Community Engagement: Creating The Community Engagement: Creating The Nation’s First School of Community MedicineNation’s First School of Community Medicine

OU College of Medicine, Tulsa StructureOU College of Medicine, Tulsa Structure

• Established as a branch Established as a branch campus in 1972 using campus in 1972 using community based model.community based model.

• Purpose – workforce and Purpose – workforce and service for northeast OK. service for northeast OK.

• OU ClinicsOU Clinics– 250,000 visits / year250,000 visits / year

• OU Departments / DivisionsOU Departments / Divisions– 186 OU employed faculty186 OU employed faculty– Pediatrics, Psychiatry, Surgery Pediatrics, Psychiatry, Surgery – Internal Medicine, OB/GynInternal Medicine, OB/Gyn– Family Medicine, Emergency Family Medicine, Emergency

Medicine, Geriatrics, Dermatology, Medicine, Geriatrics, Dermatology, Physician Assistant, Sports Physician Assistant, Sports MedicineMedicine

• Additional OU ProgramsAdditional OU Programs– Nursing, Pharmacy, Public Nursing, Pharmacy, Public

Health, Allied Health, Social Health, Allied Health, Social Work, Human Relations, Work, Human Relations, Engineering, Engineering, Telecommunications, Computer Telecommunications, Computer Science, Organizational Science, Organizational Dynamics, Knowledge Dynamics, Knowledge ManagementManagement

• Community PartnersCommunity Partners– Specialist PhysiciansSpecialist Physicians– 3 Large Private Hospitals3 Large Private Hospitals

• ResidenciesResidencies– 200 residents in 13 Residencies / 200 residents in 13 Residencies /

FellowshipsFellowships

• Medical Students Medical Students – Average 40 students each in the Average 40 students each in the

33rdrd and 4 and 4thth year classes. year classes.

– 50 Physician Assistant Students50 Physician Assistant Students

We thought we were doing fine….OU College of We thought we were doing fine….OU College of

Medicine, Tulsa alumni practicing InMedicine, Tulsa alumni practicing In OklahomaOklahoma

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151-779

……fine until we saw the fine until we saw the death curve….death curve….

While the death rate of most U.S. residents is declining, that of Tulsans is not – and the trend is going in the wrong direction

United States

Tulsa County

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Age Age Adjusted Adjusted Death RatesDeath RatesOver the Over the Past 25 Past 25 YearsYears

If you ask the public, what should If you ask the public, what should a medical school do?? AAMC – a medical school do?? AAMC – 2000 Survey2000 Survey

• Educate the next generation of Educate the next generation of physicians.physicians.

• Advance care through research.Advance care through research.• Take care of complex patients. Take care of complex patients. • Take care of the poor. Take care of the poor. • LEAD IN SOLVING HEALTH CARE LEAD IN SOLVING HEALTH CARE

PROBLEMS. PROBLEMS.

We needed a We needed a plan…..plan…..

1. OU College’s of Public Health and Medicine came together.

2. More data on health parameters, workforce, student satisfaction / trends.

3. Pilot Projects - Access.

4. Critical Mass – Clinical Services and Students

5. External Consultants

6. Prepared for Next Transformation

* Note – these are not real OU Football Players* Note – these are not real OU Football Players

Health StatusHealth Status

OK

COMMONWEALTH FUND State Scorecard Summary of Health System Performance

HEART DISEASE MORTALITY IN THE UNITED STATES

MENTAL ILLNESS PREVALENCE IN THE UNITED STATES

Tulsa Area Health Status Tulsa Area Health Status Varies Dramatically By IncomeVaries Dramatically By Income

925

989 995

1,486

HIGHEST MID-HIGH MID-LOW LOWEST

HOUSEHOLD INCOMES

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All Races

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YPLL IN TULSA COUNTY YEARS OF PRODUCTIVE LIFE LOST PER DEATH

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African-American

26

14

Tulsa Area Health Tulsa Area Health Status Varies By Race: Status Varies By Race: Years of Productive Years of Productive Life Lost Per DeathLife Lost Per Death

Tulsa Area Health Status Varies By Zip Code:

AGE ADJUSTED DEATH RATES IN TULSA COUNTY

Red = very poor health status Zip CodesYellow = worsening health status Zip CodesGreen = good health status Zip Codes

Although north, east and west Tulsa have 40% of the region’s population, they have only 4% of the region’ physicians

Shorter Life Expectancy

Access to and equity in healthcare are key health determinants. Health status is variable across the Tulsa region.

Access to and equity in healthcare are key health determinants. Health status is variable across the Tulsa region.

Rationale for Change Responsibility to Improve Health (continued)

Longer Life Expectancy

NORTH TULSA

SOUTH TULSA

14 Year difference 14 Year difference in Life Expectancyin Life Expectancy

Across Tulsa CountyAcross Tulsa County

Tulsa County Prenatal Care Tulsa County Prenatal Care

and Infant Mortality Ratesand Infant Mortality Rates

6.70%

15.90%

5.30% 6.60%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

Race/Ethnicity

Infant Mortality Rates, Tulsa County 2000-2004

25.70%

39.80%33.20%

23.10%

46.40%

0%10%20%30%40%50%

Race/Ethnicity of Mother

% of Births with No 1st Trimester CareTulsa County, 2000-2004

Initial Pilot Efforts:Initial Pilot Efforts:Focus on AccessFocus on Access

Access to Access to Care ExpansionCare Expansion

Primary Care– 2005 - New 60,000 sq ft

Family Medicine.– 2007 – New 100,000 sq ft

multispecialty clinic– 2003 – 2008 Network of 35

Bedlam Outreach Clinics, free pharmacy program, nursing and social work case management

• Schools / Head Starts

• Housing Authority Apartments

• Mobile Clinics

Specialty Care– 2003 - Mobile Psychiatric

Team– 2007 - New 10,000 sq ft

Diabetes Center– 2008 – Perinatal Outreach

Initiative – 2008 New 22,000 sq ft

Cancer Center satellite– 2008 - New 10,000 sq ft

Surgery Clinic– 2010 - 50,000 sq ft North

Tulsa Specialty Clinic.

. ..

...

UNION

TULSAHawthorne

61st St.

Mingo

Union

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81st St.

31st St.

36th St. N.

145

th E. Ave

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Admiral Pl.

86th St. N.

97th W

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66th St. N.

Peo

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193

rd E

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57th W

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Prepared by the Community Service Council of Greater Tulsa (10/2007).Supported by the Metropolitan Human Services Commission.

Yale

Tulsa Area Bedlam Clinic Sites(school-based and other locations)

October 2007

.Educare

.Frost Head Start

.Roy Clark(serving 3 schools)

. .S.S. 9th Grade Center(serving 8 schools)

.. . Disney Head Start

Bedlam Community Health.

Neighbors Along the Line

Eugene Field.Sandy Park

Apartments

Roosevelt

Mark Twain

..School sitesFree Walk-in ClinicsTulsa Public Housing AuthorityHead Start sitesMobile Clinics

..

Alcott.

.

...

. .

Jane Addams

Marshall (serving 3 schools)

McClure Head Start

Chouteau

Bryant

Celia Clinton (serving 2 schools)

Rosa Parks (serving 3 schools)

East Central Village

20 School-based OU Clinics 20 School-based OU Clinics Serving 32 SchoolsServing 32 Schools

EXAM ROOMS

OU PACT Team and OU PACT Team and Community Mental HealthCommunity Mental Health

• PACT Team provides mobile psychiatric care and PACT Team provides mobile psychiatric care and rehabilitation to those with the most severe forms rehabilitation to those with the most severe forms of mental illness (e.g homeless mentally ill).of mental illness (e.g homeless mentally ill).

Pre PACTPre PACT 1 Year in 1 Year in PACTPACT

Hospital Days / yearHospital Days / year 2898 Days2898 Days 671 Days671 Days

Jail Days / yearJail Days / year 11961196 DaysDays 535 535 DaysDays

Emerging Workforce TrendsEmerging Workforce Trends

TOTAL PHYSICIANS IN 2005PER 100K POPULATION IN THE UNITED STATES

Oklahoma ranks 45th in the number of physicians per capita

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Created by Michael Lapolla, OU College of Public Health, December 2007

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PRIMARY CARE PHYSICIANS IN 2005PER 100K POPULATION IN THE UNITED STATES

Oklahoma ranks 39th in number of primary care physicians per capita

Created by Michael Lapolla, OU College of Public Health, December 2007

SPECIALIST PHYSICIANS IN 2005PER 100K POPULATION IN THE UNITED STATES

Oklahoma ranks 47th in number of specialists per capita

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Created by Michael Lapolla, OU College of Public Health, December 2007

Access to Health Care Varies Dramatically By Tulsa Zip Code:

- For every 1 physician in north, east and west Tulsa, there are 26 in mid-town and south Tulsa.- 40% of the population and 4% of the clinicians.

Combine Workforce and Combine Workforce and Health Status DataHealth Status Data

Physicians are not practicing in the Tulsa metro areas where healthcare is needed most.

Physicians are not practicing in the Tulsa metro areas where healthcare is needed most.

Age-Adjusted Death Rate in Tulsa Physician Density in Tulsa

- Partner hospital - Partner hospital

The age-adjusted death rate is highest in those areas with the fewest physicians.

Student and Resident Student and Resident Attitudes and SkillsAttitudes and Skills

Resident Physician Skill Sets: System-Resident Physician Skill Sets: System-based Practice Core Competenciesbased Practice Core Competencies

151 OU Resident Physicians: Wrote the Dean U Resident Physicians: Wrote the Dean a paper on the worst health care problems in a paper on the worst health care problems in the region.the region.

1.1. Excellent at identifying health system Excellent at identifying health system

problems. problems. 2.2. Excellent at innovative solutions to these Excellent at innovative solutions to these

problems. problems. 3.3. No skills for researching, testing theories, No skills for researching, testing theories,

developing a plan, implementation, financing developing a plan, implementation, financing strategies to carry out their unique strategies to carry out their unique interventions. interventions.

Medical Students: Perceptions of and Needs of the Poor

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Who are the Uninsured The needs of uninsured

Changed Perceptions

BEDLAM CLINIC ANALYSIS

1-strongly disagree

2-moderately disagree

3-neutral

4-moderately agree

5-strongly agree

Medical Students: Student’s Professional Medical Students: Student’s Professional Obligation to the Health of the PoorObligation to the Health of the Poor

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Sense of Professionalism before Bedlam Sense of Professionalism after Bedlam

Professional Obligation

BEDLAM CLINIC ANALYSIS

1-strongly disagree

2-moderately disagree

3-neutral

4-moderately agree

5-strongly agree

AAMC Graduation QuestionnairesAAMC Graduation Questionnaires

“ The experiences in community medicine, particularly the Bedlam Clinics (student run free clinics), rekindled the spirit of why I wanted to be a physician.”

In 2006 – 2 Driving Factors for a In 2006 – 2 Driving Factors for a Dramatic Transformation….Dramatic Transformation….1. Physician Work Force Trends:

Future National Shortage Existing Oklahoma Shortage Expansion of medical education would

happen.

2. Oklahoma Health Status: Although access to care was improving,

much more needed to be done. A different type of physician was needed.

• Many academic…– Divisions– Departments– Centers– Institutes

• 1 “School of Community Medicine” in New South Wales Australia

http/:”Community Medicine”http/:”Community Medicine”

VisionVisionLeveraging our leadership, service, education and research expertise, we will be successful at “Improving the Health of Entire Communities”.

StrategiesStrategies1. Expanded Education Platforms – Start a physician assistant

program. Expanded medical student, residency and fellowships in Tulsa.

2. Unique Aspects of Curriculum – close alignment with the OU College of Public Health. Educational themes include excellence in individual patient care as well as improving the health of entire communities, at risk populations, the underserved, complex problem solving skills, complex project management, translational research, physician character development and medical informatics.

3. Health Services Delivery: creating community partnerships to expand healthcare access to targeted populations.

4. Research: Targeted …not comprehensive research programs: services, outcomes and translational in focus.

School of Community Medicine

Nuts and Bolts of what we think may be the Nuts and Bolts of what we think may be the Nation’s First School of Community Medicine…..Nation’s First School of Community Medicine…..

1. Transform ourselves from branch campus status to a School with a unique purpose within the OU College of Medicine.

2. Renamed as OU College of Medicine’s School of Community Medicine – “improving the health of entire communities.”

3. Tulsa Public Schools shadowing programs and Undergraduate pre-med fast-track at University of Tulsa and OU.

4. National recruitment of students with dedication to the underserved to this specific medical education track that merges traditional medical education with public health curriculum MD + Public Health Certificate or MD + MPH.

5. Creative use of “Summer Institutes” for in-depth work. 6. If possible and funding available, expand medical student class size

from 40 to 70 per year, add Physician Assistant students – initial class of 25, expand residents from 201 to 251.

7. New scholarship program with incentives to establish career serving underserved and at-risk.

February 2008 AnnouncementFebruary 2008 Announcement

“With this health data known, it is morally offensive not to act.”

George George Kaiser, Kaiser,

February February 2008.2008.

The Gift….”The Grand Experiment”The Gift….”The Grand Experiment”

$ 50,000,000 from the George Kaiser Family Foundation:– $ 35,000,000 dedicated to new endowed

chairs. Matched with $ 35,000,000 from state funds to create $ 70,000,000 endowment for faculty expansion.

– $ 7,500,000 for school infrastructure expansion.

– $ 7,500,000 for student scholarships.

6 Lessons Learned6 Lessons Learned1. Physicians in training are very smart but need

additional skills to tackle the toughest problems out there….

2. Altruism can be preserved with the right teaching / clinical environment.

3. Public health data and physician manpower data drove our planning and influenced philanthropy.

4. Important for us to create something complementary and not competitive with existing medical education and clinical services.

5. Planning:• Intimately involved students and philanthropy in planning.• Everyone Involved - Primary Care, Specialty Care, Bio-

medical Researchers, Community Partners, DO and MD….and other Colleges….because team care works.

• At the end of the day – one writer of the master plan. 180 pages and a 15 page executive summary.

6. Had to create a “Business Plan for our Social Contract”6. Had to create a “Business Plan for our Social Contract”

Mission (+)

Finance (-) Finance (+)

Mission (-)

Private supportEndowment expansionExpanding primary care networkExpanding specialty accessNative American partnerships

Corporate partnerships90% FTE time as cliniciansPractice plan efficiency initiativePatient SatisfactionJCAHO accreditation of OU Clinics

Student scholarshipsPhysician assistant programAfter-hours free clinicsChildren’s Village

THE NO-FLY ZONETHE NO-FLY ZONE

United States

Tulsa County

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Our Goal: Our Goal: Improve the Improve the Health of Health of Entire Entire CommunitiesCommunities

Age-adjusted Death Rates