Policy 2.0 : Popular Discussions - All Communities

Can telephone nurse triage take the load off Emergency Departments?

info@hopestreetgroup.org — Thu, 03 Jun 2010 12:09:11 GMT

A recent article in USA today suggests that a telephone nurse triage service established by the Louisville Metro Emergency Medical Services can ease the pressure on Emergency Departments by re-routing non-emergency health-related 911 calls to nurse call-takers. Under the program, low-risk calls are handed over to a nurse who provides advice to the caller, including alternatives to ambulance transport and presenting at the Emergency Department. See the article here. A similar program has been running for several years in Melbourne, Australia. The expectation is that this kind of service can reduce pressure on overburdened Emergency Departments by providing non-emergency calls with viable alternatives. However, experience in the United Kingdom (through NHS Direct) and Australia (through services such as NURSE-ON-CALL and HealthDirect) is that the volumes handled by these services don't make a big dent in the presentations at EDs. More importantly, diverting people from Emergency Departments relies on those people being able to access community-based alternative sources of care - and shortages mean that timely access to a primary care physician or family clinic often isn't available. In the end, telephone nurse triage can be a useful way of directing people to appropriate services, but those services have to be there in the first place.

What is effective teaching?

info@hopestreetgroup.org — Thu, 09 Jul 2009 03:21:49 GMT

UPDATE: Thanks to everyone for thoughtful contributions. This is a central question, but it's also very complicated. Please see the Discussion Summary: What is Effective Teaching? for a wrap up.

Before we can begin to identify the elements of quality teacher evaluation, we need to discuss what makes a teacher effective. Measurable student achievement? School leadership? Classroom management? Professional development? Attendance?

Before we kick off our policy work, please use this thread to discuss your thoughts on the elements of effective teaching.

Message was edited by: Catherine Cullen

Barriers To Primary Care Innovation Regarding Training: Too Many Stages in the Path

info@hopestreetgroup.org — Fri, 06 Aug 2010 22:59:04 GMT

Too many steps, Too many separations, Too many leaks in the pipeline, Too little yield across the segments, Too many accreditations, Too many funding sources, Too many determining training curricula, and very few focused on basic health access

The last rural workforce meeting of AAMC in 1990 broke up when a Dean from SD Robert Taylor suggested primary care coordination such as combining primary care. Much of his presentation and work failed to notice the talk about unifying accreditation and funding and responsibility, but as is typical when turf is discussed, the meeting went south. Immediately the talk focused on the various primary care types instead of rural workforce focus. At this meeting those at the previous meeting 17 years before noted that nothing had been done and those at the previous meeting 17 years before noted the same. Of note is that it has been 20 years now and counting, not that meeting did much anyway.

http://www.ruralmedicaleducation.org/images/Retention4.GIF These four graphics indicate that we have added lots of PC grads, but get decreased PC delivery per grad

We keep adding steps, lengthening the time in academic centers, and then claim more primary care when we have less. also note that the substantial reforms of the 1990s, barely made a dent in primary care delivery increases to stop the steady declines of past decades.

As a chemistry major I was not very good when there were multiple steps in the synthesis. With each new reaction my product yield got smaller and smaller. I was a much better teacher than I was a chemist.

The teaching pathways to primary care workforce are a real problem for primary care workforce.

Market forces training has totally failed with perhaps 10 - 20% of MD, DO, NP, and PA graduates entering primary care.

With some public assistance and some responsibility for the yield, the "quality" goes up as measured by 20 - 30% remaining in primary care.

But the problem is that the yield is far too low.

Historical standards - the Class of 1960 AMA Longitudinal study tracked graduates of primary care training and the survival curve indicated 50% remaining in primary care at retirement. The overall primary care was 71% for an entire career. Also the volume of primary care delivered was likely to be higher for a number of reasons. Activity in practice was also higher (male, more hours).

What do we have now - FM at about 75 - 80% for a career, PD beginning at less than 50%, PA beginning at 28% in primary care, NP - hard to tell as entry data is poor but about 33% would be a starting point for the first decade with lower in the last 17 years. Also all sources have increasing administrative positions with even higher levels in NP.

The problem is that there are too many stages in the pathway from entry into higher education until entry into practice.

And we have added the need for retention at every year after graduation for IM, NP, and PA - the most flexible primary care forms.

What would work?

Age 18 entry into basic health access primary care training
2 years of premed specific to health access preparation while working in a health access location
6 years of specific health access training similar to medical school and a primary care residency, although more specific to basic health access
10 years of an instate obligation for primary care delivery with 5 years in a most needed location determined by the state's primary care leadership and a second 5 years somewhere other than where primary care is sufficient

Fewer Steps

One entry point
One opt out point in the first two years for those not matching up (their call or ours)
One exit point at age 36 after providing more most needed health access than any current graduate of any source and school, and after providing the same primary care as a PD graduate or an FM non-citizen IMG, twice the primary care of an average US origin IM graduate, three to four times a current NP or PA graduate, and 5 times the non-citizen IM IMG graduate

And after the ten year obligation is over there are 28 - 30 years remaining in their career also likely to be health access after 18 years of selection, training, and dedication to such a career.

Longer years in a career
Primary care and most needed workforce during training
Nearly twice the primary care of an average US primary care graduate (only 6 and decreasing to 4 SPC years) during the obligation and all instate
Then much more remaining

But of course there are barriers as we separate preparation, admission, initial training, graduate training, short term obligation (if any), and subsequent voluntary choice to remain in primary care at all (each year) or to remain in most needed health access (each year) and the tendency over a career is to move steadily away from primary care and most needed health access.

And these steps and the accreditation process, and the funding for training, and the funding for primary care support - are all determined by panels that are 70% or greater hospital and specialty and academic.

Even those who do call for responsibility, accountability, and illustrate health access models make no headway as Butler found out (by permission of Academic Medicine) at http://www.ruralmedicaleducation.org/season_of_accountability.htm

Also the most productive years are dedicated to primary care delivery and health access as compared to primary care forms that enter age 38 and later.

Bob Bowman www.basichealthaccess.org

AACOM had a nice review by Eskew regarding the barriers to what we need http://www.aacom.org/events/annualmtg/past/2010/Documents/Eskew_Finding-a-Faster-Route.pdf

The info on Accelerated FM programs is not accurate My site has data representative of the national output, and discussions of the termination of this model that involve failure of primary care innovation support http://www.ruralmedicaleducation.org/short_and_sweet_accelerated.htm 150 grads were tracked by me from eleven programs, 3 years med school and 3 years FM residency, 40% rural (FM is 24%, US docs 10%), 19% high poverty (FM 15%, US docs 7%) - over 50% in various underserved areas at any given time 54% were four or more years older at graduation - maturation, previous life and health experience all committed to FM one year early indicating the impact of early focus on FM the Nebraska track continued at 4 to 5 per year and had 70% remaining instate in rural locations, the same as the Nebraska RTT programs, other Nebraska FM grads have about 40 - 50% rural but not the same instate rate.

The WHO Report on Rural and Remote Health also mistakenly noted that controls for origins, training, and career choices were lacking in workforce studies

Here is what various origins plus FM types of training accomplish in outcomes for the 1997 - 2003 FM grads

Birth Location	Rural % by Accelerated FM Graduate	Rural % by Usual FM Graduate
Urban	48.8%	15.7%
Large Rural	42.1%	35.5%
Medium Rural	63.6%	33.7%
Isolated Rural	87.5%	33.6%

		Urban Less than 75 docs, Poverty 19%	Rural, Less than 75 docs, Poverty 19%	All Rural by RUCA	Rural Less than 75 docs at zip	Major Medical Center 75+ docs at zip	Teaching Location (likely higher now)
Not Accelerated	20815	5.1%	6.3%	20.5%	17.3%	50.6%	3.2%
Accelerated	136	0.7%	14.0%	44.1%	42.6%	35.3%	5.9%
Control in Same Residency	587	3.1%	10.4%	27.9%	25.4%	46.8%	4.4%
Control in Same Med Sch and Residency	249	7.2%	8.8%	32.1%	26.5%	45.0%	3.2%
Same Med School Diff Residency	1026	4.2%	8.5%	28.1%	23.1%	46.9%	2.5%
	22813	5.0%	6.6%	21.3%	18.1%	50.1%	3.2%

How has education been key to your personal success?

info@hopestreetgroup.org — Thu, 15 Oct 2009 14:32:16 GMT

The Economic Opportunity Index shows us that education is a key driver of expected lifetime income. But success is more than a number. How has education has been an important part of your personal success story?

Your stories inform and enrich Hope Street Group's work, so please share them.

Draft Recommendations

info@hopestreetgroup.org — Fri, 18 Sep 2009 18:40:49 GMT

***Thank you to everyone for your comments! Please check out the Revised Recommendations.***

Team,
Congratulations! Your discussions and work produced a set of more than 50 evidence-based recommendations. Many thanks especially to the Team Leaders for their work pulling these together.

Hope Street Group has worked to pull those 50+ recommendations into a set of, currently, nine. The recommendations we merged for each will form the basis of the discussion for each recommendation within the report. So while the final recommendations will be broad, the report will include the more specific ideas and discussions that led us there.

Now is the time to comment on the recommendations. For each recommendation, you will find a link to a document that contains the “feeder recommendations.” Are the recommendations worded clearly? Are they targeted and focused or too loosely defined? Are the recommendations reflective of the team's discussions? Are the recommendations comprehensive? Do they cover an appropriate scope of issues related to teacher evaluation?

Driver: Teacher evaluation should be a meaningful part of a successful effort to provide all children with the education they need to succeed in the Opportunity Economy.

1) Multiple objective measures of student achievement must be a major component of teacher evaluation. (Recommendation 1)

2) Clearly defined standards of quality instruction should be used to assess a teacher’s classroom performance. (Recommendation 2)

3) Teacher groups and unions should be included in developing and implementing teacher evaluation systems. (Recommendation 3)

4) Teacher evaluation systems must be continually refined to improve the quality of measures and standards and to ensure fairness. (Recommendation 4)

5) Teacher evaluation systems should reflect the importance of supportive administrators and a positive school environment to effective teaching. (Recommendation 5)

6) Components of teacher evaluation that rely on observation and discussion must be in the hands of administrators or peers who have sufficient expertise, training, and capacity. (Recommendation 6)

7) Teacher evaluation must be tied to meaningful outcomes, including improving teacher performance through targeted professional development and opportunities for growth, supporting students in ineffective classrooms, and licensure and tenure decisions. (Recommendation 7)

8) Information from teacher evaluations should be comparable across schools and districts, and should be used to address equity in the distribution of teaching talent. (Recommendation 8)

9) States should be engaged in collecting and analyzing data, setting minimum standards, ensuring equitable access to effective teaching, and building capacity to continue to improve teacher evaluation. (Recommendation 9)

Why does the US tolerate primary care training that results in less than 30% of primary care graduates entering primary care?

info@hopestreetgroup.org — Wed, 21 Jul 2010 22:33:20 GMT

Why is the most reliable primary care source with 80% or more of graduates remaining in primary care (family medicine) and the one with the most consistent distribution to the elderly, poor, near poor, CHC, lower income, and middle income populations (Ferrer, Rosenblatt, Bowman, others), the one primary care source that has had zero growth of annual graduates since 1980 as compared to the 6% annual growth rate of NP and PA, the 2% growth rate of pediatrics, and the 1% growth rate of internal medicine - sources that result in only 15% to 45% of graduates entering primary care ?

Why are primary care sources with less to much less than a majority remaining in primary care, allowed to claim that they are primary care training and gain more funding for primary care even with less primary care graduates?

Standard Primary Care Years = Years in a career times % remaining in primary care times % remaining active times % volume adjuster

SPC is specific to the source of primary care and the class year of graduation

SPC is a future estimate of primary care delivery

The US has plenty of primary care graduates as only 14,000 annual permanent primary care graduates are needed to suffice past 2060, but the 25,000 current US primary care graduates are inefficient sources with lower to much lower primary care delivery per graduate.

SPC can be summed per class year and can be adapted to primary care for rural, underserved, or any population when the % rural, % underserved, or % found in any population is know.

FM = 35 years from age 30 - 65 x 80 - 85% PC x 80 - 85% active x 100% or top volume for FM or PD primary care for about 25 years

NonCitizen FM - 14 Standard Primary Care years

Pediatrics - 45 - 50% retention for about 12 - 14 SPC years

essentially few non-citizen PD

Medicine Pediatrics - who knows as 80% depart MPD in their first 10 - 12 years - probably about 8 or 9 SPC years and those remaining longest have the same schools, origins, and locations as family physicians

Internal medicine - 2 to 5 SPC years

US origin IM ranges from almost non-existent for graduates of elite schools and elite programs (some with consecutive years of no primary care entry in graduates) to an average of 3 - 5 SPC years with 20 - 25% primary care retention, 80% active, 86% volume, 35 years - senior IM residents are used for the primary care retention data, AMA data for the rest

Non-citizens that are 45% of IM graduates - lots of missing data (such as how many are really in the nation) but IMG non-citizen are known to have 7 - 8 years lost in delay in entry to get their residency program (23% of workforce lost prior to entry), 20% of graduates are lost to other nations, and 8% chronically unemployed (AMA IMG report) - ends up about half of the workforce of the US origin graduate - likely less productivity and studies indicate higher disciplinary rate - a function of many adjustments to make Because non-citizens are poorly tracked and often have primary care and underserved obligations, less is known in later careers. Bypasses of J-1 Visa obligations and uses as faculty are reasons to think that contributions will be lower. Primary care retention rates are not known to be different for US or international graduates according to IM sources (Louis Grosso) and the Masterfile has few differences although this is difficult to assess in the Masterfile.

IMG non-citizens are also stacked into the top US concentrations of physicians at the highest rates, similar to exclusive allopathic private medical school graduates. This is not a surprise as non-citizens are the highest status of their nations and have been born, raised, educated, and trained in top concentrations and they are shaped to top US concentrations which are the major places where they have lived in the United States before and during training.

Most primary care delivered per graduate - family medicine residency graduate

Second most primary care delivered per graduate - non-citizen FM and US origin pediatric graduate

All others less than 5 SPC years per graduate

In other words many more graduates are required for sources not FM or PD to reach the same primary care delivery.

Using summed primary care contributions from the six sources dating back to 1970, the US primary care graduate average began about 20 SPC years per graduate (all sources 70% retained then) and this has declined to 6 SPC years per graduate due to primary care retention declines. Another decrease is projected to about 4 SPC years per graduate by 2040 as primary care retention is already pretty bad.

Standard Primary Care Years by school

Using rates for FM, IM, and PD and school variations in office primary care rates, it is possible to estimate current primary care delivery by types of schools or individual schools

Top US schools 14 - 16 Standard Primary Care years per graduate (Duluth, some osteopathic schools used to be in this area) Mercer went from 14 - 16 (with top primary care, rural, rural underserved rates in the nation) to 4 due to declines from 32% FM to 8%

Osteopathic graduates 6 - 10, average about 8 - yes osteopathic primary care is declining as FM has gone from 70% to 35% by the 1990s to 18% now, but it is still twice the level of other sources.

Allopathic schools - about 4, or the same as NP or PA graduates or IM graduates 6 - 9 for public schools

Elite schools - 0.5 to 2 Standard Primary Care years per graduate

Because the primary care retention rate has declined more rapidly in IM, PA, and NP the Standard Primary Care year estimates for 2010 may be overestimates in these and slightly overestimated in PD and FM. No source of primary care has demonstrated steady increase in primary care retention to combat about 10 - 15 years of steady primary care retention decline.

Only the family practice MD, DO, NP, and PA distributes according to the populations in most need of primary care and only family physicians have remained in family practice mode. NP and PA have declined from 50% to 25% in the past 25 years. NP and PA workforce is moving hospital, specialty, and top concentration in location with the decline in family practice percentage as well as fewer SPC years per grad.

Educators, how do you measure student learning?

info@hopestreetgroup.org — Tue, 06 Jul 2010 12:22:04 GMT

We know that measuring student learning is essential to recognizing and responding to teacher effectiveness. (Want to know more about why teacher effectiveness and measuring student learning are so important? Check out the Hope Street Group policy team report on reforming teacher evaluation.)

Of course, educators measure student learning in their classrooms every day, using a wide range of assessments and responding immediately to feedback. But not all measures of student learning are reliable and comparable enough to be used for teacher evaluation.

So educators, tell us, how do you measure student learning in your classroom? What lessons can be learned from your classroom practice and applied to teacher evaluation policy?

Make yourself heard! Reply to this discussion by quickly and easily registering or logging in. You can even use your existing Facebook account.

What Would You Ask A Major Player in Primary Care Reform?

info@hopestreetgroup.org — Tue, 13 Apr 2010 20:08:38 GMT

On May 3, 2010 we will be hosting our first Bipartisan Working Group Dinner on Reinventing Primary Care. This dinner will be a “roll-your-sleeves-up” type session that brings to bear the tremendous knowledge base of our advisers to problem solve with project team leaders and devise credible paths of implementation for the Reinventing Primary Care Project.

We’re opening up an opportunity to all of our Policy 2.0 members to post a question that our Executive Director, Monique Nadeau will pose to the group. With that in mind, what would you ask a major player in health care reform about Primary Care?

You post, we'll ask, and then repost the responses.

To Get You Started:

- Log In/Register to Post Your Question

- Post Your Question

- Example Questions

Should people be paid to take medication?

info@hopestreetgroup.org — Wed, 16 Jun 2010 13:43:40 GMT

A recent New York Times article profiles monetary incentive programs designed to increase prescription medication adherence. Methods range from electronic lotteries, discounted copayments and monthly adherence payments for patients, through to paying pharmacists to help patients with adherence and paying doctors to prescribe medications. There is evidence that high levels of medication adherence can reduce hospitalization and lower all-cause medical costs - but is paying people to take their medication the right way to go?

Share a story about an important teacher.

info@hopestreetgroup.org — Mon, 12 Oct 2009 18:08:29 GMT

Most of us can remember a teacher who helped shape our identity and expand our horizons. I can remember the thrill of discovery during science experiments in Ms. Anderson's second grade class at my neighborhood elementary school, and now I can appreciate the hard work behind the scenes that went on to make those moments possible. Honoring teachers and recognizing excellence is key to informing our policy work in Education. Please share a story about a teacher or other educator who touched your life.