1. 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

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

3. 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

4. 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

5. 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

6. 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

7. 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 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. The University of Wisconsin Training in Urban Medicine and Public Health

14. 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

15. 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

16. Curricular Activities Longitudinal Community Projects
TRIUMPH Framework (adapted from Strelnick et al. Acad Med 2008;83: )
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

17. 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

18. 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.” M3 TRIUMPH student

19. 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

20. The University of Wisconsin Wisconsin Academy of Rural Medicine

21. 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

22. 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)

24. 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

25. 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

26. Specialty Interests 2007 (5) 2008 (13) 2009 (18) Fam Med FM/Psych 4 512 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

27. WARM in Action

28. 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

29. 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

30. 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?

31. 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?

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