CHCs and Physician Assistants: PArtners in Practice and Education Melinda Blazar, MHS, PA-C Medical Instructor Clinical Coordinator Duke University PA Program Nicholas M. Hudak, MSEd, MPA, PA-C Assistant Professor Clinical 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 ✓ 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, CHC strata samples NPs, PAs, and CNMs as well as physicians. Sample included 670 physicians, 245 NPs, and 103 PAs 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,

Percent of CHC Visits for Which the Patient has Selected Chronic Conditions by Provider, ProviderPhysicianNPPAMD vs. PANP vs. PA Mean # chronic conditions

Time Spent with Each Patient by Provider Type, (minutes) MD vs. NP p value =.53 MD vs. PA p value =.06

Percentage of Visits by Rural/Urban Status,

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. American Academy of Physician Assistants website. 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): 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): Morgan P, Everett C, Hing E. Nurse Practitioners and Physician Assistants in Community Health Centers. Unpublished data, North Carolina Health Center Fact Sheet, Accessed 6/21/13. National Commission on the Certification of Physician Assistants website. Peterson et al. J Am Board Fam Med May-Jun 2013; 26(3): Physician Assistants in American Medicine. 2nd edition. Hooker & Cawley.

THANK YOU! Jennifer Pennington Alumni / Preceptor Development Program Coordinator Duke Physician Assistant Program