chcs and physician assistants: partners in practice and education melinda blazar, mhs, pa-c medical...
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CHCs and Physician Assistants: PArtners in Practice and Education
Melinda Blazar, MHS, PA-CMedical Instructor
Clinical CoordinatorDuke University PA Program
Nicholas M. Hudak, MSEd, MPA, PA-CAssistant ProfessorClinical Coordinator
Duke University PA Program
Disclosures
Working as clinical coordinators for a Physician Assistant program, we are always looking to
develop and maintain quality clinical rotation sites for our students, which may include Community
Health and Rural Health Centers.
Session Objectives
I. Discuss the role practicing PAs have in primary care and community health centers.
II. Identify strategies for how medical learners can be effectively integrated into community health centers.
III.Describe processes for collaboration between community health centers and medical education programs.
Session Outline
✴ Health Care Workforce and the Development of the Physician Assistant Profession
✴ PAs: Education & Practice
✴ Community Health Centers: Workforce Data
✴ Medical Education in Rural and Underserved Clinical Settings
✴ Integrating Medical Learners into Clinical Practice
Health Care Workforce and Physician Assistants
Health Care Workforce – 1960s
✓ Shortage of health care providers in medically underserved areas
✓ Shortage of primary care providers
The Founding Fathers of the PA Profession
The Class of 1967, Duke PA Program
Healthcare Workforce - 2013
✓ Shortage of health care providers in medically
underserved areas
✓ Shortage of primary care providers
The Class of 2014, Duke PA Program
✴ Certified PAs: 90,000+
✴ PAs Practicing in Primary Care: 33%
✴ Projected PAs in the Workforce by 2018: 108,300
✴ Bureau of Labor Statistics: PA jobs increase 30% by 2020
✴ Over the past decade, number of physicians who work with a PA, NP, or CNM increased from 25 to 50%
The PA Profession Today
PAs were named as one of three primary healthcare providers in the Affordable Care Act.
Affordable Care Act
Kathleen Sebelius
"In medically underserved communities, and particularly
in rural areas, PAs are an incredible lifeline to patients who might not have regular access to other healthcare providers. So it's vital to do everything we can to bolster
the work done by PAs.”- AAPA Conference, May 2013
Physician Assistants - Education & Practice
Competencies
✴ Medical Knowledge
✴ Interpersonal & Communication Skills
✴ Patient Care
✴ Professionalism
✴ Practice-based Learning & Improvement
✴ Systems-based Practice
Training in the United States
✴ Accreditation Review Commission on Education for the Physician Assistant (ARC-PA)
• Number of Accredited PA Programs: 172• Number of PA Programs in Development: 70+
✴ Pre-Clinical Phase• Average Hours: 1,155
✴ Clinical Phase• Average Hours: 2,000
Duke Pre-Clinical Curriculum
✴Foundation
• Basic medical & clinical concepts
✴Evidence-based course content
✴Integrated units
✴Required enrichment assignments
✴Case-based small group clinical discussions
✴Standardized patient exercises
✴Early patient exposure
✴Diagnostic testing wet labs
✴Cadaver dissection anatomy lab
✴Fresh tissue surgery lab
Duke Clinical Curriculum
✴ Required Rotations – 4 weeks• Women’s health
• Behavioral medicine
• Emergency medicine
• General surgery
• Pediatrics
• Evidence-based medicine
✴ Required Rotations – 8 weeks• Primary care
• Internal medicine
✴ Elective Rotations – 4 weeks• Popular choices include
cardiology, dermatology , urgent care, orthopedics or surgical specialties
Qualifications to Practice
✴ Graduation from Accredited Program
✴ National Certification Exam
✴ Continuing Medical Education (CME)• 100 hours CME every two years
• Exam recertification every ten years
✴ State License through Medical Board• Supervisory agreement with licensed physician
Community Health Centers - Workforce Data
NC Community Health Centers, 2011
✴ 564,727 patient visits with a physician
✴ 381,367 patient visits with a PA, NP, or CNM
Community Health Center Expansion: Roles of Nurse Practitioners and Physician Assistants
Data Source
•National Ambulatory Medical Care Survey, Community Health Center sample, 2006-2010
•CHC strata samples NPs, PAs, and CNMs as well as physicians.
•Sample included
•670 physicians, 245 NPs, and 103 PAs
•23931 patient visits
Methods
•Excluded:•other provider types,
including nurse midwives (<2% of visits)
•visits in which a physician and NP or PA were both recorded (<1%)
Estimated Percent of Community Health Center Visits by Provider
Are You This Patient's Primary Care Provider?
Percentage of Visits by Major Reason for Visit and Provider Type, 2006-2010
Percent of CHC Visits for Which the Patient has Selected Chronic Conditions by Provider, 2006-10
Provider Physician NP PA MD vs. PA NP vs. PA
Mean # chronic conditions
1.12 0.87 1.17 0.03 0.75
Time Spent with Each Patient by Provider Type, 2008-2010 (minutes)
MD vs. NP p value = .53 MD vs. PA p value = .06
Percentage of Visits by Rural/Urban Status, 2006-2010
Summary of Results
1. NPs and PAs attended 35% of CHC visits
2. There is substantial overlap in characteristics of patients and visits in CHCs among the provider types, but differences include:
• NP patients were younger and more likely female • PAs saw more patients in rural areas, followed by NPs• NPs provided more preventive care and less chronic care than
PAs and physicians• Physicians were more likely to see patients for whom they were
the primary care provider (76%), followed by PAs (70%) and then NPs (58%).
3. Physicians, NPs, and PAs spend similar amounts of time with each patient
Medical Education - Rural and Underserved
Clinical Settings
Clinical Experiences
✴ Each institution has similar required rotations
• PA Programs follow standards outlined by ARC-PA
• Clinical experiences vary in length - 4, 6 or 8 weeks are typical
✴ Primary care, pediatrics, women’s health or behavioral health
• Common rotations for CHCs to participate
Rural and Underserved Areas: Duke Class of 2013
✴ Number of students: 79
✴ Underserved patient encounters to date: 34,416
✴ Patients seen in rural clinics to date: 16,859
✴ Medicaid patient visits to date: 23,103
✴ Uninsured patient visits to date: 8,176
The PA Student Primary Care Experiences
CHC Rotations: Duke Student Feedback
“[my preceptor] not only taught me strong evidence based medicine and skills, but how to work in a
challenging environment…”
“[my preceptor] had a community approach to medicine that I truly enjoyed. She saw a need and
educated her patients as much as possible”
“…more exposure than just typical primary care…HIV clinic and hospice house”
Underserved Community Scholarship Program
✴ Innovative longitudinal primary care training at Duke PA Program
• HRSA-funded scholarship
• 4 to 8 students per year over 5 years
✴ 5-6 months in same community
• Rural or urban
• PC, Peds, Women’s Health, Behavioral Health and PC elective
UCSP Communities
Current Sites• Lumberton, NC • Henderson, NC • Ahoskie, NC • Murphy, NC • Oxford, NC • Dunn, NC
Future Sites• Cherokee, NC• Marshall, NC• Lexington, NC• Greenville, NC
UCSP Communities
✴ In first year, 100% of students accepted positions in CHCs or MUAs (75% at their UCSP site)
- Hosting learners = excellent recruitment tool!
✴ Each site enthusiastically agreed to host another student the following year
UCSP Success Stories
Benefits of Longitudinal Model
✴ Less time orienting, more time learning - Students become productive team members
✴ Trust and rapport become well developed- Increased learning opportunities
✴ Community engagement activities- Deeper understanding of role of primary care
✴ Helps students further develop a passion for primary care & working with the underserved
- Realistic idea of what that means
Sample USCP Data
✴ 6 month experience• Lumberton, NC
✴ 1066 patients seen• 125 pediatric
• 165 geriatric
• 105 prenatal visits, 42 family planning
• 68 HIV
✴ Highly diverse population
UCSP Student Feedback“…I was able to participate in community outreach and education.”
“My preceptors went above and beyond in teaching me by making ordinary moments teaching
moments.”
“Over time, I built my skills in management of chronic diseases.”
“It was so nice to work with someone who, after 13 years, still loves what she does!”
Integrating Medical Learners into Clinical Practice
Tips for Success
✴ Have students work with several providers
✴ Students don’t need to see every patient
✴ Give students assignments
✴ Choose teaching moments appropriately
✴ Give students tasks
✴ Use teaching tools
A Word About Productivity
Study looking at preceptor productivity in CHCs found: Number of patients/session did not differ with
or without a student learner and no increase in number of minutes worked
(McKee 1998)
Preceptor Resources
✴ Course Materials• Objectives, Preceptor Responsibilities, Student
Evaluation Form, Teaching Resources
✴ Regular Communication with PA Program Faculty• Routine site visits, Quarterly newsletter, Annual
feedback letter
✴ Benefits• Electronic access to Duke Medical Center Library
• Consulting faculty appointments
• In the Near Future: Category 1 CME for preceptors
Conclusions
✓ 31% Primary Care
✓ 43% Internal Medicine specialties and hospitalists
✓ 26% Surgery and surgical specialties
✓ 28% practicing in areas designated by the federal government as underserved
2011 Duke Graduates: Employment Data
References• Accreditation and Review Commission on the Certification for the Physician Assistant website. www.arc-pa.org
• American Academy of Physician Assistants website. www.AAPA.org
• Diemer D, Leafman J, Nehrenz GM Sr, Larsen HS. “Factors that influence physician assistant program graduates to choose rural medicine practice.” J Physician Assist Educ. 2012;23(1):28-32.
• Hooker, R. S. “A Cost Analysis of Physician Assistants in Primary Care. Journal of the American Academy of Physician Assistants Nov 2002; 15 (11): 39–42, 45, 48 passim.
• McKee MD, Steiner-Grossman P, Burton W, Mulvihill M. “Quality of Student Learning and Preceptor Productivity in Urban Community Health Centers.” Fam Med 1998; 30(2):108-12.
• Morgan P, Everett C, Hing E. Nurse Practitioners and Physician Assistants in Community Health Centers. Unpublished data, 2013.
• North Carolina Health Center Fact Sheet, 2011. http://www.nachc.com/client/documents/research/NC12.pdf. Accessed 6/21/13.
• National Commission on the Certification of Physician Assistants website. www.NCCPA.net
• Peterson et al. J Am Board Fam Med May-Jun 2013; 26(3): 244-245.
• Physician Assistants in American Medicine. 2nd edition. Hooker & Cawley.
THANK YOU!
Jennifer Pennington
Alumni / Preceptor Development Program Coordinator
Duke Physician Assistant Program
919-681-3159