruitment of medical students from small towns/rural areas

23. Current Status of UTMB Fam Med IRTT The first IRTT site, The Youens & Duchicela Clinic in Weimar, is ready to accept the first cohort of residents who will move there to start second year of training on July 1, 2012 41 applicants were interviewed for the 2 IRTT positions and 2 applicants matched for Academic Year 2012-2013 One additional site will be developed for implementation in 2013

24. Youens & Duchicela Clinic 3 Partners: Drs. Robert Youens, Jorge Duchicela, and Olga Duchicela Located in Weimar, TX, 128 miles from UTMB Website: www.ydclinic.com

25. Our Mission To provide residents with quality community-based rural primary care training to serve the citizens of rural Texas.

26. Questions?