A number of reports indicate that the U.S. primary care workforce will be insufficient to meet the increasing demands for care caused by an aging population and expanded insurance coverage.1,2 Since the 1980s, the number of U.S. medical school graduates pursuing primary care specialties has decreased and falls far short of the number of currently available graduate medical education (GME) slots; U.S. graduates occupy 48.5%, 70%, and 45% of internal medicine, pediatrics, and family medicine positions, respectively, filled through the National Resident Matching Program.1,3
Primary care’s diminishing appeal has been ascribed to inadequate medical school training in ambulatory settings, few positive role models, lower compensation, and/or diminished prestige.1,2,4 The skew away from primary care increases in the years following medical school graduation, when many residents subspecialize or pursue hospital medicine.2 Further attrition occurs among those primary care physicians already in practice, where burnout may be an important factor.1 These challenges are especially problematic in rural and underserved areas faced with limited resources and increasing clinical and administrative demands.1,2
Reports focusing on the social mission of GME programs and the development of clinician leaders to meet emerging health care needs have underscored the need for primary care physicians to be trained in areas such as team-based care, cultural competency, advocacy, cost-effective care, and management of the socioeconomic determinants of health.1 These skills are particularly important for physicians caring for vulnerable populations in community settings. Many GME programs have responded by increasing trainees’ exposure to community practice in underserved areas. Such exposure during GME training is associated with choosing and continuing to practice primary care in underserved communities.2,4
For primary care providers who are practicing in community settings, opportunities for professional development, time for research and teaching, and believing in the mission of their practice site were reported to significantly impact their decision to remain in community-based primary care.4 However, there are limited GME or career development programs available to support additional education in community health for graduates of primary care residencies and scarce opportunities for research. Currently, finding the balance between carrying out the social mission, enhancing clinical skills within a public health framework, and protecting time for research is challenging for community health centers (CHCs), and they face challenges in recruitment and retention of primary care clinicians.
Program development and description
In July 2012, the Kraft Center for Community Health Leadership (hereafter, simply the Center) was developed by Partners HealthCare to improve recruitment and retention of community health providers with the skills to lead in a dynamic health care environment. The Center was designed to harness the long-standing relationship between the Massachusetts League of Community Health Centers and Partners HealthCare, a large, regional academic health system anchored by its founding academic medical centers (AMCs)—Massachusetts General Hospital and Brigham and Women’s Hospital, both affiliates of Harvard Medical School. This partnership was honed to develop and implement novel training models mirroring the Center’s principal strategy: to develop physician and nursing leaders with blended academic–community career paths and identities.
The CHCs, members of the Massachusetts League of Community Health Centers, serve as clinical practice sites, experts in the specific health priorities of their communities, and provide mentorship in clinical care and leadership. The two AMCs contribute faculty who participate in the didactic curriculum, provide research mentorship, and provide access to academic resources. Both the CHCs and the AMCs are sources of trainees for the Center.
In July 2012, the Center developed and implemented two 2-year training programs: the fellowship program and the practitioner program. The fellowship program is a physician recruitment strategy, aimed at residency program graduates from primary care or internal medicine, family medicine, pediatrics, and psychiatry. Unlike typical GME programs, the fellowship program is multidisciplinary and selects specifically for solidly differentiated frontline physicians committed to community health leadership. The fellowship program is paradigmatic in narrowing the academic–community divide. Specifically, the focus on leadership and scholarship in community settings extends these fundamental academic values, while the community and public health emphasis reinforces the mission that spawned their original career choices, caring for the underserved and promoting the health of communities.
In contrast, the practitioner program supports retention of early-career physicians and advanced practice nurses in community settings, adding new tools and knowledge to their clinical skills, creating time for them to participate in nonclinical work, and creating a peer community to diminish professional isolation. These factors were identified through earlier focus groups with CHC leaders as key to cementing young clinicians’ commitment to community health.
Both programs are grounded in a public health framework. The curriculum emphasizes the social determinants of health, population health management, health policy, advocacy, and leadership. Skills in community-related and community-based participatory research, and strategies that promote health equity and improve population health outcomes, are highlighted. Interactions between participants in the two programs create a multidisciplinary and interprofessional cohort with complementary knowledge and experiences. Fellows benefit from engaging with people who have “real-world” community health experience, and practitioners benefit from the academic focus that the fellows bring. Both fellows and practitioners get to train with people whose clinical expertise and provider role differs from their own. This creates opportunities for cross-fertilization, particularly about common issues faced across health centers.
Core elements in both programs include mentored CHC clinical practice (three sessions per week for fellows and six sessions per week for practitioners), monthly learning days, engagement in the virtual learning community (VLC), and the design and execution of a research project (all described below). Both programs require a commitment to remain in community health upon program completion (see below). The fellowship program also includes matriculation in the MPH program at Harvard T.H. Chan School of Public Health, with a concentration in either health policy and management or health and social behavior, as well as engagement in a bimonthly leadership seminar.
Candidates for the fellowship program include graduating residents from the disciplines listed above. Selection criteria include demonstrated clinical and academic excellence, leadership experience, and a commitment to community health. Practitioners are nominated by participating CHCs. To participate, CHCs must have experience with residency training, be willing to provide faculty to mentor and teach, and be committed to including the trainees in quality improvement and leadership activities.
Both fellows and practitioners attend monthly learning days. The learning days curriculum is taught by faculty and/or outside experts and includes topic-based interactive presentations and discussions aimed at (1) deepening knowledge about health disparities and health equity, social determinants of health, public policy related to safety net providers, health system organization and delivery, research and quality improvement, management, and leadership; (2) providing an understanding of CHC evolution and challenges; and (3) developing leadership skills and competencies (see Table 1). All learning days require assigned readings and interactive discussion in the VLC to complement the learning days with self-paced online learning. Using a Web-based platform, trainees discuss reading materials, share local approaches to care redesign, communicate regarding research projects, and contribute to a growing reference set. The VLC is also a vehicle to promote connection across time and space for the programs’ alumni.
In collaboration with CHC leadership and AMC advisors, each fellow and practitioner completes a quality improvement or research project reflecting health priorities specific to their community (see Table 1 for examples). The process of developing a project, which requires engagement with leaders and finding the intersection between the trainee’s interests and the CHC’s priorities, becomes the scaffolding for successful academic–community partnerships. All trainees are expected to publish or present their work. Practitioners have variable prior experience with quality improvement and research and less dedicated time for nonclinical activities than the fellows. Accordingly, there is more heterogeneity in the scope and content of practitioners’ projects.
For fellows, an MPH degree with specific concentration areas (see above) was chosen rather than other advanced degree training because of its alignment with the Center’s goals. Although elements of an MPP or MBA degree, for example, are also relevant, neither of these is organized specifically around health or shares community and public heath principles and values. The MPH program also provides opportunities for advanced training in quality improvement and community-based research methods that support career development in a combined academic–community setting.
The fellows’ bimonthly leadership seminar exposes them to community health leaders in an intimate setting. In year 1 of the fellowship program, the focus of these seminars is career development and leadership in community health, emphasizing nontraditional community-health-related career paths. In year 2, the focus shifts to community care delivery, with CHC executive directors and chief medical officers discussing their health center’s approach to common challenges such as care redesign or patient-centered medical homes, new models of funding, and behavioral health integration.
On completion of the program, fellows are required to commit 100% of their efforts for three years to community health, with at least 50% as direct clinical care, and practitioners are required to commit to remaining community health providers for two years.
Further information on these programs and the Center can be found at www.kraftcommunityhealth.com.
Fellows’ salaries are paid by the Center. Revenue generated by clinical practice is retained by the CHC in lieu of compensation for their faculty teaching and mentoring. The Center supports the 20% of the practitioners’ salaries associated with nonclinical activities, and the CHC continues to support the balance. The total cost of the programs, including salaries, tuition, mentorship, and administrative costs, is approximately $2 million per year. Philanthropy afforded the Center the unusual opportunity to establish “proof of concept” for these multidisciplinary, interprofessional programs addressing a pressing health care delivery need. This proof of concept is aiding the Center’s pursuit of more diversified private and public funding. As the programs expand, core elements can be scaled to diminish overhead costs.
The Center seeks to bolster the primary care workforce by supporting the viability of community health as a sustained career: emphasizing the social mission, creating blended identities (academic–community health professional), providing tailored educational content, engaging in a peer community, and promoting leadership. In time, we expect our graduates to practice medicine in a community setting, serve in leadership roles in CHCs, advance the knowledge base through community-focused and community-based participatory research, teach students and residents, lead public health departments, and, perhaps most important, become magnets and mentors for aspiring health care providers.
Our first classes of 5 fellows and 14 practitioners graduated in June 2014. Currently, 8 fellows and 24 practitioners are enrolled across the two years of the programs. All 5 fellowship program graduates were offered full-time (new) positions at the CHCs where they practiced clinical medicine, and 2 have accepted leadership positions at their CHCs—1 as director of pediatrics and 1 as director of behavioral health. All 14 practitioner graduates remain in community health, 13 at their original CHCs. Of these, 5 have accepted leadership positions and 2 have obtained grants to support ongoing projects.
All graduates have teaching responsibilities for medical students, residents, or nursing students. All of the CHCs seek ongoing participation in the fellowship and practitioner programs, and despite funding challenges, all are sustaining quality improvement practices initiated by Center trainees. All of the CHCs have access to key resources on the VLC to abet their efforts at broader dissemination of relevant practices. To date, fellows and practitioners have produced 12 peer-reviewed publications, 3 have presented nationally, and 5 have secured extramural funding for aspects of their trainee project. Comments from recent graduates’ personal reflections, which are formally collected at program completion, illustrate the programs’ impact (Box 1).
Box 1 Two Graduates’ Comments on the Impact of the Fellowship and Practitioner Programs, Kraft Center for Community Health Leadershipa Cited Here...
“The Kraft Center experience has reinforced for me the importance of surrounding oneself with a team that is going to support your passions and values beyond the specific educational task or career trajectory at hand.… My Kraft fellowship has put me conceptually about 10 years further in my career than I imagined I would be. The time and access to leadership has resulted in an unexpected depth and breadth of conversations about the care of our patients and the local, regional, and wider institutions that support that care.… [and] gave me the confidence and clarity to see my style of leadership as not having to remain outside of traditional leadership roles.… My project work helped me see how the weaving of community participatory work, quality improvement, systems change, and research is a wonderfulness that boggles IRBs and challenges norms, but is the true meaning of translational and applied. And while [the Kraft Center for Community Health Leadership] has supported these large-scope aspirations, it has also led to an even stronger feeling of wanting to be a phenomenal doctor for my patients and their families and fully committed to primary care for the foreseeable future (and I have incredible distance vision)!” (Fellow)
“The protected time and training provided by [the] Kraft program has been incredibly vital to my capacity to understand my contributions beyond the clinical care that I provide. Before the Kraft program, I think I could not really even entirely envision myself in a leadership position. While such a role was something that I did want, it seemed ever in the distant future, for a self wholly different from my current self. The Kraft program demystified what leadership meant, what that work could look like, and who could and should assume those roles. I think one of the most powerful lessons from the Kraft experience, was realizing that being an effective leader was something that could be learned, and that in many ways I didn’t need as radical a transformation as perhaps I thought I did. My participation with [the Kraft Center for Community Health Leadership] has above all else empowered me to see myself as a change agent in my work with vulnerable patients. If I ever feel that there is a problem with how something is done in my health center, a systems issue, or policy that is problematic or dysfunctional, I feel like I have the tools now to do something to change these.… Cultivating a community of like-minded colleagues committed to social justice and health equity is the most important outcome of the Kraft program in my mind and what I will cherish most about my experience. This community is the antidote to the isolation, burnout, despondency, and complacency that can set in among those working in CHC settings.” (Practitioner)
Abbreviations: IRB indicates institutional review board; CHC, community health center.
aGraduates’ personal reflections are formally collected at program completion. These comments are from the first classes of fellows and practitioners who graduated in June 2014 and are used with permission from the graduates.
Providing training in CHCs is a powerful mechanism to attract future community-based clinicians.4,5 Populating CHCs with clinician role models who can speak the languages of academia and community health offers promise as an approach to drawing more students to community-based primary care fields. Similarly, providing community-based clinicians with the tools to have a greater impact on their patients and communities, preserving connections to academic medicine, and creating a vibrant mission-driven peer community contribute to sustaining careers in community health.
We are collecting and scrutinizing multisource feedback, and we are making continuous adjustments to improve the quality of the programs and the experience of trainees based on internal constituent feedback. Thus far, we have enhanced academic mentorship by assigning Center-supported project advisors, modified the structure of learning days to enhance peer connection, initiated leadership training earlier, and increased required participation in the VLC. We are tracking the careers of all fellowship and practitioner program graduates, the outcomes of trainee projects, and the programs’ impact on participating CHCs.
Whereas an initial large gift enabled the launch of the programs, we have “rightsized” the number of trainees to ensure longevity, while building a fundraising strategy and seeking external grant support. We are working with CHCs to determine their ability to underwrite trainees’ quality improvement and research projects as health reform imperatives drive their need to implement the practices initiated by these projects. We are also identifying critical elements of the programs that may be amenable to a more cost-effective delivery, including the use of distant learning tools that support geographic expansion of the programs.
The growth of the community-based primary care workforce and the development of a pipeline of leaders in community-based primary care fields are responsive to recent consensus reports, including the Institute of Medicine’s recent GME report which calls for “transformation funds” to support innovation.2 These federal funds could support the expansion of the practitioner program to CHCs outside of Massachusetts to determine the potential for national expansion. To support this aspiration, we will study which aspects of the program are scalable and can be implemented independent of place and geography, determine the right balance of remote engagement and on-site participation, enhance technology to promote asynchronous learning, and strengthen CHC–academic relationships in other locations.
We also seek to use the tools of the practitioner program to increase the return on investment provided by the National Health Service Corps (NHSC), an existing program for increasing primary care capacity in underserved areas. Whereas 82% of NHSC alumni continue to practice in underserved communities a year after the completion of obligated service, only 55% continue for 10 years.6 An effort to test the effectiveness of targeted use of the practitioner program to diminish attrition of underserved community practice by NHSC participants could yield an important intervention strategy to sustain this workforce.
Our early experience suggests that this model of multidisciplinary and interprofessional training, marrying community and public health with the richness of the academic ecosystem, provides a unique opportunity to grow and enrich the community-based primary care workforce pipeline and its leadership.
Acknowledgments: The authors would like to thank Tara Murphy and John Co for their contributions to the implementation of the Kraft Center for Community Health Leadership programs. They are deeply indebted to the Kraft family for their remarkably generous gift to establish and sustain the Center.