Increasing Capacity in Northern ArizonaMarica Martinic, MPH - Education Director

Brandon Abbott, DO, MPH – Deputy Chief Medical Officer

Family Medicine Residency Program

What is North Country HealthCare?

• North Country HealthCare is a Federally Qualified Health Center (FQHC)– Private, non-profit 501(c)3

– HRSA grantee to defray the cost of care for the uninsured (10% of our budget)

– Community Governing Board: over 50% patients

– Take care of all who seek care; sliding fee scale for low income patients

Our Healthcare Services• Family Medicine

• Internal Medicine

• Obstetrics and Gynecology

• Pediatrics

• Dental Care

• Behavioral Health

• Chronic Disease Management

• Care Coordination

• Integrative Medicine

• Pharmacy

• School Based Health Services

• Telemedicine

Our LocationsServing 14 Communities

• Flagstaff

• Ash Fork• Seligman• Grand Canyon• Winslow• Holbrook • St. Johns• Round Valley• Payson• Kingman• Lake Havasu City• Show Low• Bullhead City• Williams

NAHEC History• 1987 – NAHEC Founded

• 1996 – Flagstaff Free Clinic and NAHEC merged to become North Country Community Health Center

• Teaching Health Center

• 2008 – North Country became a community campus of AT Still University (ATSU) School of Osteopathic Medicine in AZ

SEAHEC

GVAHEC

WAHEC

NAHEC

EAHEC

Program OfficeTucson

(The Universityof Arizona)

Mohave

La Paz

Navajo

Yuma

Coconino

Apache

Cochise

Pinal

Pima

Santa Cruz

Gila

Graham

Greenlee

Yavapai

Maricopa

Education Pipeline for Healthy Communities

Crisis: National Physician Shortage

• Physician recruitment and retention is affected by many factors: geography, finances, scope of practice, medical support, and hospital and community support

• The ability to recruit and retain physicians directly affects the ability to provide adequate services to the community

• Although medical school enrollment has increased significantly over the past 10 years, GME training programs, especially in primary care, have seen limited growth

• Nationally, by 2032, the AAMC estimates that up to 55,200 primary care physicians will be needed1

– This estimate accounts for the supply of mid-level providers

• In Arizona:

– 1,941 PCPs needed by 20302

– “best county” ratio of population to primary care physician is 1,200:1; “worst county” is 6,440:1. 3

Adapted from: A Roadmap to Measurably Expand Graduate Medical Education (GME) in Indiana, by Beth Wrobel, HealthLinc CEO. NACHC Policy and Issues Forum. March 29, 2019.

2019 County Health Rankings3

Ratio of Primary Care Physicians to PopulationHealth Outcomes

• Family Medicine: 10 programs– Locations: Yuma, Sierra Vista,

Flagstaff, Kingman, Phoenix area, Tucson

• Psychiatry: 3 programs– Locations: Phoenix, Tucson

• Emergency Medicine: 4 programs– Locations: Kingman, Tucson, Phoenix

• General Surgery: 3 programs– Locations: Phoenix, Tucson

• OB/GYN: 3 programs– Locations: Phoenix, Tucson

• Internal Medicine: 11 programs– Locations: Phoenix area, Cottonwood,

Sierra Vista, Tucson

• Pediatrics: 3 programs– Locations: Phoenix, Tucson

Arizona Current Accredited Primary Care-Related Residency Programs

Physicians are Most Likely to Practice Where They Train

K-12 Education

Design and implement programs in rural and underserved communities to diversify the medical school pipeline

Undergraduate/College

Support students to prepare qualified medical school applicants

Medical School

Arizona graduated 568 medical students in 2018 (UA COM-Phoenix, UA COM-Tucson, ATSU SOMA, Midwestern)

GME/Residency Training

~450 primary care-related residency slots (PGY-1) in Arizona

The time required to train a physician is at least seven years after graduation from college.

Adapted from: A Roadmap to Measurably Expand Graduate Medical Education (GME) in Indiana, by Beth Wrobel, HealthLinc CEO. NACHC Policy and Issues Forum. March 29, 2019.

Increased Demand for Physicians2

AAMC Arizona Physician Workforce Data4

Arizona ranks 42 nd in the country with 77.9 active primary care physicians per 100,000 people.

48.7% of physicians are retained in state from GME (rank 16)

Economic Impact5

• 21 physicians retained over 10 years

• 136 new jobs over 10 years

• $151.7M total economic output over 10 years

Health Care Impact Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9 Year 10 TotalExpanded Physician Residents 4 8 12 12 12 12 12 12 12 12 12 Total Graduating Physicians 4 8 12 16 20 24 28 28 Total Physicians Staying in AZ (75%) 3 6 9 12 15 18 21 21 Economic ImpactTotal Jobs 28 34 41 54 68 82 95 109 123 136 136Total Wages (in millions) $2.3 $2.6 $3.0 $4.2 $5.4 $6.6 $7.8 $9.0 $10.2 $11.4 $62.4Total Economic Output (in millions) $5.5 $6.4 $7.3 $10.2 $13.1 $16.0 $18.9 $21.9 $24.8 $27.7 $151.7Fiscal ImpactState Tax Revenue (in millions) $0.1 $0.1 $0.1 $0.2 $0.3 $0.3 $0.4 $0.4 $0.5 $0.5 2.8$ Sources: North Country HealthCareRounds Consulting Group, Inc.

Impact of Expanded Medical Residency Program at North Country HealthCare

Residents Teach• Residents spend up to 20% of their time teaching

• Residents recognize their teaching responsibility, enjoy teaching, and consider it a critical component of their education

• Preceptor availability is a significant challenge when it comes to UME (undergraduate medical education)

• Helps to meet AHEC and medical school training needs

Adapted from: A Roadmap to Measurably Expand Graduate Medical Education (GME) in Indiana, by Beth Wrobel, HealthLinc CEO. NACHC Policy and Issues Forum. March 29, 2019.

Graduate Medical Education Finance and Operations

Models

THC ModelCommunity

Training Sites Hospital/ AHC

Medicare GME $

HRSA GME $Accreditation

Teaching HealthCenter

Residency

CHC

Traditional GME Model

Community Training Site

Teaching Hospital/ Academic Health

Center (inpatient)

Residency Program(continuity clinic)

Medicare GME $

Accreditation

Benefits of GME for hospital/FQHC partnerships

• Recruitment cost savings resulting from graduating residents

• Revenue generation due to increase in physicians and residents

• Provision of care by residents (lower compensation)

• Revenue from quality outcomes

• Image enhancement as a “teaching facility”

• Workforce aligned with a culture of life-long learning

• Community-based training sites such as CHCs can improve health status, decrease costs and facilitate interdisciplinary careAdapted from: A Roadmap to Measurably Expand Graduate Medical Education (GME) in Indiana, by Beth Wrobel, HealthLinc CEO. NACHC Policy and

Issues Forum. March 29, 2019.

The Teaching Health Center Difference

Graduating Residents Practicing In:

Teaching Health Center GME

Traditional GME

Primary Care 82% 23%

Underserved Areas 55% 26%

Rural Settings 20% 5%

Community Health Centers 36% 2%

North Country HealthCare Family Medicine Residency Program

MISSION

To extend the mission of North Country HealthCare in providing

accessible, comprehensive, quality, affordable care in a primary

healthcare setting across Northern Arizona

Residency Goals• All of North Country HealthCare’s endeavors seek to

meet community needs

• The new family medicine residency will be part of expanding the educational and service missions of the organization to further meet community needs

• Will prepare a group of family physicians for autonomous practice in rural and frontier northern Arizona

• Will prepare culturally competent physicians for the region

Sponsoring Institution• North Country HealthCare is the

Sponsoring Institution for the family medicine residency– Usually academic medical centers or other large

hospitals

• Received institutional accreditation by the Accreditation Council on Graduate Medical Education (ACGME) in 2014

• Received program accreditation in 2017

Sponsoring Institution• Assumes ultimate responsibility for the program,

including all resident assignments at all participating sites.

• Makes to a commitment to Graduate Medical Education (GME) to provide the necessary financial support for administrative, educational and clinical resources.

• Maintains a Graduate Medical Education Committee (GMEC) to oversee residency operations and ensure ACGME requirements are met

Academic Partnerships

• The University of Arizona College of Medicine: Phoenix

• AT Still University School of Osteopathic Medicine in Arizona (ATSU-SOMA)

Training Partners• Flagstaff Medical Center

• Kingman Regional Medical Center

• Tuba City Regional Healthcare Corporation

• Hopi Health Care Center

• Whiteriver Indian Health Service Hospital

• Little Colorado Medical Center

• Winslow Indian Health Care Center

• Coconino County Public Health Services Department

Experiences and Partner Locations• North Country HealthCare: continuity family medicine clinic, community

medicine, oral health, pediatrics, obstetrics, obstetrics ultrasound, gynecology, and psychiatry with continuity patients

• Flagstaff Medical Center: inpatient medicine/pediatrics, obstetrics, anesthesia, newborn nursery, adult ICU, neonatal ICU

• Winslow facilities: general surgery

• Kingman Regional Medical Center: radiology and emergency medicine

• TBD-Flagstaff: longitudinal geriatrics patients

• Coconino County Health Department: community medicine, oral health

• Tuba City, Polacca and Whiteriver: rural American Indian rotations

• Tuba City: outpatient pediatrics

• Office settings for other specialities

Behavioral Health• Partner with Steward Health Choice in Flagstaff

for rotations

– Opportunities to work with behavioral health specialists in outpatient clinic, inpatient psychiatry, chemical dependence unit, methadone clinic, Child and Family Support Services, children’s group homes and telehealth

• Formal partnership with NARBHA Institute to increase behavioral health curriculum during the three years of family medicine residency

2019 Residency Updates - Program

• Hired Edward Paul, MD as Program Director

– 30 years of experience in FM residencies– Started FM residency at Yuma Regional Medical

Center

• Formal partnership with University of Arizona College of Medicine-Phoenix

– Electronic library access and faculty development

• Improved partnership with Flagstaff Medical Center for inpatient training

2019 Residency Updates - Funding

• Teaching Health Center Graduate Medical Education (HRSA)– No new programs since 2014– New NOFO due August 30

• $750K appropriated in AZ budget– Pursuing AHCCCS rule change to allow CHCs to receive

Medicaid GME. Could become $2.25M

• NARBHA Institute partnership for program development

• Arizona AHEC program support for program development

NCHC Family Medicine Residency Starts July 2020!

• Electronic Residency Application Service (ERAS)– NCHC residency is active

• Applications start in September

• Review of applications and interviews between November and December (50-60 in-person interviews)

• Match Lists submitted by programs and students in February

• Match Day in March 2020– We will accept 4 PGY-1 (post graduate year) residents

References1. https://news.aamc.org/press-releases/article/2019-workforce-

projections-update/

2. Petterson, Stephen M; Cai, Angela; Moore, Miranda; Bazemore, Andrew. State-level projections of primary care workforce, 2010-2030. September 2013, Robert Graham Center, Washington, D.C. https://www.graham-center.org/content/dam/rgc/documents/maps-data-tools/state-collections/workforce-projections/Arizona.pdf

3. https://www.countyhealthrankings.org/app/arizona/2019/measure/factors/4/data?sort=sc-2

4. https://www.aamc.org/download/484514/data/arizonaprofile.pdf

5. Rounds Consulting Group, Inc.