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New GME Design and
Development
Randall Longenecker MD
• Senior Project Advisor RTT Technical Assistance Program
• Executive Director, The RTT Collaborative
• Assistant Dean Rural and Underserved Programs, Ohio University
Heritage College of Osteopathic Medicine, Athens, Ohio
Dave Schmitz MD
• Project Advisor RTT Technical Assistance Program
• Associate Director, The RTT Collaborative
• Director of Rural Residencies, Family Medicine Residency of
Idaho
What’s New?
New accreditation reality – a unified accreditation system
New efficiency of scale – “small” is becoming the new
“better”
New ways of GME development – no longer going it alone, the rise of consortia, teaching health centers,
distributed community-based and community-engaged
medical education, and the OPTI framework (CORE
1997)
Objectives
Describe the history of RTTs and the diversity of integrated rural training track programs that have emerged from the original 1-2 RTT prototype (Spokane Model)
Articulate several evolving strategies for accreditation, faculty development, recruitment and funding of RTTs
Answer questions regarding integrated RTT development, networks, and sustainability
Begin to develop new residency programs, using a framework designed around basic questions of place(s), person(s), purpose(s), and possibility(s).
History of 1-2 RTTs: Accreditation
1985 – Proposed by Bob Maudlin of Family Medicine Spokane as a strategy to graduate more physicians to rural practice and to better prepare them professionally and personally to practice and live in rural places
1986 – ACGME approval as an “experimental pathway”
1996 – Additional formal requirements by the RRC in Family Medicine, including a separate PIF
Minimum of 2 residents at the rural site (1 PGY2, 1 PGY3)
50% precepting rule
Mandated 24 months of continuity, with the exception of 2 elective months away each year
CMS Definitions
ACGME accredited program in the “1-2 format” (alternative tracks, only in family medicine – established
by final rule in 2000)
Integrated RTT – any accredited residency program, MD
or DO, established in collaboration with an urban residency, where greater than 50% of the resident’s
training occurs in a rural place (e.g. 19 months out of 36
months – established by final rule in 2003)
History of 1-2 RTTs: Accreditation
The OSU Rural Program – Three Year Curriculum Intensive immersion experiences embedded in a continuing rural practice
1 2 3 4 5 6 7 8 9 10 11 12 13
YEAR 1
Hospital
Care (Shared)
Hospital
Care
Pediatrics
Inpatient
Hospital
Care
(NRP)
Special Care
Nursery
OB –
Newborn
Hospital
Care
Cardiology
Hospital
Care
(Wound Healing)
MICU
Hospital
Care
(ATLS)
Peds ER Scholarly
Activity
(Shared)
MRH MRH CHC MRH OSUH MRH MRH OSUH MRH OSUH MRH CHC MRH
Mad River Family Practice -- Periodic office patient care, daily hospital rounds
2 Half-days 2 Half-days 1 Half-day 2 Half-days 1 Half-day 2 Half-days 1 Half-day 2 Half-days 1 Half-day 2 Half-days 1 Half-day 3 Half-days
YEAR 2
Ambulatory
Cardiology
OB - Newborn
OB – Newborn
(High Risk Immersion)
Derma-
tology
Pediatrics
Outpatient
ICU – Intern Med Orthopedics Medical Sub -
specialty
GYN
MRH/Offic
Elective
MRH MRH Office Office MRH MRH/Office MRH/Office
Elective
Office
Mad River Family Practice -- Periodic office patient care, daily hospital rounds Scholarly Activity and Community Medicine
4 Office Half-days
0-4 Half-days
2 Half-days 2 Half-days 4 Half-days 2 Half-days 8 Half-days one week None the next
4 half-days 4 Half-days 0-4 Half-days
3 Half-days
YEAR 3
Geriatrics, Physical Medicine, and Psychiatry
GYN Surgical Subspecialiies – Opthalmology, ENT, Urology, Podiatry
Sports
Medicine
Medical Sub -
specialty
Elective
Office Office
Elective
Office
Elective
OSU Sports Ctr
Elective
MRH/Office
Mad River Family Practice -- Periodic office patient care, daily hospital rounds Practice Management and Community Intervention
0-4 Half-days
5 Office Half-days 4 Half-days 0-4 Half-days
5 Office Half-days 0-4 Half-days
4 Half-days 0-4 Half-days
0-4 Half-days
[Gray shaded rotations occur at least in part in Columbus, Ohio]
History of 1-2 RTTs: Accreditation
The OSU Rural Program – Three Year Curriculum Intensive immersion experiences embedded in a continuing rural practice
1 2 3 4 5 6 7 8 9 10 11 12 13
YEAR 1
Hospital
Care (Shared)
Hospital
Care
Pediatrics
Inpatient
Hospital
Care
(NRP)
Special Care
Nursery
OB –
Newborn
Hospital
Care
Cardiology
Hospital
Care
(Wound Healing)
MICU
Hospital
Care
(ATLS)
Peds ER Scholarly
Activity
(Shared)
MRH MRH CHC MRH OSUH MRH MRH OSUH MRH OSUH MRH CHC MRH
Mad River Family Practice -- Periodic office patient care, daily hospital rounds
2 Half-days 2 Half-days 1 Half-day 2 Half-days 1 Half-day 2 Half-days 1 Half-day 2 Half-days 1 Half-day 2 Half-days 1 Half-day 3 Half-days
YEAR 2
Ambulatory
Cardiology
OB - Newborn
OB – Newborn
(High Risk Immersion)
Derma-
tology
Pediatrics
Outpatient
ICU – Intern Med Orthopedics Medical Sub -
specialty
GYN
MRH/Offic
Elective
MRH MRH Office Office MRH MRH/Office MRH/Office
Elective
Office
Mad River Family Practice -- Periodic office patient care, daily hospital rounds Scholarly Activity and Community Medicine
4 Office Half-days
0-4 Half-days
2 Half-days 2 Half-days 4 Half-days 2 Half-days 8 Half-days one week None the next
4 half-days 4 Half-days 0-4 Half-days
3 Half-days
YEAR 3
Geriatrics, Physical Medicine, and Psychiatry
GYN Surgical Subspecialiies – Opthalmology, ENT, Urology, Podiatry
Sports
Medicine
Medical Sub -
specialty
Elective
Office Office
Elective
Office
Elective
OSU Sports Ctr
Elective
MRH/Office
Mad River Family Practice -- Periodic office patient care, daily hospital rounds Practice Management and Community Intervention
0-4 Half-days
5 Office Half-days 4 Half-days 0-4 Half-days
5 Office Half-days 0-4 Half-days
4 Half-days 0-4 Half-days
0-4 Half-days
[Gray shaded rotations occur at least in part in Columbus, Ohio]
The OSU Rural Program – Three Year Curriculum
Intensive immersion experiences embedded in a continuing rural practice
Operational Phrase:
9
“ ‘1-2’… and other integrated
rural training tracks…”
“…Section 407(c) of Public Law 106–113 which allows an
urban hospital that establishes separately accredited
approved medical residency training programs (or rural
training tracks) in a rural area or has an accredited training
program with an integrated rural track..”
Federal Register August 1, 2000 (BBRA 1999)
History of 1-2 RTTs
Rosenthal et al, Academic Medicine 1992
Maudlin et al, Journal or Rural Health 2000
Maudlin and Newkirk, Family Medicine 2010
For a series of seminal articles in the past decade, see the RTT Technical Assistance Program site –
www.raconline.org/rtt
History of 1-2 RTTs: Funding
Prior to BBA1997, which established a cap on GME positions funded through Medicare based on FY1996, RTTs were primarily funded in traditional ways, although few were able to access IME at the rural site
BBRA 1999 created a rural cap for urban hospitals seeking to establish a “1-2 RTT” or an “integrated rural track”
For lack of a definition, CMS did not implement the latter, until October 1, 2003, when they also approved an exception for programs in which >50% of the resident’s training occurs in a rural place
History of 1-2 RTTs: Funding
Medicare and Medicaid GME funding of RTTs is very state and intermediary-dependent (Most CMS
intermediaries have only one or two RTTs, and
states have their own rules around Medicaid GME)
Therefore most RTTs, to remain financially viable,
depend on state government subsidies; AHECs;
local hospital, clinic, and community support;
patient care revenues; or grant funding
History of 1-2 RTTs: Funding
Clinical Income 45%
GME Passthroughs
24%
Contracts 3%
Grants 2%
Institutional Subsidy:MRH
23%
Institutional Subsidy:DFM
0%
Institutional Subsidy:OSUH
3%
Revenue Sources OSU Rural Program 2010-2011
History of 1-2 RTTs: Recruiting
Recruiting of residents has very much been influenced by the rise and fall of US student interest
in Family Medicine and the increasing importance
of international medical graduates
US student interest in FM peaked in 1997, then
began a decade long fall and IMG applications
were impacted by the events of September 11,
2001
However, the number of GME slots is no longer that
much greater than the number of US graduates
RTT NRMP Trends 2003-2014
Source: Personal communication from Randall Longenecker MD, Senior Project Advisor,
the RTT Technical Assistance Program, March 25, 2014 (unofficial and to be confirmed)
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Match Fill Rate
Positions Offered
Positions filled
4-4-4
Closed
Active
Prior to July 1, 2010
As of July 1, 2010
4-4-4
Active
Developing
Accredited, not active
As of March 1, 2013
28 (32) Active 1-2 RTTs as of February 2014
Active 1-2 RTTs
1-2 like RTTs
*RTT Technical Assistance Program – Updated 2-5-2014, Randall Longenecker, Senior Project Advisor
Rural Training Tracks – Not 1-2 RTTs
Florida – Mandate from state for rural training in IM, Peds,
OB-GYN, as well as FM
Missouri – PCE expansion to multiple rural continuity clinics
New York – Accelerated DO residency in FM
Washington – Rural continuity, Elma, WA; Ellensburg, WA
Wisconsin – Rural immersion experiences, continuity sites
Montana – Urban 1-2 with a rural mission
Contemplative Stage
Colorado – Colorado Institute for Family Medicine, University of Colorado
Florida – University of Florida; FSU
Kansas – University of Kansas/Salina
Maryland – University of Maryland
Michigan – State Office of Rural Health, CMU, MSU
Pennsylvania – State mandate; Williamsport, State College
South Carolina SORH
Tennessee – ETSU, TSRHP
Vermont – University of Vermont
Virginia – MCV
Osteopathic GME Development
RTT Masterfile and Policy Briefs
Initial and sustained practice in rural communities (2-3 times traditional residency training
A significant contribution to the next generation of rural physician faculty (16% of graduates)
Service in areas of primary care physician shortage
http://www.raconline.org/rtt/pdf/rural-family-medicine-training-early-career-outcomes-2013.pdf
RTT Masterfile and Policy Briefs
Adaptability and Resilience
24
28 (32) Active 1-2 RTTs as of February 2014
Active 1-2 RTTs
1-2 like RTTs
! " ##$#%&' ( )&*+$, --)- .*( &%$/0120*3 $4$567*.%7$89: 98; <=>$" *( 7*++$?1( 2%( %&@%0>$A%( )10$/01B%&.$, 7C)-10$
Adaptability and Resilience
25
Urban
Rural
Urban
Rural
Creative Variations
Structure: Varying degrees of integration, from 4 -15 months in the urban place; “Spider plant”
configurations
Funding: Teaching Health Centers (e.g. Boise, ID;
Silver City, NM; Redding, CA)
Faculty Development: NIPDD Rural Fellows; annual RTT Conclave; peer consultation
Emerging Network: The RTT Collaborative
www.rttcollaborative.net
Creative Variations: Funding
Critical Access Hospitals – CMS final rule and its implications; NRHA working group
Teaching Health Consortia – CHCs, RHCs, and others
State initiatives – Florida, Wisconsin, Colorado, now South Carolina
Veteran Health Affairs (Office of Rural Health)
Foundation funding - Ohio
Justification through community benefit (e.g. Community APGAR; State Banker’s Association re economic benefit)
RTTs: A way forward
Nurtured and sustained
Community embedded
Teaching health practices
Uniquely adapted and relevant
to the needs of their particular
community
Where to begin?
1. A Rural Place (s)
2. A Passionate Person(s)
3. A Clear Purpose (rationale)
4. Explore the Possibilities
5. Save the money question for #5
Education & Initial Assessment
Identify Initial Champions
Apply for Grants
Education & In-Depth Assessment
Choose GME Path (s)
WI Collaborative for Rural GME Development Paths
ROTATION SITE
Assemble Core Team
Identify Partners
Additional Education
Simple Budget
Market Rotation
Accept Residents
INTEGRATED RURAL TRAINING TRACK (IRTT) RESIDENCY Assemble Core Team
Identify Partners
Additional Education
Proforma
Board Approval
Curriculum
Budget
Market Rural FMC Track
Interview Applicants
Accept Residents
FELLOWSHIP PROGRAM
Assemble Core Team
Identify Partners
Additional Education
Proforma
Board Approval
Curriculum
Budget
Submit for Accreditation (if
applicable)
Market Fellowship
Interview Applicants
Accept Fellows
RURAL TRAINING TRACK RESIDENCY (RTT) Assemble Core Team
Identify Partners
Additional Education
Proforma
Board Approval
Curriculum
Budget
Write Program Information Form
(PIF)
Submit PIF
Site Visit
Market Residency
Interview Applicants
Accept Residents
I N I T I A L P H A S E
D E V E L O P M E N T P H A S E
Courtesy of Kara Traxler, RWHC/WCRGME
Resources
RTT Technical Assistance Program - Policy Briefs, and other
downloadable items: www.raconline.org/rtt/
Randall Longenecker MD, Senior Project Advisor,
longenec@ohio.edu
TrainDocsRural - Student site and links to a student blog and
facebook page: www.traindocsrural.org
The RTT Collaborative – Google Group for rural tracks of all
types – medical school or residency, contact
longenec@ohio.edu to join
Questions?
The best way to predict the future is to
create it!
Abraham Lincoln/Peter Drucker
The best way to create the future is to:
Act. Learn. Build. Repeat.
Paul Brown
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