Fowkes, Virginia FNP, MHS; Blossom, H. John MD; Mitchell, Brenda; Herrera-Mata, Lydia MD
Ms. Fowkes is senior research scholar emerita in family medicine, Stanford University School of Medicine, Stanford, California, and director of evaluation, California Statewide AHEC, University of California–San Francisco, Fresno campus, Fresno, California.
Dr. Blossom is professor emeritus of family and community medicine, and director, Statewide AHEC Program, University of California–San Francisco, Fresno campus, Fresno, California.
Ms. Mitchell is program manager, Statewide AHEC Program, University of California–San Francisco, Fresno campus, Fresno, California.
Dr. Herrera-Mata is assistant clinical professor and associate director, Statewide AHEC Program, University of California–San Francisco, Fresno campus, Fresno, California, and program director, Sierra Vista Family Medicine Residency Program, Fresno, California.
Funding/Support: This work was funded through HRSA, BHPR grant U77HPO3015. The contents here are solely the responsibility of the authors and do not necessarily represent the view of HRSA.
Other disclosures: None reported.
Ethical approval: Reported as not applicable.
Correspondence should be addressed to Ms. Fowkes, Center for Education and Research in Family and Community Medicine, Modular G, 1215 Welch Rd., Palo Alto, CA 94305; e-mail: firstname.lastname@example.org.
For 45 years, the Health Resources and Services Administration (HRSA) has supported community health centers (CHCs) to provide quality primary care services to the medically underserved. HRSA has also long supported the national Area Health Education Center (AHEC) program with the mission to recruit, train, and retain health professionals for underserved populations by linking academic and clinical resources to address community health needs. CHCs and AHECs share a mission to improve access to health care and provide quality care to the underserved. Yet, as of 2011, fewer than 20% of approximately 9,000 CHCs nationwide were known to be collaborating with AHECs.1 The Affordable Care Act has expanded health care coverage to millions, thereby requiring a larger health care workforce to meet the needs of the public. To respond to increased workforce needs, academic programs require continued and expanded training sites in underserved areas to attract graduates to practice in similar sites. Teaching Health Centers, newly authorized under the Affordable Care Act, move residency training into the CHC setting.2 CHCs have important and growing roles in education and an imperative to expand and retain their workforce. They are pressed also to increase clinical productivity, introduce new models of care, and balance education and service missions.
AHECs are logical partners to enable CHCs to expand and prepare their future health workforce. AHECs can help to balance the education–service mission by developing strong relationships with CHCs, building formal academic–community partnerships, and addressing issues that arise in the process. One model is to colocate community AHECs (centers) at CHCs to more closely link and facilitate academic needs with community workforce priorities. The California Statewide AHEC (CA AHEC) reorganized and located its centers within CHCs or in close partnership with them to foster recruitment, training, and retention of the CHC workforce. CA AHEC is the largest and one of the oldest among the nation’s 56 AHEC programs, having 12 centers strategically located in underserved communities and serving specific geographic regions.
We describe issues encountered as we reorganized and realigned the CA AHEC with CHCs between 2004 and 2011. We explore changing needs of AHECs and discuss how we were able to build and strengthen these new partnerships. As federal agencies seek models for collaboration between programs, and with CHCs central to the health care for the underserved, the California experience may benefit other AHECs and CHCs.
Because of waning federal funding for AHECs and other pipeline programs, many centers have found it difficult to comply with federal requirements. Some may deviate from the AHEC mission as a result, and others are unable to survive as independent entities. In California, these issues discouraged centers from collaborating with each other and working toward a consistent program emphasis. At times, dissatisfaction with the program’s central office created organizational conflict and stress.
We sought a stronger organization, new partners, and better coordination and collaboration with and among centers. At the time, California’s 800 CHCs were organized into 15 consortia or networks of clinics and clinic systems, supported by both private and public funding. Recognizing their shared missions, CHCs and AHECs began to partner and combine resources to address workforce needs. Program leadership, along with processes to strengthen the mission and focus and build relationships with CHCs, influenced the ensuing changes.
In developing organizational change and new partnerships, particularly with CHCs, both academic and community leaders need the vision, flexibility, and cultural sensitivities to guide the process. AHEC programs nationwide are based in academic medical centers, and each AHEC program has one or more centers. The CA AHEC is based at University of California, San Francisco’s Fresno Medical Education campus and has 12 centers. CA AHEC leaders had strong backgrounds in family medicine, clinical experience with underserved populations, and teaching and evaluation skills. Their management styles were participatory and respectful of community leaders as equal partners in planning and decision making, which set the tone for developing good community relationships. Center directors were community leaders with cultural competence within their host organizations and the regions served by their centers. Many were directors of community programs, allowing the AHEC to become the umbrella for health professions education.
Strengthening the mission and focus
For an academic–community partnership to be successful, all stakeholders must agree about the mission. Our first step in addressing the challenges we were facing was to revise the CA AHEC’s mission and goals through a group process of strategic planning with the Statewide Program Advisory Committee. State, academic, and community partners participated in this process to create new energy and trust among stakeholders. This process was facilitated by two of the program’s well-known and respected academic and community leaders. The revised mission was “to improve access to and quality of health care for medically underserved populations of California using academic–community partnerships for health professions training.”
A second collaborative process conducted with program leaders and center directors identified common program themes for which each center implemented or planned educational activities based on their community needs assessments and input from advisory boards. The process enhanced collaboration among centers, positioned the CA AHEC for new initiatives, and provided a guide for evaluation and reporting. Four program-wide themes were identified: (1) community-based clinical experiences for health professions students and residents; (2) professional education for practicing health professionals; (3) teaching residents/students to conduct health education in community organizations, clinics, and educational institutions; and (4) health careers pipeline programs.
In a third group process, we explored which outcomes were important to evaluate, developed an evaluation plan focused on the four themes, and identified agreed-on measures for which centers would collect and report data assessing program progress and outcomes. This plan served as the basis for quarterly reporting and discussion of outcomes, guided program progress, reinforced objectives to be achieved, fostered accountability, enabled problem solving, oriented new center directors, and informed others about AHEC activities.
Building relationships and organization with CHCs
During the processes of redefining the CA AHEC mission and objectives, we began to gradually relocate centers into CHC consortia. Some centers elected to move to CHC consortium hosts. Others were guided by program leadership when opportunity and need emerged. When that occurred, we approached the CEO of a consortium or large network of clinics to inform him or her about the AHEC program’s role and explore how it might complement needs of the clinics. CEOs discussed this with their consortia or clinics’ own boards and, following their approval, appointed a center director, usually a staff member involved with training programs. Increasingly, centers aligned their educational activities with CHCs’ workforce needs.
Eventually, 8 of the 12 centers were hosted by CHC consortia or large clinic systems. The remaining 4 centers were located in an inner-city community-based family medicine residency, a community hospital, and two nonprofit community organizations, all closely partnered with CHCs. These formal linkages established the CA AHEC with almost half (354; 44%) of the state’s CHCs through the centers’ clinic consortia hosts or other center consortia partnerships. The CHC partnerships positioned the AHEC program to address underserved community service needs at state, regional, and local levels.
Types of partnerships.
New partnerships expand capacity for training. AHEC centers typically form a variety of academic, clinical, and community partnerships to train health professions students, residents, and practicing professionals. As AHEC resources shifted to CHCs, the types of partnerships the centers engaged in shifted to reflect this change. As of 2011, centers had 739 academic, clinical, government, and community organizations with which to conduct training activities. Of the 404 clinical partnerships, most (354; 88%) were with CHCs (see Table 1). Through these partnerships, the CA AHEC sponsored many professional and preprofessional educational activities in 29 of California’s 58 counties. Conducting training within CHCs influenced the development of other partnerships for residents and student experiences. As centers matured, center directors became stronger in their roles and positioned themselves within their host organizations as agents for health professions education, thus beginning the slow and deliberate process of expanding the CHCs’ mission in health professions education.
Examples of new programs and opportunities.
Our new relationships forged new state partnerships and opened the door for the development of programs to bring training to CHCs. These include a HRSA grant to design and conduct the California Emergency Preparedness Program, a partnership with the Office of Statewide Health Planning and Development (OSHPD) to develop and evaluate educational activities associated with the HRSA-funded California Student/Resident Experiences in Community Health program, and another HRSA project with OSHPD to develop and evaluate regional strategies to retain National Health Service Corps clinicians. Centers participated in these programs based on their interests and capacities to conduct the initiatives.3,4
A new family medicine residency program was established in the Central Valley with fundamental support from CA AHEC leadership, an AHEC center, a CHC, and other community partners. This process began with CA AHEC leadership convening interested community parties and developing a consortium model.
Defining Successful AHECs
Nationwide, AHECs differ one from another. An AHEC program is only as strong as its centers. To strengthen the centers’ identities within the CA AHEC and within their communities and new partnerships, we used another group process to assess our organizational capacity, unify the centers with the CA AHEC’s common mission and program objectives, and establish standards for centers.
Program leaders and center directors brainstormed characteristics of successful AHECs, establishing 16 organizational features, 19 functions, and 5 community impact features for successful centers. Organizational characteristics included features about the host agency’s commitment to the center’s mission and leadership, the educational and clinical partnerships, and advisory board composition. Functional characteristics emphasized developing educational programs, convening community interests, capacity building, and brokering and leveraging resources. Impact characteristics denoted evidence that AHEC activities make a difference in target communities.
We derived an instrument with these characteristics for centers to assess whether they met, partially met, or did not meet each one, allowing space to make comments or plans for improvements. This became a tool for regular self-assessments by centers and for on-site visits at centers to monitor progress and remind center directors, their host organizations, and advisory boards of these standards and determine where improvements were needed. The process had the added benefit of orienting new center directors about how centers should be organized and operate to meet the expectations of the CA AHEC program.
Challenges and Approaches
CHCs tend to be wary of political interference, perceived disruptions of clinic or consortia power relationships, intrusions of academic demands, and distractions from their core service mission. Academic program training needs often conflict with CHC clinicians’ service obligations. Where AHECs are hosted by CHCs, center directors are employees of the CHCs and can broker their workforce needs with their academic partners instead of the traditional approach of academic programs placing students or residents in clinics without relating to the clinic’s workforce or service priorities.
Other challenges for AHECs nationwide are funding, leadership changes, and contracting procedures. HRSA mandates that 75% of funds for an AHEC program be spent in the community. Distributing these funds from the medical school’s AHEC program office can be tricky. Funding expectations need to be addressed and clarified. Our changing relationships were supported by the contracting process required by the federal AHEC grant, which defined commitments and expectations and reinforced partnerships. In preparation for the HRSA grant award, centers were given an approximate dollar amount for which they could prepare a proposal request based on activities planned with their advisory boards that related to both community needs and the statewide program objectives. These were incorporated into the one statewide funding request submitted by the CA AHEC to HRSA. This process supported the community-to-academia flow of information and program priorities, avoiding preemptive decision making based on academic needs.
Federal, state, and regional budget crises with funding cuts to higher education were ongoing problems. Reduced funding for AHEC programs limited centers’ capacities for innovation and growth. Strategic placement of centers in CHC consortia and clinic systems provided important administrative support, allowed flexibility to cope with financial uncertainties, and provided a financial cushion for delays in funding from contractors.
The CA AHEC was fortunate to have a program director whose tenure during organizational changes lasted more than a decade. However, centers experienced a high turnover of directors, which occurred mostly with newer centers. In the past decade, only 3 center directors among the 12 remained part of the leadership; 1 of those moved from one center to assume leadership of another. An orientation provided by the National AHEC Organization was a helpful resource for new directors, as was a “CD [center director] Boot Camp” developed by CA AHEC staff. Staff provided orientation through workshops and site visits. Having guidelines for qualifications of new center directors, an orientation program for them, and the self-assessment standards promoted understanding of AHEC complexities.
Finally, contracting procedures involving state or university subcontracts to centers and centers’ subcontracts to their partners were cumbersome, time-consuming, and challenging to monitor fiscally because of the numbers and diversity of contracting institutions. To address this challenge, when new projects were planned, specific responsibilities were identified for each partner.
Collaborations between AHECs and CHCs are not new. However, AHEC centers being located within CHCs as their administrative homes is rare, and HRSA has expressed interest in the idea. Colocation of AHECs and CHCs creates safe space in which academic institutions and community interests can come together to support the recruitment and training of students and residents who become culturally prepared for care of the underserved and hopefully will remain to practice in these community clinics.
The reorganization and new partnerships established by CA AHEC positioned centers to serve as “educational arms” for partner CHCs, improved the statewide program’s capacity to conduct new initiatives, and fostered an environment of academic–community trust conducive for collaborations among all centers and with a few for special initiatives. In essence, the retooling not only had the positive outcome of making the CA AHEC more visible to partners but also changed its role from interesting friend to great collaborator.
Factors that made this work successful included stability of leadership along with their skill sets and sensitivities as well as transparency in decision making. Our group collaborative processes at statewide quarterly meetings enhanced team and consensus building with centers to determine the program’s direction, evaluation, and standards for centers. The processes used helped to build trust and foster “ownership” of the statewide program among all stakeholders and build confidence in the organization itself. Essentially, we agreed on and codified the elements of a successful AHEC in California and the metrics we would use to assess our progress and accomplishments. The AHEC’s clear mission and objectives to which all partners subscribed enabled a shared sense of purpose for stakeholders. Program objectives, activities, and evaluation plans derived from the mission. The organizational alignment with CHCs established the program as an important asset for their workforce needs and for health professionals training in underserved communities. As they developed and conducted programs with their community partners, centers saw themselves as conveners, facilitators, and educators providing linkages and resources for their partner academic and clinical institutions. These relationships benefited their CHC hosts/partners and extended the capacities of both to develop and retain the health professions workforce.
As HRSA’s national policies for AHECs and CHCs evolve in the context of health care reform, the CA AHEC experience suggests a model for future statewide academic–community partnerships focused on training health professionals for underserved communities. Close ties between academic institutions like AHEC programs and CHCs support vital clinical training needs for academic programs and ultimately help CHCs establish and retain their workforce.
Acknowledgments: The authors want to acknowledge the CA AHEC center directors whose thoughtful work made these results possible.