Jamie Osborn, MD

The Twenty-first National Conference on Primary Health Care Access will feature initiatives in several states, including a series of roundtables relating to the State of California. (See: 21st National Conference on Primary Health Care Access April 12-15, 2010 in Kaua’i.) One of these will explore “mission-oriented” residency linkages with innovative models of “health care delivery”.

Over the years, the National Conferences have highlighted various innovations in physician residency training in settings that both promote primary health care access for underserved populations and teach them how to provide care to such populations in ways that are culturally sensitive and cost-effective.

Yet, even though such strategic initiatives can be demonstrated as successful, they tend to be financed by disparate revenue streams and may be simultaneously subject to conflicting regulations. Even if one imagines that the follow-up to any federal health care legislation that should pass might prove to be a positive factor for such initiatives, nothing is presently certain.

This roundtable will discuss several innovations that held great promise, some of which are unambiguously successful and some of which are less so.

Doctor Jamie Osborn, director of the Loma Linda University family medicine residency program, will update the successful rural-based residency program in the Central Valley town of Hanford. She will relate her residency program’s transformative experiences with the Patient Centered Medical Home, which she believes has demonstrated its capacity to provide “whole person care”.

Charles Vega, MD

Doctor Osborn will begin a discussion of the positive and negative issues relating to the Community Health Center and Medicaid Health Maintenance Organization models of primary health care delivery. She will be joined by Doctors Charles Vega and Ana Bejinez-Eastman.

Doctor Vega’s residency program at UC Irvine has one of the longest track records of any physician training program located in a federally qualified health center, this one located in the center of Santa Ana, one of California’s largest Latino communities. An extensive discussion of Dr Vega’s outreach program may be accessed at: University of California Irvine’s Family Medicine Residency Program: Outreach to Orange County’s Latino Community.

Selected Interviews from the Coastal Research Group’s Studentdoctor.net website.

This interview was conducted by William H. Burnett and first appeared 10 November 2008.

This is the second interview in the Student Doctor Network series of “community-based medical education” interviews.

(See the previous interview with Gerard Clancy, MD, the Dean of the newly established University of Oklahoma (OU) School of Community Medicine in Tulsa.)

The A. T. Still University School of Osteopathic Medicine in Arizona is located in the Phoenix suburb of Mesa. The structure of the school differs from that of other medical schools in having only the first year of medical school in Mesa, and the remaining three years for each student located in one of 11 participating community health centers.

SDN interviewed four members of the A. T. Still University faculty in Mesa.

SDN: Doctor Wendel, as Associate Provost of the A. T. Still University, please give us an overview of your new community-based medical school.

Dr Wendel: Our understanding of the need for a new medical school grew out of a relationship the A. T. Still University had developed with the National Association of Community Health Centers (NACHC). We realized that there are an estimated 50 million people in the United States with unmet health care needs.

There has been a lot of lip service to the idea of medical schools preparing students to meet that need, but not a lot of programs designed to address unmet needs as part of the educational program.

We plan to recruit people from the community and strengthen their ties to the community in which they were raised. We educate the students we have recruited about the missions and goals of our community-based medical school from Day One.

Because three clinical years are spent in the Community Health Center, we believe that the students and their families establish roots in the communities.

SDN: When doctors graduate from your school, what happens during their postgraduate years?

Dr Wendel: We do expect challenges in this area. Although some residencies exist with compatible goals, it is an open question whether there will be funding for creating more residency positions specifically designed to deliver care within community health center facilities.

That said, our graduates will enter residency programs with far more experience with chronic disease than students educated in most tertiary care-oriented academic health centers. Tertiary care is important, but the great majority of health care is the non-acute treatment of diabetes, hypertension and depression.

As an osteopathic medical school we add public health interventions. And, we are, in fact, a campus with a complex of health professional schools, each committed to interdisciplinary training. We all believe that having a health care team improves the health care system, but there are few places where one can model interdisciplinary health care for medical students. We believe that in most community health centers (CHCs), the interdisciplinary model predominates.

SDN: How did you choose the CHCs that are your partners in this educational program?

Dr Wendel: We started with several hundred CHCs, and developed a sophisticated screening process through which we chose a group to work with directly. We conducted site visits and, utilizing criteria to rate the CHC’s dedication to education, its community ties, its administrative support and the available space, we selected 11 CHCs for the program.

SDN: Dr Kasovac, as a member of the medical school faculty, how do you envision the first year of the A. T. Still University – School of Osteopathic Medicine in Arizona (ATSU-SOMA) in Mesa, Arizona differing from a typical medical school?

Dr Kasovac: The first year will take place on the ATSU-SOMA campus in Mesa, with all of the freshman class taking courses together. All courses will be part of a “clinical presentation” model curriculum, which we adapted from one developed in 1994 at the medical school in Calgary, Alberta, Canada

SDN: Can you describe what a clinical presentation model curriculum is, and how it works?

Dr Kasovac: Unlike the typical school first year, where students take separate courses in the basic sciences – anatomy, physiology, biochemistry, microbiology – the course content will integrate all of these sciences around specific clinical presentations from the very first week. There are approximately 120 clinical presentations that patients go to see a doctor about, such as cough, headache, back pain, chest pain, upset stomach, etc.

For example, during the first year there will be six courses, which will include Principles of Medicine, Musculoskeletal, Neurosciences, Cardiopulmonary, Renal and Endocrine.

SDN: It sounds like you are well along in designing the curriculum.

Dr Kasovac: Yes, there has been considerable work by our faculty. We have had the assistance of the physician who developed the original curriculum in Calgary, who is here for a one year visiting professorship.

Some aspects of the model have been tried at two other osteopathic medical schools, and is expected to be tried at one new MD medical school, but the ATSU-SOMA program is going to fully implement the model with all of the last three years of medical school occurring in one of the 11 participating CHCs, to which Dr Wendel referred.

SDN: Professor Nayeri, you will be coordinator of one of the 11 clinical sites, based at Phoenix Community Campus. What happens in the second year to the students that will be at that site?

Prefessor Nayeri: There are several notable differences between the typical second year medical school in the 2+2 model and the curriculum requirements for ATSU-SOMA students, with the community health centers and population-based medicine being central to the unique differences.

The SOMA students will spend sixty percent of their time in small group didactics, orchestrated by the main campus. There will be substantial use of electronic media, including PowerPoint and schemes, supplemented with lectures. The School of Medicine faculty at each site will facilitate the students’ learning by leading structured small group case presentation and discussions.

Our medical students receive course-specific cases, utilizing the Case Presentation (CP) method to deliver didactic education that integrates basic sciences and facts, i.e., anatomy/physiology and pathophysiology, histology, embryology, biochemistry, immunology, pathology, pharmacology, and nutrition.

Another educational opportunity that sets us apart are the weekly CP, related to the courses of study in Osteopathic Principles and Practice followed by laboratory where the medical students receive hands-on training.

The on-site School of Medicine faculty, beyond leading the structured didactic presentations, will act as academic advisor to the medical students, and will recruit and oversee the clinical adjunct professors who will observe and train students in patient care activities.

SDN: Doctor Simon, you have administrative responsibility for evaluation of students’ academic performance, faculty, and the medical school curriculum. Will there be ongoing feedback from the 11 clinical sites on the clarity, quality and relevance of every lecture and every PowerPoint.

Dr Simon: Yes, and that is only one aspect of the evaluation processes. Each student’s progress will be continuously evaluated.

SDN: Describe how students will be evaluated.

Dr Simon: Over the course of the four years, we will use a combination of many traditional methods of evaluation – examinations of students at the midpoints and the ends of all courses.

We will look at individual skills, coupling them with evaluations that are more non-traditional. In the very first year, the students will have structured encounters with a number of standardized patients, and they will manage a number of patients that are represented by the human patient simulators.

In regards to the basic sciences, we want students to demonstrate a grasp of concepts in the most concrete way possible as soon as possible. These early clinical type encounters not only allow them to demonstrate their “book knowledge” and “hands-on” skills, but also the interpersonal skills required for dealing with difficult patients.

Once the students leave campus after the first year they will have a combination of a half -week of didactic coursework in the mornings that will be evaluated by both written and practical exams.

The clinical work in the afternoon will be evaluated daily by their preceptors, much like a traditional third year student. There will be a 360-degree examination from their onsite facilitator.

The 360-degree evaluation will gather information from each student’s clinical preceptor, from nursing staff, and from support staff. Patients will be asked to complete satisfaction surveys. Feedback will come from a much wider group than the physician evaluations that are typical of traditional medical education.

Students will take the “shelf exam” at the end of each year, although any deficiencies in skills will be exposed much earlier. Their onsite evaluator will be observing them in patient encounters taking histories, doing physical exams and providing patient education.

We think that we will have a lot more data to pass along to the residency programs to which they apply. We will have all the quantitative data, such as test scores, but we will have more qualitative data, from the first year exams and the onsite evaluators on interpersonal skills, staff and professional colleagues.

SDN: Let’s return to what happens in the second medical school year.

Dr Simon: The second year for students, regardless of the site to which they are assigned, will consist of an integrated clinical experience (ICE).
Its objective is to provide that core clinical education which is essential to the professional development of every medical student, regardless of his or her eventual choice of specialty.

Each student will have assigned community-based projects that will focus on health professions and wellness.

The individual clinical adjunct faculty members are the students’ clinical supervisors. The clinical patient care activities will comprise about 40% of the second year students’ time. Every student’s clinical activities will include broad training in family medicine, internal medicine, pediatrics, OB/GYN, behavioral health and Emergency Room.

The second year students will be involved mostly in shadowing, and preparing for their third and fourth year clinical preceptorships. However, all students will be assigned ten patients that they will continue to see over the next two years of their medical school training.

By the third and fourth year of medical school, through their preceptorships, the students will be engaged in supervised clinical practice.

SDN: Doctor Nayeri, since you are coordinating the Phoenix Community Campus, please give us some background on the what the medical students based there will experience.

Professor Nayeri: The medical school has established a successful partnership with Clinica Adelante, Inc., a community health center which will be a model of inter-professional medical care and practice. The collaboration fosters medical education and will result in an increase in the number of potential osteopathic physicians who will probably serve in the rural areas caring for the underserved, farm workers, as well as suburban constituents.

This is a wonderful opportunity for our students to gain exposure to a diverse population, each with their own subsets of cultural values, including the Latino/Latina and American Indian communities.

SDN: Would you elaborate on the access issue?

Professor Nayeri: There are remarkable disparities among certain ethnic groups in our communities in accessing healthcare. Historical data show that some members of the lower socioeconomic status and disparate population have higher incidents of morbidity and mortality rates compared with the general population. For example, the average life span of an American Indian is significantly lower than that of the general population. The Hispanic males delay accessing health care and thus present with more severity. These are but a couple of examples of the risk factors that our medical students will have the tangible opportunity to learn about.

SDN: Will the students at the Phoenix site be given special training in delivering care to American Indian and Alaskan Native populations?

Professor Nayeri: Our students may choose to explore the opportunity to gain competency in a number of cultural subsets and the unique challenges in delivering care to them, including the American Indian/Alaskan Native people.

SDN: How will your medical students be involved in addressing these access problems?

Professor Nayeri: The second year, in addition to continued didactics, as mentioned earlier, includes Early Clinical Experience where students are immersed in community health centers in the greater Phoenix area and Central Arizona, when they will focus on health promotion/disease prevention. Medical students in year-two will begin to apply their knowledge of basic sciences acquired through integrated case presentation method and schemes, along with clinical reasoning and skills, in utilizing proper medical attention, that prevents acute episodes within a chronic disease, such as diabetes or cardiovascular disease, and further complication sequlae, hence improved quality of life – wellness being the focal point of the year-two ICE curriculum objective.

SDN: Describe the third and fourth medical school years.

Professor Nayeri: All of the education during the first two years have prepared students for the third and fourth year clinical preceptorships. They are taught basic sciences, OCSE, clinical reasoning and medical skills, beginning in their first year. In second year, they are assigned longitudinal patients, perhaps a family unit, and by knowing the family, the community, and the health care institution in which they are based and given this wraparound background they begin their early clinical experience.

We use the RIME model, on which there is considerable literature. RIME stands for R (reporter) I (investigator), M (manager), E (evaluator) for each progressive phase of the clinical education to systematically train the students, based on their demonstrated knowledge, skill, abilities and other professional attributes at corresponding level when they can diagnose, manage and treat the patient using evidence-based medicine.

At our campus there is an opportunity for students to learn to provide health care to underserved and underinsured persons whose health care delivery has often been like that of the third world countries. An ongoing criticism of medical school students providing care to underserved populations, is that they learn the skills they need and leave, rather than becoming involved with the community and staying there to serve. The common perception among the underserved areas such as Indian reservations are that scientists show up to do studies, publish their findings, get academic promotions back at their institutions, but never give anything back to the community that benefited them. The community sees such behaviors – whether by medical students or their professors – as “taking” and running.

SDN: What will your medical school students do to leave a different impression?

Professor Nayeri: Our CHC-based students will learn from the community, with this difference – that they are especially recruited and encouraged to pay back by caring for the underserved in rural areas of the United States.

SDN: It seems that some of your sites will be good places to learn rural health care.

Professor Nayeri: There will be opportunities at select Indian Health Care Delivery System sites where our medical students will be able to select individual rural experiences. For instance, one particular Indian reservation comes to mind, that due to its isolation and location can only be accessed by pack mules, on foot or by helicopter.

SDN: Does the traditional holistic preference of some osteopathic medical schools resonate with certain ethnic populations your medical students may be serving?

Professor Nayeri: Our four year curriculum integrates the “whole person approach” – embedded in our mission as “Body-Mind -Spirit” – which is the foundation of the osteopathic approach to medicine, and is a traditional theme in the history of ATSU, whose venerable Kirksville, Missouri campus has deep roots in the osteopathic medical profession. The philosophy of the school, in my opinion, is complementary to the holistic spiritual beliefs across cultures, including that of the American Indian and Alaska Native communities.

SDN: How will this “whole person” medicine translate into the medical student’s broader education.

Professor Nayeri: Our medical students will have a chance to appreciate the day-to-day interdependent operational aspects of a clinic as they train with physicians, interface with interdisciplinary clinicians, patients representatives and other staff. The students may further be invited to meet the native healers and may have the opportunity to participate, by invitation from the community, in native ceremonies.

Most physicians, during their medical education, do not get the perspective on how and what the doctor does impacts the community and the other team members.

SDN: Will special attention be given to medical school applicants from American Indian and Alaskan communities.

Professor Nayeri: Yes, ATSU is invested in recruiting American Indian/Alaska Native applicants, as well as those applicants with demonstrated commitment to serving the underserved and rural areas. This year, ATSU graduated the highest number of Dental Students with Native American backgrounds of any health professions school. The Physician Assistant (PA) program graduates about 20% of the nation’s Native American PA students, and the School of Medicine proportionately has a high percentage of Native American medical students.

Traditionally, the third and fourth year clerkships in the affiliated hospital(s) have had medical students, during the year, at different rotation intervals, from a variety of settings. We have found already that the students from the CHCs have exhibited much higher skill levels than the traditional medical student.

SDN: Thank you.

Selected Interviews from the Coastal Research Group’s Studentdoctor.net website.

This interview was conducted by William H. Burnett and first appeared 9 April, 2008.

(Subsequent to this interview, Dr Clancy assumed the presidency of the University of Oklahoma, Tulsa Branch)

With this interview, Student Doctor Network begins a new series of interviews relating to “community-based medical education” and with it a new forum on this subject. To launch the series, we interviewed Gerard Clancy, MD, the Dean of the newly established University of Oklahoma (OU) School of Community Medicine in Tulsa.

SDN: Dean Clancy, how do you envision your School of Community Medicine in Tulsa differing from a typical medical school?

Clancy: First, it is important to recognize that all the students in OU’s Community Medical School in Tulsa will graduate with the same MD degree as the students in OU’s traditionally organized medical school in Oklahoma City. They will learn the basic core information about medicine that they need to be successful as a physician.

But the information will be organized and taught in an entirely different way. Instead of being as a group of discrete subjects the subject matter will be organized around the principals of population medicine and community medicine.

SDN: Would you define those terms for our readers?

Clancy: Sure. Population medicine looks at the frequency of diseases and rates of mortality by disease, either for the general population or a particular subset of it (such as the residents of a geographical area, ethnicity, or income level). Community medicine would look at the disparities between one group and the population as a whole or perhaps another group.

SDN: For those persons not familiar with Oklahoma, is that a place where health disparities between communities are very pronounced?

Clancy: Although I am sure you will find health care disparities in communities everywhere in the United States, we were shocked when we began to study and then comprehend how great the differences in health status are from one part of Tulsa County to another. There is a high level of need throughout Eastern Oklahoma.

SDN: How will your medical school incorporate community medicine into the curriculum?

Clancy: First, we are recruiting faculty who are universally in agreement with the need to have medical students involved in providing care in communities of need from the earliest point in their education. We are collectively organizing a curriculum that “fast tracks” the students out of the medical school into community-based practice sites. As an additional feature, we will have a “loan repayment for service” plan that will give students the option for paying off their loans in a loan repayment system operated by the University of Oklahoma.

We have enlisted the help of experts nationally, and already have had retreats to develop our plans. Also, the new school is not being created out of thin air, but is being built on the existing University of Oklahoma medical school branch in Tulsa.

SDN: Are students to be involved in the development of plans for your school and its curriculum?

Clancy: Yes, OU medical students have been a driving force in creating the school. We have had high levels of student involvement in community health centers operated by the OU Medical School Tulsa Branch. They will continue to be involved in all the major elements of the plans.

SDN: Do funds exist to pay for all of these innovations?

Clancy: We have received a 50 million endowment, which includes 35 million to create endowed faculty positions, and an additional $15 million split between faculty recruitment and a loan repayment fund for the school’s medical students. As the school achieves success, and it will, we expect that our success will be recognized and our efforts supported by the people of Oklahoma and the alumni of the University of Oklahoma.

SDN: How will you implement these ideas?

Clancy: We are determined to select medical school classes that are truly interested in our approach to medical education – to learn the content of medicine, but to understand it in the context of the many factors that affect a person’s health. Those factors can include where the person lives, and how ethnicity, language and family situation.

SDN: Is there a way for persons interested in finding out more about your school?

Clancy: Yes, we will be very happy to respond to questions through the studentdoctor.net forums.

[ Visit the new SDN Community Medicine forum ]

Both myself and members of the OU faculty and student body expect to participate in the new studentdoctor.net forum on community-based medical education. We certainly will be interested in connecting with medical school applicants that share our vision of how physicians should be trained.

[The National Conferences on Primary Health Care Access highlight local initiatives throughout the United States that are designed to improve the health status of populations within our nation. One of the California's largest Latino barrios, in Orange County, has been served for the past 35 years by the University of California Irvine's family medicine residency program. Current initiatives will be discussed at the Twenty-first National Conference.]

Healthcare disparities faced by the Latino population in the United States have been shown to be related to access, language barriers, and poor communication. At the University of California, Irvine Family Medicine Residency Program, we have had success in addressing barriers to health care.

However, Spanish fluency and cultural knowledge among our trainees and graduates continues to fall short of the needs of our surrounding community. While nearly two-thirds of their patients use Spanish as their preferred language, only 20% to 30% of our residents feel fluent in Spanish. At the same time, half of the residents do not feel competent in cultural issues important to Latinos.

In response, we have developed a longitudinal resident curriculum in Spanish language and Latino culture that incorporates didactic sessions, “language lab” experiences in the residents’ clinic, cultural immersion experiences in the local community, home visits, and community outreach.

Multiple outcome measurements have been or will be employed to judge the success of our efforts. We have performed baseline assessments with 2 validated surveys which assess general patient satisfaction with their physician as well as examine specific cross-cultural skills pertinent to Latino patients. The baseline surveys provided some surprising results. In addition, the UCI Family Medicine Class of 2012 received a completely redesigned objective structured clinical examination, in which each standardized patient case emphasized Spanish language and issues of culture and disparities in patient care.

The most critical outcome to our project is the number of residency graduates who go on to provide high-quality, culturally-sensitive care for poor and disenfranchised Latino communities. Overall, the Health Education and Language for the Latino Community (HEAL-LC) project has the potential to be replicated throughout the country to better prepare physicians-in-training for a multicultural environment and improve health care disparities for Latino and other populations in need.

The concept of an “Educational Health Center” has evolved over several years as a result of collaborative process between the University of Washington School of medicine’s Department of Family Medicine (Department), Community clinics as represented by the Northwest Regional Primary Care Association (NWRPCA) with connection to the National Association of Community Health Centers (NACHC), and the University of Washington Affiliated Network of Family Medicine Residencies (Network).

In short, the concept is to combine the efforts and purposes of residency training and health center service in a more intentional model to serve the interests of both entities while expanding the network of service to the uninsured and the underinsured.

While these affiliations already exist in many forms between Health Centers (HC) and Family Medicine residencies across the country, the current regulatory and accreditation standards pose significant barriers to an efficient and economically sustainable co-location.  That it is accomplished in scores of programs and clinics is a testament to the effort and shared vision the leaders of those residencies and health centers maintain. In other words, it is hard to do and it is heavily dependent on the existing leadership on site.

The current idea is not entirely new.  However it started as a “new” idea in a Network strategic planning session.  Many of our programs and many FM programs across the country were facing economic challenges to their survival.  Approximately 10% of FM residencies had closed in the preceding 7 years, most for economic reasons.  We knew that most of the physicians hired by HCs were FPs and we all considered graduates working in HC practices as a success.

We also knew they had many unfilled FP openings and yet were slated to be expanded by Federal plans as the government’s official way to provide care for the poor.  We also felt that there was a strong overlap in the type of patients seen in residencies by social, insurance, illness, and economic characteristics. We knew the reimbursement for Medicare patients far exceeded our own in the federally Qualified Health centers and felt this adjustment could be a major help in stabilizing the economics of residencies.  We felt residencies had a lot to offer Health Centers in terms of training potential employed physicians, increasing the workforce in the “safety net” for our communities, and possibly stabilizing existing physician workforce in the HCs themselves.  This latter point of view came from our own experience of residencies either in HCs or with satellites in HCs.

We learned a lot! With support from the UW, faculty members performed qualitative research on the cultures of FMRs and HCs.  Structured focus groups run by Dr. Carl Morris explored administrative, economic, service, educational, personnel, regulatory, governance, and cultural issues in these groups.  This work has been published. In short, it revealed the same categories that had made us feel there was a good fit were the areas of barriers to collaboration.  It confirmed that there was a very similar view as to the potential benefits and alignment of values related to service and education.

However, the basic regulatory and accreditation rules posed conflicting measures of successful performance that were critical to each group’s fundamental purpose.  That is, direct clinical service to a defined volume of patients as versus successful provision of educational experiences that included service to patients but required significant elements other than patient service.  There were many apprehensions each group had about the other in terms of erosion of their core commitments and purpose if collaboration occurred.  These areas were explored and defined.

Dr. Morris, Dr. Frederick Chen, and others also reviewed our network’s history in future practice of our grads.  They found that residents trained in a HC environment were significantly more likely to work in a HC after training as well as much more likely to work in a health professions shortage area after graduation. These trends have since been confirmed by other residency networks with similar differences of training sites within them.

Finally, a varied group of residency directors, faculty, health center administrators, and others developed a concept each group could support.  It was felt that this type of entity could help supply an increased number of FPs for HC practice in the future, stabilize FMR finances, and simultaneously increase the role residencies play in “safety net” care in our communities.  It was appreciated that not all HCs and not all residencies could or would wish to transform into this new entity.  It was also appreciated that many legislative and regulatory changes were necessary to implement the Educational Health Center as we envisioned and defined.  A copy of this is appended in what we often call our “one pager”.

Recently, a close version of this was proposed in Senate health reform legislative language as the “Teaching Health Center”.  At the time of this writing, it has disappeared from the bill’s language but another bill creating funding for Medicare Pilots may allow it to be tried.  As you will note, key to this new model clinic working will be allowing GME funding to flow to it for the educational expenses.  Currently the GME funds flowing to residency training sites, or not, is totally dependent on voluntary agreements between the programs and their hospital sponsors.  To stabilize these new programs, a stable funds flow for the educational enterprise will be critical.

]]> http://coastalresearch.org/2009/09/forum-on-educational-health-centers/feed/ 0 http://coastalresearch.org/2009/04/discussion-points-physician-residency-programs-and-los-angeles-countys-safety-net/ http://coastalresearch.org/2009/04/discussion-points-physician-residency-programs-and-los-angeles-countys-safety-net/#comments Fri, 03 Apr 2009 23:35:09 +0000 CRG http://coastalresearch.org/?p=947 One of the scheduled presentations for the Tuesday morning plenary sessions at the Twentieth National Conference on Primary Health Care Access is by Doctor Rick Flinders of the Santa Rosa Family Medicine Residency Program. His topic is “The Family Medicine Residency as Change Agent”.

In preparation for the discussion panel that will follow Dr Flinders’ presentation, Doctor Hector Flores of the White Memorial Medical Center has developed graphical and visual representations of points he will be making about the development of new relationships between local government entities concerned with health care delivery to “safety net” populations and the White Memorial Medical Center family medicine residency program.

The following slides supplement Doctor Flores’ discussion.

Doctor Flores adapts a chart from the policy document Healthy People 2010

Dr Flores the overarching ideas behind key Institute of Medicine reports published during the past decade:

Doctor Flores discusses the major tiers of care in Los Angeles County.

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Dr Flores observes that Los Angeles County cannot properly be called a “system of care” – instead it might be characterized as a “non-system”.

Dr Flores then looks at the impact of public policy initiatives in the study area.

Dr Flores discusses the interaction of different “sectors” in providing care in East Los Angeles

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Dr Flores presents the following policy ideas:

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Dr Flores then raises the prospect of genuine health care reform taking place at the local level, incorporating a much wider group of providers and facilities than is often considered feasible in current policy proposals.

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