Creating and sustaining a successful primary care residency program in a community-based ambulatory care center is challenging.20–23 The health center must successfully marry its service and education missions while maintaining its financial stability, and it must develop administrative and governance structures that include educational systems. To be eligible for the THCGME program, health centers face additional regulatory challenges: The ACA5 requires that the institutional sponsor of record be the applicant health center or an educational consortium that includes a health center. Partnerships also play a role: Although THCs are not required to be FQHCs, many of the first THCs are partnerships between FQHCs and residency programs. Below, we describe the first THCs’ sponsorship models, leadership models, and partnerships with FQHCs, hospitals, and medical schools.
Sponsorship models. To meet the ACA’s requirements, the THC’s community-based training site must be the accredited institutional sponsor of the residency program, or it must be a central partner in a sponsoring GME consortium. In the latter case, HRSA specifies that the THCGME payments must directly support the ambulatory care site.24
Health center sponsor. Residency programs at 5 of the 11 THCs are directly sponsored by a health center. In one case, an existing residency program worked with the Accreditation Council for Graduate Medical Education to change its institutional sponsor to the health center in order to qualify for the THCGME program. An osteopathic residency program worked with the AOA, which accredits such GME programs, to change the AOA’s sponsorship requirements to allow health centers to act as sponsoring institutions. Previously, the AOA required institutional sponsors to be hospitals or osteopathic medical schools.
Consortium sponsor. Six of the 11 THCs qualified under the GME consortium model. In 4 of these, the THC entity is a not-for-profit, multi-institution corporation that operates the residency program and includes a health center. The other 2 consortia include independent, not-for-profit GME organizations affiliated with health centers. In 1 of these 2 consortia, the health center was the entity that applied for the THCGME program, whereas the GME foundation was the accredited institutional sponsor. In this case, the affiliation agreement required the health center to operate the residency program.
Leadership models. Most of the THCs integrate the residency program and health center leadership. At 6 of the 11 THCs, the residency program director also holds the position of health center CEO or chief medical officer or fills another clinical leadership role. One THC’s FQHC community board has oversight of resident education in addition to patient care and community service.
Partnerships with FQHCs and teaching hospitals. All 11 THCs include FQHCs or FQHC Look-Alikes. In two cases, residency programs are partnering with new FQHC sites: One program that has existing arrangements with FQHCs is placing residents at more FQHC sites, and the other program has developed new partnerships with FQHCs. The additional clinical training sites are necessary for the expansion of these two residency programs, and health care access is expected to increase at the new sites.
All of the THCs report affiliations with at least one university or medical school. Each partners with a teaching hospital or academic medical center to provide its residents with training in the inpatient setting. Nine of the THCs receive direct financial support for their residency programs from the hospital or medical center, most often in the form of “pass-through” Medicare GME funding (i.e., funding provided to nonhospital sites by affiliated teaching hospitals that receive Medicare GME payments for preexisting resident positions).
Delivery models for primary care
To ensure that residents are prepared to deliver high-quality care and have the skills they need to practice in a primary care setting, THCs are implementing delivery models that support the provision of primary care services, including electronic health records (EHRs), interdisciplinary care teams, and management/leadership training.
EHRs. The 11 THCs have implemented EHR systems at their community-based training sites. In their THCGME program applications, 4 THCs discussed plans to train residents to use EHRs to support clinical decisions, provide patient education materials, track patient outcomes, and connect to other health centers and hospitals.
Interdisciplinary health care teams. All of the THCs use interdisciplinary health care teams, and residents will practice as part of these teams. Two THCs plan to evaluate residents on the basis of their ability to practice in teams.
Patient-centered medical homes. At the time of their initial applications for the THCGME program in 2010, six of the THCs had applied or were in the process of applying for National Committee for Quality Assurance (NCQA) Patient-Centered Medical Home (PCMH) status. One THC achieved Level 3 NCQA status in 2009.
Management/leadership training. Five THCs offer residents training in practice management and leadership. Two of the five provide training in interprofessional team management. One of the five programs has created a leadership curriculum that includes training in managing teams, conflict resolution, negotiation skills, creation and management of an FQHC, health care reform, political advocacy, and safety-net hospital management. Each resident in that program will serve for two months as an “acting medical director” of the THC, working alongside the health center medical director.
Quality improvement. Ten of the 11 THCs are integrating quality improvement training and projects in their health centers and residency programs.
The THCs’ curricula include a number of educational initiatives that are relevant to primary care practice and will produce graduates who are well prepared to provide the array of needed primary care services:
* Community medicine (10 THCs): Most include community needs assessments and a focus on population health
* Cultural competency (10 THCs)
* Focused rural training (5 THCs): Rural training rotations at 2 THCs are supported through additional stipends for travel and housing
* Geriatrics training (3 THCs)
* Primary care mental health training (3 THCs)
In addition, one THC includes a module on resident mental health aimed at reducing resident and primary care physician burnout. This curriculum includes resident wellness assessment and planning guides, workshops on burnout and compassion fatigue, monthly support groups, and vouchers for complementary medicine services to promote wellness.
Plans for evaluation
All 11 THCs plan to survey their graduates to determine whether they are practicing in primary care and in underserved settings; most surveys are planned for one year and five years after graduation. Other planned evaluations of graduate outcomes include practice in interprofessional teams, patient outcomes, use of EHRs and PCMH models, teaching, scholarship, community activities, leadership, and board certification. One THC plans to survey graduates’ employers concerning its former residents’ demonstration of the critical knowledge, skills, and attitudes needed for effective practice.
All THCs have systems in place for evaluating resident performance. Residents generally are evaluated by faculty and in-training exams. Eight THCs also plan to evaluate residents’ quality of care or patient outcomes using chart reviews for application of national guidelines and outcomes, patient satisfaction surveys, and/or evidence that QI efforts improve care and outcomes. Three THCs plan to track the number of patients served to determine the effect of new or expanded residency training programs on access to health center clinical services.
Implications for the GME System
The ACA5 established the THCGME program to support increased primary care residency training to address critical national workforce needs. This first look at the inaugural 11 THCs shows that they are training additional primary care residents in relevant delivery models (e.g., interdisciplinary teams and PCMHs) and in quality improvement processes. They are partnering with FQHCs and implementing curricula with community medicine, cultural competency, and practice management components to prepare their graduates for careers in primary care, particularly in underserved areas.
These first THCs are also helping reshape U.S. health care delivery and GME systems to support community-based primary care residency training. The work of the initial THCs to expand the types of entities eligible for GME accreditation and funding may reduce future sponsorship-related barriers for other community-based settings that wish to establish residency training programs. Although balancing service and education missions is a challenge for health-center-based residency training programs, the organizational structures that the THCs have established offer examples of the successful integration of these two missions. Our review of the THC leadership structures suggests that balancing the leadership of the service and education programs is an important component of balancing the two missions. At most of the THCs, this has been addressed through dual leadership roles.
The THCGME program also introduces a new level of accountability into the GME funding system. The program’s payments target the achievement of a specific outcome: increasing the number of primary care providers who are well prepared and willing to practice in community-based, often-underserved, settings. Legislation5 requires the THCs receiving this funding to report the numbers and specialties of the residents trained and the number who go on to care for vulnerable populations. This level of evaluation does not currently exist in the Medicare GME payment system. In addition, the THCs plan to evaluate additional outcomes, such as the effect of residency training on patient care services, trainees’ patient outcomes during and after residency, primary care career choices, implementation of primary care delivery models in practice, and community and leadership activities.
Funding, however, continues to be a critical issue in establishing, expanding, and maintaining training programs in community-based settings. Whereas the THCGME program now provides support for successful applicants, the ACA guarantees funding for only five years5; in contrast, annual Medicare GME support is guaranteed as part of a federal entitlement program.12 The THCGME program’s limited funding period may act as a barrier for health centers that are considering expanding or establishing new primary care residency programs. Because the average length of a primary care residency is three years, at the end of the five-year period, THCs may have residents in the middle of their training without guaranteed GME payments to support them. Any additional funding, which will be critical to the continuation of this program, must be appropriated by Congress for fiscal years 2016 and beyond.
Start-up funds are also a limiting factor, particularly for health centers that would require funding for up-front costs (e.g., hiring new faculty and staff, developing curricula, obtaining accreditation) to start a new primary care residency program. Although the ACA authorized a THC development grant to complement the THCGME payment program and support these activities, it has not received funding.
In conclusion, the THCGME program offers a legislative solution for funding GME to better meet the nation’s health care workforce needs. This look at the inaugural 11 THCs suggests that these residency programs are training primary care providers in relevant delivery models and preparing them for practice in community-based, underserved settings. The THCs are developing organizational and funding structures to address barriers to community-based training, and they are working with existing organizations, such as accrediting bodies, to support training in this setting. The THCGME program is small and faces significant funding challenges, and its outcomes have yet to be evaluated over time. However, these first THCs show great promise, and further study of their efforts and outcomes has the potential to shape primary care training and the GME system at large.
Acknowledgments: The authors wish to thank the 11 inaugural teaching health centers for participating in this study and in the teaching health center conference held in May 2011. Dr. C. Chen would also like to thank Dr. Marion Danis in the Department of Clinical Bioethics in the Clinical Center of the National Institutes of Health for acting as her intramural mentor for her Disparities Research and Education Advancing Mission (DREAM) Career Transition Award.
Funding/Support: The Josiah Macy Jr. Foundation supported this work through the grant entitled “Assessing Graduate Medical Education: How Are Teaching Hospitals and Teaching Health Centers Meeting Society’s Needs?” Dr. C. Chen was supported through a DREAM Award by the National Institute of Minority Health and Health Disparities, National Institutes of Health.
Other disclosures: None.
Ethical approval: Not applicable.
Disclaimer: The views expressed are those of the authors and do not represent the views of the Department of Health and Human Services or the National Institutes of Health.
2. Colwill JM, Cultice JM, Kruse RL. Will generalist physician supply meet demands of an increasing and aging population? Health Aff (Millwood). 2008;27:w232–w241
3. Center for Workforce Studies. The Complexities of Physician Supply and Demand: Projections Through 2025. 2008 Washington, DC Association of American Medical Colleges
4. National Association of Community Health Centers, Robert Graham Center, George Washington University School of Public Health and Health Services. . Access Transformed: Building a Primary Care Workforce for the 21st Century.. 2008 Bethesda, Md National Association of Community Health Centers
6. Morris CG, Johnson B, Kim S, Chen F. Training family physicians in community health centers: A health workforce solution. Fam Med. 2008;40:271–276
7. Brooks RG, Walsh M, Mardon RE, Lewis M, Clawson A. The roles of nature and nurture in the recruitment and retention of primary care physicians in rural areas: A review of the literature. Acad Med. 2002;77:790–798
8. Rosenthal TC, McGuigan MH, Anderson G. Rural residency tracks in family practice: Graduate outcomes. Fam Med. 2000;32:174–177
9. Noble J, Friedman RH, Starfield B, Ash A, Black C. Career differences between primary care and traditional trainees in internal medicine and pediatrics. Ann Intern Med. 1992;116:482–487
10. Dick JF 3rd, Wilper AP, Smith S, Wipf J. The effect of rural training experiences during residency on the selection of primary care careers: A retrospective cohort study from a single large internal medicine residency program. Teach Learn Med. 2011;23:53–57
12. Social Security Act, Section 1886: Payment to hospitals for inpatient hospital services [42 U.S.C. §1395ww].Social Security Administration. Compilation of the Social Security Laws. http://www.ssa.gov/OP_Home/ssact/title18/1886.htm
. Accessed August 17, 2012
13. Weida NA, Phillips RL Jr, Bazemore AW. Does graduate medical education also follow green? Arch Intern Med. 2010;170:389–390
14. Salsberg E, Rockey PH, Rivers KL, Brotherton SE, Jackson GR. US residency training before and after the 1997 Balanced Budget Act. JAMA. 2008;300:1174–1180
15. Medicare Payment Advisory Committee.Report to Congress: Aligning Incentives in Medicare.. 2010 Washington, DC Medicare Payment Advisory Committee
16. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457–502
17. Chang CH, Stukel TA, Flood AB, Goodman DC. Primary care physician workforce and Medicare beneficiaries’ health outcomes. JAMA. 2011;305:2096–2104
18. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 1: The content, quality, and accessibility of care. Ann Intern Med. 2003;138:273–287
19. Congressional Budget Office.Geographic Variation in Health Care Spending. Pub. no. 2978.. 2008 Washington, DC Congressional Budget Office
20. Zweifler J. Balancing service and education: Linking community health centers and family practice residency programs. Fam Med. 1993;25:306–311
21. Redington TJ, Lippincott J, Lindsay D, Wones R. How an academic health center and a community health center found common ground. Acad Med. 1995;70:21–26
22. Jones TF. The cost of outpatient training of residents in a community health center. Fam Med. 1997;29:347–352
23. Morris CG, Chen FM. Training residents in community health centers: Facilitators and barriers. Ann Fam Med. 2009;7:488–494
© 2012 Association of American Medical Colleges
This article has been cited