New GME Design and Development

New GME Design and Development Randall Longenecker MD Senior Project Advisor RTT Technical Assistance Program Executive Director, The RTT Collaborative Assistant Dean Rural and Underserved Programs, Ohio University Heritage College of Osteopathic Medicine, Athens, Ohio Dave Schmitz MD Project Advisor RTT Technical Assistance Program Associate Director, The RTT Collaborative Director of Rural Residencies, Family Medicine Residency of Idaho

What s New? New accreditation reality a unified accreditation system New efficiency of scale small is becoming the new better New ways of GME development no longer going it alone, the rise of consortia, teaching health centers, distributed community-based and community-engaged medical education, and the OPTI framework (CORE 1997)

Objectives Describe the history of RTTs and the diversity of integrated rural training track programs that have emerged from the original 1-2 RTT prototype (Spokane Model) Articulate several evolving strategies for accreditation, faculty development, recruitment and funding of RTTs Answer questions regarding integrated RTT development, networks, and sustainability Begin to develop new residency programs, using a framework designed around basic questions of place(s), person(s), purpose(s), and possibility(s).

History of 1-2 RTTs: Accreditation 1985 Proposed by Bob Maudlin of Family Medicine Spokane as a strategy to graduate more physicians to rural practice and to better prepare them professionally and personally to practice and live in rural places 1986 ACGME approval as an experimental pathway 1996 Additional formal requirements by the RRC in Family Medicine, including a separate PIF Minimum of 2 residents at the rural site (1 PGY2, 1 PGY3) 50% precepting rule Mandated 24 months of continuity, with the exception of 2 elective months away each year

CMS Definitions ACGME accredited program in the 1-2 format (alternative tracks, only in family medicine established by final rule in 2000) Integrated RTT any accredited residency program, MD or DO, established in collaboration with an urban residency, where greater than 50% of the resident s training occurs in a rural place (e.g. 19 months out of 36 months established by final rule in 2003)

History of 1-2 RTTs: Accreditation The OSU Rural Program Three Year Curriculum Intensive immersion experiences embedded in a continuing rural practice 1 2 3 4 5 6 7 8 9 10 11 12 13 YEAR 1 Hospital Care (Shared) Hospital Care Pediatrics Inpatient Hospital Care (NRP) Special Care Nursery OB Newborn Hospital Care Cardiology Hospital Care (Wound Healing) MICU Hospital Care (ATLS) Peds ER MRH MRH CHC MRH OSUH MRH MRH OSUH MRH OSUH MRH CHC MRH Mad River Family Practice -- Periodic office patient care, daily hospital rounds Scholarly Activity (Shared) 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 Ambulatory Cardiology Elective OB - Newborn OB Newborn (High Risk Immersion) Dermatology Pediatrics Outpatient ICU Intern Med Orthopedics Medical Sub - specialty Elective GYN MRH/Offic 4 Office Half-days 0-4 Halfdays MRH MRH Office Office MRH MRH/Office MRH/Office Mad River Family Practice -- Periodic office patient care, daily hospital rounds Scholarly Activity and Community Medicine 2 Half-days 2 Half-days 4 Half-days 2 Half-days 8 Half-days one week None the next 4 half-days 4 Half-days 0-4 Halfdays Office 3 Half-days YEAR 3 Elective 0-4 Halfdays Geriatrics, Physical Medicine, and Psychiatry Office GYN Elective Surgical Subspecialiies Opthalmology, ENT, Urology, Podiatry Office Office Elective Sports Medicine OSU Sports Ctr Mad River Family Practice -- Periodic office patient care, daily hospital rounds Practice Management and Community Intervention 5 Office Half-days 4 Half-days 0-4 Halfdays 5 Office Half-days 0-4 Halfdays [Gray shaded rotations occur at least in part in Columbus, Ohio] Elective 4 Half-days 0-4 Halfdays Medical Sub - specialty MRH/Office 0-4 Halfdays

History of 1-2 RTTs: Accreditation The OSU Rural Program Three Year Curriculum Intensive immersion experiences embedded in a continuing rural practice 1 2 3 4 5 6 7 8 9 10 11 12 13 YEAR 1 Hospital Care (Shared) Hospital Care Pediatrics Inpatient Hospital Care (NRP) Special Care Nursery OB Newborn Hospital Care Cardiology Hospital Care (Wound Healing) MICU Hospital Care (ATLS) Peds ER MRH MRH CHC MRH OSUH MRH MRH OSUH MRH OSUH MRH CHC MRH Mad River Family Practice -- Periodic office patient care, daily hospital rounds Scholarly Activity (Shared) The OSU Rural Program Three Year Curriculum 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 Intensive immersion experiences embedded in a continuing rural practice Ambulatory Cardiology Elective OB - Newborn OB Newborn Dermatology Pediatrics Outpatient Elective GYN MRH/Offic 4 Office Half-days YEAR 3 0-4 Halfdays (High Risk Immersion) ICU Intern Med Orthopedics Medical Sub - specialty MRH MRH Office Office MRH MRH/Office MRH/Office Mad River Family Practice -- Periodic office patient care, daily hospital rounds Scholarly Activity and Community Medicine 2 Half-days 2 Half-days 4 Half-days 2 Half-days 8 Half-days one week None the next 4 half-days 4 Half-days 0-4 Halfdays Office 3 Half-days Elective 0-4 Halfdays Geriatrics, Physical Medicine, and Psychiatry Office GYN Elective Surgical Subspecialiies Opthalmology, ENT, Urology, Podiatry Office Office Elective Sports Medicine OSU Sports Ctr Mad River Family Practice -- Periodic office patient care, daily hospital rounds Practice Management and Community Intervention 5 Office Half-days 4 Half-days 0-4 Halfdays 5 Office Half-days 0-4 Halfdays [Gray shaded rotations occur at least in part in Columbus, Ohio] Elective 4 Half-days 0-4 Halfdays Medical Sub - specialty MRH/Office 0-4 Halfdays

9 Operational Phrase: 1-2 and other integrated rural training tracks Section 407(c) of Public Law 106 113 which allows an urban hospital that establishes separately accredited approved medical residency training programs (or rural training tracks) in a rural area or has an accredited training program with an integrated rural track.. Federal Register August 1, 2000 (BBRA 1999)

History of 1-2 RTTs Rosenthal et al, Academic Medicine 1992 Maudlin et al, Journal or Rural Health 2000 Maudlin and Newkirk, Family Medicine 2010 For a series of seminal articles in the past decade, see the RTT Technical Assistance Program site www.raconline.org/rtt

History of 1-2 RTTs: Funding Prior to BBA1997, which established a cap on GME positions funded through Medicare based on FY1996, RTTs were primarily funded in traditional ways, although few were able to access IME at the rural site BBRA 1999 created a rural cap for urban hospitals seeking to establish a 1-2 RTT or an integrated rural track For lack of a definition, CMS did not implement the 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

History of 1-2 RTTs: Funding Medicare and Medicaid GME funding of RTTs is very state and intermediary-dependent (Most CMS intermediaries have only one or two RTTs, and states have their own rules around Medicaid GME) Therefore most RTTs, to remain financially viable, depend on state government subsidies; AHECs; local hospital, clinic, and community support; patient care revenues; or grant funding

History of 1-2 RTTs: Funding Revenue Sources OSU Rural Program 2010-2011 GME Passthroughs 24% Contracts 3% Grants 2% Institutional Subsidy:MRH 23% Institutional Subsidy:DFM 0% Clinical Income 45% Institutional Subsidy:OSUH 3%

History of 1-2 RTTs: Recruiting Recruiting of residents has very much been influenced by the rise and fall of US student interest in Family Medicine and the increasing importance of international medical graduates US student interest in FM peaked in 1997, then began a decade long fall and IMG applications were impacted by the events of September 11, 2001 However, the number of GME slots is no longer that much greater than the number of US graduates

RTT NRMP Trends 2003-2014 100.00 90.00 80.00 70.00 60.00 50.00 40.00 Match Fill Rate Positions Offered Positions filled 30.00 20.00 10.00 0.00 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Source: Personal communication from Randall Longenecker MD, Senior Project Advisor, the RTT Technical Assistance Program, March 25, 2014 (unofficial and to be confirmed)

Prior to July 1, 2010 4-4-4 Closed Active

As of July 1, 2010

As of March 1, 2013 Developing 4-4-4 Active Accredited, not active

28 (32) Active 1-2 RTTs as of February 2014 Active 1-2 RTTs 1-2 like RTTs *RTT Technical Assistance Program Updated 2-5-2014, Randall Longenecker, Senior Project Advisor

Rural Training Tracks Not 1-2 RTTs Florida Mandate from state for rural training in IM, Peds, OB-GYN, as well as FM Missouri PCE expansion to multiple rural continuity clinics New York Accelerated DO residency in FM Washington Rural continuity, Elma, WA; Ellensburg, WA Wisconsin Rural immersion experiences, continuity sites Montana Urban 1-2 with a rural mission

Contemplative Stage Colorado Colorado Institute for Family Medicine, University of Colorado Florida University of Florida; FSU Kansas University of Kansas/Salina Maryland University of Maryland Michigan State Office of Rural Health, CMU, MSU Pennsylvania State mandate; Williamsport, State College South Carolina SORH Tennessee ETSU, TSRHP Vermont University of Vermont Virginia MCV Osteopathic GME Development

RTT Masterfile and Policy Briefs Initial and sustained practice in rural communities (2-3 times traditional residency training A significant contribution to the next generation of rural physician faculty (16% of graduates) Service in areas of primary care physician shortage http://www.raconline.org/rtt/pdf/rural-family-medicine-training-early-career-outcomes-2013.pdf

RTT Masterfile and Policy Briefs

Adaptability and Resilience 24

25 Adaptability and Resilience 28 (32) Active 1-2 RTTs as of February 2014 Rural Urban Urban Active 1-2 RTTs Rural 1-2 like RTTs! " ##$#%&' ( )&*+$, --)-.*( &%$/ 0120*3 $4$5 67*.%7$89: 98; <=>$" *( 7*++$?1( 2%( %&@%0>$A%( )10$/ 01B%&.$, 7C)-10$

Creative Variations Structure: Varying degrees of integration, from 4-15 months in the urban place; Spider plant configurations Funding: Teaching Health Centers (e.g. Boise, ID; Silver City, NM; Redding, CA) Faculty Development: NIPDD Rural Fellows; annual RTT Conclave; peer consultation Emerging Network: The RTT Collaborative www.rttcollaborative.net

Creative Variations: Funding Critical Access Hospitals CMS final rule and its implications; NRHA working group Teaching Health Consortia CHCs, RHCs, and others State initiatives Florida, Wisconsin, Colorado, now South Carolina Veteran Health Affairs (Office of Rural Health) Foundation funding - Ohio Justification through community benefit (e.g. Community APGAR; State Banker s Association re economic benefit)

RTTs: A way forward Nurtured and sustained Community embedded Teaching health practices Uniquely adapted and relevant to the needs of their particular community

Where to begin? 1. A Rural Place (s) 2. A Passionate Person(s) 3. A Clear Purpose (rationale) 4. Explore the Possibilities 5. Save the money question for #5

WI Collaborative for Rural GME Development Paths I N I T I A L P H A S E Education & Initial Assessment Identify Initial Champions Apply for Grants Education & In-Depth Assessment Choose GME Path (s) ROTATION SITE Assemble Core Team Identify Partners Additional Education Simple Budget Market Rotation Accept Residents INTEGRATED RURAL TRAINING TRACK (IRTT) RESIDENCY Assemble Core Team Identify Partners Additional Education Proforma Board Approval Curriculum Budget Market Rural FMC Track Interview Applicants Accept Residents Courtesy of Kara Traxler, RWHC/WCRGME D E V E L O P M E N T P H A S E FELLOWSHIP PROGRAM Assemble Core Team Identify Partners Additional Education Proforma Board Approval Curriculum Budget Submit for Accreditation (if applicable) Market Fellowship Interview Applicants Accept Fellows RURAL TRAINING TRACK RESIDENCY (RTT) Assemble Core Team Identify Partners Additional Education Proforma Board Approval Curriculum Budget Write Program Information Form (PIF) Submit PIF Site Visit Market Residency Interview Applicants Accept Residents

Resources RTT Technical Assistance Program - Policy Briefs, and other downloadable items: www.raconline.org/rtt/ Randall Longenecker MD, Senior Project Advisor, longenec@ohio.edu TrainDocsRural - Student site and links to a student blog and facebook page: www.traindocsrural.org The RTT Collaborative Google Group for rural tracks of all types medical school or residency, contact longenec@ohio.edu to join

Questions? The best way to predict the future is to create it! Abraham Lincoln/Peter Drucker The best way to create the future is to: Act. Learn. Build. Repeat. Paul Brown