Rural Training Tracks: Growing your own rural workforce Randall - PDF document

11/14/12 ¡ Rural Training Tracks: Growing your own rural workforce Randall Longenecker MD Project Director, RTT Technical Assistance Program November 16, 2012 RTT Technical Assistance Program RTT ¡Technical ¡Assistance ¡Program ¡ “A ¡consortium ¡of ¡organizations ¡and ¡individuals ¡committed ¡to ¡ ¡ sustaining ¡RTTs ¡as ¡a ¡strategy ¡in ¡rural ¡medical ¡education” ¡ 1. Sustain established RTTs www.raconline.org/rtt/ ¡ 2. Assist in the development of new RTTs ¡ 3. Increase the number of students who match to RTTs through student initiatives and alliances • Focus groups and dine outs • Parallel web site www.traindocsrural.org; various social media • NRHA Student Constituency Group Blog • Medical School Rural Training Track inventory and network (Deutchman) ④ RTT Masterfile – Data on program characteristics and outcomes Participants will be able to: History of 1-2 RTTs: Accreditation • Describe the variations of "1-2" RTTs that have emerged • 1985 – Proposed by Bob Maudlin of Family Medicine Spokane as a strategy to graduate more physicians to rural practice and to from the original 1-2 RTT prototype (Spokane Model) better prepare them professionally and personally to practice • Understand current limitations in sustaining such training and live in rural places streams • 1986 – ACGME approval as an “experimental pathway” the “1-2 • Articulate evolving conditions and design other place- RTT” (one year in the urban sponsoring program, two years in based strategies for rural training the rural place) 1 ¡

11/14/12 ¡ History of 1-2 RTTs: Accreditation History of 1-2 RTTs: Accreditation The OSU Rural Program – Three Year Curriculum • 1996 – Additional formal requirements by the RRC in Family Intensive immersion experiences embedded in a continuing rural practice 1 2 3 4 5 6 7 8 9 10 11 12 13 Medicine, including a separate PIF YEAR 1 Hospital Hospital Pediatrics Hospital Special OB – Hospital Cardiology Hospital MICU Hospital Peds ER Scholarly Activity Care Care Inpatient Care Care Newborn Care Care Care Nursery • Minimum of 2 residents at the rural site (1 (Shared) (NRP) (Wound (ATLS) (Shared) Healing) MRH MRH CHC MRH OSUH MRH MRH OSUH MRH OSUH MRH CHC MRH Mad River Family Practice -- Periodic office patient care, daily hospital rounds PGY2, 1 PGY3 or 2 every other year) 2 Half-days 2 Half-days 1 Half-day 2 Half-days 1 Half-day 2 Half-days 1 Half-day 2 Half-days 1 Half-day 2 Half-days 1 Half-day 3 Half-days YEAR 2 • 50% precepting rule Ambulatory Elective OB - OB – Derma- Pediatrics ICU – Intern Med Orthopedics Medical Elective GYN Newborn Newborn Sub - Cardiology tology Outpatient specialty (High Risk Immersion) MRH/Offic MRH MRH Office Office MRH MRH/Office MRH/Office Office • Mandated 24 months of continuity, with the Mad River Family Practice -- Periodic office patient care, daily hospital rounds Scholarly Activity and Community Medicine 4 Office 0-4 Half- 2 Half-days 2 Half-days 4 Half-days 2 Half-days 8 Half-days one week 4 half-days 4 Half-days 0-4 Half- 3 Half-days Half-days days None the next days exception of 2 elective months away each year YEAR 3 Elective Geriatrics, Physical Medicine, and GYN Elective Surgical Subspecialiies – Elective Sports Elective Medical Psychiatry Opthalmology, ENT, Urology, Podiatry Medicine Sub - specialty Office Office Office OSU MRH/Office Sports Ctr Mad River Family Practice -- Periodic office patient care, daily hospital rounds Practice Management and Community Intervention 0-4 Half- 5 Office Half-days 4 Half-days 0-4 Half- 5 Office Half-days 0-4 Half- 4 Half-days 0-4 Half- 0-4 Half- days days days days days [Gray shaded rotations occur at least in part in Columbus, Ohio] History of 1-2 RTTs: Accreditation History of 1-2 RTTs The OSU Rural Program – Three Year Curriculum Intensive immersion experiences embedded in a continuing rural practice • Rosenthal et al, Academic Medicine 1992 1 2 3 4 5 6 7 8 9 10 11 12 13 YEAR 1 • Maudlin et al, Journal or Rural Health 2000 Scholarly Hospital Hospital Pediatrics Hospital Special OB – Hospital Cardiology Hospital MICU Hospital Peds ER Care Care Newborn Care Care Care Activity Care Care Inpatient (NRP) Nursery (Wound (ATLS) (Shared) (Shared) Healing) MRH MRH CHC MRH OSUH MRH MRH OSUH MRH OSUH MRH CHC MRH • Maudlin and Newkirk, Family Medicine 2010 Mad River Family Practice -- Periodic office patient care, daily hospital rounds 2 Half-days 2 Half-days 1 Half-day 2 Half-days 1 Half-day 2 Half-days 1 Half-day 2 Half-days 1 Half-day 2 Half-days 1 Half-day 3 Half-days • For additional history and information see the YEAR 2 Ambulatory Elective OB - OB – Derma- Pediatrics ICU – Intern Med Orthopedics Medical Elective GYN RTT Technical Assistance Program site – Cardiology Newborn Newborn tology Outpatient Sub - specialty (High Risk The ¡OSU ¡Rural ¡Program ¡– ¡Three ¡Year ¡Curriculum ¡ Immersion) MRH/Offic MRH MRH Office Office MRH MRH/Office Office www.raconline.org/rtt MRH/Office Intensive ¡immersion ¡experiences ¡embedded ¡in ¡a ¡con?nuing ¡rural ¡prac?ce ¡ Mad River Family Practice -- Periodic office patient care, daily hospital rounds Scholarly Activity and Community Medicine 4 Office 0-4 Half- 2 Half-days 2 Half-days 4 Half-days 2 Half-days 8 Half-days one week 4 half-days 4 Half-days 0-4 Half- 3 Half-days Half-days days None the next days YEAR 3 Elective Geriatrics, Physical Medicine, and GYN Elective Surgical Subspecialiies – Elective Sports Elective Medical Psychiatry Opthalmology, ENT, Urology, Podiatry Medicine Sub - specialty Office Office Office OSU MRH/Office Sports Ctr Mad River Family Practice -- Periodic office patient care, daily hospital rounds Practice Management and Community Intervention 0-4 Half- 5 Office Half-days 4 Half-days 0-4 Half- 5 Office Half-days 0-4 Half- 4 Half-days 0-4 Half- 0-4 Half- days days days days days [Gray shaded rotations occur at least in part in Columbus, Ohio] History of 1-2 RTTs: Funding History of 1-2 RTTs: Funding • Medicare and Medicaid GME funding of RTTs is very • Prior to BBA1997, which established a cap on GME state and intermediary-dependent (Most CMS positions funded through Medicare based on FY1996, RTTs were primarily funded in traditional ways, intermediaries have only one or two RTTs, and states although few were able to access IME at the rural site have their own rules around Medicaid GME) • BBRA 1999 created an exception for urban hospitals • Most RTTs, to remain financially viable, depend on state seeking to establish a “1-2 RTT” or an “integrated government subsidies; AHECs; local hospital, clinic, RTT” and community support; patient care revenues; or grant • For lack of a definition, CMS did not implement the funding latter, until October 1, 2003, when they also approved an exception for programs in which >50% of the resident’s training occurs in a rural place 2 ¡

11/14/12 ¡ History of 1-2 RTTs: Funding History of 1-2 RTTs: Recruiting • Recruiting of residents has very much been Revenue Sources OSU Rural Program influenced by the rise and fall of US student interest 2010-2011 in Family Medicine and the increasing importance of international medical graduates Contracts Grants GME 3% 2% Passthroughs • US student interest peaked in 1997, then began a 24% Institutional Subsidy:MRH decade long fall 23% Institutional • IMG applications were impacted by the events of Subsidy:DFM 0% September 11, 2001 Institutional Clinical Income Subsidy:OSUH 45% 3% RTT NRMP Trends 2003-2012 Prior to July 1, 2010 90.00 80.00 70.00 60.00 Percentage NRMP Match 50.00 Positions Available 40.00 Number Filled 30.00 20.00 10.00 4-4-4 0.00 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Closed Active As of July 1, 2012 As of July 1, 2010 • 22 active 1-2 RTTs (two closed, one suspended for financial hardship) • 3 accredited RTTs, but not active, one of them to be implemented July 1, 2013 • 9 actual 1-2 RTT programs in various stages of development in 9 states (1 prior to grant; another recently failed to get accredited) • 8 states in the contemplative stage 4-4-4 • 6 states with rural training track development, but not Inactive 1-2 RTTs Active 3 ¡