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A sense of community

RPAP students broaden their focus to tackle community health problems in Greater Minnesota

Over the years, the University of Minnesota’s Rural Physician Associate Program (RPAP) has received accolades from numerous sources, including the Carnegie Foundation and the New England Journal of Medicine. And this year, the popular program has more participants than ever before. But like every good leader, RPAP director Gwen Halaas, M.D., raised the bar, demanding a bit more of the program and its students, knowing that both would benefit in the long run.

The state legislature launched RPAP in 1971 as a way to address the dire shortage of primary-care physicians in rural Minnesota. The idea was innovative yet simple: Third-year medical students would spend 36 weeks living, learning, and caring for patients in a rural Minnesota community. They’d work closely with rural physicians in a range of health-care settings, and if the program worked as planned (which it has), their experience would encourage them to return to a rural setting when they began their careers.

Among the oldest and largest programs of its kind, RPAP has now graduated 1,127 physicians—some 60 percent practice in rural communities, and about 80 percent provide primary care. RPAP has served as a model for programs in other states, including New York, Florida, and Alaska—and medical schools as far away as Australia have studied it. This year, 47 students are participating in RPAP communities—the largest group in the program’s history.

Looking for a way to involve students more broadly in their host communities, Halaas revamped the program’s community health component after becoming RPAP director in 2004. The new community health assessment projects she initiated in 2005 require students to examine a health-care issue confronting their host community and to collaborate with local experts to seek solutions. Students may choose to investigate smoking cessation, teen pregnancy, depression in the elderly, obesity—any health-care issue of concern to the community.

“These projects are an opportunity for us to return something of value to the community for hosting and teaching our students,” says Halaas, who this spring became director of the Academic Health Center’s new Center for Interprofessional Education. “I really wanted students to go further than just the clinic or hospital they were working with—to learn from others in the community.”

The following three community health assessment projects completed by RPAP students last year demonstrate what Halaas envisioned: students gaining a deeper understanding of community health; physicians and other health-care providers obtaining valuable information from the students’ research; and, ultimately, patients receiving better care.

For his RPAP project last year, Andy Mulder recommended ways to improve diabetes care among Latino patients in Willmar, a Minnesota town with a large and growing Latino population.

Breaking down barriers to care

RPAP student Andy Mulder, Class of 2007, listened carefully during the young Latino woman’s appointment with a diabetes management nurse at the Willmar clinic. Afterward he asked the patient how the health-care system might better serve her.

What would help her follow the diabetes management program? A Spanish-speaking nurse? Access to translators? More information about diet?

No, she said—what she really needed was a ride to the clinic, since she didn’t always have access to a car.

For Mulder, that was an “aha” moment. “Several of the people I talked to had transportation issues—they lived in a one-vehicle household, or they didn’t drive at all,” he says. The conversation was just one of many experiences that helped him realize that Latino patients confront a multitude of barriers to health care, and that some challenges, like transportation, are both easy to address and easy to overlook.

For his RPAP community health assessment project, Mulder spent several months last fall and winter studying diabetes care among Latino patients in Willmar (population 18,918), which has a large and growing Latino population. As Mulder knew, Latinos as a group have a higher incidence of diabetes than the general population.

With the help of Deb Lippert, clinical coordinator at the Rice Diabetes and Nutrition Center (RDNC), Mulder had access to a wide range of statistics and other nonconfidential data. He was also able to meet with Latino patients so he could talk with the people behind the numbers.

Based on his research, Mulder made several recommendations to the RDNC. Some of his suggestions, like providing transportation vouchers and calling patients a day in advance to remind them about appointments, have already been implemented, says Lippert. Others, such as training interpreters in diabetes management, may be incorporated in long-term plans. “Andy’s [research] is very much part of our ongoing quality-improvement process,” she says. “It’s wonderful to be able to tap into a resource like that.”

Mulder, who starts a preliminary surgery residency later this year at the University, says his project helped him gain not only an appreciation for the challenges Latinos face in getting diabetes care but also for the meaningful changes—both large and small—that can improve their care. “Some of the barriers to health care that Latino patients face aren’t readily apparent,” he says. “But just putting up signs in Spanish that explain where to register or where to get prescriptions can make a difference.”

A health-care team in Fergus Falls used Heather Hamernick’s RPAP project recommendations to launch a pilot program aimed at reducing falls among elderly patients.

Preventing falls in the elderly

Trip on a stair when you’re 20, and you might skin a knee. If you’re 70, however, you might wind up with a broken bone, a hospital stay, and weeks or months of rehabilitation. Falls are the leading cause of injury among seniors nationwide, and an aging baby-boomer population makes finding ways to prevent them more crucial than ever.

Todd Johnson, Pharm.D., a pharmacist at Lake Region Hospital in Fergus Falls (population 13,658), knows the scenario all too well. For 30 years, he has consulted at local nursing homes to make sure patients are getting the proper medications, paying particular attention to the charts of patients who have recently fallen. “Just today, I was looking at the medication of an elderly woman who fell after getting light-headed when she stood up,” says Johnson, who is also an assistant professor in the University’s College of Pharmacy. The woman was fine, he notes, but many others in similar situations end up with broken hips and other serious complications.

When Heather Hamernick, Class of 2007, chose to focus her RPAP community health assessment project last year on falls among the elderly, Johnson encouraged her to take a broad view and to seek solutions. Hamernick quickly discovered that dozens of factors contribute to the problem, including certain medications, arthritis, cluttered environments, and vision problems.

Her research paper described the scope of the problem and called for assembling teams of doctors, nurses, pharmacists, and others to help reduce the risks. “A pharmacist might look at what drugs contribute to drowsiness, but a physical therapist might say that that doesn’t matter if the patient can’t get out of bed,” says Hamernick. “Everyone is trained to solve problems differently.”

She presented her findings and recommendations last spring to a team that has since launched a pilot program to help assess the risks of falls among elderly patients. Current RPAP student Mandy Hoffman worked on the Fergus Falls pilot project and says a more comprehensive falls-prevention program may be ready next year.

Hamernick, who is working in Uganda this spring as part of a global health rotation and will soon start her family practice residency at St. John’s Hospital in suburban Maplewood, says it was gratifying to complete a project that she knew was important to the local community. “There was a lot of excitement for this project, and it was great to see so many people who wanted to work on it,” she says.

Johnson concurs, describing the project as “a win for students and a win for the community.”

Josh Chapman’s RPAP project encouraging patients in Staples to complete their own health-care directives has spurred important conversations between patients and their doctors about end-of-life care.

Calling attention to health-care directives

Increasingly, medically savvy patients expect their physicians to help them take control of their own health. But, as an RPAP student in Staples (population 3,019) last year, Josh Chapman, Class of 2007, found that patients tend to be a lot more reticent when it comes to making end-of-life decisions.

For his community health assessment project, Chapman wanted to promote the use of health-care directives, the documents that guide physicians in caring for patients who can’t speak for themselves because of debilitating injury or illness. When his research showed that less than 2 percent of patients had health-care directives on file with Staples’ Lakewood Health System, he was determined to find out why—and to help improve those numbers.

Chapman distributed hundreds of questionnaires about health-care directives to patients. When he sifted through the results, he found that people gave many reasons for not having a health-care directive. Some simply hadn’t committed their wishes to paper, some weren’t sure where to obtain the form or how to fill it out, some figured they were too healthy to have one, and others had never heard of such directives. “I realized there was a need for education,” Chapman says.

David Freeman, M.D., Chapman’s RPAP preceptor, says that health-care directives give patients control over their care. “Today in medicine we can do a lot of things to people, but it doesn’t mean we have to,” he says. “Health-care directives are a way of giving patients choices in a crisis.”

“End-of-life issues are especially relevant for primary-care doctors and their patients,” says Chapman. “These physicians know their patients well and have an understanding that can allow that discussion to happen.”

To get people thinking about their options, Chapman produced a brochure and posters to be placed around the hospital that explained what health-care directives are, why they’re important, and how patients could complete their own directive and file it at the hospital.

Freeman says that Chapman’s project got the hospital off to a good start on an issue that needs more attention. “Now patients can pick up a flier and see what health-care directives are all about,” he says. “That will get the conversation started.”

Chapman, who begins his medicine/pediatrics residency at the University later this year, says the project helped him see how his expertise could bene-fit patients other than the ones he saw on a given day. “It showed me how my training can serve the needs of the larger community,” he says. “And that’s really valuable.” 

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