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Nurse Practitioner Residency Training In FQHCs Preparing tomorrow’s primary care providers May 28, 2009 Nurse Practitioner Residency Training In FQHCs Preparing tomorrow’s primary care providers May 28, 2009 Community Health Center, Inc. © 2009

Who We are… CHC, Inc. is a statewide, world-class primary care organization dedicated to Who We are… CHC, Inc. is a statewide, world-class primary care organization dedicated to transformative health care for individuals, families, and communities. We are driven by our passion and commitment to: • Clinical excellence • Research and innovation • Training of the next generation of primary care providers and other health-care professionals Community Health Center, Inc. © 2009

Why NP Residency Training? • The U. S. recognizes that it has a short Why NP Residency Training? • The U. S. recognizes that it has a short and long –term shortage of primary care providers for all populations • FQHCs currently document 6, 000 primary care vacancies, including nearly 1, 000 NP vacancies • Physician trend continues to be towards specialties and away from primary care • Literature and the experience of FQHCs confirm that new NPs find transition to complex demands as primary care providers in FQHCs extremely challenging • NPs, with focus on prevention, comprehensive care and holistic focus are ideally suited for FQHC practice • Residency is the training bridge between education and practice Community Health Center, Inc. © 2009

Nurse Practitioners and Health Centers • Community Health Centers and Nurse Practitioners are innovations Nurse Practitioners and Health Centers • Community Health Centers and Nurse Practitioners are innovations that appeared in the mid-1960 s • Dr. Loretta Ford started the first nurse practitioner program at the University of Colorado in 1965 • Early support of programs through federal Nurse Training Acts and Health Manpower acts • National Health Service Corps (1970) supported nurse practitioner scholars and assigned them to health professional shortage areas • In 2007 - 2, 677 NPs provided 7, 528, 154 visits in FQHCs Community Health Center, Inc. © 2009

Why is the 1 st ? • Nurse Practitioner education and training have historically Why is the 1 st ? • Nurse Practitioner education and training have historically been combined during the academic preparation (master’s or DNP); postgraduate residency training has never been established as an option • Federal Graduate Medical Education (GME) funds have supported physician residency training programs in hospitals since the 1960 s • 1998 amendment to Social Security Act Section 1886(k) expanded the type of nonhospital providers eligible to receive DME reimbursement, including FQHCs, but maintained restriction to physician residency training Community Health Center, Inc. © 2009

CHC Philosophy of Care • Eliminate waits, waste and delays: advanced access scheduling, team-based, CHC Philosophy of Care • Eliminate waits, waste and delays: advanced access scheduling, team-based, planned care model • Full application of the chronic care model: Pro active and engaged patients and providers • Make what should be done automatically, automatic: Incorporate prevention and health promotion into every visit, every time • Harness power of electronic health records for quality, safety, efficiency and clinical outcomes Community Health Center, Inc. © 2009

Everyone is Talking • Obama administration “alarmed at doctor shortages”, particularly “primary care providers, Everyone is Talking • Obama administration “alarmed at doctor shortages”, particularly “primary care providers, who are the main source of health care. ” • Senator Hatch – “workforce shortage is reaching crisis proportions” • – “we’re not producing enough primary care physicians” Community Health Center, Inc. © 2009

AAMC Demand-Supply Projections AAMC Demand-Supply Projections

Federally Qualified Health Centers • Started in 1965 during War on Poverty • Serve Federally Qualified Health Centers • Started in 1965 during War on Poverty • Serve as health-care home for 17 million people in over 6, 000 communities – Disproportionately low income – Predominately uninsured or publicly insured – Mostly racial/ethnic minorities • Invaluable to health delivery in the United States • Provide primary and preventive health services in medically underserved communities • Serve all people, regardless of income, health insurance status, race, culture or health status Community Health Center, Inc. © 2009

Health Centers Highlights • Institute of Medicine (IOM) and General Accountability Office (GAO) – Health Centers Highlights • Institute of Medicine (IOM) and General Accountability Office (GAO) – community health centers are effective models for: – Reducing health disparities – Managing chronic diseases • White House Office of Management and Budget – One of the ten most effective government programs • Robert Graham Center for Policy Studies in Family Medicine and Primary Care: – Health Center Costs 41% lower annually – Savings of $18 Billion in 2007 Community Health Center, Inc. © 2009

Training for Excellence in Primary Care • Primary care is changing; training needs to Training for Excellence in Primary Care • Primary care is changing; training needs to change – Patient centered (language, cultural competence, health literacy, psychosocial) – Data driven – Increased complexity of care – Must be expert at managing multiple chronic diseases and retaining focus on prevention – Timely access to primary care during and between visits – Multi-disciplinary – Team-based Community Health Center, Inc. © 2009

Solutions Discussed at National Level Train more physicians Entice more physicians to primary care Solutions Discussed at National Level Train more physicians Entice more physicians to primary care Expand the reach Diversify the workforce • Increase medical school enrollment • Increase residency enrollment • Review primary care payment/reimbursement structure • Change Medicare payment strategies • Expand the National Health Service Corps • Encourage rural and inner-city deployment • Increase investment in both education and training of nurse practitioners specializing in primary care • Remove barriers to full scope of practice Community Health Center, Inc. © 2009

Hallmarks Of All Residency Training • Service-institution based; historically hospitals, but BBA of 1995 Hallmarks Of All Residency Training • Service-institution based; historically hospitals, but BBA of 1995 allowed FQHCs to receive GME funding • Residents are typically employees, salaried, with benefits • Preceptors are assigned exclusively to the teaching and supervision of residents during precepted sessions • Residents have continuity clinics with panel of assigned patients over time • Mix of additional didactic and specialty experiences • Clearning objectives and evaluation plan Community Health Center, Inc. © 2009

CHC’s Goals in Establishing Residency • Provide new nurse practitioners with a depth, breadth, CHC’s Goals in Establishing Residency • Provide new nurse practitioners with a depth, breadth, volume, and intensity of clinical training necessary to serve as primary care providers in the complex setting of the country’s FQHCs. • Train new nurse practitioners to a model of primary care consistent with the IOM principles of health care and the needs of vulnerable populations • Create a nationally replicable model of FQHC-based Residency training for nurse practitioners • Prepare new NPs for practice in an setting—rural, urban, large or small Community Health Center, Inc. © 2009

CHC’s NP Residency In Primary Care & Community Health • Requirements: Licensed as APRN, CHC’s NP Residency In Primary Care & Community Health • Requirements: Licensed as APRN, eligible or board-certified as family nurse practitioner • Bilingual (Spanish) • Committed to practice careers as primary care providers in FQHCs • Now accepting 3 rd class of 4 residents • Applicants come from across the U. S. Community Health Center, Inc. © 2009

Structure of Residency • 12 months, full time employment at CHC, Inc. • 4 Structure of Residency • 12 months, full time employment at CHC, Inc. • 4 core elements – Precepted “continuity clinics” (4 sessions/week); expert CHC NPs and physicians as preceptors – Specialty rotations (3 sessions/wk x 1 month) in and out of CHC in orthopedics, women’s health/prenatal care, adult and child psychiatry, geriatrics, healthcare for the homeless, HIV care, – “Independent clinics”: assigned to a CHC “team” – Didactic education sessions on high volume/high risk problems – Continuous training to CHC model of high performance health system: access, continuity, planned care, team-based, prevention focused, use of electronic technology Community Health Center, Inc. © 2009

Structure of Residency • 12 months (52 weeks) • Participate in call & weekend Structure of Residency • 12 months (52 weeks) • Participate in call & weekend rotations • Clinical committees and task force involvement • Each week includes 4 elements: – Didactic sessions (1 session/week) – Precepted clinic sessions (4 sessions/week) – Specialty clinic sessions (3 sessions/week) – “Independent” clinics (2 sessions/week) Community Health Center, Inc. © 2009

Results to Date • The Connecticut legislature unanimously approved a bill supporting the NP Results to Date • The Connecticut legislature unanimously approved a bill supporting the NP Residency Program in 2007 • National Health Service Corps approved one-year deferrals of obligated service for Residents who had NHSC scholar service obligations • 1 st graduates are all in FQHC practice; 2 nd class now interviewing in FQHCs; 3 rd class just accepted. • Discussion underway with FQHCs around the country that are interested in developing NP residency training programs • Developing strategies for replicability, scaleability, and sustainability Community Health Center, Inc. © 2009

Next Steps Replicability: CHC has created a model, documented each element of the model, Next Steps Replicability: CHC has created a model, documented each element of the model, and positioned the residency for other FQHCs to adopt and replicate. Scaleability: CHC is requesting HRSA to consider a demonstration project funding 10 or more NP residency training programs in FQHCs to fully test and refine the model; develop standards for eventual accreditation Community Health Center, Inc. © 2009

Next Steps Sustainability: Medicare; Graduate Medical Education funding —would require statutory changes to allow Next Steps Sustainability: Medicare; Graduate Medical Education funding —would require statutory changes to allow funding of NP residency Medicaid; Graduate Medical Education funding —only exists informally at this time HRSA demonstration project funding for multiple FQHCs Community Health Center, Inc. © 2009

Comments or Questions ? Please Contact: Margaret Flinter, APRN, MSN, VP and Clinical Director, Comments or Questions ? Please Contact: Margaret Flinter, APRN, MSN, VP and Clinical Director, Weitzman Center for Innovation Community Health Center, Inc. [email protected] 1. com 860 347 6971 x 3622 Mark Masselli, President and CEO, Community Health Center, Inc. [email protected] 1. com 860. 347. 6971. x 3620 Nwando Olayiwola, MD, MPH, Chief Medical Officer Community Health Center, Inc. [email protected] 1. com 860. 347. 6971 x 3728 Community Health Center, Inc. © 2009