Transcript Slide 1

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 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 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 that appeared in
the mid-1960s
• 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 this the1st ?
• Nurse Practitioner education and training
have historically been combined during the
academic preparation (master’s or DNP);
post-graduate 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 1960s
• 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, 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,
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
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) – 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 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
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 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
• Clear learning objectives and evaluation plan
Community Health Center, Inc. © 2009
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,
eligible or board-certified as family
nurse practitioner
• Bilingual (Spanish)
• Committed to practice careers as
primary care providers in FQHCs
• Now accepting 3rd 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 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 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 Residency Program in 2007
• National Health Service Corps approved one-year
deferrals of obligated service for Residents who had
NHSC scholar service obligations
• 1st graduates are all in FQHC practice; 2nd class now
interviewing in FQHCs; 3rd 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, 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 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
Director, Weitzman Center for Innovation
Community Health Center, Inc.
[email protected]
860 347 6971 x 3622
Mark Masselli, President and CEO,
Community Health Center, Inc.
[email protected]
860.347.6971.x3620
Nwando Olayiwola, MD, MPH, Chief Medical Officer
Community Health Center, Inc.
[email protected]
860.347.6971 x 3728
Community Health Center, Inc. © 2009