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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 RiverStone Health Residency and Fellowship Director - PowerPoint PPT Presentation

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Educational Health CentersTeaching Health Centers

April 3, 2011Roxanne Fahrenwald MDKevin Murray MDMike Maples MDWhat IS a Community Health Center Anyway

Roxanne Fahrenwald, MDSenior VP Educational and Clinical ServicesRiverStone HealthResidency and Fellowship DirectorMontana Family Medicine Residency and Sports Medicine FellowshipRPS ConsultantRoxanne.Fah@RiverStonehealth.org

Moses Maimonides 12th 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.MaimonidesCHCs - OriginCivil Rights / Social Justice MovementRecognition of health disparities and community/public health needsFirst Health Center Mississippi 1965Growth paralleled the emergence of Family Medicine specialtySimilar social drivers and goals: healthcare for all

CHCs Now1200 health centers7000 delivery sites18 million patients and 63 million encounters per year70% of CHC patients live in povertyEstimated to save the US health care system $9.9B - $17.6 Billion annually Who Is Served in the CHC Income

Insurance sources for those served in the CHC

Health Center National OutcomesDiabetic pts higher rates of eye exams, foot exams, flu shots and PneumovaxUninsured and Medicaid patients receive more health promotion counselingLower rates of low birth weight babiesReduced disparities in access to:Mammograms and PAP testing

Service EducationPreserve 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.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. MaimonidesHealth Centers Have RequirementsServe high need communityHPSA, 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 payGoverned by a consumer majority Board - minimum 51% patients, rest represents community

RequirementsHospital Privileges or equivalentContinuum of CareQI ProgramProgram data reporting systems annually submit UDS Uniform Data System reportAccessible hoursRegs may specify what providers are billable, services allowable11FQHC/CHC Covered Providers and ServicesInfluenced by state Medicaid requirements and federal regulationsComplex and sometimes non-intuitive list

Why be a Health Center?Serve medically disenfranchisedFederal grant for sliding fee scale offsetCost based Medicare/Medicaid reimbursement340B Drug ProgramFederal Tort Claims Act (FTCA) instead of traditional liability insuranceWhat do patients pay?Medicare the usual coinsurance (options)Medicaid may have copaymentUninsured SFS amount plus labs -- based on income/ FPLIndividual CHC Board input into the SFS

HOW CAN I USE THIS MODELTeaching Health Centers only one modelMany of us taught in CHCs before thisMany opportunities for modelsEHCI provides tools and assistanceRPS consultants have experienceACGME exceptions for CHCPD control over educational activities signed agreement with CHC boardAppointment and assignment of faculty preceptorsAdmit patients and have continuity CHC must have all required areas and staff incuding BH, lab and imaging access. RRC decides if adequateFunding - Diversifies OpportunityService:Sliding Fee Scale grant 330, expansion and service grants, health care for homeless grantsFee for service self pay and private insurance Cost based Medicare and MedicaidFTCA liability insuranceEducation:GME through the hospitals, potentially DME can go to CHC Residency targeted grants: training and equipmentStudent program funding: AHEC, University programsBothTeaching Health Center funding

Residency : Advantages of the CHCA plethora of patientsEndless medical needExperience with resource managementAttract physicians as faculty who understand service in medicineSolid model for rural and frontier careAccess to funding stream for uninsured patient care supportAttraction of residents with the right stuff

The Right StuffMaimonides, 12th century CEMay 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 goodGrant 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 strategicallyMike Maples, MDCEOCHCWYakima, WAmike.maples@commhealthcw.orgFor AAFP/RPS: April 3, 2011

Round 1 HistoryFunding opportunity timelineNov. 29, 2010: Guidance IssuedDec. 30, 2010: Application DeadlineJan. 25, 2011: Funding Awards Announced~July 1, 2011: THC funded residents start trainingRound 1 AwardsApplications23 completed applicationsAwardsEleven awardsPrimarily funding expansion of existing programs8 programs; 22 R1 positions/yrTwo conversionsOne established, full conversion, with expansion (9 + 1), 10 R1 positions/yrOne full conversion of new in 2010 program: 8 R1 positions/yrOne NEW program W. Va.: 4 R1 positions/yr

Round 1 Outcome SummaryTotal R1 positions/yr funded or created44FFY 2011 awards announced$1.9MFunds Committed25-30 % (of the $230M appropriation)

.do the mathCHCW/Yakima, WA example: 2 residents per year expansionNGA amount = $75,000 NGA initial period = 7/1/11 9/30/11Annualized for first year (x4) = $300,000If renewed forYear 2 (4 funded residents)=$600,000Year 3-5 (6 funded residents)= $900K x 3=$2.7MTotal potential commitment=$3.6MTHC PotentialAssuming that the current appropriation of $230M over 5 years survives.Likely to fund a maximum of 130-160 THC positions per year (relative to ~3,000 Fam Med R1 positions offered annually)Advocacy for expanded fundingTHC as Demonstration ProjectDefine the outcomesMeasure the outcomesCan we?Very few pure THC residents to be measuredContaminated by history and hybridizationDo we need to?Ample data currently available to demonstrate that the community-based training model works!THC Decision MakingMajor commitment to be in a position to applyCommunity-based agency must be the accredited agencyHighly competitivePlan B?Current funding expires 2016 (? Sooner)THC Competitive StrategyCompetitive advantagesClear and direct payment to the community-based accredited agency/teaching programComplianceMerit? Funding Preferences? Distribution of fundingGeographicSpecialtyOtherTHC Timeline: round 2RenewalSummerNew funding awardsFallMay be concurrentTHC Guidance: round 2Award amountDirect ExpenseIndirect ExpenseNew legislation to change rulesBecoming a Teaching Health Center-A compass to help navigate the systemKevin Murray, MDMedical Director, Faculty Division, MultiCare Medical Associates, MultiCare Health SystemFormer Program Director, Tacoma Family Medicine Tacoma Washington31 ResourcesExisting legislationLocal Health Center RPSNACHCExisting residencies in HCsEHCI

32EHCI brief progressionFormed 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 effortRelationship; design and content; advocacyInput to HRSADevelopment of materials to assist exploration and creation of THCsDeveloping consultation services now Funding expired

EHCI??Educational Health Center Initiative was name we gave ourselves in early stages.Website developed with that nameLegislation created name and they didnt ask us!EHCI meant to address more than just residencies in scope of med ed. and health centersEHCI SpectrumHeavily influenced by collaboration with HCs and their needs nursing, dentistry, otherAlso influenced by political advocacy/lobbying realitiesEducation of various clinical disciplines social workers, nurses, dentists, pharmacists, etcEducation of various medical specialties Mainly primary care, but psychiatry is also big needEducation of varied time and administrative commitment:Occasional rotation, fixed rotation, FMC, sponsor residency ToolkitDeveloped with funding from Macy Foundation.Intended as a public domain set of materials with ongoing revisionWant feedback to improve or correct itPresent on website with additional materials related to THC.Will visit nowHomepage of EHCI http://www.teachinghealthcenter.org/

ConclusionOne more location for informationContacting current new THCsCollaborate by sharing experience and learning for augmentation the websiteEHCI 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?Chart20.0860.0670.1430.704

151-200% FPL 6.7%Over 200% FPL, 8.6%101-150% FPL 14.3%

Sheet1Nation-wide CHC Patient DemographicsIncomeOver 200% FPL8.6%151-20% FPL6.7%101-150%14.3%100% FPL and Below70.4%

Sheet1

101-150% FPL 14.3%Over 200% FPL, 8.6%151-200% FPL 6.7%

Sheet2

Sheet3

Chart60.3890.3540.1550.0760.026

Sheet1Nation-wide CHC Patient DemographicsIncomeOver 200% FPL8.6%151-20% FPL6.7%101-150%14.3%100% FPL and Below70.4%

Sheet1

Over 200% FPL, 8.6%151-200% FPL 6.7%101-150% FPL 14.3%

Sheet2National CHC DataRace/EthnicityAmerican Indian/Alaske Native1%Asian/Hawaiian4%More than One Race4%African American28%White62%

Sheet2

American Indian 1%Asian or Hawaiian 4%More than One Race 4%African American 28%White 62%

Sheet4National CHC Demographics - 2007 UDS DataInsurance StatusUninsured38.9%Medicaid35.4%Private15.5%Medicare7.6%Other Public2.6%

Sheet4

Sheet3National CHC DemographicsEthnicityHispanic or Latino34%All Others66%

Sheet3

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