A new approach to ensuring oral health care for people living with HIV/AIDS: the dental case manager

INTRODUCTION: The American Dental Association has identified several barriers to adequate dental care for vulnerable populations, including appropriate case management. The objective of this study was to examine the perceptions, attitudes, and beliefs of dental patients living with HIV/AIDS on the role and value of the dental case manager (DCM) and the effect of DCM services on their oral or overall health. METHODS: We used a qualitative descriptive study design and focus groups. Twenty-five people who had received DCM services on Cape Cod, Massachusetts, attended 1 of 5 focus groups in 2009 and 2010. Digital recordings of the groups were transcribed verbatim. Textual data were categorized using directed qualitative content analysis techniques. We identified major themes and representative quotes. RESULTS: The following themes emerged from discussions on the DCM\u27s role: being available, knowledgeable about clients and insurance, and empathetic; increasing access; and providing comfort. Most participants credited their oral and overall health improvements to the DCM. All participants believed that the DCM was a valuable addition to the clinic and noted that other at-risk populations, including the elderly and developmentally disabled, likely would benefit from working with a DCM. CONCLUSION: The addition of a DCM facilitated access to dental care among this sample of people living with HIV/AIDS, providing them with an advocate and resulting in self-reported improvements to oral and overall health

Community dimensions and HPSA practice location: 30 years of family medicine training

BACKGROUND AND OBJECTIVES: Our objective was to assess practicing family physicians\u27 confidence and participation in a range of community-related activities. Additionally, we assessed the strength of the relationship between the physicians\u27 reported medical school and residency training in community-related activities and their current community activities, as well as whether they were practicing in an underserved location. METHODS: All 347 graduates of the University of Massachusetts Family Medicine Residency were surveyed about practice location and type, involvement and training in community work, confidence in community-related skills, and sociodemographic characteristics. Analyses were conducted by residency graduation decade (1976-1985, 1986-1995, and 1996-2005). RESULTS: Earlier graduates (19761985) were significantly more likely to engage in an array of community-related activities, but recent graduates (1996-2005) were more likely to report having been trained in these skills. There was a significant positive association between practice in an underserved area and confidence in issues related to sociocultural aspects of care. While recent graduates were more likely to locate both initial and current practices in a Health Professions Shortage Area (HPSA), 20.6% of all graduates reported an initial practice in a HPSA. CONCLUSIONS: While family physician involvement in community-related activities increases with years out of residency, a higher proportion of recent graduates report having learned community-related skills while in medical school. Physician relocation tends to be away from HPSA toward non-HPSA sites

Eat Walk Sleep for Health: Primary Prevention in a Refugee Community

Background: Refugees resettling in the US historically follow a trajectory of declining health as they adopt American diet and physical activity. Methods: This participatory research study explored health beliefs and behaviors of refugees from Burma currently resettling in New England. Community members and researchers adapted a healthy living bilingual educational flipchart, which was piloted in two workshops with a total of 20 adult men and women. An interpreter translated the audio taped discussions which were transcribed and analyzed using standard qualitative methods. Conclusions/ Discussion: Refugee camps constrain food and physical activity related health behaviors. Refugees rely on traditional healing practices but are familiar with western public health care and preventive education. In camps, close living quarters encouraged social interaction and group play. Physical activity was built into daily life as transportation, occupation and food gathering method. Exercise was a byproduct of a busy day, walking to work or school, collecting bamboo in the woods. New arrivals are often housebound and isolated; they seek simple maps that assist in locating resources in their new communities. Asking about sleep appears to open the conversation about emotional and mental health problems. Refugees want specific information about healthy foods and better understanding of how to determine need for exercise. They also seek consistent information on prevention of health problems common in the US coupled with assistance preserving their traditional beliefs. Discussion: Post-settlement in the US, retaining good health is challenging. Flipcharts and neighborhood map drawing provide avenues for open discussion leading to areas for Prevention Research Centers to partner for health

Family medicine residency characteristics associated with practice in a health professions shortage area

BACKGROUND AND OBJECTIVES: While some family medicine residency programs are designed to train residents in community health centers (CHCs) for future careers serving underserved populations, there are few outcome studies on such programs. Our residency program provides three options for ambulatory health center training, but otherwise residents participate in the same curriculum. We analyzed relationships between ambulatory training site and likelihood of practice in health professions shortage areas (HPSAs). METHODS: We sent a mail survey to all graduates of one family medicine residency about practice locations, types, and populations; influences on practice choice; and sociodemographic characteristics. RESULTS: Training in a CHC had a statistically significant association with the likelihood of practice in an HPSA for both initial and current practice. Training in a rural residency site was associated with initial and current rural practice. Logistic regression analysis showed that physicians who completed ambulatory training in the CHC were nearly six times more likely to report having practiced initially and four times more likely to cite current practice in an HPSA. CONCLUSIONS: Outpatient CHC residency training increases the likelihood of practice in an underserved setting. This finding has policy implications for supporting workforce training in practice settings that care for underserved populations

Facilitating Access to Health Coverage and Care by Advancing Health Insurance Literacy

Although Massachusetts currently has the highest rate of health insurance coverage in the nation, reports suggest health care consumers do not fully understand how their insurance works. Thus, the insured and uninsured populations alike need ongoing support in order to develop health insurance literacy, defined as the degree to which individuals obtain, process, and understand information about health insurance in order to make informed decisions about choosing and using their coverage, which in turn can lead to positive health outcomes. Educating consumers and giving them tools and resources are strategies that advance health insurance literacy. Since 2001, the Blue Cross Blue Shield of Massachusetts Foundation (the Foundation) has awarded over $5 million to community health centers and community-based organizations throughout Massachusetts, through its Connecting Consumers with Care (CCC) grant program, to conduct outreach, provide education and help consumers enroll in health insurance and access primary care. In 2015, the Foundation focused its CCC grant activities to improve health insurance literacy and engage consumers to utilize the health care system more effectively. Grantees have collected data on common measures, using adaptable data collection tools (e.g., brief client surveys), to assess changes in clients\u27 knowledge, confidence, and/or preparedness to better navigate complex systems of coverage and care. The poster presentation will discuss: - the importance of health insurance literacy and its relevance to improving population and community health - strategies currently used to increase health insurance literacy among diverse populations, including successes and challenges - how the impact of these strategies was measured - how assessments were designed to reflect consumers\u27 voices

An Analysis of Implicit Bias in Medical Education

Background: The Implicit Association Test (IAT) is a well-researched method of identifying an individual\u27s implicit bias. Occurring outside of conscious awareness, implicit bias manifests itself in the form of nonverbal thoughts, behaviors and actions that influence an individual and that are suggestive of unequal treatment. In the undergraduate medical education curriculum, the IAT is commonly used to assess the medical students\u27 personal bias. Studies from the American Association of Medical Colleges (AAMC) have shown that bias is ranked highly as one of the least addressed educational goals in medical education and training. The medical literature suggests that implicit bias affects how clinical faculty make patient care decisions, and that this in turn affects medical student education. Data collected from our medical school\u27s first year curriculum suggest that there are missed opportunities to explore the effects of bias on health outcomes. Objective: The purpose of this study was to analyze comments in reflection papers submitted by students enrolled in the required Determinants of Health (DoH) course during the Fall 2014- Spring 2015 curriculum at the University of Massachusetts Medical School (UMMS). The DoH course assignment asked students to select a reading, experience in taking the IAT or class discussion, and comment on how the material led to new insight about the potential effect of biases or stereotyping on future clinical decisions. The themes from this analysis provided context for relevant areas for further exploration of the impact of implicit bias in medical education. Method: 125 first-year medical students (48% female, 52% male; mean age 25 years; 95% from Massachusetts, 9% identified as under-represented ethnic/racial minorities) in the entering class of 2014 submitted written reflections following attendance and discussion-based learning in the DoH course. Grounded theory methodology was used for the qualitative analysis of the comments. Papers were de-identified, read, and codes were constructed according to emerging themes (descriptive, diagnostic, and prescriptive) found. The codebook development focused on bias, systemic/institutional bias, individual bias, awareness and health disparities . Student commentary was coded for themes and tallied for total amount of discussion for each theme. Inter-rater reliability was calculated for 20% of the sample using Cohen\u27s kappa. Results: The following themes emerged: 1) an understanding of the IAT and the results of the IAT; 2) a definition of bias; 3) a suggestion of source of bias; 4) factors informing bias; and 5) action items to combat the effects of implicit bias on future physicians. Ninety-five of 125 students\u27 comments (76%) mapped to descriptive themes associated with bias; 27% (n=26/95) of comments suggested all individuals have bias; 57% (n=55) of comments suggested potential sources of bias, ranging from cultural and community upbringings to societal media; 83% (n=79) of comments focused on the negative effect implicit bias can have on decision-making in patient care; and nearly 96% (n=91) of comments felt that acknowledging their own implicit bias would benefit their interactions with patients in their future medical careers. Additionally, 58% (n=73/125) of students\u27 comments noted that making a conscious effort to self-reflect and address bias would improve decision-making, and 32% (n=40) of comments noted it was a physician\u27s responsibility to dismantle the bias found in the healthcare system (15 comments suggested this happen through avenues such as advocacy and legislation). Seventy students\u27 comments (56%) mapped to comments discussing the lAT. Forty-three percent (n=30) comments noted students surprised by their results and 29% (n=20) of comments suggested that the student was not surprised. While 75 students (60%) did not comment on their reaction, the IAT sparked self-reflection of implicit bias and its origin in 68 of these students, and 16% (n=20) of comments found the IAT to be a valuable tool in identifying implicit bias. With regard to the current climate ofhealthcare, 40 responding students (32%) identified racism or racial bias existing within the medical field, noting potential sources of racism including lack of trust in physicians from historical events such as the Tuskegee Syphilis Experiment and societal inequalities as a whole. Additionally, 29 students\u27 comments (23%) mentioned systemic/institutional bias as potentially having an impact on individual bias and vice versa. Conclusions: The use of the IAT in the medical education curriculum is informative and the medical student response to it is impactful. Medical students gain insight into the importance of understanding personal implicit bias and the effect it may have on clinical decision-making through courses such as Determinants of Health. Students have the ability and the desire to identify and self-reflect on the development of behaviors and skills that will facilitate improved decision-making in the care of patients, and improved patient interactions. This analysis also points to the significance of further exploration of faculty involvement in these topics to further engage medical students throughout their undergraduate medical training. As over 93% of the first-year medical school courses did not utilize race identifiers and non-medical factors in clinical vignettes, this is another opportunity to apply real-life scenarios to the educational curriculum

Mapping Patient Distributions Informs Community-Oriented Primary Care in Four Community Health Centers in Central Massachusetts

Background Based on the philosophy that family medicine training should occur in community-based practices and hospitals, the Worcester Family Medicine Residency (WFMR) training program was structured to combine learning opportunities in an academic medical center with outpatient care training in three unique community-based practices: the Barre Family Health Center, a rural site thirty miles west of Worcester, the Family Health Center of Worcester, a federally funded community health center serving a poor and culturally diverse urban population, and the Hahnemann Family Health Center, a hospital-owned health center serving a socioeconomically diverse population in the northeast part of Worcester. The WFMR received an AAMC “Regional Medicine-Public Health Education Centers-Graduate Medical Education (RMPHEC-GME)” grant to further integrate public health training into the clinical training experience. As part of the effort, collaboration was begun between the department of Family Medicine and Community Health at UMASS Medical School, the academic home of the WFMR, and geographers at Clark University, a local resource providing expertise in mapping of data using Geographic Information Systems (GIS). Mapping Patient Distribution A series of thematic maps were generated from actual practice data on the patients being served by each residency site and also by Fitchburg Community Health Center. Faculty champions from each site attended two training sessions to learn more about the capabilities of mapping. They were then asked to lead faculty at their site in discussion to define five maps they would like to see made from their own patient data. Most sites chose a map showing the distribution of the entire patient population, some requested a map of their pediatric patients, and then the rest were designed to depict the spread of certain chronic diseases, including asthma, hypertension, coronary disease, and diabetes. Maps were generated using geocoding and point density tools in ArcGIS Desktop software. The main goal of this mapping activity was to educate physicians in training about where their patients live and facilitate discussion about environmental factors that impact health. These maps can also be used by practitioners to communicate important information to their patients about available community resources such as gyms, parks, health clinics, and supermarkets (as shown on some maps). Making Maps Available Online One element of the grant initiative was to build an online resource to aid faculty in teaching about population health concepts. This portal, the Community Health Toolkit (http://www.umassmed.edu/fmch/toolkit.aspx), provides three types of information to aid clinicians in both their teaching and their practice. The “Data on Communities” section was developed as part of the UMMS/Clark University collaboration. In total, 24 thematic maps were generated by the GIS team at Clark University and uploaded to the “Data on Communities” web section of the Community Health Toolkit. Other sections of the Community Health Toolkit include “Learning about Populations” which provides links to a variety of local, regional and national health indicators, and a “Community Resources” section which provides links to community resources for patients. The Toolkit is presented to learners along the continuum of medical education, including second year students in the Population Health Clerkship, first year residents in the Family Medicine and Community Health rotation, then used as a resource by residents as they complete presentations and research projects

Pre-clinical medical student reflections on implicit bias: Implications for learning and teaching

CONTEXT: Implicit bias affects health professionals\u27 clinical decision-making; nevertheless, published reports of medical education curricula exploring this concept have been limited. This research documents a recent approach to teaching implicit bias. METHODS: Medical students matriculating during 2014 and 2015 participated in a determinants of health course including instruction about implicit bias. Each submitted a reflective essay discussing implicit bias, the experience of taking the Implicit Association Test (IAT), and other course content. Using grounded theory methodology, student essays that discussed reactions to the IAT were analyzed for content themes based on specific statements mapping to each theme. Twenty-five percent of essays underwent a second review to calculate agreement between raters regarding identification of statements mapping to themes. OUTCOME: Of 250 essays, three-quarters discussed students\u27 results on the IAT. Theme comments related to: a) experience taking the IAT, b) bias in medicine, and c) prescriptive comments. Most of the comments (84%) related to students\u27 acknowledging the importance of recognizing implicit bias. More than one-half (60%) noted that bias affects clinical decision-making, and one-fifth (19%) stated that they believe it is the physician\u27s responsibility to advocate for dismantling bias. CONCLUSIONS: Through taking the IAT and developing an understanding of implicit bias, medical students can gain insight into the effect it may have on clinical decision-making. Having pre-clinical medical students explore implicit bias through the IAT can lay a foundation for discussing this very human tendency

Multi-Disciplinary Experts Supporting Graduate Medical Education through Participation in COMPLETE Chart Rounds

Learning Objective: As a result of this presentation, attendees will learn skills that they can use to implement collaborative graduate medical education learning experiences using a community of multi-disciplinary professionals within their own institutions. Background: Inter-professional Chart Rounds were implemented to provide residents an opportunity to review and present patient cases utilizing “COMPLETE” guidelines developed by residency leadership as the result of a “Regional Medicine – Public Health Education Centers” grant. COMPLETE guidelines explicitly direct residents to include consideration of: - Context – Culture of context – who is the patient? - Outside Visitors/Resources – incorporate visitors/experts such as librarians, pharmacists and psychologists and utilize their resources - Mental Health – assess behavioral health aspects of the case - Population Perspective – address prevalence of the condition in the community - Learn From Others – consider specialists, home care, and complementary therapies - Expectations – clear goals set between physician and patient - Time – Start on time, end on time. Respect everyone’s time. - End with “Culture of Continuity” – what are the key lessons? Is there a follow-up plan? Through the attendance of librarians, psychologists, pharmacologists, medical students and other faculty, discussion ensues which leads to continued resident education and support. Methods: Chart Rounds are held daily at each residency practice site. Residents are required to attend along with medical and pharmacy students rotating at the centers. The preceptor leads Chart Rounds and other faculty physicians join as they are able. Residents present cases while maintaining patient confidentiality. The preceptor leads the group discussion of the case. Faculty members discuss clinical and administrative implications, the psychologist addresses potential behavioral aspects of the case, the librarian searches for Evidence-Based information to support decisions and the pharmacologist advises on medication management. The group also discusses how individual patient care reflects the public health needs and profile of the community. Residents (n=32) were invited to complete a survey asking them to evaluate their experience with multi-disciplinary COMPLETE Chart Rounds. Results: Survey results as well as observational analysis will be used to improve the resident’s experience at Chart Rounds with the goal of making this experience an even more rewarding collaborative educational experience. Some sample findings include: - 66% of residents report satisfaction of Chart Rounds challenging the academic aspects of their work - 100% of residents in the early portion of their program report that Chart Rounds assists them in building collaborative relationships with faculty and other providers/experts - Residents report the greatest satisfaction (92% overall) with pharmacist participation in Chart Rounds across all Post Graduate Years - Satisfaction with librarian participation increases through each year (from only 10% in PGY1 to over 60% in PGY3) , possibly due to limited exposure early in the program Although these guidelines were developed for use in a Family Medicine Graduate Medical Education program and fit well into this practice model, the findings can be utilized in other resident training programs. Presented at the Patients and Populations: Public Health in Medical Education conference sponsored by the Association of American Medical Colleges (AAMC) and the Centers for Disease Control and Prevention (CDC), held September 14-15, 2010, in Cleveland, OH

Eat Walk Sleep Discuss: Building a Multi-Dimensional Participatory Relationship

A multi-faceted relationship has developed between UMass Worcester and the Worcester Refugee Assistance Project (WRAP). The relationship has its roots in student engagement, and has grown to include faculty, students and community members in a range of community-based participatory activities, which can be shaped in response to needs as they are identified and defined. This poster describes the different ways student engagement and community partnerships worked together in a research project