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