Barriers to reducing health disparities in a primary care curriculum for the underserved

1. Barriers to reducing health disparities in a primary care curriculum for the underserved • Elliot Montgomery Sklar, PhD, MS • Kristi Messer, MSW, MPH The project described is supported by grant number D56HP20778 from HRSA BHPr

2. Presenter Disclosure NO RELATIONSHIPS TO DISCLOSE

3. Project HOPE In 2010, Nova Southeastern University’s College of Osteopathic Medicine was awarded a five-year Pre-doctoral Primary Care Training grant from the Health Resources Administration (HRSA) of the U.S. Department of Health and Human Services. Project HOPE – Homelessness in Pre-doctoral Osteopathic Education - responds to a curricular deficit in the education of medical students toward the health care needs of those experiencing homelessness; responds to a workforce shortage area. Challenges have yielded great insights into ways to integrate special population foci.

4. Project Goals • Provide a primary care curriculum for medical students that focuses on the homeless, ensuring patient safety and minimizing medical error. • Improve the attitudes and knowledge that students have with regard to people who experience homelessness. • Expand student experiences in primary health care to the homeless in a required rural/urban underserved primary care clerkship. • Provide a template for a curriculum that can be used by both osteopathic and allopathic medical schools that can be used to plan, develop, implement, and evaluate primary care health services for homeless populations.

5. Curricular Overview YEAR ONE • Humanism & Health: (3 hours) • Foundations and Applications of Clinical Reasoning I: (2 hours) Case presentation focused upon homelessness and health. • Community Service-Learning (4 hours) 4 hours of direct/indirect community service that is specific to individuals experiencing homelessness YEAR TWO • Principles of Clinical Medicine II: (2 hours) Homeless-specific specialized patient exam  YEAR THREE • Internal Medicine I: (8 hours) Web-based module, incorporated into 3 month Internal Medicine Rotation YEAR FOUR • Medical Informatics: (8 hours) Online health information technology focused on homelessness. • Rural / Underserved 2 month core placement and / or 1 month selective placement: Students will conduct intake in concert with preceptor / facility to determine housing status by federal definition of homelessness. Rural / Underserved log includes data on number of homeless-specific encounters per month. • 27 total hours to date; expansion is ongoing

6. The Case for Primary Care Training in HCH An aging health care for the homeless (HCH) workforce; high burnout. Fewer young physicians entering primary care. Adverse attitudes of medical providers contribute to reduced quality and access to care for those experiencing homelessness and most likely stem from training that did not adequately prepare students and physicians to sensitivities in working with this population. Similar indications exist with other special populations. No exposure = no interest / limited skill set = lack of efficacy.

7. An Integrative Approach Focus groups with students, faculty, homeless consumers toward ongoing curricular and project quality improvement. Advisory board meetings include homeless consumers, clinical partners, university faculty, staff and students. Project support of student society activities across the health professions to benefit the community. Project membership in NCHCH education committee. HUD affordable senior housing board. Attendance of local CAB meetings.

8. The Hidden Homeless: An Apparent Challenge Many who are transient in their housing and are not “on the streets” do not self-identify as homeless. Due to issues at intake, funding policy and procedure - many clinics / clinicians do not track patients experiencing homelessness. Language is important in assessment of housing and in its related continuum of care. Thus, a need to broaden perspective and raise awareness.

9. Tracking Exposure: A Way to Integrate Tracking of housing status, irrespective of service point provides a service to the student, preceptor, and even to the clinic. Along with the need to broaden perspective, we have broadened approach to include all medical students. The model that has been developed asks students to track the housing of patients with whom they interact. The concept is easy to replicate, and can be tailored for any minority or vulnerable or special population group.

10. Data from 2284 completed logs (based upon self-report) revealed a 6.9% encounter rate with individuals experiencing homelessness across all rotations • This represents an average of 11 patients encountered per student who were experiencing homelessness. • Correlate health and housing, exposure, experience and attitude. • Logs went live in March, 2012 within Rural / Underserved rotations and across all rotations – July 2012.

11. Why Address Attitudes? Negative attitudes perceived by patients increase their sense of alienation, stigmatization, and despair. The result is a decrease in the effectiveness of counseling, treatment recommendations, and spirit —the core tenets of osteopathic principles.

12. Attitude Survey Health Professional Attitudes Toward the Homeless Inventory (HPATHI) Developed by Dr. David Buck et al., 2005. Baylor College of Medicine, TX

13. Health Professional’s Attitude & Experience Toward the Homeless Inventory In an effort better understand the variability in attitudes as related to experiences, an addendum was created. This addendum addresses proximity of experience to the homeless in the following four categories of: Awareness, Personal Experience, Volunteer Experience and Direct Care Experience. Additionally, the frequency of those experiences through a five-point Likert scale from ‘Never' to ‘Very Often' was determined.

14. Trends in Attitudes 456 completed pre-tests: 236 first year medical students 2013-14, and 220 medical students in the 2012-13 cohort completed the HPAETHI pre-test. 219 completed post-tests; 219 medical students graduating in 2013 completed the HPAETHI post-test. The 2013 graduating class received about ½ of the full 27 hour curricula.

15. Trends in Attitudes • We discovered that 81% graduating medical students believe that homelessness is a major problem in our society, while 75% of the first year students held that perception. • A small percentage of students believe that homeless people choose to be homeless, according to 11% of graduating students and 6% of first year students. • In terms of whether healthcare dollars should be directed toward serving the poor and homeless, this belief is held by 53% of graduating students and 45% of first year students. • Current student perceptions correlate with improved quality of health care to underserved populations, with 84% of first year medical students and 87% graduating students agreeing that homeless people have the right to basic health care.

16. Trends in Attitudes • The curriculum encourages advocacy and working with individuals experiencing homelessness and is evidenced by student agreement with the question: “I am interest in working with the underserved” (64% graduating seniors and 71% first year students.) • According to 41% of graduating students, they have provided direct care to those experiencing homelessness through health fairs, social services activities, etc. while 20% of the first year students responded that they have participated in similar activities.

17. Opportunities • Students and faculty have reported their surprise when conducting this intake in hospital and clinic settings where they do not anticipate patients experience homelessness. • Attitude data shapes future curricula. • This data can be meaningful for the preceptor / clinic to better understand their patient population, attached care plans, etc. • The data can provide the impetus for demonstrating the need to address the homeless population in medical education.

18. “My personal take-away from the rotation was not just about a catalog of data or facts, but also about the hope that my restored sense of humanismand social responsibilitywill be more durable and intrinsic in the future.” Mark Alexander Gonzales, DO, 2012

19. Questions? Homelessness in Osteopathic Pre-doctoral Education http://medicine.nova.edu/epr/project-hope.html es1054@nova.edu km1320@nova.edu