Leaders as Change AgentsLeaders as Change Agents

Community service needs to be an integral part of the life of all health professionals and, as such, should be integrated into the training of all providers. This workshop will examine the role of AHECs as change agents in their communities and regions. Participants will be given an overview of the critical issues in caring for migrant

populations. Methods of building volunteer coalitions will be discussed and real life experience in initiating these

programs will be described. Participants will develop "a personal action plan" in small groups using the workshop leaders as facilitators. Efforts to replicate a service learningmodel from one health professions school to another will be described and barriers and challenges identified. Discussion will focus on opportunities and barriers to implementation at

participant sites.

Leaders (AHECs)Leaders (AHECs)

as Change Agentsas Change Agents

AHECs,AHECs, Community Health Centers, Health Community Health Centers, Health

Professions Schools and a Cast of Thousands: Professions Schools and a Cast of Thousands:

Leading Partnerships in Creating Access Points to Care Leading Partnerships in Creating Access Points to Care

for Underserved Populationsfor Underserved Populations

Bruce Gould MDDirector, CT AHEC Program

Associate Dean for Primary Care

University of Connecticut School of Medicine

Farmington, CT

Medical Director

Burgdorf Health Center

Hartford, CT

ObjectivesObjectives

� Understand the nature, values, tools of

leadership/partnership AHEC style

� Review a successful effort in Connecticut

� Generalize knowledge and skills to other locally

identified unmet needs and efforts

� Identify a potential need/effort/project in your

home environment and develop a personalized

action plan for implementation when you return

Leadership: a definitionLeadership: a definition

� Leadership as defined by Webster’s: a person who leads : as a : GUIDE, CONDUCTOR b (1) : a person who directs a military force or unit (2) : a person who has commanding authority or influence c (1) : the principal officer of a British political party (2) : a party member chosen to manage party activities in a legislative body (3) :such a party member presiding over the whole legislative body when the party constitutes a majority d (1) : CONDUCTOR c (2) : a first or principal performer of a group

Leadership: a definitionLeadership: a definition

� What is a leader? Industrial/Organizational psychologists do not seem to be able to agree on a definition. One way to understand leadership, however, is through the differences between a leader and an authority. Authorities are those Authorities are those who hold formal positions that give them the power to who hold formal positions that give them the power to direct the behavior of their subordinates.direct the behavior of their subordinates.Managers, supervisors, and bosses are authorities. They may or may not also be leaders, depending on whether they rely solely on their official positions when applying influence on others. A true leader does not use force and coercion to A true leader does not use force and coercion to direct his or her followers toward a common goal. direct his or her followers toward a common goal.

http://psychology.about.com/library/weekly/aa040102a.htm

Partnership: a definitionPartnership: a definition

� part·ner·ship (pärt n r-sh p ) n.

� 1. The state of being a partner.

� 2. – a. A legal contract entered into by two or more persons in which each agrees to

furnish a part of the capital and labor for a business enterprise, and by which each shares a fixed proportion of profits and losses.

– b. The persons bound by such a contract.

� 3. A relationship between individuals or groups that is characterized by mutual cooperation and responsibility, as for the achievement of a specified goal:Neighborhood groups formed a partnership to fight crime.

The American Heritage® Dictionary of the English Language, Fourth Edition copyright ©2000 by Houghton Mifflin Company.Updated in 2003. Published by Houghton Mifflin Company. All rights reserved

Leadership/Partnership Leadership/Partnership

� Carpe Diem – Seize the Day!

� True Leadership = Partnership Skills

– Identifying needs

– Identifying resources

– Identifying barriers and creative alignments

– Taking a seat at the table

Values of PartnershipValues of Partnership

�� Partners advocate for self, keep system in Partners advocate for self, keep system in mindmind

�� Diversity as valuable resource as opposed to Diversity as valuable resource as opposed to problem to be solvedproblem to be solved

�� Communication and negotiation enhance Communication and negotiation enhance trust and commitmenttrust and commitment

�� Individuals possess internal predisposition Individuals possess internal predisposition to partnershipto partnership

Tools for PartnershipTools for Partnership

�� Group/team facilitation skillsGroup/team facilitation skills

�� Communication skills (individual, group, Communication skills (individual, group, organization)organization)

�� Conflict resolution skillsConflict resolution skills

�� Leadership skillsLeadership skills

�� Comfort with Comfort with ““role blurringrole blurring”” (overlapping (overlapping competencies/complementary roles)competencies/complementary roles)

Rules of PartnershipRules of Partnership

� Agreed upon mission, values, goals and outcomes (keeping everyone’s eyes on the prize)

� Builds on strengths, addresses areas that need improvement

� Balances power, shares resources and credit

� Open communication and establishment of rules, operating procedures

� Feedback essential, established improvement as goal (improvement of health status of the population in the center of the table)

Partnership AttitudesPartnership Attitudes

TrustFearCore affect

Objective/

Subjective

ObjectiveRelevant

experience

Win-winWin-loseNegotiation

strategy

PartnershipHierarchicalSocial Structure

ConnectednessPredictabilityCore Values

RelationControl

University of ConnecticutUniversity of Connecticut

School of MedicineSchool of Medicine

� CT Area Health Education Center Program with centers in Hartford, Norwich, Fairfield and Torrington – A Resource for Recruitment and involvement!

– Health Career Opportunity Programs – need for mentors, tutors, club advisors...

– STATIC (Students Teaching Against Tobacco In Connecticut) – mentors, advisors, speakers….

– CT Youth Health Service Corps/Medical Reserve Corps – BT for Kids

– National Primary Care Week –

– Interpreter Services and Health Literacy

� Student Run Clinics – Learn and Teach by Doing!

– South Park Homeless Shelter Clinic

– South Marshall Street Salvation Army Shelter Clinic

– YMCA Homeless Shelter Clinic

– Migrant Farmworker Free Clinic

� Cover the UnInsured Week – Lead the revolution; appeal to their activism!

� Don’t Forget Admissions Committee!

Increasing FarmworkersIncreasing Farmworkers’’ Access to Access to

Health Care Through CommunityHealth Care Through Community--

University PartnershipsUniversity PartnershipsThe Farmworkers

� 3-4 million persons hired as seasonal/MFW

� Contract and Seasonal

� 70% work in crop agriculture

� Relatively Young (sexually active)

� Single or married with or without their

families but all are displaced (depression)

� Predominantly Latino (cultural and linguistic

competence)

� Average of 6 years of formal education

� All are poor (weigh illness against wages)

� 1/3 are undocumented (fear of accessing care)

The Schools� Health Professions Programs:

– Medical: 125 Allopathic; 19 Osteopathic

– Nursing: Associate and Bachelors (RN); Nurse Practioner

– Physician Assistant:

– Dental:

– Social Work:

– Pharmacy:

– Other

� Curriculum: New Focus– Population and public health

– cultural competence

– “experiential learning experiences”

� Geography:– Catchment often includes MFW populations

– Outposts near MFW populations (AHEC, rural rotations or faculty, etc.)

Connecticut Migrant Health NetworkConnecticut Migrant Health Network

Connecticut = Migrant Farm Workers

Does

Not

Compute

=

An invisible population

Recipe for CollaborationRecipe for Collaboration� Ingredients:

� Migrant Farm Workers (individuals and organizations)

� FQHCs (Federally Qualified Community Health Centers)

� Health Professions School(s)

• Faculty Champion

• School Leadership

• Students and student leadership

� Area Health Education Center

� Public Health

• Local or state

� Growers

� Other: Labor, Education, Outreach, Faith Community, etc.

Connecticut Migrant Health NetworkConnecticut Migrant Health NetworkA History in Brief:A History in Brief:

� 1996/97 - Partners in CT and MA (PCAs, NGOs, PH) worked together to organize outreach efforts to farms throughout the region, culminating in application for a voucher grant from Bureau of Primary Health Care forming the CT Migrant Heath Network and the CT River Valley Farmworker Health Program (CRVFHP) .

� Summer/Fall 1998 – A Tale of Two Students: teams of volunteer physicians and medical students in collaboration with outreach workers held clinics and health fairs at farms during weekday evenings and weekends coordinated with CRVFHP with referrals to FQHCs.

� Summers ‘98-05 - Two to Three medical students under the auspices of the NHSC (SEARCH), AHEC, UCSOM and the S. Park Inn Board and in collaboration with other partners organized physicians and students, obtained medicine samples, developed schedules, etc.

Connecticut Migrant Health Network Connecticut Migrant Health Network

PartnersPartners

� Connecticut and Primary Care Association

– Community Health Services, CHC’s and Clinics

� Mass League of Community Health Centers

– CT. River Valley Farm worker Health Program (CRVFHP – voucher program)

� CT Council on Occupational Safety and Health (CTCOSH)

� Area Health Education Center Program (AHEC)

� Hispanic Health Council

� Latinos Contra SIDA

� West Indian Social Club

� NYCAMH

Connecticut Migrant Health Network Connecticut Migrant Health Network

PartnersPartners

� University of CT. School of Medicine and Dental Medicine

� Medical, PA, NP, students from Yale, Quinnipiac, Tunxis CC.

� South Park Inn Clinic Board (Med Students)

� Bulkeley, Weaver and Simsbury High Schools

� CT Departments of Public Health, Labor, and Education

� Hartford County Medical Association

– Docs, Drugs and Dollars

� Others…..

Who Did We See (2003)?Who Did We See (2003)?

Jamaica

52%Puerto Rico

30%

Mexico

13%

US

3%

Guatemala

1%

Honduras

1%

Sex:197 Males and 1 Female

2004 Users by Race / Ethnicity2004 Users by Race / Ethnicity

Hispanic = 73%

Jamaican

26%

Dominican

1%

Mexican

52%

Guatemalan

4%

Puerto Rican

11%

Other Hispanic

6%

Entered into CRVFHP Access DB as of 2/15/2005.

Age Distribution (2003)Age Distribution (2003)

<18

1%18-25

8%26-35

13%

36-45

39%

46-55

26%

56-65

13%

Mean Age: 41 Years old

Major Diagnoses (2003)Major Diagnoses (2003)

HTN

10%GERD

3%

URI

17%

Musculoskeletal

27%

Allergy

9%

Other

14%

Dermatitis

7%

Diabetes

2%

Fungal

11%

Total # of Patients: 198

Total # of Encounters: 292

Medications DispensedMedications Dispensed

Analgesics

37%

Topical Antifungals

13%

Topical Steroids

6%

Antibiotics

5%

Allergy

21%

Other

11%

Antitussives

7%

How the Clinic WorksHow the Clinic WorksPatient comes to clinic

Student H&P

Student presents to attending

Student and attending develop assessment & plan

Student and attending see patient together

Treat Follow-up Refer

Medical TeamMedical Team

� Two attending MD’s

� Residents (UCONN Internal Med/Family Med)

� Medical students (MSI-MSIV)

� Nurse Practitioners and PA students

� Non-Medical Volunteers

– Premeds & High School Students

– Outreach workers

The Crops: Tobacco, Fruit, The Crops: Tobacco, Fruit,

Nursery, MushroomsNursery, Mushrooms

Clinic SetClinic Set--upup

PopPop--up Exam Roomsup Exam Rooms

The StudentsThe Students

The Role of the Health The Role of the Health

Professions StudentProfessions Student

� Coordinators are the hands of the migrant

health network.

� Student volunteers are the first contact with

health care that many workers receive.

�Mutual benefits for the worker, the student,

and the physician.

Potential for MentorshipPotential for Mentorship

� For the Physician:

– Reconnect to

motivations

– Fulfill obligation to

pass along knowledge

– New awareness and

perspective

� For the Student:

– Inspiration

– Clinical knowledge

– New awareness and

perspective

Bridging Cultures: Bridging Cultures:

TranslatingTranslating

Vital Signs and ScreeningVital Signs and Screening

A Neurological ExamA Neurological Exam

Discussing a caseDiscussing a case

All patients are discussed and All patients are discussed and

seen by an attendingseen by an attending

PharmacyPharmacy

Whose pocket are you picking anyway? Whose pocket are you picking anyway?

The Patchwork of ResourcesThe Patchwork of Resources

� Funds: UCSOM, HCMA, NYCAMH, Rotary Clubs, NHSCFP (SEARCH)

� Preceptors: UCSOM/DM/RN, Yale SOM/PA, Quinipiac PA Program, HCMA, Private Physicians

� Students: UC, Yale, Quinipiac, Tunxis CC - dental hygiene program, Inner city and suburban high schools

� Outreach: Mass League CHCs, CPCA, CTCosh, VISTA

� Health Care: Federal Voucher Program, FQHCs, UConn, Privates

� Coordination: AHEC, UCSOM, CPCA, CTCosh, Hispanic Health Council

� Other: Foodshare, SFH (lighting), Skip Langan (odds, ends and commitment), Drug Companies (Meds)

20002000--04 CRVFHP Trends:04 CRVFHP Trends:

Users* & EncountersUsers* & Encounters

* Unduplicated users

512

1,056

740

1,665

539

1,512

626

1,799

758

2,294

-

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

2,200

2000 2001 2002 2003 2004

Users Encounters

Entered into CRVFHP Access DB as of 2/15/2005.

SuccessesSuccesses

� Provision of health care to the underserved

� Extensive community network

� Increased public awareness

� Education, for students & physicians

� Fun!

Making the TransferMaking the Transfer

� The Syracuse Connection:� First Contact:

• Public Health @ E. Migrant Stream (10/02)

• Med School Deans @ AAMC (11/02)

� Laying the groundwork:

• Work with faculty champion and students by phone

� Getting together:

• March 2003: visited Syracuse for meeting with stakeholders

� Making it happen:

• June-August 2003: Students and faculty champion plan and

implement clinic

EmailEmail

Bruce,

We went out to the camps last night. I’m

hooked!

Peter

(Peter Cronkright, MD, faculty champion,

SUNY Upstate Medical University,

Syracuse, New York

SUNY Upstate Medical SUNY Upstate Medical

UniversityUniversity

Possible Future Programs in Possible Future Programs in

DevelopmentDevelopment

� Springfield, Massachusetts in collaboration

with the Springfield College PA Program

and the regional AHEC program

� Southern New Jersey in collaboration with a

local osteopathic school and the regional

AHEC program

Community Health Center Community Health Center -- University University

Collaborations in Migrant Health: Collaborations in Migrant Health:

What Can We Learn?What Can We Learn?

Shared Mission!Shared Mission!

A lesson in:

�Collaboration

�Advocacy

�Social Conscience

ACTION PLAN DEVELOPMENT!

ReferencesReferences

� Suchman A, Bothelo RJ, Hinton-Walker P. Partnerships in healthcare: Transforming relational process. 1998. U Rochester Press. Rochester, NY.

� Calleson DC, Seifer SD, Maurana C. Forces affecting community involvement of AHCs: perspectives of institutional and faculty leaders. Acad Med. 2002;77:72-81.

� Seifer SD. Service-learning: community campus partnerships for health professions education. Acad Med. 1998;73:273-277.