Educational Health Centers Teaching Health Centers April 3

Educational Health Centers Teaching Health Centers April 3, 2011 Roxanne Fahrenwald MD Kevin Murray MD Mike Maples MD

What IS a Community Health Center Anyway Roxanne Fahrenwald, MD Senior VP Educational and Clinical Services River. Stone Health Residency and Fellowship Director Montana Family Medicine Residency and Sports Medicine Fellowship RPS Consultant Roxanne. Fah@River. Stonehealth. org

Moses Maimonides 12 th Century CE “Do not allow thirst for profit, ambition for renown and admiration, to interfere with my profession, for these are the enemies of truth and of love for mankind, and they can lead astray in the great task of attending to the welfare of thy creatures. ” Maimonides

CHC’s - Origin • Civil Rights / Social Justice Movement – Recognition of health disparities and community/public health needs • First Health Center – Mississippi 1965 • Growth paralleled the emergence of Family Medicine specialty – Similar social drivers and goals: healthcare for all

CHC’s Now • 1200 health centers • 7000 delivery sites • 18 million patients and 63 million encounters per year • 70% of CHC patients live in poverty • Estimated to save the US health care system $9. 9 B - $17. 6 Billion annually

Who Is Served in the CHC Income

Insurance sources for those served in the CHC

Health Center National Outcomes • Diabetic pts – higher rates of eye exams, foot exams, flu shots and Pneumovax • Uninsured and Medicaid patients receive more health promotion counseling • Lower rates of low birth weight babies • Reduced disparities in access to: – Mammograms and PAP testing

Service “Preserve the strength of my body and of my soul that they ever be ready to cheerfully help and support rich and poor, good and bad, enemy as well as friend. In the sufferer let me see only the human being. ” Education “Let me be contented in everything except in the great science of my profession. Never allow the thought to arise in me that I have attained to sufficient knowledge …for art is great but the mind of man is ever expanding. ” Maimonides

Health Centers Have Requirements • Serve high need community – HPSA, Medically Underserved Area (MUA) or Medically Underserved Population (MUP) • Provision of comprehensive primary & preventive care and enabling services (education, translation, transportation) • Services available to all – fees based on ability to pay • Governed by a consumer majority Board minimum 51% patients, rest represents community

Requirements • • Hospital Privileges or equivalent Continuum of Care QI Program data reporting systems – annually submit “UDS” Uniform Data System report • Accessible hours • Regs may specify what providers are billable, services allowable

FQHC/CHC Covered Providers and Services • Influenced by state Medicaid requirements and federal regulations • Complex and sometimes non-intuitive list

Why be a Health Center? • Serve medically disenfranchised • Federal grant for sliding fee scale offset • Cost based Medicare/Medicaid reimbursement • “ 340 B” Drug Program • Federal Tort Claims Act (FTCA) instead of traditional liability insurance

What do patients pay? • Medicare – the usual coinsurance (options) • Medicaid – may have copayment • Uninsured – SFS amount plus labs -based on income/ FPL • Individual CHC Board input into the SFS

HOW CAN I USE THIS MODEL • Teaching Health Centers only one model • Many of us taught in CHCs before this • Many opportunities for models • EHCI provides tools and assistance • RPS consultants have experience

ACGME exceptions for CHC • PD control over educational activities – signed agreement with CHC board – Appointment and assignment of faculty preceptors • Admit patients and have continuity • CHC must have all required areas and staff incuding BH, lab and imaging access. RRC decides if adequate

Funding - Diversifies Opportunity • Service: – Sliding Fee Scale grant “ 330”, expansion and service grants, health care for homeless grants – Fee for service – self pay and private insurance – Cost based Medicare and Medicaid – FTCA liability insurance • Education: – GME through the hospitals, potentially DME can go to CHC – Residency targeted grants: training and equipment – Student program funding: AHEC, University programs • Both – Teaching Health Center funding

Residency : Advantages of the CHC • A plethora of patients – Endless medical need – Experience with resource management • Attract physicians as faculty who understand service in medicine • Solid model for rural and frontier care • Access to funding stream for uninsured patient care support • Attraction of residents with “the right stuff”

The Right Stuff Maimonides, 12 th century CE “May the love for my art actuate me at all times; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good…” “Grant me the strength, time and opportunity always to correct what I have acquired, always to extend its domain; for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements. ”

Teaching Health Centers: thinking strategically Mike Maples, MD CEO CHCW Yakima, WA mike. maples@commhealthcw. org For AAFP/RPS: April 3, 2011

Round 1 History • Funding opportunity timeline – Nov. 29, 2010: Guidance Issued – Dec. 30, 2010: Application Deadline – Jan. 25, 2011: Funding Awards Announced – ~July 1, 2011: THC funded residents start training

Round 1 Awards • Applications – 23 completed applications • Awards – Eleven awards • Primarily funding expansion of existing programs – 8 programs; 22 R 1 positions/yr • Two “conversions” – One established, full conversion, with expansion (9 + 1), 10 R 1 positions/yr – One full conversion of new in 2010 program: 8 R 1 positions/yr • One NEW program – W. Va. : 4 R 1 positions/yr

Round 1 Outcome Summary • Total R 1 positions/yr funded or created – 44 • FFY 2011 awards announced – $1. 9 M • Funds Committed – 25 -30 % (of the $230 M appropriation)

…. do the math • CHCW/Yakima, WA example: 2 residents per year expansion – NGA amount = $75, 000 – NGA initial period = 7/1/11 – 9/30/11 – Annualized for first year (x 4) = $300, 000 – If renewed for • Year 2 (4 funded residents)=$600, 000 • Year 3 -5 (6 funded residents)= $900 K x 3=$2. 7 M – Total potential commitment=$3. 6 M

THC Potential • Assuming that the current appropriation of $230 M over 5 years survives…. • Likely to fund a maximum of 130 -160 THC positions per year (relative to ~3, 000 Fam Med R 1 positions offered annually) • Advocacy for expanded funding

THC as “Demonstration” Project • Define the outcomes • Measure the outcomes • Can we? – Very few “pure” THC residents to be measured – Contaminated by history and hybridization • Do we need to? – Ample data currently available to demonstrate that the community-based training model works!

THC Decision Making • Major commitment to be in a position to apply – “Community-based” agency must be the accredited agency • Highly competitive – Plan B? • Current funding expires 2016 (? Sooner)

THC Competitive Strategy • Competitive advantages – Clear and direct payment to the communitybased accredited agency/teaching program – Compliance – Merit • ? Funding Preferences • ? Distribution of funding – Geographic – Specialty – Other…

THC Timeline: round 2 • Renewal – Summer • New funding awards – Fall • May be concurrent

THC Guidance: round 2 • Award amount – Direct Expense – Indirect Expense • New legislation to change rules

Becoming a Teaching Health Center -A compass to help navigate the system Kevin Murray, MD Medical Director, Faculty Division, Multi. Care Medical Associates, Multi. Care Health System Former Program Director, Tacoma Family Medicine Tacoma Washington

Resources • • • Existing legislation Local Health Center RPS NACHC Existing residencies in HCs EHCI

EHCI brief progression • • Formed from concern about FM residency stabilization needs and HCs workforce challenges in 2004 in WWAMI. Grew to collaborative group of UWSOM; UW Dept of Family Med; Network FM program directors; NWRPCA; CHAMPS. Mainly volunteer effort Relationship; design and content; advocacy Input to HRSA Development of materials to assist exploration and creation of THCs Developing consultation services now Funding expired

EHCI? ? • Educational Health Center Initiative was name we gave ourselves in early stages. • Website developed with that name • Legislation created name and they didn’t ask us! • EHCI meant to address more than just residencies in scope of med ed. and health centers

EHCI Spectrum • Heavily influenced by collaboration with HCs and their needs nursing, dentistry, other • Also influenced by political advocacy/lobbying realities • Education of various clinical disciplines social workers, nurses, dentists, pharmacists, etc • Education of various medical specialties Mainly primary care, but psychiatry is also big need • Education of varied time and administrative commitment: Occasional rotation, fixed rotation, FMC, sponsor residency

Toolkit • Developed with funding from Macy Foundation. • Intended as a public domain set of materials with ongoing revision • Want feedback to improve or correct it • Present on website with additional materials related to THC. • Will visit now

Homepage of EHCI http: //www. teachinghealthcenter. org/

Conclusion • One more location for information • Contacting current new THC’s • Collaborate by sharing experience and learning for augmentation the website • EHCI currently forming technical advisory consulting capacity. Contact us if wish to learn more about this. • What resources have you found helpful to share with your colleagues here? • Thanks

Questions?