Virtual Medically Underserved Areas and Populations Interest Group Meeting Notes

Announcements

The purpose of the sessions is to connect the GME community working in medically underserved areas and populations with the ACGME, fostering information and knowledge sharing.
An article was published in JGME last August introducing the common program requirements major revisions process, which occurs every ten years.
- The first opportunity for public input will be a survey with specific questions and open-ended comments.
- This process aims to reduce barriers to GME development for rural and underserved programs.
- Focus groups with MUAP stakeholders have started to gather input on suggested changes.
- The goal is to ensure MUAP voices are heard by communicating suggested changes for the MUAP community to include in the survey

Chat Check-In

Wins:
- Recent publications.
- Promotions.
- Positive personal updates.
Resources:
- Links to articles or websites.
- Other resources for GME colleagues.
Support:
- Answers to questions.
- Needed resources.
- Facing challenges.
- Other requests for support.

Presenters

Angela Cole: DIO of the Detroit Wayne County Health Authority in Michigan (Authority Health).
Dr. Veronica Hooper: Chief Health Officer and DIO at Yakima Valley Farm Workers Clinic in Washington State.

Angela Cole Presentation: Partnerships in Underserved GME Teaching Health Centers

Introduction to Graduate Medical Education (GME) in Underserved Areas
- GME programs in underserved areas like Detroit are essential for addressing healthcare disparities and enhancing access to quality care.
- These programs train physicians within the communities they serve, promoting long-term commitment.
Role of Partnerships in Enhancing GME Programs
- Partnerships are critical for GME programs in underserved areas, bringing together resources, expertise, and community engagement.
- Types of Partnerships:
  - Academic Partnerships: Medical schools and universities.
  - Clinical Partnerships: Federally Qualified Health Centers (FQHCs).
  - Government and Public Health: HRSA funds Teaching Health Centers (THCs).
  - Community-Based Organizations and Advocacy Groups: e.g., Association for American Teaching Health Centers.
  - Health systems and hospital affiliations: subspecialty rotations and procedural training, faculty development, access to broader clinical/academic infrastructure, post-residency employment and fellowship placement.
  - Workforce and Policy Collaborations: workforce boards, health alliances, legislators to advocate for GME funding and address physician shortages.
- Strategic partnerships are foundational for the success, relevance, and sustainability of GME programs in underserved communities like Detroit, ensuring clinically competent resident physicians who are deeply rooted in their communities.
Objectives of Partnerships in Underserved GME Teaching Health Centers
- Aims to enhance training quality, expand clinical capacity, support sustainability, address health disparities, and strengthen the workforce pipeline.
- Fosters a mission-driven learning environment equipping residents to serve, lead, and remain in communities in need.
Teaching Health Center (THC) GME Programs
- Community-based residency training programs in FQHCs, rural health centers, and safety net settings.
- Funded by HRSA to train physicians in primary care specialties within underserved communities.
- Purposes:
  - Address physician shortages and retain primary care physicians in medically underserved communities.
  - Create a pipeline of physicians likely to practice in rural and urban safety net settings post-residency.
  - Promote community-centered, ambulatory-based training, shifting the focus from inpatient hospitals to outpatient community health settings.
  - Emphasize continuity of care, preventative medicine, and population health.
  - Enhance health equity and access by training residents to address social determinants of health and health disparities.
  - Support innovative, mission-driven medical education, advancing trauma-informed care, behavioral health integration, and chronic disease management.
  - Encourage physician leadership and advocacy in public health policy and healthcare reform.
  - Strengthen the primary care workforce, building a sustainable and diverse healthcare workforce.
- Represent a transformative model of medical education aligned with health equity, primary care access, and community wellness.
Teaching Health Centers vs. Traditional Hospital-Based Residency Programs
- Focus: Community-based (FQHCs) vs. Hospital-based.
- Mission: Underserved care and primary care vs. Broad clinical training.
- Funding: HRSA vs. Medicare (CMS, GME).
- Curriculum: Health equity and outpatient care vs. Inpatient medicine and specialty focus.
- Community Involvement: High vs. Variable.
- Likelihood of Local Retention: High vs. Lower.
Legislative Background and Funding Sources
- Established by the Affordable Care Act in 2010 (Section 5508), creating the Teaching Health Centers Graduate Medical Education Program to address primary care physician shortages by funding community-based residency training in FQHCs and similar sites.
- Aimed to decentralize GME from hospitals and expand primary care access in underserved areas.
- Reauthorization and extensions through various legislative actions, including the Teaching Health Center Extensions Act of 2021, which reauthorized funding for fiscal years 2021-2023, providing $126,500,000.00$ per year.
- Ongoing advocacy for permanent authorization, increased per resident allocation, and expansion of eligible training sites and programs through organizations like AATHC, NACHC, ACGME, and HRSA-funded institutions.
- Funding source: HRSA, currently at a per resident rate of $160,000$ (up from $150,000$ ).
  - Recent cost studies estimate the true cost of training a THC resident is approximately $227,000$ , highlighting a significant funding gap.
- Institutional and community support: Many THC programs are embedded in FQHCs, hospitals, and health departments that contribute in-kind support, grant matching, or supplemental funding.
- University partners may provide shared educational resources and faculty time.
- Additional grant opportunities are necessary to meet program funding needs.
The Need for Teaching Health Centers in Underserved Communities
- Physician Shortages and Their Impact:
  - Challenge: Shortages of primary care physicians, psychiatrists, pediatricians, and obstetricians in underserved urban and rural areas.
    - Over 100 million Americans live in Health Professional Shortage Areas (HPSAs).
    - Projected shortfall of up to 86,000 physicians by 2036, particularly in primary care and mental health.
  - Solution: THC programs are intentionally placed in high-need communities like FQHCs and rural clinics, increasing the likelihood that physicians will stay and practice locally.
    - Up to 65% of THC graduates practice in underserved areas, directly addressing workforce gaps.
- Addressing Healthcare Disparities Through GME:
  - Challenge: Underserved populations face disparities in access, quality, and outcomes; traditional GME models often lack structured training.
  - Solution: THC programs are rooted in the community and often partner with public health agencies, housing services, and schools.
    - Residents receive formal training in health equity, population health, and community engagement, creating a new generation of physician advocates.
- The role of teaching health centers in improving patient outcomes.
  - Challenge: Communities without access to primary care providers often experience higher emergency department usage, poor chronic disease management, and preventable hospitalization.
  - Solution: Emphasize continuity of care, preventative medicine, and team-based approaches in outpatient settings. Residents care for the same panel of patients over multiple years.
Stakeholders in THC Partnerships
- Federally Qualified Health Centers (FQHCs):
  - Role: Primary care training sites, providing real-world, community-based training environments and continuity of care for underserved populations.
  - Contribution: Clinical space, patient populations, preceptors, community access, and support services.
- Academic Institutions (Medical Schools):
  - Role: Academic and curriculum oversight, ensuring ACGME accreditation standards are met.
  - Contribution: Curriculum development, shared faculty resources, and educational infrastructure.
  - Awarding of dual programs or certificates, for example, in population health or health equity.
- Residents and Faculty (Learners and Mentors):
  - Role: Residents serve as learners and care providers in high-need areas; faculty provide mentorship, supervision, and leadership.
  - Contribution: Residents contribute to high care delivery while being trained; faculty ensure education quality and alignment with mission-based goals.
- Government Agencies and Policymakers (Health Resources and Services Administration - HRSA):
  - Role: Federal funder and policy driver, administering THC GME programs through the Bureau of Health Workforce.
  - Contribution: Provides resident allocation funding to supporting the training costs and shapes national GME policy to address workforce needs.
- Sponsoring Institutions (GME Consortium):
  - Role: Administrative and compliance oversight, overseeing accreditation, compliance, and program evaluation.
  - Contribution: Centralized management of multiple residency programs, strategic planning, advocacy, and reporting to accrediting and funding bodies.
- Community-Based Organizations and Public Health Agencies:
  - Role: Social and public health integration, collaborating on addressing broader health needs beyond the clinic walls.
  - Contribution: Enhancing resident understanding of community challenges and nonclinical solutions while providing opportunities for outreach, education, and joint initiatives.
- State and Local Policies:
  - Role: Policy advocacy and support, shaping workforce development strategies and funding and incentives.
  - Contribution: Potential for additional funding, loan forgiveness programs, and legislative support while helping to integrate THCs into broader public health and workforce planning efforts.
- National Advocacy Organizations (e.g., AATHC, NACHC, AAFP, ACGME):
  - Role: Providing research, policy, and legislative advocacy.
  - Contribution: Drive national support and visibility of THCs while shaping policies that ensure the long-term sustainability of community-based GME.
Benefits of Partnerships in Teaching Health Centers (THCs)
- Enhanced training quality.
- Expanded clinical capacity.
- Improved workforce retention.
- Program sustainability and funding support.
- Community engagement and health equity.
- Policy and advocacy leverage.
Challenges in Establishing Partnerships
- Funding limitations and sustainability concerns (dependence on federal funding, delays in reauthorization).
- Misalignment of institutional goals (academic institutions, clinical sites, and community organizations have different timelines, priorities, or expectations).
- Administrative and regulatory complexity (navigating ACGME accreditation, HRSA compliance, and multiple legal agreements).
- Limited faculty and preceptor availability (shortage of experienced clinicians willing or able to serve as faculty).
- Resource constraints at training sites.
- Cultural or operational differences between the partners.
- Community trust and engagement barriers.
Strategies for Building Partnerships
- Aligning missions and goals between partners.
- Securing sustainable funding sources.
- Leveraging policy support and advocacy.
Case Studies and Best Practices
- Authority Health as an example of a successful partnership, being the second-largest teaching health center with partnerships across Southeastern Michigan.
- Shared vision is critical.
- Faculty development requires investment.
- Flexibility and adaptability wins.
- Data-driven impact demonstration.
Authority Health Residency Outcomes
- Since the first graduating class in 2015, 90 residents have completed the program, with 22 more graduating next month.
- 56% have gone into medically underserved areas and populations to practice (14% at health centers, 40% in ambulatory sites, 6% rural).
- 43% have remained in Michigan to practice after completion.
Recap
- Teaching Health Centers (THCs) are a transformative model of graduate medical education focused on training primary care physicians in underserved community-based settings.
- THCs address physician shortages, reduce health disparities, and improve community health outcomes through partnerships. Key elements for success include aligned missions, sustainable funding, faculty development, and active policy advocacy.
- Emerging trends like behavioral health integration, telehealth, and interprofessional education are shaping the future of community-based graduate medical education.

Dr. Veronica Hooper Presentation: Yakima Valley Farm Workers Clinic

Vision: The health of each person is the health of humanity.
Mission: Together we transform our communities through compassionate individualized care, eliminating barriers to health and well-being.
Values: Incorporating mission, vision, and values as programs are developed.
Yakima Valley Farm Workers Clinic: Located across two states with numerous medical, dental, and pharmacy locations, as well as behavioral health locations and other programs.
Residency Location: Grandview, Washington, a rural area in need of healthcare.
Services: Range from family practice to integrated team-based approaches, including behavioral health, dietitians, nurse practitioners, PAs, and specialized services like dermatology.
Patient Volume: Over 200,000 patients served in 2024, with 42% being children.
Patients Below Poverty Line: Over 100,000 patients living below the poverty line, emphasizing the need for care in a rural setting.
Engaging Clinicians: Importance of engaging clinicians to teach the next generation, as HRSA grants do not generate profit. Stats are used to show community need.