An Unexpected Education: Teaching Health Center Training in a Global Pandemic

By Marsha Regenstein, Ted Epperly, Cristine Serrano, Jennifer Trott, and Alexis AcostaIn a few short weeks, newly trained primary care physicians and dentists will complete their residencies at the nation’s 56 Teaching Health Centers (THCs) and join a desperately needed cadre of health professionals serving rural and underserved communities. Their experiences will be unlike residents who preceded them. They are now part of the COVID-19 class of 2020. The Teaching Health Center Graduate Medical Education (THCGME) program was created in 2010 through the Affordable Care Act to expand the primary care physician workforce in underserved and rural communities. THCs offer a different training experience than traditional, hospital-based graduate medical education residency programs. THCs are accredited primary care residency programs sponsored by community-based clinical organizations such as federally qualified health centers, rural health clinics, or consortia of non-profit health care organizations. Residents train in continuity clinics that serve as their educational and practice home base. THCs create strong partnerships with hospitals to meet all accreditation requirements, but hospitals are ineligible to sponsor a THC. The Health Resources and Services Administration, which will provide $126.5 million this year in GME funding and oversees the program, reports that as of 2019, more than 1,100 graduates have completed a THC residency. THC residents spend a lot of time in clinic at their sponsoring institution’s continuity care site. They know their clinic leadership well and are encouraged to participate in community projects and advocacy on behalf of their patients and community priorities. In the words of a THC resident at the Erie Family Health Centers clinic in Humboldt Park, Chicago, they learn from people “in the trenches of underserved care.” Nearly four out of five THC residents continue to work in underserved settings after they graduate, with many choosing to practice in the clinics where they trained.COVID-19 Poses New Challenges, Opportunities for Residency TrainingResidents have gotten quite an education these past few months. Third-year residents, who are mastering the art of providing high-quality patient-centered care in a busy safety net environment, have seen visit volumes take a swift nosedive; a HRSA survey of federally qualified health centers (FQHCs) in May 2020 found that patient weekly visits were down 57 percent compared to pre-COVID-19 weekly visits, while telehealth visits are up 51 percent. As part of their training, residents need to complete a certain number of continuity patient visits to comply with accreditation requirements. While many residents met their required visit volumes to successfully complete their residency or advance in their training by the time the pandemic took hold, some have not. The programs’ quick ability to adapt and innovate as the coronavirus pandemic unfolds and plagues their communities is a testament to their vitality in an ever-changing health care landscape. The Accreditation Council for Graduate Medical Education (ACGME), the accrediting body for all medical THC programs, has developed a new conceptual framework for GME that classifies residency programs according to the disruption caused by the pandemic. The ACGME suggests that residency programs self-declare an Increased Clinical Demands Status or Pandemic Emergency Status based on the degree of clinical resources that have shifted and educational activities that are suspended due to the pandemic. First- and second- year residents will undoubtedly leave their training with a very different mix of didactics and clinical practice than their predecessors. How this affects long-term primary care practice in underserved communities will play out in unknown ways in the years to come. It is possible that the arrival of COVID-19 will have some positive consequences for THC residency training. An informal survey of members of the American Association of Teaching Health Centers found:1.    THC residents were an integral part of their sponsoring organizations’ rapid pivot to telehealth, creating new mechanisms for enhancing access to primary care well beyond the pandemic. In March, Ozark Center, a THC psychiatry residency program located in Joplin, Missouri, moved to telemedicine (including phone and video appointments) for 90 percent of its outpatients and inpatients. UAMS West, a family medicine THC sponsored by an Area Health Education Center (AHEC) in Little Rock, Arkansas, also went virtual in the span of one month -- something that leadership at the program said would normally require about two years of planning. One of the largest THCs, the Family Medicine Residency of (Boise) Idaho, is now providing about 40 percent of all visits via telemedicine, with 69 first-, second- and third-year residents across its multiple residency sites actively taking part in the logistics and planning to make that a reality. Because of their location in safety net organizations that see high numbers of low-income patients, THCs have been able to take advantage of new telehealth reimbursement opportunities through 1135 Emergency Waivers. Consequently, residents are now training in an environment that offers more flexibility for patients and providers alike. They watched their residency programs, continuity clinics, and organizational sponsors re-engineer the ways that care is delivered and rapidly respond to a public health crisis almost overnight. That’s a valuable lesson that may provide the vision to redesign new processes and systems that are more responsive to patient needs within resource-stressed environments. 2.    THC residents are getting a crash course in the importance of public health and are being redeployed to support COVID-related activities in the community. THCs report that residents have been front and center in setting up and staffing screening and testing sites at designated clinics run by their sponsoring organizations. For example, the City of Boise and three homeless shelters reached out to the Family Medicine Residency of Idaho to help create a homeless hotel for people with COVID-19 symptoms. The THC faculty and residents screen any homeless shelter guests with respiratory symptoms and admit them to the homeless hotel. They then conduct visits with these guests at the hotel to monitor their systems and advise on safe discharge. The residents and faculty stood that program up, with residents involved in every aspect of the undertaking. Whether working the drive-through testing site at Cahaba Medical Care in Centreville, Alabama, participating in county Emergency Preparedness Task Forces at the Wright Center in Scranton, Pennsylvania, or launching an initiative with the Detroit Wayne County Health Authority to test individuals experiencing homelessness at a Salvation Army facility, THC residents have become steeped in public health practice in their communities. The extra time available from decreases in patient care responsibilities has allowed THC residents to take on new roles in their communities that they might not have otherwise experienced in their training. 3.    THC residents are learning to make do with fewer subspecialty rotations. One consequence of the pandemic on residency training is that many subspecialists have stopped serving as rotation sites for residents. Some of these subspecialty practices have closed temporarily or have experienced drastically reduced visit volumes. With subspecialists redesigning their own systems to provide care primarily through telemedicine, many indicated that the teaching responsibilities had to be dropped, at least in the short term. It is too early to know how soon subspecialty sites will come back on board for THC residents. In the interim, THC faculty will need to creatively restructure clinical experiences and didactics to provide on-going longitudinal curriculum instead of the standard time-based linear curriculum.  This could be very beneficial in the long run in accelerating curricular innovation.Graduates Face an Uncertain World of Primary Care PracticeThese silver linings notwithstanding, THCs face enormous challenges in the months and years ahead. THC residency programs have shown adaptability and commitment in the first phase of COVID-19; however, this pandemic calls for endurance for a marathon and not a sprint. Subsequent phases will require agility, ingenuity, and a whole lot of energy in rethinking a new ambulatory care environment -- particularly for practices that focus on the underserved. THCs are planning for a surge of patients who will come back to their own medical home base sicker and needier, having delayed care for months. These medical homes may find themselves light on staff, having redeployed primary care residents and physicians to COVID-19 screening and testing sites, and to higher acuity hospital-based treatment efforts. Additionally, other family medicine and primary care practices in the community that might have previously offset THC patient volumes may have since closed their doors due to financial pressures of the pandemic. And yet, the timeline for fully reopening primary care remains undetermined and will vary by state. THCs will welcome a new group of first-year residents in July in this uncertain world of primary care practice, and these residents will begin their training facing either empty or overcrowded waiting rooms. Funding for Teaching Health Centers is Critical to the Safety Net in Pandemic Recovery EffortsTHCGME funding is far from certain. Despite enjoying strong bipartisan support in Congress, the THCGME program has lived under the constant threat of funding cuts or elimination. For now, the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) has granted the program an extension through November 30, 2020. The need for a permanent and stable source of funding for THCs is essential, especially at a time when sponsoring organizations are balancing tentative GME funding with major unexpected financial losses that threaten the stability of training sites. Safety net organizations with low margins and enormous community need are particularly vulnerable. THCs must also be able to accommodate new, unforeseen costs such as telehealth investments and significant Personal Protective Equipment (PPE) costs for the foreseeable future. Mercifully, some financial help has come from HRSA to FQHCs, which represent about half of all THCs. After a small initial cash infusion of $100 million in March to boost preparedness supplies and telehealth capacity, health centers nationwide received a total of $1.3 billion under the CARES Act to enhance capacity to diagnose, treat, and prevent COVID-19. Additionally, a supplement of $583 million was recently awarded to HRSA-funded health centers to expand testing capacity as a part of the Paycheck Protection Program and Healthcare Enhancement Act. However, THCs that are sponsored by organizations other than FQHCs are not eligible for these resources and must figure out how to staunch the financial bleeding through other means.The COVID-19 pandemic has exposed a critical need for primary care access to health care and for community-wide partnership to support public health efforts. If adequately funded, the THCGME program is well poised to help support these needs now and for the long haul. It is designed to train primary care residents in a community-based setting and to retain medical talent in the areas of the country where they are needed most. Thus far, THC residents have adapted to their circumstances and exceeded what is normally asked of them in their training by immersing themselves in telehealth, staffing various COVID-19 needs in their community, and working with state and local public health efforts to stand up testing and screening programs in record time. The outlook for primary care may be uncertain, but the need for a place to call medical home -- whether it’s virtual or not -- is clear. THCs and their residents will continue to be critically necessary soldiers on the frontlines of COVID-19 and dealing with its lasting impacts. The silver lining may be in THC programs’ ability to adapt and innovate, which could translate to new and positive changes for the very foundations of primary care and residency training. Marsha Regenstein, PhD, Professor, Department of Health Policy and Management at The George Washington University Milken Institute School of Public HealthTed Epperly, MD, President and CEO, Family Medicine Residency of IdahoCristine Serrano, MPH, MBA, Executive Director, The American Association of Teaching Health CentersJennifer Trott, MPH, Senior Research Scientist, Department of Health Policy and Management at The George Washington University Milken Institute School of Public HealthAlexis Acosta, MSc, Research Assistant, Department of Health Policy and Management at The George Washington University Milken Institute School of Public Health