Advisory Committee on Training in Primary Care Medicine and Dentistry

Approved on December 7, 2007

Minutes of Meeting, September 6-7, 2007

Advisory Committee Members Present
Joseph A. Leming, MD, Chair
Lolita M. McDavid, MD, MPA (newly elected Chair)
Sanford J. Fenton, DDS, MDS, Vice Chair
Lauren L. Patton, DDS (newly elected Vice Chair)
Diego Chaves-Gnecco, MD, MPH
William Alton Curry, MD
Kevin J. Donly, DDS, MS
Katherine A. Flores, MD
Karen A. Gunter, MS, PA-C
Sheila H. Koh, DDS, RN
Eugene Mochan, DO, PhD
Perri Morgan, Ph.D., PA-C, Vice Chair
Charles P. Mouton, MD, MS
Joseph L. Price, PhD
Raymond J. Tseng, DDS, PhD
Barbara J. Turner, MD, MSEd
Surendra K. Varma, MD

Others Present
Elizabeth M. Duke, PhD, Administrator, HRSA
Marcia K. Brand, PhD, Associate Administrator, Bureau of Health Professions
Marilyn Biviano, PhD, Director, Division of Medicine and Dentistry
Jerilyn K. Glass, MD, PhD, Acting Executive Secretary, Advisory Committee

Thursday, September 6, 2007

The Advisory Committee on Training in Primary Care Medicine and Dentistry (Advisory Committee) convened its meeting at 8:32 a.m. at the Hilton Rockville Executive Meeting Center, 1750 Rockville Pike, Rockville, MD 20852.  Joseph A. Leming, MD, Chair, opened the meeting.  He referenced the Advisory Committee’s seventh report on primary care serving as a medical/dental home.  He commented on the importance of small increments adding up to make a difference.  He introduced Elizabeth M. Duke, PhD, HRSA Administrator, who applauded the report’s topic which she felt was essential for quality health care.  She said that family-centered, community-based care provides a tremendous return for the American investment in health care.  Dr. Duke described HRSA efforts to get health centers into the highest poverty counties in the country, to integrate oral and mental health care services into primary care, and to encourage people into the health professions workforce.

Dr. Leming introduced Marcia K. Brand, PhD., Associate Administrator for the Bureau of Health Professions who also directs HRSA’s Office of Rural Health Policy.  She related her prior work experience and expressed her wish to work on improving relationships with the Agency’s external partners, such as professional associations.

An update was provided on the work of several advisory committees within the Bureau of Health Professions.  Russell G. Robertson, MD, Chair of the Council on Graduate Medical Education, reviewed COGME’s last report recommending an increase in the number of students matriculating in U.S. allopathic and osteopathic medical schools.  COGME is currently working on two papers, one on graduate medical education flexibility and the other on physician service.

Annette Debisette, PhD, RN, Chair of the National Advisory Council on Nurse Education and Practice (NACNEP), described the various nursing programs funded under Title VIII legislation.  She presented the issues of an aging nursing workforce, retention, and quality of care outcomes.  The topic of  NACNEP’s last report was information technology and nursing education and practice.  The topic for the next one is not yet determined.

The annual election for Advisory Committee officers was held with the election of Lolita M. McDavid, MD as Chair, Lauren L. Patton, DDS as Vice Chair, and Perri Morgan, PhD, PA-C as Vice Chair.  Dr. McDavid took over as Chair immediately after the election.  The Advisory Committee issued a vote of thanks to Dr. Leming, outgoing Chair, for his outstanding service to the Committee. 

Three speakers gave presentations on primary care as a medical/dental home.  The first was Robert L. Phillips, Jr., MD, Director of the Robert Graham Center in Washington, D.C.   He focused on training physicians, dentists, and physician assistants for this new kind of practice model.  He referred to a joint set of principles by the American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Academy of Family Physicians (AAFP), and American Osteopathic Association (AOA).  A medical/dental home is a setting that facilitates partnerships among patients, their family, their personal physician, and a medical team.  The concept is characterized by a continuous healing relationship with a personal physician; a team that delivers a set of services; a focus on the whole person; enhanced access; and care that is coordinated, integrated, safe, and of high quality. 

Dr. Phillips referenced four key papers on training competencies.  Skill is needed in multimodal communication, use of an electronic platform for healthcare information; application of locally useful knowledge; and ability to conduct time intensive visits, group visits, and evaluations linked to system improvement.   He sees the role of the Advisory Committee as a facilitator of experimentation and the redesign of a new model of training for a new model of practice that incorporates Title VII funds, community health centers, and National Health Service Corps staffing.  He proposed collaboration with COGME and NACNEP and urged that the Advisory Committee develop a communication path with the Accreditation Council for Graduate Medical Education to align funding and training, leading to new competencies and standards.

The second speaker was Thomas G. DeWitt, MD, Director of the Division of General and Community Pediatrics at the University of Cincinnati in Ohio.  He said the challenge is to place trainees so they actually do what they will be expected to do in real practice.  Dr. DeWitt reviewed the history of the medical home concept starting with its introduction forty years ago by the AAP.  From an early emphasis on special needs patients, children with chronic illness and complex illness, the concept broadened to include all patients.  What started out as a concept of a central location for archiving children’s medical records, evolved into an approach to comprehensive primary care.  The AAP also noted that pediatricians, pediatric medical sub-specialists, pediatric surgical specialist, and family practitioners are all included in the definition of physician. 

Dr. DeWitt enumerated the features of a medical home as set forth by the Institutes of Medicine:  accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.  He discussed the need for the development of a different payment system that recognizes the things of added value done within a medical home.  Additional challenges are whether the concept should be considered more a health home, how to research the effectiveness of the model, and how to deal with alternative sources of care that draw patients away from a comprehensive primary care system. 

The third speaker was James J. Crall, DDS, ScD, Professor and Chair of Pediatric Dentistry at the University of California-Los Angeles School of Dentistry.  He said that dentists deal primarily with the two chronic, multi-factorial diseases:  dental caries which appear in primary teeth and periodontal disease.  While the American Academy of Pediatric Dentistry (AAPD) developed a policy statement about dental home in 2001, the concept has been built into dental care for a long time.  The AAPD encourages general dentists to be part of the movement.  It defines dental home as an ongoing relationship between a dentist and a patient including all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated and family-centered way, and ideally established by 12 months of age.

Dr. Crall said that the primary care delivery system is establishing better linkages between medical and dental homes.  He cited a program in Michigan where the dental community is organized in geographic communities and lists generated of dentists willing to see children in need and other examples of the use of patient navigators and community oral health coordinators.  He stressed the importance of identifying high risk children early and modifying their risk factors.  Interdisciplinary primary care training should reengineer how people are taught and consequently how they will practice.

The afternoon session began with public comment from constituent organizations about the concept of medical/dental home.  Dr. Atul Grover from the Association of American Medical Colleges pointed out that the concept actually is not provider or specialty specific.  Rather, it focuses more on the functions of delivering care.  He said that physicians, both specialists and generalists, are going to need to be trained, along with other health professionals, to better coordinate and integrate care across the spectrum.  It may be that patients have successive medical homes that change over time and that transitions from one medical home to another will require new provider and patient skills as well as an enhanced information system.  Further research is needed to evaluate the core components of the medical home to determine how best to implement the model and assess workforce implications.  He added that there is some concern that the medical home is seen as a way of restricting access to certain physicians and penalizing some providers to benefit others.  Upfront investment in the system and in training demonstration projects will be required.

Dr. Keith Morley from the AAPD, which has just over 7,000 pediatric dentists, said that early childhood decay is a huge problem, requiring the participation of both general and pediatric dentists.  The dental home concept, with a heavy emphasis on prevention, has been recognized by 140,000 plus dentists in the American Dental Association.  A dental home would give millions of children a place where they would become a “patient of record.”  More funding is needed because currently dentistry constitutes only 1 to 2 percent of the Medicaid budget.  He pointed out that as a result of Title VII funding, the number of residencies for pediatric dentistry training in the Nation has gone from 150 to just over 300 and the number of general dentists trained has increased.   

Dr. Dennis Kuo from the Ambulatory Pediatric Association, with a membership of 2,000, gave examples of successful medical homes.  Some effective features were a registry of children with special health care needs, a dedicated care coordinator, community directories for families, pre-visit contact with select families, written care plans, an analysis of resource utilization, and parent surveys.  Challenges include lack of awareness of the concept by many primary care providers, maldistribution of primary care providers in the country, lack of training resources and assistance for providers who do want to make changes, sub-optimal reimbursement for key aspects of the medical home, and general lack of outcomes research to inform policy.

Dr. Michael Barr from the ACP said that the advanced medical home is a credible alternative to the current state of health care delivery, which is predominantly based on a fragmented, volume-based fee-for-service system.  The ACP is significantly concerned that health care quality, access, and cost will continue to deteriorate as shortages of appropriately trained primary care physicians become evident.  He pointed out the significant decline in the number of medical students selecting primary care specialties and said that more general internists leave the ranks of practicing physicians than do peers who entered sub-specialty training.  A system of patient care needs to be created and tested that promotes primary care as intellectually rewarding, life style accommodating, and economically viable.  Training needs to address the use of technology for patient improvement, population management, and practice improvement.  Communication with patients, families, and colleagues and the management of transitions in care will be important.

Dr. C. Robin Walker from the AAP provided papers that show the benefit of medical homes for special needs children, rural youth, and asthmatic children.  He pointed out that while the medical home concept is widely supported by pediatricians, those who actually implement it is far less.  He provided a clinical vignette of a medical home effectively designed for a rural community.  His organization provides educational resources on the medical home concept to various constituencies, not just physicians.  He said that ACGME includes training in the medical home in its accreditation requirements for pediatric residency programs.  His organization supports more research on effective implementation and payment systems for medical homes.

Dr. Rick Kellerman from the AAFP related his experience with a Title VII grant that dealt with chronic care management, which he found was a new concept for residents and faculty.  He described a program examining innovation and education in family medicine residency programs.  Additions to programs have included a fourth year to residency training, obstetrics training for those going into rural areas, training in chronic care management, and placement of residents into rural communities that have an electronic health record.  He described an AAFP demonstration project called Transfer Med, which works with practicing physicians to convert practices into medical homes.

Dr. Joan Kowolik from the American Dental Education Association, which represents the 57 dental schools in the United States and Canada, proposed the idea of a dental home for life.  She said that children who see a dentist at one year of age, have dental costs that are five times less than children who are not seen until they have dental pain.  Her organization favors education of physicians and other clinicians who see babies to advise parents about the care of the mouth and disease prevention.  The child who has caries becomes the adult who has caries and develops periodontal disease.  Teachers should be educated about oral health so they can properly instruct children and their parents.  She described a caries risk assessment tool used by general dentists which determines how often an adult patient needs to be seen.  By extension, the tool used with parents can help identify high-risk children and determine the intervals at which they should be seen.  The public needs to understand that a medical/dental home can be of great value.

Following the public comment, the Chair acknowledged Dr. Marie Mann from HRSA’s Maternal and Child Health Bureau, which has funded many of the projects previously  described by those giving comment.  She said the Bureau sees the need to develop validated tools for care coordination in order to optimize implementation of medical homes.  The Bureau has supported the AAP resource center for medical homes which can provide technical assistance.  The Bureau is in the process of reviewing policy statements and developing a business case model for the medical home concept.  She offered the Advisory Committee her Bureau’s resources and experience.

The Advisory Committee discussed the content of the presentations and public comment as it would impact their seventh report.  The members had the opportunity to ask Bryan Johnson, the contract writer for the report, questions about the summary of literature articles that Insight Policy Research prepared.  The articles were grouped according to the report outline developed at the last meeting.

During the public comment period, Stephen C. Shannon, DO, President of the American Association of Colleges of Osteopathic Medicine pointed out that many features of the medical home are congruent with osteopathic medical education traditions.  The concept could renew and invigorate interest in primary care as an important way to proceed.  He pointed out the need to consider the connection between medical home and the shortage of healthcare providers which will worsen as many from the baby boom generation retire in the next several years.  He said that Title VII funding could help to address the tensions between primary care and specialty care.  He urged collaboration with other Government agencies to do much needed research.  He said that both the ACGME and the AOA approve programs and some programs have dual approval. 

The meeting adjourned at 4:20 p.m.  

Friday, September 7, 2007

Dr. McDavid began the session by introducing Thomas A. Cavalieri, DO, Chair of the Bureau’s Advisory Committee on Interdisciplinary, Community-Based Linkages, who gave an update on committee activities.  He applauded the notion of collaboration among advisory committees.  His committee provides advice to the Secretary and Congress on activities relating to programs that aim to increase the number of health professionals who function in an interdisciplinary community-based setting:  the Area Health Education Centers, The Health Education Training Centers, the Geriatric Education and Training Programs, the Quentin Burdick Program for rural interdisciplinary training and education, and training for the Allied Health Professions.  Another goal of these programs is to promote a redistribution of the health care workforce to underserved areas.  Dr. Cavalieri reviewed the topics of the committee’s reports.  The sixth report focused on best practices and models for training, how programs are important to access to care, and the preparation for future health care needs.  The seventh report will focus on the issue of health information technology and implications for health professions training. 

The Advisory Committee broke into three workgroups to:  1) discuss the idea of a Title VII symposium of several advisory committees, 2) examine the literature review done by the contract writer, and 3) as the seventh report writing group, determine any changes to the report recommendations drafted at the last meeting.

Eugene Mochan, DO, PhD, gave the report for the group that examined the previous outline for the seventh report.  The group felt that the idea of a medical/dental home left some important pieces out.  The group favored the concept of a health care home or a health home.  The report could provide the status of the health care system, explain the decline in primary care, and then present the health home as an approach to solving some of the current issues.  In the discussion that followed, mention was made of including some of the literature on chronic care management, a discussion of information technology and electronic health records, literature on what influences medical student specialty choice, and information on how the medical home concept is perceived by the public.  The Advisory Committee decided to keep the topic name of medical/dental home, rather than health home.

Katherine A. Flores, MD gave the report on the idea of a collaborative conference.  Her group felt that collaboration could produce stronger and more comprehensive advisory committee recommendations made to the Secretary and to Congress that could have greater impact than current recommendations have had.  Collaboration would foster multi-disciplinary communication and bring together program and policy individuals which could work to the advantage of all committees and likely produce cost savings.  On the other hand, it has to be recognized that individual committees might lose some autonomy.  The Advisory Committee passed the following resolution: 

The Advisory Committee on Training in Primary Care Medicine and Dentistry recommends that HRSA convene a collaborative conference of the four Title VII and Title VIII Bureau advisory committees in the spring of 2008 for the purpose of alignment of work products along common themes such as health professions workforce, health professions training, access to care, and workforce diversification.  The Committee further recommends that it communicate this message to the chairs of the other advisory committees and invite them to join in the recommendation. 

Dr. Flores volunteered to electronically communicate the resolution to the other chairs. 

Charles P. Mouton, MD gave the report on revisions to the recommendations for the seventh report.  A few changes were made including combining bullets, adding clarifying language, and adding bullets and sub-bullets.

The plan is to have the writing group (Co-Chairs Barbara Turner, MD, Joseph F. Cawley, PA-C, and Kevin J. Donly, DDS, and members Surendra K. Varma, MD, William Alton Curry, MD, Alan K. David, MD, Diego Chaves-Gnecco, MD, Sheila H. Koh, DDS, RN, and Perri Morgan, PhD, PA-C) convene periodically by conference call prior to the next meeting.  The goal is a complete draft of the seventh report for the next meeting.

The Advisory Committee meeting adjourned at 12 noon.