Current Status of the Program:

• The Nebraska SEARCH Community Connections program has trained 20 - 40 students each year since 1995. The students have been placed in over 20 different underserved communities including migrant centers, community health centers, and rural communities.

• The current locations include: Broken Bow, Callaway, Chadron, Charles Drew Community Health Center in Omaha, Indian-Chicano in South Omaha, Panhandle Community Services in Gering, Columbus, Lexington, Macy, Winnebago, O'Neill, Ord, Pawnee City, Rosebud SD, Tecumseh, and West Point. Community Health Centers, Tribal Reservations, Community Action Agencies, Extension groups, state agencies, hospital administrators, and physicians have facilitated projects

• As of September, 1995, students in the program have prepared over 50 participated in 10 needs assessments and helped groups and communities in a number of ways. These include multiple grant awards, certifications, health prevention projects, and collecting and disseminating information on community resources such as mental health, AIDS prevention and treatment, and other preventive health projects .

• Faculty work with Community Connections resulted in a National Health Service Corp Award of Excellence for the program in October of 1995.

• Preliminary analysis of evaluations by the communities has been excellent. Hospital administrators have universally benefited from the program through increased contact with leaders in the community, better public relations, increased understanding of health needs, grant applications, and general reassurance about their future direction.

• The program is still dependent on federal funds. It has obtained limited funding from non-NHSC sources. Communities have provided projects, room, and other support in most cases. Decreases in NHSC funding would result in fewer students and the program would need to be consolidated into another program or the curricula of health professions schools to continue at its current level. 

 

What Has Been Learned:

• The communities have been very supportive of the efforts of the students.

• The training of the students was brief  with the main orientation and training provided by the communities. Expertise from the academic centers was helpful in many projects. Site visits before, during, and after have been critical components. The major determinate of the project has been the quality and skills of the student and the local contact. Younger students (just before entering health professions school) have had a more difficult time adjusting and have fewer skills. This can be addressed by pairing the student with other more experienced students and project selection. The hope is that younger students can be influenced more by the early contact to community service and early orientation to the underserved. 

• Care has been taken to insure that the communities actually received results and the results remained confidential. Many communities have been studied by other programs or personnel in the past and some have been frustrated by having not received the results of studies. Having the primary location at the site has helped in this process.

• Communities often have very helpful internal resources such as librarians, extension personnel, health administrators, utility employees, and others. The local newspapers have provided coverage in many cases, assisting greatly in the project progress as well as community acceptance for the student and project. 

• Communities were often not prepared for students to work on projects. From previous experience, many expected the students to have a project and were not ready with the project, despite the site visits and other contacts by faculty. It seemed as though they were so used to outside intervention without their participation, that they took on a passive role. Others planned a clinical experience, even though instructions directed them elsewhere and providers were not well prepared for clinical emphasis. After an initial delay, most communities were able to utilize the students well. This may also be a function of the selection of underserved sites who may be so busy that new efforts take a back seat to more essential functions. Keeping sites and contacts for several years has greatly facilitated the quality of the projects.

• Students enjoyed the interaction with the community and the contact person, often to the point that they did not leave enough time to do their reports.

• The amount of funding for the students allowed only three to four weeks of work. A longer period of time would have allowed more interaction and more project work.

• Students can be too busy to do their best in the projects. The summer of the first year of medical school is often very busy with students working one or two jobs, getting married, moving, or doing other training. PA students have very little free time available for project work. Nurse practitioner students can often make money in other areas or else they have family responsibilities. In later years, students have been asked to face reality regarding their summer plans.

• Some sites require "kid glove" approaches with community, tribal, or health center leaders to avoid causing problems for students, faculty, and the institution. Contacts have to be carefully selected and site visits and frequent contacts have been critical. The more mature students are a better choice for such locations. It is very important to know the "informal" leadership in such locations.

• Some sites could not be used due to turnover of administrators or providers, often with little warning. Others reduced the number of students, causing turmoil as the coordinator scrambled to meet student needs.

• It is difficult to predict the student component of the grant budget. Students might use all or only some of their allotted funding. Last minute applications can overwhelm the funds and drop outs can result in extra funds.

• Students on clinical rotations are not be able to utilize the program well on a part time basis as they are often busy on rotations. For actual project work for clinical students, a full time elective may be a better choice.

• Reports were often slow in coming and some needed revision although communities had already benefited from the effort and the early information from the project. Requiring the projects to be completed before the stipend was paid reduced this problem significantly.

 • The institution required that the students become employees and this resulted in federal withholding and FICA costs, not anticipated by the program.

Plans:

• Pursue alternative sources of funding to ensure the continuation of the program as well as increasing the "buy-in" and the utilization of the students by the communities. The program plans to use remaining funds to bring community contacts to an annual rural association meeting to get feed back and provide training. Students and graduates can return to add to the process.

• Having communities buy-in with funds should help their local participation and buy-in. This should result in better preparation on site, especially for communities that participate in the training. This could save an initial slow week for students.

• Students would be encouraged to return to their initial sites for a second year where possible.

• Government funds would be matched with community funds.

• Training would also involve a day or two of local contact in an underserved population, preferably with community people. Seeing the health needs of different groups or populations helps to illustrate local needs as well.

• The Project will look closely at the impact of the program to see if students at earlier stages benefit more than those at later or clinical stages.

• Improved communication and preparation and improved organization and delegation at the sites could assist tasks such as report writing by assigning the tasks ahead of time and continually working with the student responsible for the final report.

• Site contacts at critical times could improve the program. The week before and after the student begins are important to preparation and utilization. Expectations can be verified and communicated.

 

For the Future:

• Developers should continue to work with communities who can most benefit from the program. The near future could prove difficult for medium and small rural communities as well as underserved urban ones.

• The program could involve more key local leaders such as extension, county and city government, school officials and teachers, hospital board members, and others. Efforts with local high school or college students and teachers could facilitate interactions between them and local practitioners and health administrators. Community work can be done by high school and college students to add to the potential resources of the project.

• The project demonstrates much promise in meeting the needs of communities, the state, and students. The program should examine various sources of funds to enable the program to be offered to all interested health professions students.

• The program should continue to coordinate or originate ongoing interdisciplinary and project-related courses at UNMC. This work includes offering interdisciplinary training classes on the community approach and informing students about courses such as Medical Spanish. The program should continue to distribute information about community needs and projects and support student organizations that support the community approach to training and practice Students for Rural Health. Others that could use the support and benefit from Community Connections include Global Outreach, Doctors Ought to Care, Christian Medical and Dental Society, the Rural Physician Assistant Group, and the Family Practice Interest Group.

• If evaluations look promising, Community Connections could be in a position to impact on the admissions process to health professions training. Admissions tests, grade point averages, and brief interviews have never been sufficient to evaluate candidates for their willingness to learn or to serve. As a demonstration, the program could be offered to students just after they have been accepted to health professions training. The data phase would begin as information would be gathered to see which students show interest in the program and who actually participates. In future years, the data would be used to compare the community-oriented population of students with health professions students as a whole to see if predictions can be made regarding those who choose primary care or those who choose to serve rural or underserved populations.

The developers of any health education program for the State of Nebraska must take into account the strengths and weaknesses of the State's Health Systems. Innovative health professions training programs can take advantages of these strengths and address some of the weaknesses. The National Health Service Corp's Community Connections is in an excellent position to impact on health professions education and improve the health of people in the state.

Strengths at UNMC and Nebraska:

• These include an emphasis on education at the state and community levels in all geographic areas, providing a good foundation for health professions training.

• Another strength is established rural community rotations for health professions students. Physician assistant, nurse practitioner, and medical students and family practice residents train in over 70 sites across the state.

• The rural career goals of many students are reinforced by loan and scholarship funds.

• Nebraska is a leader in the nation in special entry tracks for health professions training. It accepts rural-interested medical and physician assistant students early, supports them throughout, and provides specialized preparation for key need areas such as rural practice with programs such as Rural Training Tracks that train family practice residents specifically for rural practice. The physician assistant and family nurse practitioner programs have similar rural emphasis and training.

• The primary care emphasis in training programs continues to be a real strength.

• The primary care departments connect to each other, the state health department, and many communities in the state. Although Nebraska has no Area Health Education Center, it does have the Rural Health Opportunity Network with its hubs and spokes approach.

 

 

Challenges for Health Education in Nebraska:

• Public health expenditure is far below average when compared to other states. This is particularly a problem for rural health systems. One state recruiter attempts to service over 60 rural hospitals and other underserved sites.

• Nebraska ranks second in the nation in counties of less than 10,000 that still have a doctor and a hospital. These are the systems most threatened with survival, the ones that have the most difficult time recruiting and retaining practitioners. Many of these are essential service areas due to the need for emergency services and to provide service for the most elderly patients who cannot or will not travel to more distant towns for care. Current proposals in Congress could close 10-20 of these hospitals with some loss of access to health service and the loss of many needed jobs.

• The state has only two Community Health/Migrant Health Centers, Charles Drew in Omaha and Panhandle Community Services in Scottsbluff. Rural health clinics have fared well so far, but changes in reimbursement could hurt them in the near future.

 

 

• A concern is failing economies in many rural communities. Several underserved rural and urban communities are not well-organized, especially in the area of health services. Few have planned for the future. The end result is that many are not prepared to contact likely practitioners, much less attract them for an interview or offer a relevant contract. One frustrating result is that students who have been selected and trained for rural areas often leave the state to choose rural practices in other states. Because of some recent grant funding, the state is improving in its ability to assist communities in organizing more effectively, but the continual changes in state and federal programs continue to challenge rural health systems.

• Other challenges include the skewed eastern distribution of population and services, rapid increases in migrant and hispanic populations in several small rural communities (where there are fewer educational, social, or health concerns), increasing numbers of teenage pregnancies, and the increasing needs of the disabled elderly.

 

 

• Major changes in reimbursement and the reorganization of health care already are having an impact on the willingness or capacity of practitioners and providers to provide education on a voluntary basis. Students can have some positive impacts that will need to be illustrated.

• The future of rural health education will continue to be affected by the lack of opportunities for advanced training. The presence of two medical schools and multiple graduate medical education programs in one town (Omaha) dilutes the experience and reduces the potential for trainees to actually care for patients and do procedures. Often the advantage of rural sites for training is not so much the site as it is the opportunity to actually deliver health care to patients.

• Educators face the difficulty of carving out more time from curriculums that are already overloaded. The physician assistant students have no time for an extra month. Medical students can participate in some programs between their first and second year, but many hope to earn some income during this time period. Medical education has advanced to producing graduates that have a better potential for improved doctor-patient relationships, but at great cost to certain educators. The effort to focus on population-based medicine and seeing the community as patient would need significant institutional leadership and resources.

• Any program that attempts to add a new perspective to an established curricula such as medical education must deal with the socialization process. Medical training starts with molecules and move up to diseases and therapies. Prevention, epidemiology, and addressing the needs of populations has little priority in the minds and hearts and time of students. Much of this training is rushed and impersonal, often demonstrating calculations and statistics which cannot capture the attention of students.

• There are few formal interdisciplinary efforts at the health professions schools.

 

 

 

No program could deal with all of the requirements of a grant and address all of the areas noted above, but the Community Connections program offers several opportunities for working in many of the above areas. Whereas NHSC Fellowships in other states have established clinical rotations in underserved areas, the Nebraska program takes full advantage of the rural preceptor sites with their established housing and contacts. It is thus well-positioned to take community rotations to a new level. Students are mainly located in Omaha and are close to underserved populations in various parts of the city as well.

Opportunities for the Program:

• The literature on recruitment and retention indicates the potential for health professions training programs to influence students to choose primary care as well as rural and underserved practices by involving them in the community (Pathman, AMSA HPDP, Appalachian Preceptorship, WAMI RUOP, MN RPAP). For many years, faculty have noticed this impact on students who trained in certain locations or with certain practitioners who took the time and effort to accomplish this. Although no formal study documents the results of such labors in the state, efforts to increase health profession student involvement in rural and underserved communities could provide long term benefits. This may be even more important for Creighton students who often come from outside the state and could be enticed to stay here are relieve workforce shortages.

• Students have acted as technical assistant workforce (public health infrastructure) to assist communities with planning efforts regarding health services. This fits a real need in Nebraska by extending and expanding existing resources out to communties. The training and community involvement benefits the students by broadening their perspective, helping them to understand the roles of various health providers in the community.

• Student work benefits the community by providing much needed information. With this information, communities could pursue health interventions, address the root causes of health needs, or apply for grants to address those needs. Rural communities often have little baseline data collection and this can inhibit innovative efforts at rural sites.

• Practitioners benefit from reduced frustration as they have assistance in helping the community to address health concerns that they experience first hand. Without student help in this area, practitioners are usually so busy delivering health services that they cannot assist with planning, prevention, or helping the community to utilize them more effectively.

• By choosing students earlier in their health professions training, or even before it begins, students may be able to recognize the importance of dealing with community level interactions. With the expansions of managed care and the challenge of meeting health care needs with fewer resources, health professionals of the future must recognize that their responsibilities include regarding communities as patients also.