Crafting long-term health reforms through future health-care workforce
True health-care reform requires more than an act of Congress. It calls for easier access to health care in rural areas, primary-care physicians and registered nurses who understand the health issues facing underserved communities and teams of health-care professionals who can collaborate to meet a patient's total needs, whether they are health, psychiatric or social.
In short, true reform requires a transformation in the way health care and health are viewed and delivered, not just in who pays for it.
Within UC Davis Health System, faculty are redefining how health-care professionals meet these and other health challenges of the future. From cutting-edge telehealth programs and an innovative new school of nursing focused on interprofessional education to multi-layered residency programs that train physicians in medicine and community advocacy, UC Davis is enacting health-care and health reform from the inside out.
Evolution of innovation
Indeed, over the 40 years the School of Medicine has been producing physicians, traditionally isolated and fragmented courses employing largely passive teaching methods have given way to innovative, integrated curricula. New curricula feature multiple opportunities for small-group and problem-based learning to develop critical-thinking skills and to integrate basic sciences with clinical practice, ethics, epidemiology and skilled interviewing techniques.
In addition, interprofessional learning is uniting medical and nursing graduate students to expand perspectives for better patient care and health leadership.
Partnerships with communities model the connections future health leaders must develop in their own towns and cities to transform the health of those they serve.
For instance, pediatrician Richard Pan founded a program for pediatric residents called Communities and Health Professionals Together. Under the program, physicians-in-training are encouraged to build partnerships with grassroots community organizations to improve child health.
Understanding the needs
What better way to fight childhood obesity than to help start community gardens in neighborhoods without adequate grocery stores? Medical residents in the program are encouraged to ride public buses through the neighborhoods they serve to better understand the community's needs.
Pan also has worked with the Sacramento City Unified School District to facilitate the diagnosis and treatment of students with attention-deficit/hyperactivity disorder by collaborating with school nurses to coordinate care and interventions between a student's health and educational teams.
"We're lucky to live in a day when we understand there are no solo actions in health care. It’s all teamwork."
The Department of Family and Community Medicine also hosts the University of California's only physician assistant/family nurse practitioner program. The physician assistants and nurse practitioners are specially trained in teams with medical residents and other health professionals in culturally relevant health care for underserved populations. Nearly two-thirds of the program's graduates in 2008 chose to practice in underserved areas.
At UC Davis, educators recognize that reforms to the nation's health-care delivery system require health-care professionals to implement. Yet forecasters estimate that within a decade, California will face a shortage of between 5,000 to 17,000 physicians.
The shortage in nursing is expected to be even more dire. Experts say California already is experiencing a shortage of 43,000 nurses. According to the Kaiser Family Foundation, the shortage of registered nurses is expected to grow to 340,000 nationwide by 2020.
Under proposed federal health-care reforms, more people will have access to health coverage, further increasing the need for clinicians. The need for primary-care physicians, physician assistants, nurse practitioners and nurses in rural areas will be particularly acute.
Addressing rural needs
"We're in an evolution of innovation
here at UC Davis."
The Rural-PRIME Program is designed to help meet the health needs in rural areas. A combined five-year M.D. and master's degree program, Rural-PRIME is geared toward students from rural backgrounds who wish to serve communities similar to the ones in which they were raised. The students are trained in the public health and health issues specific to rural communities.
"Without adequate local health care, rural residents have more chronic conditions," says program director Don Hilty. "There's little or no access to specialist care unless they travel, which requires money and time, so sometimes they don't."
Founded in 2007 by family physician Thomas S. Nesbitt, associate vice chancellor for strategic technologies and alliances, Rural-PRIME also trains medical students in the use of health-care technologies such as telehealth. Telehealth allows health-care professionals to meet with patients via video conferencing. It is particularly useful in rural areas with few specialists.
Today, nearly two dozen specialties, involving physicians and clinical nurse specialists, are offered to more than 100 rural clinics and hospitals via telehealth links.
Telehealth also allows the nursing school and others to conduct health research with targeted populations.
In one of its first funded research studies, the Betty Irene Moore School of Nursing will use telehealth to better understand and prove the impact of nursing interventions on overall health care and safety.
Led by Heather M. Young, the school's dean and vice chancellor for nursing, the study explores ways to strengthen daily health management of diabetes with common and easy-to-use communications with nurses who serve as health coaches. The communications will utilize telehealth video.
The lure of more lucrative specialties is another factor contributing to the nation's shortage in primary-care providers. To address this issue, Balsbaugh oversees a program that allows medical residents to be trained in family medicine as well as psychiatry or obstetrics.
In addition to satisfying the residents' desire to have additional skill sets, dual certification allows physicians to treat patients more holistically. If a patient's physical illness is complicated by mental illness, the same physician can treat both diseases, perhaps keeping a closer watch on how the conditions complicate each other.
The program also helps to fill the critical need for specialists in underserved areas.
"The physicians can take care of a wide array of patients, from the newborn to pregnant women to the elderly," says Balsbaugh.
In a different approach, the Department of Family and Community Medicine is seeking to coordinate health-care services to increase access and reduce costs. The program aims for coordinated case management with teams of health-care providers under the same roof. Under this model, nurses, physicians, nurse practitioners, specialists and other providers confer about a patient's needs. Since health providers are closely connected, a patient who requires specialty care knows that his or her primary-care team and the specialty team are on the "same page."
This program and another, the Department of Internal Medicine's Transforming Education and Community Health (TEACH) program, are being evaluated by the RAND Corp. under contract to the federal Medicare Payment Advisory Commission to learn how residency programs can better prepare a workforce to meet the challenges of caring for patients with chronic illnesses.
Both programs reach well beyond hospital and clinic walls to immerse medical residents in community settings that provide invaluable insights into the needs and strengths of underserved populations. Residents rotate through ambulatory clinics at the medical center, but also spend considerable time working at local community clinics and with neighborhood organizations.
Collaboration, with community partners and within educational programs, is a basic tenet at UC Davis. In fact, the team approach – or interprofessionalism – is the foundation for the new Betty Irene Moore School of Nursing. The school, which will welcome its first graduate classes this fall, will emphasize the collaboration of health providers that is critical in disease management and prevention.
"It's down with silos and up with teamwork," says associate dean Debbie Ward, a doctorally prepared registered nurse. "We're lucky to live in a day when we understand there are no solo actions in health care. It's all teamwork."
Teams of providers can better meet people's health needs, Ward says, by ensuring that "multiple skills are brought to bear on health problems."
For instance, even a brief team meeting before patient visits can have a significant effect on health outcomes as well as on patient satisfaction.
"Quick team ‘huddles' to plan patient care turn out to save time, money, and contribute to better care," says Ward. "It's not an automatic skill. Teams need to learn and practice the art of the ‘huddle' but once it becomes part of clinic routine, benefits abound."
Ward says that clinicians must re-think their relationship with their clients.
"We know that changing behavior is very difficult, and that we all need support to institute healthy patterns. Clinicians have to change their behaviors, too," says Ward.
"Patients should no longer hear words from their caregivers such as ‘you must lose weight; you must stop smoking.' Those words don't work. The patient needs to set the goal. The clinician's role is not lecturer, scolder or finger-wagger. The role is support, expert knowledge and coaching."
These health-care changes are backed by solid academic research. At the UC Davis Center for Healthcare Policy and Research, scholars are strongly focused on comparative-effective studies to provide information that helps clinicians and patients choose which option best fits an individual patient's needs and preferences.
In one study, researchers are evaluating the social risks in coronary heart failure to help reduce disparities in treatment and care. Another is looking at the decision-making process among women in choosing hormonal treatments, while another still is exploring the potential receptivity for practicing clinicians to learn to retrieve relevant information from electronic medical record systems to help with clinical decision-making and communication with patients. The answers to all these studies will help inform how diseases are managed and prevented.
It is true health-care reform, launched from the inside of an evolving health care delivery system.
Spring / Summer 2010
UC Davis Health System is proud to be home to medical, nursing, family nurse practitioner / physician assistant, public health and health informatics students and to also be the internship site for pharmacy, nutrition and other programs. Improving the health of our communities requires that we bring together these perspectives, and UC Davis is well positioned to do so.