SCHOOL OF COMMUNITY MEDICINE - University of Oklahoma

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CREATING THE NATION'S FIRST. SCHOOL OF. COMMUNITY MEDICINE. A PLATFORM TO IMPROVE THE HEALTH STATUS OF THE TULSA REGION.
CREATING THE NATION’S FIRST

SCHOOL OF COMMUNITY MEDICINE

A PLATFORM TO IMPROVE THE HEALTH STATUS OF THE TULSA REGION (FLATTENING TULSA 2.0)

Gerard P. Clancy, M.D., President, University of Oklahoma-Tulsa

DIRECTORY EXECUTIVE SUMMARY ................................................................................................ 4 INTRODUCTION ......................................................................................................... 12 A FRAMEWORK FOR CHANGE ................................................................................. 13 FOUR BASIC INGREDIENTS Improving the Health of the Tulsa Region Understanding of the Problems ........................................................................... Study of Best Practices for Improving Health ....................................................... Committed and Stable Team of Organizations and Individuals ............................. Strategic Planning with a Long-term View. ...........................................................

17 17 18 18

THE TULSA REGION Health Status ...................................................................................................... Health Delivery System ....................................................................................... Community Impact .............................................................................................. Funding Shortfalls ...............................................................................................

19 21 23 23

BEST PRACTICES Prevention .......................................................................................................... 24 Direct Services .................................................................................................... 25 Community Health/Medical Education ................................................................. 29 THE ROLE OF A UNIVERSITY ................................................................................... 33 OU-TULSA: THE BEST PLATFORM .......................................................................... 33 Leading the Health Improvement of Tulsa THE PROPOSED PARTNERSHIP ............................................................................... 34 WHY NOW?................................................................................................................. 36 THE FIRST FIVE YEARS Prevention: Five Projects .................................................................................... Clinical Services: Four New Approaches ............................................................. Medical Education: Five Programs ...................................................................... Quality Improvement ........................................................................................... Increase Public/Private Funds .............................................................................

37 38 39 40 41

THE NEXT 12 MONTHS: 7 THINGS TO DO ................................................................ 42 THE TULSA HEALTH STATUS IMPROVEMENT MATRIX ......................................... 44

Flattening Tulsa v2.0: A Proposed School of Community Medicine

EXECUTIVE SUMMARY

3 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

EXECUTIVE SUMMARY Ken Levit once said, “compared to health care, the CIA was easy.” He was right. Among developed countries, the US spends the most per capita on health care but ranks in the lower third in numerous health indicators. Beyond the moral argument that everyone should have access to high quality health care, health status is a factor in the economic vitality of a community (and state and Country). The Tulsa region’s health status is extremely poor. Every regional health care system in the US is exceeding complex and bringing about the necessary changes to significantly improve the health status of the Tulsa region will take time (years), money (millions), a plan and a commitment to stay the course. This report lays the foundation for that plan by proposing a long-term partnership between the University of Oklahoma and the George Kaiser Family Foundation. This partnership will create the first School of Community Medicine in the United States. This School of Community Medicine will serve as a primary platform for change in the healthcare delivery system, research on how to improve the health of an entire region and physician commitment to the health of an entire community. “The World Is Flat” (Friedman) highlights how new attitudes regarding capitalism, internet connectivity and the efficient / immediate transfer of information is leveling the playing field for China, India and the former Soviet Union to be able to compete on a global level. He refers to the leveling of the playing field as a “flattening” of parts of the world. Despite the economic gains within these countries, he argues that distinct segments of the population within these countries are being left behind during the flattening process – in part due to abject poverty, poor education and poor health. We can the say the same for Tulsa. The Tulsa region is on the upswing regarding economic development but large geographic areas and at risk populations are being left behind in part due to extremely poor health status. The original Flattening Tulsa Report, written in 2005, was an initial attempt to provide a broad survey of health status problems for the Tulsa region as well as some initial prioritized strategies to reverse the trends of worsening health status in the Tulsa region. Since 2005, some progress has been made in improving the healthcare delivery system for the Tulsa region. The Community Hospital Authority, a state agency charged with coordinating health care for the poor has expanded its Board composition to include hospital, medical school, public health, private foundation and business leaders. Tulsa’s first Federally Qualified Health Center, Morton Comprehensive Health Services, has opened a new 50,000 square foot facility. A new Federally Qualified Health Center has opened – Community Health Connections. St. John Health System has established an MRI and CT center in north Tulsa. OU-Tulsa has applied for Federally Qualified Health Center status for their west Tulsa clinics. The network of OU sponsored school-based clinics has expanded. OU Bedlam now offers a chronic care clinic for improved continuity of care for patients referred from the afterhours clinic. A network of community pharmacies offers medications for a minimal charge for Bedlam patients using a generic formulary.

4 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

The faculty, resident physicians, students and staff of the multiple colleges and programs within the University of Oklahoma, Tulsa (OU-Tulsa) now have a focused commitment to lead efforts to improve the health status of the region. All of this progress is laudable and individual lives have been improved but these initiatives will not be enough to significantly change the region’s health status. Much more needs to be done over an extended period of time. Before any next steps are proposed – it is important to review what we know. Over the past 3 years, numerous studies have been completed which give a clear picture of the problems and options for intervention: WE KNOW THAT … We know the health status of the Tulsa region is awful. Oklahoma is the only state where the age-adjusted death rate has worsened over the past 25 years. Oklahomans smoke too much, eat too much, seek pre-natal care too late and exercise too little. These unhealthy behaviors lead to high rates of heart disease, diabetes, cancer and pre-mature birth. These high rates of chronic diseases lead to acute medical emergencies and early death from myocardial infarctions, stroke, renal failure and complicated pregnancies. We know of numerous health initiatives that have been deemed “Best Practices” regarding improving the health of high-risk groups. Several health systems in partnership with medical schools have dedicated their efforts towards improving the health of high risk and underserved patient populations. Common characteristics of these successful health improvement efforts include a long-term commitment to the community, a long-term plan, diverse sources of funding and the development of infrastructure for the measurement of community needs and outcomes of initiatives. We know of model systems for tracking health needs and the outcomes of health improvement initiatives. Programs such as Parkland’s CHIMES (Community Health Improvement, Measurement and Evaluation System) allow leadership to track success of particular interventions. This objective data is then used to advocate for additional private, local, State and Federal funds. Clinical practices that have been able to establish electronic medical records have new capacities to measure outcomes on a much broader basis. We know we will be short of physicians. US medical school graduation numbers have not kept pace with the growth of the general population. The demand for health care services will only increase as the baby boomer generation moves into higher health care utilization categories. Oklahoma is far below the national average for physicians per capita. This is expected to worsen as it is predicted that the U.S. will be short 200,000 physicians in the next 10 years. We know we have missed numerous opportunities to access public and private funds to improve the health status of the Tulsa region. Oklahoma receives far less Federally Qualified Health Center, Disproportionate Share and National Institutes of Health funding compared to national averages. State funds to the Tulsa region are less than to the Oklahoma City region. Large national foundations have rarely invested in Tulsa health initiatives. 5 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

It is clear that additional studies are not necessary to highlight Tulsa health problems. The already identified numerous best practices across the US point us in the direction of what prevention, health services and medical education programs we should incorporate to improve the health of the Tulsa region. What has not happened to date, is a full integration of these proven clinical service, medical education and health outcomes research programs in a coordinated fashion with a long-term commitment to improving the health of an entire region. What is needed in the Tulsa region is an infrastructure for long-term planning efforts and a means to implement these plans. OU-Tulsa is a major supplier of physicians for the Tulsa region, has an extensive array of community based clinical services across the region, a team of clinicians dedicated to serving the poor and will soon open an advanced outpatient clinic, a cancer center and a diabetes center. The George Kaiser Family Foundation has identified health improvement for the poor of the Tulsa region as one of 4 areas for future investment. We believe the best form of this infrastructure is through the development of a School of Community Medicine. Using the research, teaching and clinical resources of OU-Tulsa in partnership with the George Kaiser Family Foundation and other community agencies, the overarching goal of the School of Community Medicine would be to improve the health status of the Tulsa region. The following agreements are proposed to initiate this partnership of OU-Tulsa and the George Kaiser Family Foundation (GKFF). The 10 agreements (articles) below are proposed to initiate a partnership of OU-Tulsa and the George Kaiser Family Foundation (GKFF):

6 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

Ten Articles for the Partnership to Improve Health 1. Declaration by GKFF and OU of a commitment to the health of the entire community through renaming of the College of Medicine, Tulsa as the School of Community Medicine. The Chapman Trust and the University of Tulsa may be considered as additional partners if their respective leaders have interest. 2. The School of Community Medicine becomes a planning, organizing and coordinating unit for initiatives to improve the region’s health status. 3. Declaration of a focusing of OU academic efforts (teaching, research and service) to improve health of Tulsa region. 4. The Kaiser name would used prominently as it is respected throughout the world. The use of the Kaiser name and renamed School of Community Medicine would herald a new version of an American medical school. 5. Develop a Joint Operating Agreement – OU promises a long-term dedication to the partnership, will focus resources to help improve community health status and commits to increase State and Federal annual funds to Tulsa region. The George Kaiser Family Foundation promises a long-term dedication to the partnership, would bring financial, planning, critique and lobby expertise to the partnership. 6. Each year, GKFF funds would be used to seed prevention, clinical service, medical education and research / outcome projects that improve the health of the region. Through a yearly Tactical Plan, individual projects and funding levels would be jointly agreed upon by OU-Tulsa and GKFF and would fit into the long-term Strategic Plan. 7. A Health Advisory Council would be created to make recommendations to the George Kaiser Family Foundation Board. Dr. Steven Landgarten would initially chair this Council. Additional Council members would include Ken Levit, Monica Basu, Mike Lapolla and Drs. Gerard Clancy, David Adelson, William Geffen, F. Daniel Duffy and Peter Budetti. 8. There would be quarterly updates on the progress of these projects to the GKFF Board. 9. Beyond directly improving the health of the Tulsa region, these private funds would be used to bring additional public and private funds to these health initiatives. 10. The School of Community Medicine pilot would serve as a role model for other communities and medical schools with the same goals of improving the health of their community.

7 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

SCHOOL OF COMMUNITY MEDICINE FIVE-YEAR GOALS Prevention, Clinical Service, Medical Education, Funding and Outcomes There are many health associated needs in the Tulsa region – probably too many to list and certainly too many to take on immediately. Using the numerous studies on the Tulsa region, categories with the highest need and with the potential for greatest impact are identified below. It is proposed that these will be the initial focus areas for the proposed partnership of OU-Tulsa and the George Kaiser Family Foundation: 1. Prevention: Expand Pre-natal Care Outreach, Increase Access to HPV Vaccine through Outreach, Establish Access to Colonoscopy through Outreach, Reduce Risk of Myocardial Infarction through Medication Outreach, Obesity Reduction in High Risk Preadolescents Utilizing School-based Clinics and North Tulsa Obesity Prevention Program. 2. Direct Clinical Service: Expand Primary Services in Underserved Areas, Increase Underserved Access to Obstetrical Clinicians, Increase Underserved Access to Low Cost Medications, Increase Access to Advanced Outpatient Care for the Underserved. 3. Clinician Manpower: Increase the number of clinicians with interest and skill in providing care to the underserved of the Tulsa region. 4. Outcomes Measurement: Expand the region’s community health research capacity and develop an information technology infrastructure that facilitates predictive modeling of disease rates and impact, needs assessments, quality improvement, disease registries, efficiencies in care and measurement of outcomes of School of Community Medicine interventions. 5. Funding: Increase One-time and Recurring Health Care, Research and Medical Education Funding through the Creation of a Grants and Financing Development Office within the School of Community Medicine. TIMELINE OF CRITICAL ACTIONS There are many efforts converging in the next 12 months that make the possibility of the School of Community Medicine a distinct possibility. If the concept of renaming and repurposing the University of Oklahoma College of Medicine, Tulsa to the School of Community Medicine is endorsed by the George Kaiser Family Foundation, there is much work that needs to be done in a short amount of time.

REGENTS APPROVAL

SITE VISITS

ECG CONSULT

CREATE INFRASTRUCTURE

ADVISORY COUNCIL

PLAN INSTITUTE

UNIVERITY OF TULSA

8 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007



OU Board of Regents Approval – The University of Oklahoma College of Medicine, Tulsa was established in 1972. A change in name and a focusing of purpose of this nature would require full discussion and approval by the OU Board of Regents. The OU Board of Regents has an extended meeting each year in June where each campus is allowed several hours to discuss major projects for the upcoming year. This would be an ideal time to propose such a change.



ECG Consultation – The Seattle based ECG Consulting firm has begun its initial work on the OU College of Medicine, Tulsa Five Year Strategic Plan. ECG will soon need direction on whether the School of Community Medicine is a viable concept. If the School of Community Medicine does receive endorsement by the OU Board of Regents and the George Kaiser Family Foundation, ECG will be tasked with developing a plan for “how” the Flattening Tulsa v2.0 Plan should be carried out. This would include timelines, yearly goals, Gant charts and budgets for each initiative. ECG will also be tasked with assisting the School of Community Medicine in the development of a viable professional practice plan for the OU Physicians group.



Site Visits to Parkland Health System (Dallas), Albert Einstein School of Medicine and Denver Health – In looking at medical school based Best Practices for improving the health of a community, programs in Dallas, the Bronx and Denver appear to have programs and structures that the School of Medicine could continue to learn from. Contacts have been established with each school and site visits to these programs is planned later in 2007. Perinatal and prenatal programs will be a particular area of focus.



Creation of the George Kaiser Family Foundation Health Advisory Council – This group would make recommendations regarding health programs to the George Kaiser Family Foundation Board. This Council would be initially chaired by Dr. Landgarten. Additional Council members would include Monica Basu, Michael Lapolla and Drs. Clancy, Adelson, Upham, Geffen, Duffy and Budetti.



School of Community Medicine Infrastructure – The existing OU College of Medicine, Tulsa administrative infrastructure is currently not at the necessary level of size and sophistication needed to successfully carry out the goals of this proposal. Working closely with ECG Consultants, a redesign of the medical school’s infrastructure would be initiated.



Begin discussions with the University of Tulsa - A pilot program with the University of Tulsa and OU-Tulsa to create a joint Physician Assistant program in Tulsa is progressing nicely. In addition, the University of Tulsa, the Oklahoma Medical Research Foundation, the Warren Medical Research Institute and OU-Tulsa have come together to create a consortia around neuroscience themed research. There appears to be a common set of values and common areas of interest between the University of Tulsa and OU-Tulsa. As the School of Community Medicine initiative begins, there may be an increasing role for partnerships with the University of Tulsa.



Begin discussions for the creation of a companion Institute for Community Health. This would allow other OU-Tulsa programs (outside of the College of Medicine, Tulsa) and community agencies to participate in these health improvement efforts.

9 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

YEAR ONE PRIORITY PROJECTS The George Kaiser Family Foundation has invested significantly in OU-Tulsa health and education programs over the past two years. Areas for additional priority consideration for 2007 are listed below: 

Prevention – funds have already been received for planning efforts and for pilot prevention projects around Colon Cancer Detection and Obesity / Diabetes Interventions. A $1.7 million proposal from the OU College of Public Health for Myocardial Infarction Risk Reduction through Medication Interventions is under study.



Direct Clinical Services – funding for expansion of the school-based clinics has been received. A pledge to support the construction of the north Tulsa HealthPlex has been received. Augmentation of prenatal and perinatal services must be initiated but a coordinated community plan must be completed first.



Clinician Manpower - A vulnerable area in clinician manpower that has developed is access to mid-wives, obstetrics trained family medicine physicians and obstetricians. The newly established Physician Assistant program is currently under-funded.



Outcomes Measurement – Further development of an outcomes measurement team is necessary if the School of Community Medicine initiative is approved.



Funding Efforts – With the initial success of an FQHC development officer, the creation of the Grants and Financing Development Office to increase public and private funding of the School of Community Medicine initiative would appear to have reasonable return on investment.

10 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

A Proposed School of Community Medicine

FLATTENING TULSA v2.0

11 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

INTRODUCTION Flattening Tulsa v2.0: A Complete Report Thomas Friedman’s best selling book “The World Is Flat” highlights how new attitudes regarding capitalism, internet connectivity and the efficient / immediate transfer of information globally is leveling the playing field for China, India and the former Soviet Union to be able to compete in the new global market place. He refers to the leveling of the playing field as a “flattening” of parts of the world. Despite the economic gains within these countries, he also highlights the fact that distinct segments of the population within these countries are being left behind during the flattening process – in part due to abject poverty, poor education and poor health. Friedman argues that entire countries are being left behind in this “flattening” process. Africa for example, has little chance to compete on a global scale with diseases such as HIV and malaria affecting so many of its citizens. Diarrheal illnesses from poor sanitation and nonpotable water continue to be the primary cause of death in India and Bangladesh. Frustrating to many health care workers is the fact that HIV, Malaria and infectious diarrheal diseases are preventable in a well-organized health care system. Parts of the US are not yet flat due to severe poverty and poor health status. Beyond just the poor, the US middle class is being stretched to a point of haves and have-nots. Tulsa is no exception. Tulsa is a region with areas of excellent health and areas with very poor health status. Not surprising is the fact that health - wealth and poverty - poor health are intimately linked. What was not apparent was the degree of poor health in parts of the Tulsa region and how this is having an effect on the health care delivery system and the entire economic potential of this region. The original Flattening Tulsa Report, written in 2005, was an initial attempt to provide a broad survey of health status problems for the Tulsa region as well as some initial prioritized strategies to reverse the trends of worsening health status in the Tulsa region. The George Kaiser Family Foundation and the Chapman Trust invested significantly in these recommendations. Investments, coordinated through the University of Oklahoma, Tulsa included support of after-hours primary care services, school-based clinics, obstetrics outreach, additional planning initiatives (the Lewin Report) and administrative infrastructure to increase public funding. Those investments have been successful at improving access to health care, focusing the University of Oklahoma Health Science Center Colleges in Tulsa around improving community health, increasing health science student interest in providing care to the poor and to a lesser degree bringing in additional public funds. With the success of these initial investments and the realization that sustainable change in the health status of the Tulsa region will take many years, it is now time to increase the level of commitment to reach this goal through a partnership of the University of Oklahoma, Tulsa and the major private foundations in the Tulsa region. This report will provide an update on current Tulsa health status problems, health delivery system problems, a proposed new structure of the University of Oklahoma College of Medicine - Tulsa, specific programs to be developed and funding strategies to meet the ultimate goal of sustainable change it the health status of the Tulsa region.

12 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

A FRAMEWORK FOR CHANGE Improving Health Using Collins’ Good To Great Model

The Association of American Medical Colleges surveyed over 5,000 U.S. citizens in 1999. The respondents provided the following list of “what medical schools should do”: • • • • •

Educate the next generation of physicians. Advance medical knowledge through research initiatives. Provide care for the most complex disease states. Care for the poor. Help solve medicine’s most pressing problems.

In looking at these public expectations of a medical school, The University of Oklahoma College of Medicine, Tulsa is a good medical school, but not a great medical school. The school is the region’s lead in caring for poor patients, has graduated more than 50% of Tulsa area practicing physicians and is deeply involved in trying to help solve some of medicine’s most pressing health problems. But, despite this body of work over the past 35 years of existence of the medical school, the overall health status of the Tulsa region has worsened

COLLEGE OF MEDICINE - TULSA

This begs the question, “what could the University of Oklahoma College of Medicine, Tulsa do to become a great medical school?” One answer is to lead a long-term strategy to successfully improve the health status of the entire Tulsa region.

13 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

A GREAT MEDICAL SCHOOL WOULD … DEATH RATES AGE ADJUSTED

1,100

IMPROVE HEALTH A great medical school would lead the long-term effort to bring the Tulsa health status in line with national averages and trends.

1,000

RATE

Tulsa County

United States

850

800 1980

1990

2000

2010

2020

2030

Age adjusted death rates factor age bands and expected ages of death. They are expressed as deaths per 100,000 people. Source: Oklahoma State Department of Health.

YPLL IN TULSA COUNTY YEARS OF PRODUCTIVE LIFE LOST

30

IMPROVE PRODUCTIVITY A great medical school would lead the long-term effort to increase productivity (reduce years of productive life lost) and work towards eliminating racial disparities in Tulsa.

YEARS

26

African-American

14

All Races 10 1990

1995

2000

2005

2010

2015

YPLL is calculated as the difference between age of death and 85 years old. Source: Oklahoma State Department of Health.

AGE-ADJUSTED DEATH RATES

1,486

OFFSET POVERTY

989

A great medical school would lead the effort to bring better health status to those in poverty, especially children.

995

925

HIGHEST

MID-HIGH

MID-LOW

LOWEST

Tulsa County data. Age adjusted death rates factor age bands and expected ages of death. They are expressed as deaths per 100,000 people. Sources: Bureau of the Census; OU College of Public Health; and Oklahoma State Department of Health.

HOUSEHOLD INCOMES

14 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

GOOD TO GREAT Jim Collins’ research team and book, Good To Great, studied what common characteristics were present in US corporations that were able to move their financial performance from a “Good” level to a sustainable “Great” level. (See chart below for graph of corporate performance). 7.00

THE GOOD TO GREAT STUDY Y-Axis:Ratio of cumulative stock returns to general market. X-Axis: Years from transition.

Good-to-Great Companies

Direct Comparison Companies 1.00 Market baseline -15

-10

Transition Point -5

0

+5

+10

+15

THEORY From Collins’ in-depth study, key components of the eleven “Great” corporations were: 1. Good is the Enemy of Great. A realization that good organizational performance was the

enemy or a barrier to great performance. 2. Level 5 Leadership. Leadership of the organization that was passionate and driven but

not individually ego-centered. 3. Right People on the Bus in the Right Seats. A first step that focused on who should be

on the leadership team and then what roles those on the leadership team would play - or getting the right leaders of the organization “on the bus and in the right seats”. 4. Confronting the Brutal Facts. A willingness to confront the brutal facts both internal to the

organization and in the marketplace. 5. Focus. The organization focused on being the best they could be around a single theme

– the hedgehog concept. 6. Discipline. A culture of discipline and commitment to the organization’s long term plan. 7. Getting the Fly Wheel Moving. Attention to long-term planning and incremental change

to create sustaining momentum. 8. Technology Accelerators. Use of, but not over reliance on, technology to accelerate

change in organizational performance.

15 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

APPLYING THEORY TO TULSA Although Collins’ research focused upon corporate performance, subsequent research efforts report that these core characteristics also translate to success in the non-profit social sector. In examining the key components of moving from a good to great organization, the University of Oklahoma, Tulsa and the supportive private foundations, appear to be in a strong position to move the health delivery system efforts from good to great: Good is the Enemy of Great There is a realization that there are many good health services efforts in the Tulsa region but the existing network of services need to be dramatically changed and enhanced to significantly improve the health status. Level 5 Leadership The leadership teams of the medical school and of these private foundations are deeply committed to improving Tulsa and the lives of the underserved. Both sets of organizations are searching for the best use of public and private funds to bring this to realization. Right People on the Bus in the Right Seats Both sets of organizations have assembled leadership teams to begin to bring change in the health care delivery system and ultimately improve the health status of the region. Confronting the Brutal Facts The original Flattening Tulsa Report, the Lewin Report, the Institute for Community Change Report and the 2007 Tulsa City County Health Department Report on the state of health by Tulsa County zip code have provided us with a long list of problems in the health status. From several national reports, it is clear that we are on the brink of a physician shortage. With this shortage, an adequate supply of physicians in Tulsa willing to care for the poor will need to be developed. In addition, we have a long list of best practices for health care services that have a good chance at making significant improvements. Discipline and Getting the Fly Wheel Moving Both organizations appear committed to focus on improving health. What is needed to move forward is a plan to follow and the long-term (15 year) commitment to follow this plan. Technology Accelerators The transition to the use of the electronic medical record can go beyond more accurate medical record keeping. More advanced electronic medical record systems will allow for the development of large data bases, identification in gaps of services and the impact of interventions on larger groups of patients. THE ROAD FROM GOOD TO GREAT

LEADERSHIP

THE BUS

THE FLYWHEEL

TECHNOLOGY

16 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

FOUR BASIC INGREDIENTS IMPROVING HEALTH IN THE TULSA REGION In taking a broad view of what ingredients must be in place before progress can be made in redesigning the health education and health care delivery system, the following four ingredients are suggested: 1. Understanding of the Problems Much work has been done in understanding health status and health delivery system problems for the Tulsa region. The Flattening Tulsa Report (2005) – identified Tulsa area health status problems, prioritized initial interventions to improve health and linked health status improvement to economic development for the region. The Lewin Report (2006) identified additional service delivery shortages and provided strategies to improve the health planning and funding of the Tulsa region. The Tulsa City County Health Department Health Status Report (2007) provided indepth analyses of the health status, specific disease rates and health behaviors by zip code in the Tulsa region. The Institute for Community Change Interim Report (2007) provided additional information on health, public education and social problems of the Tulsa region and recommendations for investments. 2. Study of Best Practices for Improving Health An extensive survey of health programs across the US has been undertaken. This has included Parkland Health System and the University of Texas Southwestern Medical Branch, Denver Health and the University of Colorado, the Massachusetts League of Community Health Centers and Harvard, Boston and Tufts Universities, Atlanta and New Haven school-based clinics, the University of New Mexico, Baylor University, Johns Hopkins University, the University of Pennsylvania, Duke University, The University of Rochester, Albert Einstein University and Montefiore Medical Centers and the University of California Los Angeles Drew Medical School. No one community and no one institution has been successful in the implementation of all of these interventions but much can be learned from individual projects. In each of these initiatives, medical schools have played a major role in providing clinical services, on-going clinical manpower and stability.

17 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

3. Committed and Stable Team of Organizations and Individuals Leadership of The George Kaiser Family Foundation, the Chapman Trust and The University of Oklahoma, Tulsa have a 3 year history of working together on improving access to care through the Bedlam After-hours and School-based Clinics. There also appears to be a commitment to the long-term investments and development of services and clinicians to make more significant and long lasting improvements to the health status of the Tulsa region. The chart below indicates the “determinants of health”

10% HEALTH CARE SYSTEM

20%

50%

PHYSICAL ENVIRONMENT

20%

SOCIAL ENVIRONMENT

GENETICS

(Source: Evans, R.G. and G.L. Stoddart, Producing Health, Consuming Health Care. Soc Sci Med, 31(12), 1247-1363)

Realizing that these determinants of health go far beyond health care delivery, the University of Oklahoma Colleges of Nursing, Pharmacy, Public Health and Allied Health, the Center for Outreach, Research and Education, along with programs in Social Work, Urban Design, Organizational Dynamics have also demonstrated a commitment to longterm investments in improving health of the Tulsa region. Additional possible partners in these efforts include the University of Tulsa, the Tulsa City / County Health Department and the Community Service Council. 1990. 4. Strategic Planning with a Long-term View. With the deep level of understanding of current health status problems, a set of model health care delivery interventions and organizational commitment to improving health, it is now time for a long-term regional health status improvement plan for these organizations to jointly develop, seek funding for and implement. What follows is an update of Tulsa area health status indicators, best practices, a set of initiatives to improve health and a proposed partnership to lead the implementation of this plan.

18 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

THE TULSA REGION Health Status, Delivery, Funding and Economic Development HEALTH STATUS Oklahomans engage in unhealthy behaviors at rates higher than national averages. These behaviors include child abuse, domestic violence, use of tobacco, over-eating and lack of exercise. Oklahomans have high rates of premature births – particularly in minority populations - which are strongly linked to lack of first trimester pre-natal care. These unhealthy behaviors lead to higher rates of chronic diseases such as heart disease, chronic obstructive pulmonary disease, diabetes and hypertension. This high rate of chronic disease extends to mental illnesses. Oklahoma leads the nation in percent of population with serious and persistent mental illnesses. These unhealthy behaviors and chronic diseases lead to higher rates of acute episodes leading to early death. Oklahoma leads the nation in percent of population with cardiovascular disease. Stroke and cancer deaths are also high than national averages.

MENTAL HEALTH

HEART DISEASE

SERIOUS PSYCHOLOGICAL DISTRESS IN PAST YEAR PERSONS AGED 18 AND OLDER

CARDIOVASCULAR DEATH RATES 1999-2003

(L) There are 360 mental health-planning regions in the nation. Tulsa and Eastern Oklahoma are among the five worst (dark red). (R) Oklahoma has the highest (dark red) cardiovascular death rates in the U.S. Tulsa helps drive both rates.

Oklahoma is in the bottom 20% nationally in providing health care coverage for its citizens. As many as 1 in 4 Tulsans has no health care coverage. It is well documented that those without health care coverage rarely receive preventive and health maintenance clinical services as well as care of chronic illnesses. Those without health care coverage are more likely to be diagnosed late in the disease process of cardiovascular disease and cancer. The sum of these unhealthy behaviors, access to care difficulties for the uninsured and higher chronic disease rates is a set of startling statistics around age adjusted death rates. Beginning is 1990, Oklahoma’s age adjusted death began to diverge from the national trend and worsen. In 2007, Oklahoma is the only state that has experienced a worsening of the age adjusted death over the past 15 years.

19 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

AGE-ADJUSTED DEATH RATES A LOOK AT THE PAST 25 YEARS

1,050

1,000

Tulsa County

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

950

900

United States 850

800 1980

1985

1990

1995

2000

2005

AGE-ADJUSTED DEATH RATES RED IS WORST – GREEN IS BEST – WHITE/YELLOW IS AVERAGE

TULSA METROPOLITAN AREA

TULSA COUNTY

20 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

HEALTH DELIVERY SYSTEM The current health care delivery system is out of balance with a great emphasis on episodes of illness and high-end complex interventions. The system does not reimburse or only minimally encourages many aspects of proven preventive health care.

100,000 50,000

46,320

ER

31,199

Other Clinics

150,000

30,000 Primary 90,000 Specialty

37,300

Free Clinics

250,000

130,494

101,661

Major Clinics

300,000

200,000

Access to the right level of services at the right time continues to be a major problem within the Tulsa health care system. The Oklahoma State University College of Osteopathic Medicine has established a formal relationship with Ardent Health System to rename Tulsa Regional Medical Center as the Oklahoma State University Medical Center. It is unclear at this time what effect this relationship will have on increasing inpatient and advanced clinical service availability for the uninsured.

346,976

350,000 UNSERVED

It took almost 10 years after the release of major beneficial research findings for the use of beta blocker medications after myocardial infarctions to be broadly prescribed across the US.

THE UNINSURED IN THE TULSA REGION ESTIMATES OF OUTPATIENT CARE VISITS BY SITE

SERVED BY SAFETY NET

New medical findings that can raise the health of many at risk patients are very slow to be translated to general medical practice. It takes, on average 17 years, for a new chemotherapy agent to move from design to broad spectrum use.

0

The Lewin Report highlighted that inpatient services were not a critical shortage area for the uninsured in Tulsa. Over use of the emergency rooms for non-urgent services and for delayed care of complex clinical situations were the areas of greatest concern. It was estimated that the current health care delivery system was unable to accommodate 130,000 visits per year for the uninsured in the Tulsa region. Outpatient primary care visits were short by approximately 40,000 visits per year and advanced outpatient specialty services were short by approximately 90,000 visits per year. The priority recommendations from the Lewin Group Report was to increase primary care access through expansion of Federally Qualified Health Centers and the creation of advanced outpatient diagnostic and treatment centers (HealthPlexes) in geographic health care shortage areas – particularly north, east and west Tulsa. . Physician Supply Although the US has seen growth in the general population and there has been a dramatic increase in demand for health services as life expectancy increase and baby-boomers move into higher health utilization categories, US medical schools have not significantly increased the number of graduates per year. This has resulted in a drop of physicians per capita at a time when demand for services is increasing.

21 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

WORKFORCE IS AGING

First year MD school enrollment per 100,000 population has declined since 1980.

The physician workforce is aging 250,000 active physicians are over age 55.

NUMBER OF ENROLLEES (PER 100K)

8

7

7.3 6.8 6.4

6

6.2 5.8

5

5.6

5.4

5.2

5.0

4 1980

1990 2000 2010 PROJECTIONS

2020

NUMBER OF PHYSICIANS (THOUSANDS)

SCHOOL ENROLLMENTS DOWN

250

231

224

200

150

1985 2005

133

139

153

146

99

94

100

73 44

50

0 Under 35

35-44

45-54

55-64

65 and over

AGE OF PHYSICIANS

Source Both Charts: American Association of Medical Colleges

An additional factor is that there are many practicing physicians – particularly in the primary care specialties, that are nearing retirement. Recent studies predict a national shortage of physicians in the range of 200,000 by 2020. With medical school loan debts increasing, students are choosing specialties with higher earning potential and more predictable hours. The greatest increase in medical student choice of specialty has been in the surgical subspecialties, anesthesia, radiology, dermatology and emergency medicine. Primary care specialties have noted a dramatic drop in medical student specialty choice. The net result of these factors is that there will dramatic shortages in primary care and academic physician availability – particularly those willing to provide care for the poor. Oklahoma Physician Supply: Oklahoma already trails national averages in number of general practitioner and specialist physicians per 100,000 population: PHYSICIAN SUPPLY US

OK

TUL

GENERAL PRACTITIONER

113

88

72

SPECIALIST PHYSICIANS

168

117

138

OVERALL

281

205

210

As the demand for health care increases in Oklahoma, newly trained Oklahoma physicians will have many choices regarding site of practice, specialties and patient populations. For example, a growing number of physicians are choosing to create physician owned for-profit specialty hospitals. As physician supply shifts, there is great concern that specialties that are particularly important in providing cost efficient care to the poor such as family medicine, pediatrics, internal medicine, psychiatry and obstetrics will see further reductions in availability.

22 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

Community Impact of Poor Health Status and Health Delivery System Problems The impact of inadequate prevention programs and in sufficient access to health care goes beyond those without health care coverage. Over-utilization of Tulsa area emergency rooms for uninsured patient primary care and non-urgent care accounts for 35% of emergency room visits. This contributes to emergency room overcrowding and at times gridlock. When gridlock is reached, area emergency rooms must go on divert status until sufficient patients can be moved through. While on divert status, these emergency rooms are prohibited from accepting additional patients including trauma and critical care patients. The cost shift to those with insurance for the care of the uninsured is significant. Insured Oklahomans pay between $500 and $1,000 in additional cost per insurance premium per year for care of the uninsured. Oklahoma’s health insurance costs are 10th highest in the nation despite being a relatively low cost of living region. The poor overall health status of Oklahomans may also be a deterrent to new business locating in Oklahoma. Funding Shortfalls Oklahoma has a long history of underfunding health care. Oklahoma Medicaid has expanded coverage, benefits and reimbursement over the past five years. Although approximately 650,000 individuals are now covered by Oklahoma Medicaid, another approximately 650,000 have no health care coverage. The Bush administration’s primary strategy to extend care to the uninsured has been through expansion of Federally Qualified Health Centers which offer significant financial and clinical service advantages to those that qualify. Although Oklahoma has seen the addition of FQHCs, the state is still second to last in the nation in number of FQHCs per capita. Disproportionate Share (DSH) funds from the Federal government provide hospitals that provide a disproportionate share of the care to the poor additional financial assistance. Oklahoma is in the midst of a 5 year increase in DSH funds from approximately $25 million per year to $50 million. Despite this gain, Oklahoma receives one of the lowest rates of DSH in the nation. Louisiana, in comparison, receives $ 800 million per year in DSH funds. Through the University Hospital Authority and Trust, the University of Oklahoma Health Science Center receives additional State and Federal funds that are not matched to any significant degree in the Tulsa region.

23 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

BEST PRACTICES NATIONWIDE There are model prevention and healthcare delivery programs across the US that improve health outcomes to high risk populations at reasonable levels of financial investment. There are also model medical education programs that graduate physicians with skill and interest in serving the underserved. Common characteristics of these successful medical education and clinical service programs are services delivered in the community setting rather than the hospital setting and delivery models that are sensitive to cultural aspects and neighborhood differences. What has yet to be accomplished is a full integration of these proven clinical services, medical education and health outcomes research programs in a coordinated fashion with a long-term commitment to improving the health of an entire region. Below is an overview of prevention, direct service and medical education programs that have proven to be highly effective and cost efficient methods of improving the health of high risk populations. PREVENTION MEASURES There are hosts of well intended prevention programs that have yet to show significant risk reduction in the intended target populations e.g. suicide “hotlines” do not reduce suicide rates. On the other hand – there are several prevention interventions that have shown long term benefits in several different settings that could have a direct influence on the Tulsa region’s health status. These include: 

Infant Mortality – the strongest predictor of infant mortality is premature birth. The strongest predictor of premature birth is lack of access to early prenatal care. Nurse outreach programs that bring early prenatal care to underserved pregnant women through community outreach efforts reduces infant mortality.



Cancer – Prevention of cancer through vaccination is now available. The Human Papilloma Virus vaccine reduces the risk of cervical cancer when offered to adolescents The vaccine is expensive and not available to many of the underserved. Early detection of treatable cancers through screening programs can significantly reduce morbidity and mortality. Funding programs for the poor provide mammography and treatment of breast cancers. Funding for treatment of cervical cancer is available but not for the screening to detect early cervical cancer through PAP smears. Although the second most common cancer in the US is colon cancer, no funds are available for the early detection through colonoscopies.



Heart Disease is the leading cause of death in Oklahoma. The use of antihypertensive, cholesterol lowering statins and aspirin in high risk individuals has been shown to significantly reduce the risk of myocardial infarction.



Type II Diabetes – Obesity in children and adolescents is the strongest predictor for the development of Type II Diabetes. Cherokee Nation and North Tulsa Basket of Dreams exercise programs for at risk individuals have shown significant weight reduction and lowering of Hemoglobin H1C (blood marker of severity of diabetes).

24 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007



Tobacco - Prevention or cessation of tobacco use is the most modifiable behavior to reduce overall cancer and heart disease risk. Tobacco Settlement Endowment Trust funds are now available for application to smoking cessation programs.

DIRECT SERVICES Networks of community based and outreach clinical services are mainstays of the successful community health improvement initiatives at Denver Health – University of Colorado, Montefiore-Albert Einstein in the Bronx and Parkland-University of Texas Southwestern in Dallas. The Dallas based network of services is mapped below: PARKLAND HEALTH SYSTEM (DALLAS)

PARKLAND HEALTH SYSTEM (DALLAS)

8 FAMILY HEALTH CENTERS

10 YOUTH AND FAMILY CENTERS DFW AIRPORT

DFW AIRPORT

MAPS ARE OF DALLAS (TX) METROPLEX 

Outcomes from Parkland’s Community Oriented Primary Care Network of Primary Care Outreach and School Based Clinics – Relying heavily on nurse practitioners, physician assistants and family medicine trained physicians for staffing, these clinics provide culturally sensitive primary care services in neighborhoods of need. The school based clinics have reduced Medicaid expenditures, emergency room use and hospitalization rates for acute asthma. Overall, these services have been able to reduce the demand for more expensive emergency room care. See “annual visits” chart below: 1,200,000 PARKLAND HEALTH SYSTEM (DALLAS)

ANNUAL PATIENT VISITS 1,000,000

800,000

COMMUNITY CLINICS 600,000

400,000

PARKLAND CLINICS

PARKLAND CLINICS Over the past 15 years, Parkland’s Outreach Clinics have been the primary source of expanded health services to the Dallas Region’s poor.

200,000

EMERGENCY ROOM 0 1980

1985

1990

1995

2000

2004

25 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007



Mobile Psychiatric Services/PACT – Programs of Assertive Community Treatment Teams (PACTs) provide a mobile team of mental health professionals providing daily psychiatric and rehabilitative care to patients with severe mental illnesses. PACT programs are now a significant part of the mental health care delivery system in Wisconsin, Iowa, Michigan and Rhode Island In these states, PACTs have been shown to be quite effective in reducing hospitalization rates, incarceration rates, overall cost of care and severity of psychiatric symptoms Comparison of Hospitalization and Incarceration Rates Patients with Severe Mental Illness Before and After Participation in PACT Program. Initial Data from First 50 Patients in OU PACT Program. MEASURE

PRE-PACT

POST-PACT

Hospitalization Days

2,898 Days

671 Days

Incarceration Days



1,196

535 Days

Linking Primary Care with Specialists Through Telemedicine – Advances in telemedicine technology has allowed for telemedicine services to go beyond simple interactions with patients and physicians. Digital camera technologies allow for high resolution skin and inner ear examinations. Digital audio-devices such as digital echocardiograms and digital stethoscopes allow for in-depth evaluation of the heart. With the growing shortage in physicians, the need to rely upon nurse practitioners and physicians assistant for basic care is apparent. These clinicians will need ready access to specialists when complex patient scenarios are presented. These advances in digital diagnostic testing provide an opportunity to link primary care clinicians in outreach clinics with specialists at advanced outpatient clinics and at academic health centers. Texas Tech University has the most extensive network of telemedicine services linking specialists with primary care clinicians and has seen significant reductions in the need for face to face visits with specialists.



Days

Outpatient Perinatal Centers Additional risk factors for infant mortality. Particularly in the Tulsa region include a lack of coordination between outreach workers and obstetrics physicians, inadequate access to an integrated team of obstetrical clinicians – including midwives, obstetrics trained family medicine physicians, general obstetricians and maternal fetal medicine / high risk obstetricians. Within the Parkland system, community based Perinatal Centers serve as a hub for prenatal outreach workers as well as obstetrical clinicians. This model – linking outreach worker and medical

PARKLAND HEALTH SYSTEM (DALLAS)

COMPARATIVE INFANT MORTALITY 9.3

U. S. (2000) Texas (2001) Parkland (1999-01) 7.2

5.6 4.4 3.8 3.7

White

3.7

Black

3.3 3.2

Hispanic

Infant Mortality Rates per 100,000 Deliveries: Comparing Parkland’s 1) Outreach, 2) Community Oriented Primary Care and 3) Perinatal Outpatient Centers approach to Obstetrics care compared with standard obstetrics care (Tulsa currently at 8.1 deaths / 100,000 deliveries)

26 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

specialist in the community based setting has reduced infant mortality dramatically in the Dallas region. The accompanying chart (next page) shows Parkland’s infant mortality rate by race compared to that for the state of Texas and the United States. The Oklahoma rate for all births is 8.1. 

Advanced Outpatient Clinics/HealthPlexes – The demand for health services will continue to increase as the “baby boomer” generation ages. With the construction of new hospitals costing more than $1 million per bed, new models of health care delivery services need to be developed that fill the gap between hospital care and the primary care setting. Parkland / Dallas and Montefiore/the Bronx have developed advanced outpatient clinics, located in geographically underserved areas. St. Louis, Kansas City and Las Vegas are developing similar facilities. The Lewin Report recommended that Tulsa begin with two advanced outpatient clinics (HealthPlexes) in geographically underserved areas.

HEALTHPLEXES AND THE CONTINUUM OF HEALTH SERVICES HealthPlexes offer advanced outpatient services such as 24 hour urgent care, observation units, endoscopy, chemotherapy, cardiac evaluations, outpatient surgery, diabetes care and mental health care,

CONTINUUM OF HEALTH SERVICES

Prenatal Care Live Birth

Primary Disease Prevention

Health Promotion

Treatment of Acute Disease

Diagnosis of Disease

PRIMARY CARE PHYSICIAN OFFICE

Tertiary Disease Prevention

Secondary Disease Prevention

Rehabilitative Care

Treatment of Chronic Illness

HEALTHPLEX

Palliative Care

Long Term Care

End of Life

HOSPITALS & INSTITUTIONS

27 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007



Pharmacy Assistance Programs – As learned from the Bedlam After-hours Clinic initial pilot, access to physician diagnostic skills alone is insufficient to improve the health of the uninsured. Diagnosed illnesses need treatment – usually through pharmacological intervention. There are numerous forms of pharmacy assistance programs that attempt to provide a broad array of medications to the poor: -

Compassionate drug programs where eligible patients receive medications directly from pharmaceutical companies. This requires an application process often requiring the assistance of a social worker or a pharmacist.

-

On-line software network services that streamline the link between patients / clinics and the above described corporate pharmaceutical programs.

-

Corporate pharmacy discount programs such as Wal-Mart where a limited generic formulary has been developed with medications offered at a significant discount ($4 per prescription).

-

Local pharmacy discount programs such as through Bedlam where a group of local pharmacies have developed a generic formulary with medications offered at a significant ($5 per prescription with a sliding scale to zero when necessary).

-

Federally Qualified Health Center 340B pharmacies where FQHC eligible patients receive medications at roughly a 40% discount.

-

Unused medication programs that “recycle” medications, often from nursing homes.

SAFETY

TOLERABILITY

EFFICACY

PRICE

What has not yet happened is a merging of these above described programs to create an efficient and cost effective integrated pharmacy system for the poor. However – should the Chapman Trust/St. John Medical Center fund proposed programs, there will be the structure for more coordinated pharmacy care for the needy.

28 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

COMMUNITY HEALTH/MEDICAL EDUCATION TRACKS Ernest Boyer’s landmark 1990 report Scholarship Reconsidered, highlighted the need for universities to become intimately involved in the needs of society and communities: … ”the scholarship engagement means connecting the rich resources of the university to our most pressing social, civic and ethical problems, to our children, to our schools, to our teachers and to our cities…I have this growing conviction that what’s needed is not just more programs, but a larger purpose, a sense of mission, a larger clarity of direction in the nation’s life as we move toward century twenty one”. The Institute of Medicine’s 2002 Report Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century made strong recommendations to academic institutions to develop criteria for recognizing and rewarding faculty scholarship related to service activities that strengthen public health practice. In addition, the Report urged the National Institutes of Health to increase the proportion of its budget allocated to population and community-based prevention research. There is evidence that medical student backgrounds and experiences shape their career choices. Medical students from underserved areas are more likely to seek medical careers serving the underserved. UCLA - Drew Medical School in inner city Los Angeles has been able to demonstrate that medical students exposed to high quality clinical experiences in underserved areas are more likely to establish careers serving the poor. Several high profile universities have declared that stewardship, service learning and community involvement are now major components of their student experiences and the clinical services offered through their health science programs. Institutions that have had an impact on improving community health have done so with the following common characteristics:

1. 2. 3. 4.

Long-term commitment Long-term planning Diverse sources of funding Infrastructure for the measurement of community needs & outcomes of initiatives.

29 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

Below is a list of university-based initiatives around community and health sorted by level of stated commitment to community health: Schools of Community Medicine 

University of New South Wales School of Public Health and Community Medicine This is the only formally named “school of community medicine” found with an integrated medical and public health curriculum leading to a Bachelors and MD degree over a six year period. The service, research and medical education focus of the school is three fold: (1) preventing major public health problems, (2) improving health services and health systems and (3) health equity, social justice and diversity.



University of Washington School of Public Health and Community Medicine Although this university claims an effort towards community medicine, most programs appear to be focused on traditional public health research. There are no clinical services and no MD programs included in this school.



The University of Rochester. This award winning medical school has an explicit mission to make Rochester the “healthiest city in the world”. The school has numerous community based clinical programs, school based clinics, Federally Qualified Health Centers, neighborhood revitalization programs, medical students tutoring in disadvantaged schools and over $40 million annually in community health related research from the Federal Government. Medical school leaders at the University of Rochester readily admit that their clinic and hospital system is designed as an academic health center and that the community based components are a relatively small part of the overall operation.

Institutes for Community Medicine 

Albert Einstein College of Medicine Institute for Community and Collaborative Health – Several centers and programs come under this institute. The institute’s mission is to improve the health of the Bronx and other communities served by the clinical affiliates of Albert Einstein College of Medicine through research, education, service and collaborative partnerships with these communities. As many as 60% of this program’s medical school graduates choose careers caring for the underserved. Montefiore Hospital System plays a major partnership role in this program.

Departments of Community Medicine Each of the below has a Department within their Colleges of Medicine that declare commitment to community health initiatives. Each has special medical student education tracks and resident physician fellowships that focus on community health.     

Mount Sinai School of Medicine – Department of Community and Preventive Medicine. West Virginia University Department of Community Medicine Eastern Virginia Department of Family and Community Medicine University of California San Francisco Department of Family and Community Medicine University of Texas – Southwestern in Dallas sponsors a Community Action Research Track for medical students which introduces them to the needs of the underserved and how to implement initiatives to improve health of the underserved. 30 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

Divisions of Community Medicine The following have declared a commitment to community health through the creation of a division of community health within the Department of Family Medicine. 

Division of Community Health within the Department of Family Medicine, Duke University College of Medicine.

University-wide Offices for Community Programs Several universities have created central offices dedicated to improvement of the community using academic – community partnerships.     

Harvard Office for Diversity and Community Partnerships Penn Center for Community Partnerships University of Rochester Community Health Program University of Tulsa Center for Community Research and Development University of Oklahoma - Tulsa Center for Outreach, Research and Education (CORE)

Affiliate Models The two programs below bring together a large public hospital and clinic system, dedicated to serving the underserved, with a medical school. The medical school in these examples does not explicitly commit to serving the poor but instead provides physicians in a clinical service role.  

Parkland Health System – Dallas and University of Texas Southwestern Denver Health and University of Colorado.

Creative Financing The above described Best Clinical Practices and Community Focused Medical Schools have developed a diverse set of funding streams to support their education and service programs. All have dedicated resources, staff and Offices with the primary responsibility of acquiring funds to power these programs. Many take advantage of the following Private, Federal and State programs. 

Federally Qualified Health Centers (FQHC) provide distinct advantages for clinics providing care to the poor including: o o o o o

Reimbursement at twice the usual rates for Medicare and Medicaid. Block grants for care of the uninsured of $ 650,000/year. 40% pharmacy discount. Federal Tort Claims Malpractice Protection Medical school loan repayment of $160,000 for clinic physicians.

Note - OK still ranks 49th in the nation in Federally Qualified Health Centers per capita. •

Disproportionate Share Federal (DSH) Funds - are funds to support hospitals caring for a high percentage of indigent patients. Oklahoma is among the lowest in the nation in DSH funds. Oklahoma DSH will be increasing from $35 million annually to $50 million over the next 2 years. In addition, new DSH funds totaling more than $2 billion annually may become available for innovative programs, such as the HealthPlexes, that offer many hospital based services to the poor in an outpatient setting.

31 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007



The National Institutes of Health (NIH) – The annual NIH budget is in excess of $28,000,000,000. With the implementation of the NIH’s Research Roadmap, there has been greater attention to research efforts focused on high-risk patient groups and health interventions for larger populations. Several of the future pilot initiatives of the School of Community Medicine could qualify for NIH support in the following areas: NIH Category Health Disparities Health Services Homelessness Infant Mortality Minority Health Women’s Health

2008 NIH Funding $2,700,000,000 $900,000,000 $22,000,000 $474,000,000 $2,400,000,000 $3,500,000,000

The US Centers for Disease Control have recently initiated large grant programs focused on 

New Medicare and Medicaid Graduate Medical Education (GME) and Indirect Medical Education (IME) Funds – The College of Medicine, Tulsa receives $16.5 million in GME and IME funds. The Tulsa Medical Education Foundation hospitals receive $ 19 million in GME and IME funds and spend $13 million on OU Resident programs. GME and IME funds are the primary sources of funds for support of resident physician training and associated medial care. Currently, Oklahoma medical education programs have reached their “cap” regarding GME and IME funds. As the physician shortage in the US intensifies, it is expected that additional GME and IME funds will be made available to expand medical education efforts.



State Funding – The College of Medicine, Tulsa receives approximately $9 million per year in State funds. Infrequently, the College of Medicine, Tulsa has received additional distributions from the University Hospital Trust.



National Foundations - Several major national foundations have dedicate significant grant funds to programs in line with the goals of the School of Community Medicine. The Robert Wood Johnson Foundation currently has grant programs for: The uninsured; Vulnerable populations; Community change and Health disparities.

Best Practice Tracking Systems / Outcomes – The above model health system / medical schools dedicated to improving community health have developed extensive needs assessment, outcomes measurement and research infrastructure. The needs assessment functions allows for accurate planning of prevention programs and direct clinical services. The outcomes function allows for quality improvement efforts and redesign of prevention programs and direct clinical services. Both needs assessment and outcomes measurement support successful public and private grant acquisition. For example, the CHIMES (Community Health Improvement, Measurement and Evaluation System) allows Parkland leadership to track success of particular interventions. This objective data is then used to advocate for additional private, local, State and Federal funds. Clinical practices that have been able to establish electronic medical records have new capacities to measure outcomes on a much broader basis.

32 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

THE CENTRAL AND ENDURING ROLE OF THE UNIVERSITY There are 85 institutions in the world that exist as they did 500 years ago. They include the English Parliament, the Papacy, eight Swiss cantons – and of the 75 remaining, 70 are universities. Universities have survived because of the broad recognition of the central role they play in preparing the next generation for work that advances our society. With that recognition, has come significant public and private investment.

OU TULSA: THE BEST PLATFORM Positioned to Lead the Health Improvement of Tulsa

OU-Tulsa, with its capacity to educate and influence the next generation of area clinicians – including physicians, nurses, pharmacists, occupational therapists, physical therapists, social workers and public health officers is the natural choice for investment in improving our health care delivery system. OU-Tulsa provides the bulk of inpatient and outpatient uninsured care in the northeast Oklahoma region using a network of 40 clinical sites across the region. Last year OU-Tulsa physicians provided medical care for more than 250,000 clinic/office visits. The annual budget for the OU College of Medicine, Tulsa is $80 million. In 2006, OU-Tulsa clinics provided more than $16 million in uncompensated care. OU-Tulsa has some ability to track the outcomes of interventions through research infrastructure and the ability to access new private, State and Federal funds. OU-Tulsa and Oklahoma Physician Supply. The University of Oklahoma College of Medicine Tulsa plays the major role in supplying physicians to the Tulsa area. Over the past 35 years, over 2,300 medical students and resident physicians have been trained at this College with approximately 70% choosing to practice in Oklahoma and 55% in northeast Oklahoma. Despite not offering a full set of residency options, the College of Medicine, Tulsa has trained 50% of the Tulsa area’s practicing physicians.

ALUMNI PRACTICING IN OKLAHOMA OU COLLEGE OF MEDICINE-TULSA GRADUATES

LEGEND: WHITE-NONE; LIGHT-AT LEAST FOUR; MEDIUM: 5-50; DARK-OVER 50 THERE ARE 779 GRADUATES IN TULSA COUNTY AND 123 IN OKLAHOMA COUNTY

33 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

THE PROPOSED PARTNERSHIP Basic Building Blocks of a Formal Partnership with the George Kaiser Family Foundation

To summarize the previous sections: •

We already know what is wrong with health status and the health care delivery system of this region - thus no more studies are necessary for us to begin our improvement efforts.



We know of proven best practices to remedy these problems – thus no further studies are needed to begin our improvement efforts.



We have a committed university (OU-Tulsa) that is willing to focus its resources to improve health.



We have major foundations with capacity and core values that are aligned with OUTulsa.



Significant work will need to be done which will take significant time, perhaps up to 15 years.



Although medical schools receive significant public funds, are responsible for training the next generation of physicians, are the primary source of medical research in the US and the lead providers of care to the poor, few medical schools in US have declared improving health as their mission.



No medical school in US has declared itself a “School of Community Medicine” integrating medical education, services and research around improvement in the health of the community.

It is time to move the relationship of these organizations to a formal level through long-term commitments and joint plans through the creation of a School of Community Medicine. To accelerate efforts to improve the health of the Tulsa region, the following Ten Articles for the Partnership to Improve Health are proposed:

34 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

Ten Articles for the Partnership to Improve Health 1. Declaration by GKFF and OU of a commitment to the health of the entire community through renaming of the College of Medicine, Tulsa as the School of Community Medicine. The Chapman Trust and the University of Tulsa may also be considered for this partnership. 2. The School of Community Medicine becomes a planning, organizing and coordinating unit for initiatives to improve the regional health status. 3. Declaration of a focusing of OU academic efforts (teaching, research and service) to improve health of Tulsa region. 4. The Kaiser name would used prominently as it is respected throughout the world. The use of the Kaiser name and renamed School of Community Medicine would herald a new version of an American medical school. 5. Develop a Joint Operating Agreement – OU promises a long-term dedication to the partnership, will focus resources to help improve community health status and commits to increase State and Federal annual funds to Tulsa region. The George Kaiser Family Foundation promises a long-term dedication to the partnership, would bring financial, planning, critique and lobby expertise to the partnership. 6. Each year, GKFF funds could be used to seed prevention, clinical service, medical education and research / outcome projects that improve the health of the region. Through a yearly Tactical Plan, individual projects and funding levels would be jointly agreed upon by OU-Tulsa and GKFF and would fit into the long-term Strategic Plan. 7. A Health Advisory Council would be created to make recommendations to the George Kaiser Family Foundation Board. Dr. Steven Landgarten would initially chair this Council. Additional Council members would include Ken Levit, Monica Basu, Mike Lapolla and Drs. Gerard Clancy, David Adelson, William Geffen, F. Daniel Duffy and Peter Budetti. 8. There would be quarterly updates on the progress of these projects to the GKFF Board. 9. Beyond directly improving the health of the Tulsa region, these private funds would be used to bring additional public and private funds to these health initiatives. 10. The School of Community Medicine pilot would serve as a role model for other communities and medical schools with the same goals of improving the health of their community.

35 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

WHY NOW FOR THIS PARTNERSHIP? The timing for this proposed partnership is very good. The opportunities to leverage public and private activities around prevention, direct clinical services, clinician manpower and funding are great. 

OU-Tulsa now has a critical mass of faculty and services to lead this major effort. This is part of a deliberate plan over the past 5 years to advance the College through 5 phases: (1) Add faculty to reach a critical mass of clinical physicians. (2) Improve the quality of facilities to assist in the expansion of services and recruitment of resident and faculty physicians. (3) Expand services to the poor to signify to community and state leaders the commitment of the College to leading the effort to solve some of Tulsa’s most pressing problems and to be able to justify additional public and private investments in OU-Tulsa. (4) Increase the quality of clinical services offered through seeking Joint Commission on the Accreditation of Health Care Organizations new physician group ambulatory accreditation standards. This demonstrates that large physician groups can offer care to all in need and provide the highest quality care in the region. (5) Creation of a distinct identity for the College of Medicine, Tulsa with an opportunity to play a role as a national leader in community medicine.



Other OU-Tulsa health science and graduate school programs have bought into community engagement as a defining role for OU-Tulsa within the broader University of Oklahoma system.



The University of Oklahoma College of Medicine, Tulsa is in the initial phases of the recruitment of four new Clinical Department Chairmen. These chairs will play a key role in implementing the 15-year Strategic Plan.



President Boren and OU Board of Regent leaders from Tulsa are supportive of this initiative.



GKFF is in ramping up phases of long-term investments in key areas.



Additional private foundations are investing to significant degrees in complementary programs at OU-Tulsa. This includes the Schusterman, Oxley, Morningside, Zarrow, Warren, Ida McFarlin, St, John and HA Chapman Foundations and Trusts.



The State Legislature will most likely pass Senate Bill 903 that will create a task force to study future physician manpower needs for Oklahoma. If this study demonstrates the need for the expansion of medical education programs in Oklahoma, a State Bond (HERO Bonds) issue could be proposed in 2008 to fund this medical education expansion.



Tulsa area hospital board members have voiced frustrations with physician groups building facilities that compete for commercially covered patients. Board members realize the stability and commitment of OU - which provides care to broad groups of patients and is the leading provider of future physicians

36 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

THE FIRST FIVE YEARS Initial Prevention, Clinical Service, Medical Education and Funding Projects:

There are many health associated needs in the Tulsa region – probably too many to list and certainly too many to take on immediately. Using the numerous studies on the Tulsa region, categories with the highest need and with the potential for greatest impact are identified below. Many of these projects will need to be confined to a high risk zip code to demonstrate the impact of the intervention – e.g. the myocardial infarction prevention initiative and 74126 zip code. It is proposed that these will be the initial focus areas for the proposed partnership of OU-Tulsa and the George Kaiser Family Foundation: PREVENTION: FIVE PROJECTS Goals: Expand Pre-natal Care Outreach, Increase Access to HPV Vaccine through Outreach, Establish Access to Colonoscopy through Outreach, Reduce Risk of Myocardial Infarction through Medication Outreach, Obesity Reduction in High Risk Pre-adolescents Utilizing School-based Clinics and North Tulsa Obesity Prevention Program. 

Prenatal Outreach – Outreach nurses would target high risk zip codes in the Tulsa region and case find women early in pregnancy, initiate prenatal care and link the patient to an established network of obstetrical clinicians. Project led by OU Department of Family Medicine and OU Department of Obstetrics and Gynecology.



Myocardial Infarction Prevention Through Medication Outreach - Patients at risk of myocardial infarction would be aggressively recruited through outreach case managers. Patients would be placed on statins, aspirin and anti-hypertensive medications and carefully monitored for compliance. Project led by the OU College of Public Health.



Cancer Prevention Interventions – Breast, Colon, and Cervical cancers are high in prevalence, have available screening capacities and when identified early, each of these cancers are very treatable. In the Tulsa region, there are adequate services available for breast and cervical cancer screening and treatment. o

Cervical Cancer Prevention - Human Papilloma Virus (HPV) is a major risk factor for cervical cancer. The newly developed HPV vaccine, when administered to adolescent girls, is highly effective at reducing cervical cancer rates. Unfortunately the availability of HPV vaccine for the underserved is very limited. It is proposed that an outreach pilot program be established that aims to demonstrate the benefits of HPV vaccine to at-risk underserved adolescents. Project led by the OU Departments of Pediatrics and Family Medicine.

o

Colon Cancer Prevention - Although colon cancer is the second leading cause of cancer death and colonoscopy for higher risk patients provides an excellent screening for early lesions, no programs are in place to provide colonoscopy services for at risk underserved individuals. It is proposed that the primary clinics in north east and west Tulsa would be able to refer at-risk individuals for colon cancer screening. Project led by the OU Department of Surgery and OU Department of Internal Medicine.

37 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007



Diabetes Prevention - The north Tulsa based Basket of Dreams program would identify at risk for diabetes obese 11- 14 year olds. Utilizing health education and team based physical activities, children would learn life skills to reduce their risk of diabetes. Utilizing the network of OU school-based clinics, public school teachers would team with OU clinicians to reduce risk and complications of their students. Project led by OU / Oklahoma Diabetes Center.

CLINICAL SERVICES: FOUR NEW APPROACHES Goals: Expand Primary Services in Underserved Areas, Increase Underserved Access to Obstetrical Clinicians, Increase Underserved Access to Low Cost Medications, Increase Access to Advanced Outpatient Care for the Underserved.

A PYRAMID OF HEALTH PROGRAMS School of Community Medicine Clinical Service Framework

Advanced Outpatient Care - HealthPlex HP

Provides advanced outpatient services such as 24 hour urgent care, observation units, endoscopy, chemotherapy, cardiac evaluations, outpatient surgery, diabetes care and mental health care.

Outpatient Specialty Services CLINICS

OU Perinatal Center and High Risk OB Clinics, OU Diabetes Center, OU Cancer Center, OU Surgery Clinics, OU GI Clinics, OU Dermatology Clinics, OU Psychiatry Clinics, Family and Children’s Services, OU Mobile Psychiatric Services (PACT Team)

STEP Pharmacy STEP PHARMACY

Using generic formularies, discount drug plans and e-based links to pharmaceutical corporations, provides low cost medications to the underserved.

Community Oriented Primary Care Clinics PRIMARY CARE SERVICES

PRIMARY PREVENTION INITIATIVES

OU Pediatrics Clinics, OU Internal Medicine Clinics, OU Family Medicine Clinics, OU Bedlam Clinics, OU Schoolbased Clinics, OU Mobile Clinics, , Morton Comprehensive Health Services Clinics, Community Health Connections, Neighbor for Neighbor, Good Samaritan Health Services

Prevention Initiatives Prenatal Outreach, MI Prevention, HPV Vaccine Program, Colonoscopy Outreach, Diabetes / Obesity Prevention



Community Oriented Primary Care – following the Community Oriented Primary Care model of Parkland Health in Dallas, additional primary care clinics, mobile clinics and school-based would be developed in underserved areas. These clinic would feed into the Advanced Outpatient Clinics / Health Plexes, the Perinatal Centers, OU Diabetes Center and OU Cancer Center through referral or telemedicine.



Perinatal Center – There are numerous case management, social service and nursing programs designed to extend care and social services to pregnant women. The extremely low rate of early prenatal care in African American and Hispanic women in the Tulsa region demonstrates a failure of the current outreach system. There is a shortage of obstetrical clinicians able to provide medical care to these pregnant women. There is 38 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

a severe shortage of maternal fetal medicine obstetricians able to provide care to women with high risk pregnancies. A Perinatal Center is proposed that brings together prenatal outreach services, social services with a spectrum of clinicians including midwives, Family Medicine physicians with obstetrics training, Obstetricians and Maternal fetal Medicine specialists. 

STEP Pharmacy - Funded by the St. John Foundation, the STEP (Safety, Tolerability, Efficacy, Price) Pharmacy will integrate generic formularies, discount drug programs, creative sampling and e-links to pharmaceutical corporations to provide an expanded level of access to prescription medications for the underserved.



Advanced Outpatient Services – The Lewin Report recommended the development of advanced outpatient services in geographically underserved area. The North Tulsa HealthPlex / JLHO is planned for 36th Street North and Hartford. Services planned include advanced outpatient services such as 24 hour urgent care, observation units, endoscopy, chemotherapy, cardiac evaluations, outpatient surgery, diabetes care and mental health care. The OU Diabetes Center, OU Cancer Institute and the Perinatal Center would be closely aligned with this HealthPlex.

MEDICAL EDUCATION: FIVE PROGRAMS Goals: Increase the number of clinicians with interest and skill in providing care to the underserved of the Tulsa region. Cost effective strategies to increase the number of clinicians with skills and interest in caring for the poor include expanding physician education programs and graduate education programs for Physician Assistants, Nurse Practitioners and Midwives. Rather than creating new basic science education programs at OU-Tulsa, partnering with the University of Tulsa, with their established basic science programs, provides another cost effective strategy to expand available clinicians. 

Expand Non- Physician Health Graduate Education Programs at OU-Tulsa– A 30 month Physician’s Assistant program will start at OU-Tulsa in 2008 and graduate 24 practitioners per year. This program is inadequately funded at this time. The OU graduate program for nurse practitioners has far more qualified applicants than slots for students. A key shortage area is nurse educators for the program. There are 43 Nurse Mid-wife education programs across the US but none in Oklahoma. Oklahomans interested in training as a nurse mid-wife must train through distance education programs or travel out of state with Kansas City having the nearest program.



Medical Student Grant Programs – With average Oklahoma medical student debt more than $110,000, our students are choosing medical specialties based on earning potential. Several Federal and State Programs (National Health Service, FQHCs, US Military) provide student loan relief and stipends in exchange for several years of service. Continued work to qualify as many of the OU Clinics as possible as FQHCs will continue. An additional opportunity exists for private funds to be matched with Oklahoma Physician Manpower Training Commission (PMTC) funds for loan repayment in exchange for service in caring for the underserved. To retain these physicians once their obligation to the loan payment program is complete, these physicians should be employed by the OU School of Community Medicine from the start.

39 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007



Residency and Fellowship Program Expansion – Emergency Medicine was added this year as a new residency training program at OU-Tulsa. If funding becomes available through Federal GME funds or through the proposed Oklahoma’s HERO bonds, residency programs expansion in Tulsa would focus on child psychiatry, cardiology, oncology and endocrinology (diabetes) training as priority areas.



Faculty Development Programs – The creation of the School of Community Medicine offers an opportunity to recruit ant retain talented physicians to care for the underserved and train other physicians to do so. A Kaiser / Chapman Fellows program is proposed to recruit young faculty for careers in community medicine. Funding would be used for recruitment, start up packages and protecting some time for community-based research. A Kaiser / Chapman Scholars program is proposed for more established faculty with funds used to establish endowed chairs in community medicine. Design of these programs would be such that designation as a Kaiser / Chapman Fellow or Scholar would be seen as a significant accomplishment.



Medical Student Program Expansion – If a need for medical student class to increase, the School of Community Medicine could partner with the University of Tulsa to create a full 4 year allopathic medical school program.

QUALITY IMPROVEMENT Goal: Expand the region’s community health research capacity and develop an information technology infrastructure that facilitates predictive modeling of disease rates and impact, needs assessments, quality improvement, disease registries, efficiencies in care and measurement of outcomes of School of Community Medicine interventions. Accurate measurement of community needs and the impact of particular interventions is a key factor in assessing the best use of available clinical manpower and health care funds. In addition, pilot interventions that are grounded in solid outcomes measurement stand a much better chance of receiving additional grant support and recurring public funds. Led by Michael Lapolla and supported by the George Kaiser Family Foundation, the University of Oklahoma, Tulsa has established the OU-CHAMP (Community Health Assessment, Measurement and Policy) program. Studies to assess health status by zip code, physician distribution, and clinical service gaps performed through CHAMP have been very useful in the initial efforts to provide the right level of clinical services in the right areas of the region to improve health services to the poor. There is much more that can be accomplished through monitoring and measurement using newly available information technologies. By the summer of 2007, OU-Tulsa will have fully implemented an electronic medical record network across the roughly 40 OU clinical sites. Beyond increasing the accuracy and portability of individual patient records, electronic medical records allow for the development of specific disease data-bases (disease registries). The impact of specific prevention and clinical service interventions with thousands of patients can be easily measured. With 75% of this implementation already completed across the OU Clinics network, disease registries for clinical depression, diabetes and children’s asthma have been developed.

40 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

Oklahoma native Dr. David Kendrick is currently working with Dr. David Eddy in San Francisco as part of the Archimedes project. Archimedes is a spin-off project from Kaiser Permanente HMO that has developed a predictive modeling or “health system war game” to predict the resource use, morbidity and mortality impact of a particular disease over time for a specific community. Dr. Kendrick has strong interest in joining OU-Tulsa as part of a soon to be developed Medical Informatics Department. As the breadth and depth of prevention, clinical service and medical education programs expand through the School of Community Medicine, a strong measurement and monitoring research / outcomes arm needs to be developed through the creation of an OU Medical Informatics Department. INCREASE PUBLIC/PRIVATE FUNDS Goal: Increase One-time and Recurring Health Care, Research and Medical Education Funding through the Creation of a Grants and Financing Development Office within the School of Community Medicine. An initial $75,000 GKFF investment through OU-Tulsa for an FQHC development officer resulted in new public and private grants to OU-Tulsa totaling more than $400,000. As stated in earlier sections of this report, there are numerous public and private funds that are available for prevention, clinical services, research and medical education. It is proposed that a full staff of grant writers and administrators be hired to create a Grants and Financing Development Office. The primary purpose of this Office would be to acquire new public and private funds to assist in the financing of the long-term strategic aims of the School of Community Medicine.

41 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

THE NEXT 12 MONTHS: 7 THINGS TO DO As stated earlier, there are many efforts converging in the next 12 months that make the possibility of the School of Community Medicine a distinct possibility. If the concept of renaming and repurposing the University of Oklahoma College of Medicine, Tulsa to the School of Community Medicine is endorsed by the George Kaiser Family Foundation, there is much work that needs to be done in a short amount of time. REGENTS APPROVAL

SITE VISITS

ECG CONSULT

CREATE INFRASTRUCTURE

ADVISORY COUNCIL

PLAN INSTITUTE

UNIVERITY OF TULSA

1. OU Board of Regents Approval The University of Oklahoma College of Medicine, Tulsa was established in 1972. A change in name and a focusing of purpose of this nature would require full discussion and approval by the OU Board of Regents. The OU Board of Regents has an extended meeting each year in June where each campus is allowed several hours to discuss major projects for the upcoming year. This would be an ideal time to propose such a change. 2. ECG Consultation The Seattle based ECG Consulting firm has begun its initial work on the OU College of Medicine, Tulsa Five Year Strategic Plan. ECG will soon need direction on whether the School of Community Medicine is a viable concept. If the School of Community Medicine does receive endorsement by the OU Board of Regents and the George Kaiser Family Foundation, ECG will be tasked with developing a plan for “how” the Flattening Tulsa II Plan should be carried out. This would include timelines, yearly goals, Gant charts and budgets for each initiative. ECG will also be tasked with assisting the School of Community Medicine in the development of a viable professional practice plan for the OU Physicians group. 3. Site Visits to Parkland Health System (Dallas), Albert Einstein School of Medicine and Denver Health In looking at medical school based Best Practices for improving the health of a community, programs in Dallas, the Bronx and Denver appear to have programs and structures that the School of Medicine could continue to learn from. Contacts have been established with each school and site visits to these programs is planned later in 2007. Prenatal and Perinatal programs would be a focus area. 4. Creation of the George Kaiser Family Foundation Health Advisory Council This group would make recommendations regarding health programs to the George Kaiser Family Foundation Board. This Council would be initially chaired by Dr. Landgarten. Additional Council members would include Ken Levit, Monica Basu, Michael Lapolla and Drs. Clancy, Adelson, Upham, Geffen, Duffy and Budetti.

42 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

5. School of Community Medicine Infrastructure The existing OU College of Medicine, Tulsa administrative infrastructure is currently not at the necessary level of size and sophistication needed to successfully carry out the goals of this proposal. Working closely with ECG Consultants, a redesign of the medical school’s infrastructure would be initiated. 6. Begin discussions with the University of Tulsa A pilot program with the University of Tulsa and OU-Tulsa to create a joint Physician Assistant program in Tulsa is progressing nicely. In addition, the University of Tulsa, the Oklahoma Medical Research Foundation, the Warren Medical Research Institute and the OU-Tulsa have come together to create a consortia around neuroscience themed research. There appears to be a common set of values and common areas of interest between the University of Tulsa and OU-Tulsa. As the School of Community Medicine initiative begins, there may be an increasing role for partnerships with the University of Tulsa. 7. Begin discussions for the creation of a companion Institute for Community Health. This would allow other OU-Tulsa programs (outside of the College of Medicine, Tulsa) and community agencies to participate in these health improvement efforts. Year One Priority Projects The George Kaiser Family Foundation has invested significantly in OU-Tulsa health and education programs over the past two years. Areas for additional priority consideration for 2007 are listed below: 

Prevention Funds have already been received for planning efforts and for pilot prevention projects around Colon Cancer Detection and Obesity / Diabetes Interventions. A $1.7 million proposal from the OU College of Public Health for Myocardial Infarction Risk Reduction through Medication Interventions is under study.



Direct Clinical Services Funding for expansion of the school-based clinics has been received. A pledge to support the construction of the north Tulsa HealthPlex has been received. Augmentation of prenatal and perinatal services is a top priority but a coordinated community plan must be completed first.



Clinician Manpower A vulnerable area in clinician manpower that has developed is access to mid-wives, obstetrics trained family medicine physicians and obstetricians. The newly established Physician Assistant program is currently under-funded.



Outcomes Measurement Further development of an outcomes measurement team is necessary if the School of Community Medicine initiative is approved.



Funding Efforts With the initial success of an FQHC development officer, the creation of the Grants and Financing Development Office to increase public and private funding of the School of Community Medicine initiative would appear to have reasonable return on investment. 43 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

HEALTH STATUS IMPROVEMENT MATRIX

44 Flattening Tulsa v2.0: A Proposed School of Community Medicine by Gerard P. Clancy, M.D. May 21, 2007

OUTCOME

SERVICES

WORKFORCE

FINANCE

Denver Health and University Colorado: FQHCs, Health Dept, EMSA, Insurance Product Albert Einstein – Yeshiva SOM and Montefiore Health System

1.

2.

3.

Accurately assess impact of intervention on health status

Improve overall health status of region; e.g. infant mortality; age adjusted death rate

Focused zip code intervention 74126; e.g. MI rate; early cancer detection; infant mortality; premature birth rates; school attendance; standardized test scores; ER use

Increase clinical involvement in caring for the poor

Increase new physicians choosing careers and serving poor in Tulsa

Increase physician involvement in improving health status of region

Increase public finding of research, service, manpower initiatives

Focus private funds

1.

2.

1.

2.

3.

1.

2.

Denver Health University Colorado Einstein Yeshiva Montefiore Medical Center

3.

Parkland University of Texas Southwestern

UCLA-Drew School of Medicine

Albert Einstein – Yeshiva SOM and Montefiore Health System

Parkland Health System and University of Texas - Community Oriented Primary Care Model

Long-term Studies e.g. Framingham Heart Disease, Iowa 500 - Mental Illness, Abecedarian - Learning

2.

1.

2.

1.

3.

Parkland CHIMES

3.

2.

Measure need for new MDs

University of Rochester

2.

1.

Accurately assess health needs

ROLE MODELS

1.

GOALS

2.

FEDERAL: HRSA – FQHCs and loan payment; DSH for HealthPlex operations; New GME/IME; AHRQ

STATE: Appropriation for HealthPlex construction and operations; state funds for medical school expenses

Graduate with distinction in community health track; Loan reduction programs for service agreements.; “Kaiser Fellows” program for young faculty dedicated to improving community health.; “Kaiser Scholars” program for well established faculty improving health; Endowed Chairs

5.

1.

Community Health Track.

Augment Prenatal/Perinatal Services 4.

3.

PA/Nurse Practitioner Expansion

Team care: Cancer, Diabetes, PACT

6.

2.

Advanced outpatient: HealthPlex

5.

Service curriculum e.g. Bedlam

Adult primary care: After hours clinic

4.

1.

Pediatrics: School based clinics

Prenatal Outreach/Perinatal Care

2. 3.

Prevention: Heart Disease Medication Intervention (HD – MI): Colon Cancer and Colonoscopies: Cervical Cancer and HPV vaccine, Diabetes/Obesity Education

Full implementation of EMR

Institute for Health Care Quality

OU Community Health Assessment Measurement and Policy (CHAMP)

1.

3.

2.

1.

NEEDS & PROJECTS

2.

1.

5.

4.

3.

2.

1.

5.

4.

Federal Legislators: Congressmen Sullivan and Boren

University Hospital Authority

Federal HRSA

Oklahoma Physician Manpower Training Commission

OSRHE Endowed Chairs Program

Community Health Connection

Morton Comprehensive Health

St. John Medical Center

Community Service Council

Community Health Connection

Morton Comprehensive Health

2. 3.

Tulsa City County Health Department

Community Service Council

Tulsa City County Health Department

PARTNERS

1.

2.

1.

TULSA HEALTH STATUS IMPROVEMENT MATRIX