Graduate Medical Education in a Rural Tribal Health System

1. Graduate Medical Education in a Rural Tribal Health System Choctaw Nation Family Medicine Residency Todd Hallmark Executive Officer of Health Services Choctaw Nation Health Services Authority

2. Halito (Choctaw for Hello)

3. Choctaw Nation Health Services Authority Excellence in Rural Health Care

4. Overview • Choctaw Nation Family Medicine Residency • Key Elements for Starting a Residency Program • Concept of being Academically Friendly • Funding - HRSA THC Grant • Benefits of Having a Residency Program • CNFMR

5. Choctaw Nation Health Services Authority • Tribal Health System • SE Oklahoma • About 900 Primary Care visits per day • Hospital – Talihina Oklahoma • 9 Satellite Clinics • 1600 FTE • 500-600 newborn deliveries per year

7. Clinic Locations Atoka Broken Bow Durant Hugo Idabel McAlester Poteau Stigler Talihina

10. Specialties Cardiology Emergency & Urgent Care Endocrinology (Adult and Pediatric) ENT Surgery Family Practice Gastroenterology General Surgery Geriatrics Internal Medicine Neurology Obstetrics & Gynecology Ophthalmology Orthopedics Osteopathic Manipulative Medicine Pediatrics Psychiatry Pulmonology Rheumatology • Other Services • Optometry • Podiatry • Dentistry (General and Pediatric) • Radiology (digital) • CT, MRI, US • Bone Densitometry • Diabetes Wellness Center • Audiology • Speech Pathology • Physical Therapy • Pharmacy • Laboratory • Respiratory • Nutrition • Memory Loss Clinic • Large Refill Center • Electronic Medical Records

11. Definitions • GraduateMedical Education (GME) • Residents • Faculty • Teaching Health Center (THC)

12. HRSA THC GME Program • Health Resources and Services Administration • THC GME: Teaching Health Center Graduate Medical Education Program, 2010 AFA • Purpose is to increase the number of primary care residents and dentists trained in community-based ambulatory patient care settings • Residents trained in THC’s about 3X more likely to practice in underserved settings 3.4X more likely to practice in health centers

13. HRSA THC Program (cont’d) • Eligibility • “Federally Qualified Health Centers, Community Mental Health Centers, Rural Health Clinics, Health Centers operated by the Indian Health Service, an Indian Tribe or Tribal Organization, or an Urban Indian Organization” • Primary Care Residencies • “an accredited graduate medical residency training program in: Family Medicine; Internal Medicine; Pediatrics; Internal Medicine-Pediatrics; Obstetrics and Gynecology; Psychiatry; General Dentistry; Pediatric Dentistry; and Geriatrics”

14. HRSA THC Program (cont’d) • Funding • THC GME payments support: Direct expenses associated with sponsoring an approved graduate medical or dental residency training program; andIndirect expenses associated with the additional costs relating to teaching residents in such programs. • $150K per resident per year • Congress must vote every two years to fund program (Affordable Care Act)

15. Academically Friendly • Mindset that views our local students as a precious natural resource for our health system • High School • Lectures on health topics by physicians in local high schools • Health Career day for Juniors and Seniors • Visit and tour hospital in various departments • Department Recruiting Booths • Pharmacy, PT, IT, Med Staff, Radiology, Lab • Quick Fact sheets: Educational requirements, Duties, Starting salaries

16. Sample Fact Sheet

17. Academically Friendly • College – “Pre-Med” • Policies in place that allow for “shadowing” • Shadowing Program • Must be enrolled in a pre-med program, at least 19 years old • Covers cost of PPD, Background check, UDS, Temporary ID Badges, Meals • Requires Department Supervisor and CMO Approval

18. Academically Friendly • Medical Students • Policies in place that allow for Preceptorships • Partnerships with Medical Schools for “Rural Hospital” rotations • Provide Student Housing • Cover typical costs – Meals, PPD’s, Background checks, UDS, Temporary ID Badges • “Grand Rounds”

19. Academically Friendly • Opportunity to showcase your system to your future staff • Take advantage to your most valuable resource • Engages the Medical Staff • Fosters an environment of continuous learning

20. CNFMR Residents

23. Key Elements for Starting a Residency Program • System that is primed for medical training • A Physician Champion • Attending Physicians on the staff are willing to support a residency program • Sufficient number of dedicated faculty within the department who will practice in the residency program • Hospital administration willing to support the program • Adequate volume and acuity of patients to support the training curriculum

24. Basic Requirements for Starting a Residency Program • Program Director in the same specialty with AOA / AMBS Board Certification • Sufficient faculty to implement the program • Outpatient Clinical Faculty • Library Support • On Call Quarters • Didactic Program • Affiliation agreements with other institutions for resident rotations that cannot be provided in the hospital or outpatient area

25. Basic Requirements for Starting a Residency Program (cont’d) • Accreditation by ACGME • Lengthy process, heavy on paperwork • Will Designate program size • Usually takes about one year • A relationship with a medical school

26. Benefits of Having a Residency • For the Health System • Physician Recruiting • A Marker of Quality • In House Physician Coverage • Community Service • “Grow Your Own Medical Staff” • Community Retention of Residency Graduates

27. Benefits of Having a Residency • For the Medical Staff • Life Long Learning • Enhanced CME Opportunities • Encourages Medical Staff to be up on current literature and topics • Engages staff and is seen as a “breath of fresh air”

28. Rural Residency Benefits • 100% Board Certification Exam Pass Rate • 80% of CNFMR graduates practice in Rural Settings • 60% of CNFMR graduates work for CNHSA

30. Benefits of Having a Residency • For the Patients • Presence of Residents 24/7 • Increases Patient Contact with Physicians • Provides patients with the latest in medical science

32. Choctaw Nation Family Medicine Residency (CNFMR) • Accredited by the American Osteopathic Association and the American College of Osteopathic Family Practice • Accredited for 12 total residents • 3 years (4+4+4) • All residency spots are filled (100%) • National average for FP Residencies is 53% filled • Recruiting, recruiting, recruiting

33. Choctaw Nation Family Medicine Residency • Affiliation Agreements with Regional Hospitals in Muskogee, OK, Tulsa, OK and Fort Smith, Arkansas • Rotations not available within our system • Residents have “Continuity Clinic” where they see their own panel of patients under the supervision of Board Certified Family Physicians • Didactics 5 hours per week • Resident lectures, Attending Physician lectures • Journal Article Review • Case Reviews • Board Study Review • Encourage Medical Staff Participation when possible

34. Choctaw Nation Family Medicine Residency • Academic Research Projects • Must abide by Medicare duty hour rules • Staff Required • Director of Medical Education (Physician Champion) • Program Director (Physician Champion) • Residency Coordinator

35. Choctaw Nation Family Medicine Residency • Resident Benefits • Resident Salary is about $60K/yr • Full Benefits Package • Housing • Call rooms – very specific requirements • Library with access to a certified librarian (may be via telecommunication link) • Pagers, Lab Coats, Scrubs, Meals while on duty, in service testing, board testing • Paid attendance to one National Conference (required)

37. Choctaw Nation Health Services Authority Excellence in Rural Health Care