Assessing clinical quality performance and staffing capacity differences between urban and rural Health Resources and Services Administration-funded health centers in the United States: A cross sectional study.

BACKGROUND: In the United States, there are nearly 1,400 Health Resources and Services Administration-funded health centers (HCs) serving low-income and underserved populations and more than 600 of these HCs are located in rural areas. Disparities in quality of medical care in urban vs. rural areas exist but data on such differences between urban and rural HCs is limited in the literature. We examined whether urban and rural HCs differed in their performance on clinical quality measures before and after controlling for patient, organizational, and contextual characteristics. METHODS AND FINDINGS: We used the 2017 Uniform Data System to examine performance on clinical quality measures between urban and rural HCs (n = 1,373). We used generalized linear regression models with the logit link function and binomial distribution, controlling for confounding factors. After adjusting for potential confounders, we found on par performance between urban and rural HCs in all but one clinical quality measure. Rural HCs had lower rates of linking patients newly diagnosed with HIV to care (74% [95% CI: 69%, 80%] vs. 83% [95% CI: 80%, 86%]). We identified control variables that systematically accounted for eliminating urban vs. rural differences in performance on clinical quality measures. We also found that both urban and rural HCs had some clinical quality performance measures that were lower than available national benchmarks. Main limitations included potential discrepancy of urban or rural designation across all HC sites within a HC organization. CONCLUSIONS: Findings highlight HCs' contributions in addressing rural disparities in quality of care and identify opportunities for improvement. Performance in both rural and urban HCs may be improved by supporting programs that increase the availability of providers, training, and provision of technical resources.

Examining trends in substance use disorder capacity and service delivery by Health Resources and Services Administration-funded health centers: A time series regression analysis.

BACKGROUND: The opioid epidemic and subsequent mortality is a national concern in the U.S. The burden of this problem is disproportionately high among low-income and uninsured populations who are more likely to experience unmet need for substance use services. We assessed the impact of two Health Resources and Services Administration (HRSA) substance use disorder (SUD) service capacity grants on SUD staffing and service use in HRSA -funded health centers (HCs). METHODS AND FINDINGS: We conducted cross-sectional analyses of the Uniform Data System (UDS) from 2010 to 2017 to assess HC (n = 1,341) trends in capacity measured by supply of SUD and medication-assisted treatment (MAT) providers, utilization of SUD and MAT services, and panel size and visit ratio measured by the number of patients seen and visits delivered by SUD and MAT providers. We merged mortality and national survey data to incorporate SUD mortality and SUD treatment services availability, respectively. From 2010 to 2015, 20% of HC organizations had any SUD staff, had an average of one full-time equivalent SUD employee, and did not report an increase in SUD patients or SUD services. SUD capacity grew significantly in 2016 (43%) and 2017 (22%). MAT capacity growth was measured only in 2016 and 2017 and grew by 29% between those years. Receipt of both supplementary grants increased the probability of any SUD capacity by 35% (95% CI: 26%, 44%) and service use, but decreased the probability of SUD visit ratio by 680 visits (95% CI: -1,013, -347), compared to not receiving grants. CONCLUSIONS: The significant growth in HC specialized SUD capacity is likely due to supplemental SUD-specific HRSA grants and may vary by structure of grants. Expanding SUD capacity in HCs is an important step in increasing SUD access for low income and uninsured populations broadly and for patients of these organizations.

Adolescence as a critical stage in the MCH Life Course Model: commentary for the Leadership Education in Adolescent Health (LEAH) interdisciplinary training program projects.

The Life Course Perspective (LCP), or Model, is now a guiding framework in Maternal and Child Health (MCH) activities, including training, supported by the Health Resources and Services Administration's Maternal and Child Health Bureau. As generally applied, the LCP tends to focus on pre- through post-natal stages, infancy and early childhood, with less attention paid to adolescents as either the "maternal" or "child" elements of MCH discourse. Adolescence is a distinct developmental period with unique opportunities for the development of health, competence and capacity and not merely a transitional phase between childhood and adulthood. Adequately addressing adolescents' emergent and ongoing health needs requires well-trained and specialized professionals who recognize the unique role of this developmental period in the LCP.

Title VII and the development and promotion of national initiatives in training primary care clinicians in the United States.

The Title VII, Section 747 (Title VII) legislation, which authorizes the Training in Primary Care Medicine and Dentistry grant program, provides statutory authority to the Health Resources and Services Administration (HRSA) to award contracts and cooperative agreements aimed at enhancing the quality of primary care training in the United States.More than 35 contracts and cooperative agreements have been issued by HRSA with Title VII federal funds, most often to national organizations promoting the training of physician assistants and medical students and representing the primary care disciplines of family medicine, general internal medicine, and general pediatrics. These activities have influenced generalist medicine through three mechanisms: (1) building collaboration among the primary care disciplines and between primary care and specialty medicine, (2) strengthening primary care generally through national initiatives designed to develop and implement new models of primary care training, and (3) enhancing the quality of primary care training in specific disease areas determined to be of national importance.The most significant outcomes of the Title VII contracts awarded to national primary care organizations are increased collaboration and enhanced innovation in ambulatory training for students, residents, and faculty. Overall, generalist competencies and education in new content areas have been the distinguishing features of these initiatives. This effort has enhanced not only generalist training but also the general medical education of all students, including future specialists, because so much of the generalist competency agenda is germane to the general medical education mission.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Learning from history: the legacy of Title VII in academic family medicine.

The current renaissance of interest in primary care could benefit from reviewing the history of federal investment in academic family medicine. The authors review 30 years of experience with the Title VII, Section 747 Training in Primary Care Medicine and Dentistry (Title VII) grant program, addressing three questions: (1) What Title VII grant programs were available to family medicine, and what were their goals? (2) How did Title VII change the discipline? and (3) What impact did Title VII family medicine programs have outside the discipline?Title VII grant programs evolved from broad support for the new discipline of family medicine to a sharper focus on specific national workforce objectives such as improving care for underserved and vulnerable populations and increasing diversity in the health professions. Grant programs were instrumental in establishing family medicine in nearly all medical schools and in supporting the educational underpinnings of the field. Title VII grants helped enhance the social capital of the discipline. Outside family medicine, Title VII fostered the development of innovative ambulatory education, institutional initiatives focusing on underserved and vulnerable populations, and primary care research capacity. Adverse effects include relative inattention to clinical and research missions in family medicine academic units and, institutionally, the development of medical education initiatives without core institutional support, which has put innovation and extension of education to communities at risk as grant funding has decreased. Reinvestment in academic family medicine can yield substantial benefits for family medicine and help reorient academic health centers. This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Two decades of Title VII support of a primary care residency: process and outcomes.

PURPOSE: To assess 23 years of Health Resources and Services Administration (HRSA) Title VII Training in Primary Care Medicine and Dentistry funding to the New York University School of Medicine/Bellevue Primary Care Internal Medicine Residency Program. The program, begun in 1983 within a traditional, inner-city, subspecialty-oriented internal medicine program, evolved into a crucible of systematic innovation, catalyzed and made feasible by initiatives funded by the HRSA. The curriculum stressed three pillars of generalism: psychosocial medicine, clinical epidemiology, and health policy. It developed tight, objectives-driven, effective, nonmedical specialty blocks and five weekly primary care activities that created a paradigm-driven, community-based, role-modeling matrix. Innovation was built in. Every block and activity was evaluated immediately and in an annual, program-wide retreat. Evaluation evolved from behavioral checklists of taped interviews to performance-based, systematic, annual objective structured clinical examinations. METHOD: The authors reviewed eight grant proposals, project reports, and curriculum and program evaluations. They also quantitatively and qualitatively surveyed the 122 reachable graduates from the first 20 graduating classes of the program. RESULTS: Analysis of program documents revealed recurring emphases on the use of proven educational models, strategic innovation, and assessment and evaluation to design and refine the program. There were 104 respondents (85%) to the survey. A total of 87% of the graduates practice as primary care physicians, 83% teach, and 90% work with the underserved; 54% do research, 36% actively advocate on health issues for their patients, programs, and other constituencies, and 30% publish. Graduates cited work in the community and faculty excitement and energy as essential elements of the program's impact; overall, graduates reported high personal and career satisfaction and low burnout. CONCLUSIONS: With HRSA support, a focused, innovative program evolved which has already met each of the six recommendations for future innovation of the Alliance for Academic Internal Medicine Education Redesign Task Force. This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Providing culturally competent care: residents in HRSA Title VII funded residency programs feel better prepared.

BACKGROUND: The Health Resources and Services Administration (HRSA) funds primary care residency programs through its Title VII training grants, with a goal of ensuring a well-prepared, culturally competent physician workforce. The authors sought to determine whether primary care residents in Title VII-funded training programs feel better prepared than those in nonfunded programs to provide care to culturally diverse patients. METHOD: The authors analyzed data from a national mailed survey of senior resident physicians conducted in 2003-2004. Of 1,467 randomly selected family medicine, internal medicine, and pediatrics residents, 866 responded--403 in Title VII-funded programs and 463 in nonfunded programs (response rate = 59%). The survey included 28 Likert-response questions about residents' preparedness and perceived skills to provide cross-cultural care, sociodemographics, and residency characteristics. RESULTS: Residents in Title VII-funded programs were more likely than others to report being prepared to provide cross-cultural care across all 8 measures (odds ratio [OR] = 1.54-2.61, P < .01) and feeling more skilled in cross-cultural care for 6 of 10 measures (OR = 1.30-1.95, P < .05). Regression analyses showed that characteristics of the Title VII-funded residency training experience related to cross-cultural care (e.g., role models, cross-cultural training, and attitudes of attending physicians) accounted for many of the differences in self-reported preparedness and skills. CONCLUSIONS: Senior residents in HRSA Title VII-funded primary care residency training programs feel better prepared than others to provide culturally competent care. This may be partially explained by better cross-cultural training experiences in HRSA Title VII-funded programs.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Changing conversations: teaching safety and quality in residency training.

Improving patient safety and quality in health care is one of medicine's most pressing challenges. Residency training programs have a unique opportunity to meet this challenge by training physicians in the science and methods of patient safety and quality improvement (QI).With support from the Health Resources and Services Administration, the authors developed an innovative, longitudinal, experiential curriculum in patient safety and QI for internal medicine residents at the University of Virginia. This two-year curriculum teaches the critical concepts and skills of patient safety and QI: systems thinking and human factors analysis, root cause analysis (RCA), and process mapping. Residents apply these skills in a series of QI and patient safety projects. The constructivist educational model creates a learning environment that actively engages residents in improving the quality and safety of their medical practice.Between 2003 and 2005, 38 residents completed RCAs of adverse events. The RCAs identified causes and proposed useful interventions that have produced important care improvements. Qualitative analysis demonstrates that the curriculum shifted residents' thinking about patient safety to a systems-based approach. Residents completed 237 outcome assessments during three years. Results indicate that seminars met predefined learning objectives and were interactive and enjoyable. Residents strongly believe they gained important skills in all domains.The challenge to improve quality and safety in health care requires physicians to learn new knowledge and skills. Graduate medical education can equip new physicians with the skills necessary to lead the movement to safer and better quality of care for all patients.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Addressing the health needs of the underserved: a national faculty development program.

The authors developed a three-week faculty development program, "Addressing the Health Needs of the Underserved" (funded by Title VII), and later incorporated a year long Fellowship in Underserved Medicine. This article describes these programs from 1999 to 2007, focusing on participants, curricula, outcomes, and potential impact.Participants (n = 107) in the three-week faculty development program came from 29 states and Puerto Rico, with more than 25% from underrepresented minorities in the health professions. The program focused on three skill sets: creating and sustaining community programs and partnerships; core faculty development/academic skills; and personal and professional renewal. Outcomes measured with follow-up surveys and interviews in 2003 revealed that since their participation, the first 53 participants to complete the program had created 30 new or modified residency curricula, 19 new student curricula, and 7 new student-run free clinic projects. Pre-post measures from 2003 to 2007 identified an overall 46% increase in skill confidence, with the greatest increase reported for designing a promotora (community lay health promoter) program. Participants expressed particular satisfaction with becoming part of a national community of scholars in the field of underserved medicine.For the year long, on-site Fellowship in Underserved Medicine, four of the first six fellows who completed the fellowship were former University of California-San Diego Student-Run Free Clinic Project student leaders who left San Diego to complete family medicine residency and returned to complete the fellowship. All six currently work with underserved communities as their primary focus, five in the United States and one internationally with Doctors Without Borders.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

The role of Title VII funding in academic general pediatrics fellowships and leadership.

Since 1979, the Health Resources and Services Administration, Bureau of Health Professionals Title VII, Section 747 (Title VII) programs have been critical to both fellowship and leadership training in academic general pediatrics. Title VII-funded faculty development programs and targeted contract funding have played an important role in training pediatric academic generalist faculty, supporting individual fellowship programs, defining the core elements of such programs, and expanding faculty development to include leadership training. As the major continuing source of external funding for these programs, Title VII has produced documented successful outcomes in all areas in terms of both numbers and accomplishments of trainees. Title VII-funded fellows, as well as the leaders trained, have formed and extended the field of general pediatrics, ultimately improving the health of children, especially in underserved and vulnerable populations.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Impact of Title VII training programs on community health center staffing and national health service corps participation.

PURPOSE: Community health centers (CHCs) are a critical component of the health care safety net. President Bush's recent effort to expand CHC capacity coincides with difficulty recruiting primary care physicians and substantial cuts in federal grant programs designed to prepare and motivate physicians to practice in underserved settings. This article examines the association between physicians' attendance in training programs funded by Health Resources and Services Administration (HRSA) Title VII Section 747 Primary Care Training Grants and 2 outcome variables: work in a CHC and participation in the National Health Service Corps Loan Repayment Program (NHSC LRP). METHODS: We linked the 2004 American Medical Association Physician Master-file to HRSA Title VII grants files, Medicare claims data, and data from the NHSC. We then conducted retrospective analyses to compare the proportions of physicians working in CHCs among physicians who either had or had not attended Title VII-funded medical schools or residency programs and to determine the association between having attended Title VII-funded residency programs and subsequent NHSC LRP participation. RESULTS: Three percent (5,934) of physicians who had attended Title VII-funded medical schools worked in CHCs in 2001-2003, compared with 1.9% of physicians who attended medical schools without Title VII funding (P<.001). We found a similar association between Title VII funding during residency and subsequent work in CHCs. These associations remained significant (P<.001) in logistic regression models controlling for NHSC participation, public vs private medical school, residency completion date, and physician sex. A strong association was also found between attending Title VII-funded residency programs and participation in the NHSC LRP, controlling for year completed training, physician sex, and private vs public medical school. CONCLUSIONS: Continued federal support of Title VII training grant programs is consistent with federal efforts to increase participation in the NHSC and improve access to quality health care for underserved populations through expanded CHC capacity.

Ryan White CARE Act Title IV programs: a preliminary characterization of benefits and costs.

Congress enacted the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act in 1990 to address the unmet health needs of persons living with HIV (PLWH) by funding primary healthcare and support services to enhance access to and retention in care. The CARE Act was amended and reauthorized in 1996 and in 2000, and again in December 2006. As originally enacted, the CARE Act was a compromise across a wide political divide. A structure was established that distributed Ryan White CARE Act (RWCA) funds through five federal titles, with different parameters set for each title. Some funds were placed under federal control, while others were controlled locally and distributed to cities and states. Some funds were earmarked for specific services or populations, such as medications; others could be assigned according to a community's priorities. Title IV, the section of the RWCA dedicated to serving women, children, youth, and families who are infected with and affected by HIV/AIDS, is unique, even given the diversity of the other titles. The Title IV program was first implemented in 1988 as the Pediatric AIDS Demonstration Program. It became part of the CARE Act in 1994, and its purpose was expanded at that time to create better links between medical and support services. Although it is the smallest of the titles, with less than 4 percent of the RWCA budget, it may have the broadest mission: providing medical, logistical, psychosocial, and developmental care not just to persons living with the virus, but to entire families. In addition to its focus on this target population, Title IV is unique in its recognition of the need for, and historic support of, comprehensive systems of care to improve, expand, and coordinate service delivery, HIV-prevention efforts, and clinical research. Title IV was excluded from a 10 percent administrative cap on administrative expenses, which enables its funded programs to accomplish this mission. As of 2003, Title IV supported 74 family projects in 34 states (including Puerto Rico, the District of Columbia, and the Virgin Islands), which was a 28 percent increase in funded grantees and a 35 percent increase in participating states since 1999. However, the program's expansion was not matched with a comparable examination of its impact. Rather, the U.S. Health Resources and Services Administration (HRSA), the agency responsible for administering the RWCA, has focussed its evaluation interests on developing goals to use in evaluating its overall RWCA program and in evaluating shorter-term demonstration projects that have more-limited goals. Previous assessments of HIV/AIDS provider networks have examined the following: The process of network development and the determinants of successful implementation, The feasibility of collecting data from network providers, and The mechanisms of agency collaboration and care coordination at the provider level. Only recently has HRSA begun work on developing theoretical frameworks that are useful in exploring the relationships between network characteristics, participating providers, and clients' health and psychosocial outcomes. An examination of Title IV projects is appropriate for a number of reasons. No systematic study of the program has been published to date. Knowledge of the organization of Title IV projects, as well as the services they provide, will improve policy makers' understanding of the range and importance of the strategies that Title IV programs use to meet the needs of the populations they serve. Moreover, as the demand for RWCA funding grows, Title IV projects could offer a model for the efficient deployment of scarce resources.

Analysis of Human Resources and Services Administration-funded services for HIV-positive substance users: a study of Ryan White CARE Act Title III, Title IV, and Special Projects of National Significance providers.

In this study, 175 organizations providing health care and/or social services to HIV-positive substance users responded to a questionnaire to: (1) investigate how programs were configured to serve consumer needs and (2) identify potential innovative strategies to be explored in greater depth in a subsequent study. The results demonstrated wide variability in types of services provided, racial and ethnic diversity, methods of addressing cultural and linguistic needs, accessibility provisions, strategies for engagement and retention, strategies for coordination and integrations of care, most difficult barriers to care, and funding sources.