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I had previously written about grant writing (here and here) in some depth and mused on it several times as well. This past summer, HRSA put out an RFP (request for proposals) for their training grants. These are difficult grants to write, requiring a lot of data and imagination. The success rate is typically about 50% and usually you have a matter of months to prepare them. We were given 3 weeks and identified three areas of need we felt we should apply for. So far, we have heard that we got two funded and are awaiting word on the third. The good news is that we will be given resources to completely transform the residency training program and the student program into programs that train physicians for the 21st century (only 10 years late). The bad news is that we have to now do the work. Wish me luck!

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As I sit on the Gulf Coast of Alabama, awaiting te arrival of the biggest environmental disaster of my lifetime, I am trying to anticipate what I will need to teach physicians to do to be effective in 2015 and have to admit I am drawing a blank. I am continuing to work on the HRSA Title VII funding request. The difficulty is that they have changes the number of years that the project should be developed over to 5. In the spring of 2005, Katrina was the name of a potential storm, the healthcare delivery system was to be market based, and primary care was seen by the feds (who paid a majority of the bills) to be a quaint method of providing low intensity health services that people probably didn’t need anyway. I’m glad I wasn’t asked to predict out for those 5 years.

But I am being asked to predict what I will need to train physicians for the next 5 years. Maybe I should focus on the need for a different kind of doctor in 2015. One who can spend more time with the patients, helping them to navigate the system, working with them to make sure they are taking advantage of appropriate medical care (including preventive services), and delivering this care in a personalized manner. Oh, wait, we already have this type of provider. He or she is a family physician, underpaid and burned out under the current payment model. Unfortunately, I can’t write a grant to improve the payment structure.

Maybe I should write a grant to deal with the lingering effects of the ecological disaster of cataclysmic proportions heading to a shoreline near you. We know from Katrina that there will be an increase in depression, physical ailments related to depression, as well as ailments related to exposure to hydrocarbons. In addition, folks will lose their ability to make a living off of the land, leading to more ill effects as described above. In the long run will be an increase in certain cancers. The grant I would like to write would have been one to point out that one shouldn’t drill holes that are too deep to plug up if something goes terribly wrong. Anyway, I still want to believe in miracles. This may, however, be the grant that I write.

The other dilemma that is of potential interest to granting agencies is childhood obesity. The President’s Council on Physical Fitness began during the Eisenhower adminstration in part because of a concern that our young men and women were in no physical shape to fight another World War. After 60 years we noticed that it was working in the opposite way with the future fighting men and women of 2010 being more out-of-shape by far than their 1950’s counterparts. Doesn’t speak for the success of the President’s Council, does it.  If only we had measures that worked better than eating less and exercising more. As a physician, not a lot of either activity takes place in my office so I’ll have to think about a medical approach to this problem for a while.

Grant writing is hard work. The needs are often overwhelming and the solutions not forthcoming. I guess now it’s time to get back to my predicting on a much smaller scale.

Writing a grant is all about trying to convince an agency/not-for-profit/rich person that their money will make a difference in the activities of your organization. Being in a medical school, I typically look to several federal agencies who are looking to improve medical education when I’m asking for money. This money typically cannot go towards “operating expenses” but must go towards changing the activities of the applying organization to bring them more in line with the goals of the granting agency. This is why it is important that the agency shares the goals of the person or group requesting the money.

The agency that typically funds family medicine education is the Health Resources Services Adminstration (HRSA). This agency has been charged with “improving access to health care services for people who are uninsured, isolated or medically vulnerable.” Over the years that I have been involved with this agency, I have sought and acquired funding for Community Oriented Primary Care, care of victims of domestic abuse, care of underserved rural Americans, and care of underserved urban Americans. Fortunately, the goals of this agency dovetail with my interests and the interests of the department.

The Patient Protection and Affordability Act has outlined what the primary care priorities are going to be for HRSA this year (listed below). Wish me luck:

  • Programs that develop programs between academic administrative units of primary care;
  • Programs that Propose innovative approaches to clinical teaching using models of primary care, such as the patient centered medical home, team management of chronic disease, and interprofessional integrated models of health care that incorporate transitions in health care settings and integration of physical and mental health provision;
  • Programs that have a record of training the greatest percentage of providers, or that have demonstrated significant improvements in the percentage of providers trained, who enter and remain in primary care practice;
  • Programs that have a record of training individuals who are from underrepresented minority groups or from a rural or disadvantaged background;
  • Programs that provide training in the care of vulnerable populations such as children, older adults, homeless individuals, victims of abuse or trauma, individuals with mental health or substance-related disorders, individuals with HIV/AIDS, and individuals with disabilities;
  • Programs that establish formal relationships and submit joint applications with federally qualified health centers, rural health clinics, area health education centers, or clinics located in underserved areas or that serve underserved populations
  • Programs that teach trainees the skills to provide interprofessional, integrated care through collaboration among health professionals;
  • Programs that provide training in enhanced communication with patients, evidence-based practice, chronic disease management, preventive care, health information technology, or other competencies as recommended by the Advisory Committee on Training in Primary Care Medicine and Dentistry and the National Health Care Workforce Commission established in section 5101 of the Patient Protection and Affordable Care Act; or
  • Programs that provide training in cultural competency and health literacy.
community-medicine

Kaplan GA. Ann NY Acad Sci 1999, 896:117-199

Most residency training is paid for by Medicare through the sponsoring hospital. HRSA Title VII provides money specifically to support programs who train physicians that leave training and practice among underserved populations. The previous administration had eliminated the program despite evidence of great success. There is $400,000,000 in the stimulus package for this year for this program. Additionally, the renewal will be put before Congress this year as well. Below are the key aspects of “Health Professions and Primary Care Reinvestment Act” which were H.R. 7302 and S. 3708 but will be renumbered in the 111th Congress.

In addition to the traditional emphasis in Family Medicine training, the following is included in the language of the bill for the “pre-doc” (programs that offer training to medical students) and residency grants:

·        to plan, develop, and operate an interdisciplinary training program that includes at least 1 of the following which demonstrates a team approach to care and may demonstrate a patient-centered medical home model:

o   A program designed to teach trainees the skills to provide interdisciplinary patient care through collaboration among various professionals, including those trained in geriatrics, physician assistants, nurse practitioners, pharmacists, or social workers.

o   A program developed in collaboration with dental students or residency training programs to improve integration and access to dental care.

o   A program developed in collaboration with psychologists and other behavioral and mental health professionals to integrate mental and behavioral health and primary health care

 

For the programs to develop primary care departments, the emphasis will be on: 

 

·     innovative approaches to clinical teaching using models of primary care, such as the patient centered medical home, team management of chronic disease, and interdisciplinary integrated models of health care that incorporate transitions in health care settings and integration physical and mental health provision.

·     Generating the capacity to do Community Health Needs Assessment-

 

Lastly, they will create a new entity, the Primary Care Training Institutes, whose purpose is

 

·      To prepare and train primary care providers by enhancing and coordinating multiple aims within academic health centers in order to lead to improving patient care delivered to health disparity populations and reduce health disparities;

·      To enhance the status of primary care within undergraduate and graduate medical education through influencing priorities in practice, education, and research;

·     To develop innovative approaches to primary care education and scholarship by transforming and integrating health care systems through interdisciplinary, team-based, and collaborative models that may demonstrate improved quality or lower costs;

·     To create economies of scale through academic and community collaborations by enabling academic infrastructure support for multiple community programs.

 

This money is needed to improve our training and make it more targeted towards what will imporve health, not just attack illness. Let’s all work to put this program back on track.

 

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