Community Partnerships: Going Beyond Curriculum to Change Health Professions Education*
Rebecca C. Henry, Ph.D., Michigan State University
Health care reform is a concept the American public has become accustomed to since the early 1990's. While most of this reform is targeted toward access, cost and workforce issues in healthcare delivery, there have also been numerous attempts to reform m m m medical education.(1,2) Private foundations, accreditation bodies, the Public Health Service and numerous professional associations have supported and financed specific reform efforts for undergraduate and graduate medical education.
In 1991 the WK Kellogg Foundation began a five year $47.5 million initiative to create seven linkages between educational institutions and communities to train health professionals. Known as the Community Partnerships in Health Professions Education (CPHPE) this program's goal is to enhance education by moving students out of hospitals and into community academic settings where clinical experiences are most relevant to primary care practice. The rationale for CPHPE is to create organizational structures that link academic health centers and the community. In the community based academic health centers, health professions students spend significant amounts of time in out of hospital settings. Health professions education thus moves from a culture of academia and hospitals to a culture of communities. The governance structures that formalize the community academic partnership generally exist as boards with representation from the academic institutions, the community centers where service is provided, and the consumers receiving those services. These boards oversee implementation and financing of the new models of education. Finally, the CPHPE model is built on the assumption that the essence of health professions education is less a matter of knowledge acquisition and more a process of socialization influenced by experience, professional setting and role modeling.(3)
The Seven Partnership Sites
The following excerpts (3) describe each of the partnership sites.
Georgia: Morehouse School of Medicine, in collaboration with Georgia State University's School of Nursing and Clark Atlanta University's programs in social work and allied health, has established partnership with five federally funded com m m mmunity health centers and clinics. Together with community representatives, these institutions have established the nonprofit Southeastern Primary Care Consortium (SPCC), which serves as the organizational body responsible for the program. The SPCC board is made up of seven representatives from the health centers and related organizations, nine (including the board chairperson) from the communities served, eight from Morehouse School of Medicine, three from Georgia State University, and two from Clark Atlanta.
Hawaii: The University of Hawaii has developed a partnership between its Schools of Medicine, Nursing, Social Work, and Public Health and four community health centers: the Waianae Coast Comprehensive Health Center, the Kalihi-Palama Health Clinic, the Queen Emma Clinic, and the Kakua Kalihi Valley Community Health Center. The university's approach to developing model, comprehensive, multidisciplinary care systems for teaching, service, and research is to strengthen existing clinics.
A non-profit corporation, Ke Ola O Hawaii, Inc. has been established to formalize the association between the University of Hawaii and the community health centers and to ensure community representation. A fourteen-member board guides the program. Board members include deans of the four health professions schools, a board member and administrative officer from each of the clinics, a provost from a community college, a state deputy director of health, and a representative from the physician community.
Massachusetts: The Center for Community Health Education, Research, and Services (CCHERS) represents Boston and Northeastern Universities, city government, communities, and ten community health centers. CCHERS has developed a comprehensive model of care, education, and research; it has reformed curricula in nursing and medicine toward community-based learning; it has empowered residents living in identified communities to address their own needs; and it has developed leadership among partners. A twenty-two-member board representing all of the partners governs CCHERS and determines policy for its overall efforts. Majority control rests with community representatives.
Michigan:Community/University Health Partnerships (C/UHP) is a cooperative effort in interdisciplinary health professions education between Michigan State University's (MSU) Colleges of Human Medicine, Nursing, and Osteopathic Medicine an n n nd Saginaw Valley State University's (SVSU) College of Nursing and Allied Health Sciences. In the underserved rural northern Michigan communities of Alcona, Atlanta, East Jordan, Hillman, Houghton Lake, and Roscommon, and in the urban environments of Muskegon and Saginaw, community health centers have been adapted to educate medical and nursing students in a collaborative environment that stresses primary, rather than specialty, care.
An executive board oversees C/UHP functioning; but in the northern Michigan communities and the Saginaw area, separate not-for-profit organizations have also been formed to establish and foster the growth of health professions education in their regions.
Tennessee:The Community partnership in Tennessee links the Office of Rural and Community Health - part of East Tennessee State University's (ETSU) Division of Health Sciences --- and ETSU's Schools of Nursing, Medicine, and Public and Allied Health. Through this partnership, ETSU has developed academic community health systems in two rural communities located one hour from its Johnson City campus. A wide variety of health and human service organizations have coalesced in developing com m m mmunity-based interdisciplinary educational experiences in schools, rural hospitals, mental health centers, private physician offices, industries, home health agencies, and nursing homes. A community-dominated governing board draws representation from community advisory boards and the deans of the three ETSU Health Sciences Colleges.
Texas:The University of Texas at El Paso (UTEP), Texas Tech University's Health Sciences Center in El Paso, and the Lower Valley Task Force, (made up of health care consumers and providers in El Paso's Lower Valley) established the El Paso Institute for Community Health. This program has created school-based academic primary health clinics in the school districts of Fabens, San Elizario, Socorro, and Montana Vista. The Institute's objectives are to provide opportunities for health prof f f fessions education, encourage health professions careers, develop a community-focused approach to health care, promote and coordinate community-based health research, encourage interdisciplinary collaboration, and develop a model program for linking commu u u unity health workers with community people.
The Institute has a twenty-three-member advisory committee made up of the county judge and representatives from UTEP,. Texas Tech, the Lower Valley Task Force, the city/county health department, the Lower Valley citizen committee, and the school districts.
West Virginia: The University of West Virginia System's (UWVS) seven health professions education programs located at Marshall University of Huntington, West Virginia University Health Sciences Center in Morgantown, and the West Virginia School of Osteopathic Medicine in Lewisburg are in widely divergent parts of the state. These institutions have collaborated with rural communities to transform primary care centers into rural academic centers for education, research, and service. They include three schools of medicine, two schools of nursing, a school of dentistry, and a school of pharmacy.
A joint governing committee made up of twelve community members and seven deans a policy-making body oversees the project. Community members represent minority groups (including women), business, industry, and labor.
While the ultimate goal of the Community Partnerships is to increase the number of suitably prepared primary care practitioners, there are many intermediate and supportive outcomes that reflect the breadth and depth of achieved change. Curriculum is of course, at the heart of the institutional change, however, there are other indicators that tell an interesting story of how institutions can alter many of the ways they do business.
Each Community Partnership created a governance structure of institutional and community members to oversee joint decisions guiding implementation and sustainability. One measure of a partnership is the extent to which decisions are shared. In the early years of the program all organizational structures were dominated by representatives of the health professions institutions. Five years later, all but one of the seven structures have a majority of community representatives; five of the seven have a community member as chair of the organization. Community is not wrestling power from institutions in regard to curricular and faculty decisions, but they are giving a very strong voice to community interest in these partnership models. Academic institutions and communities have experienced the risks and benefits of such a nontraditional arrangement. Giving up some control and power but gaining a broad base of program support appears to be a tradeoff many of the Partnerships embrace.
In describing Wright State University's partnership with the Dayton community, Maurana, and Goldenberg distinguish between "doing with" instead of "doing to" or "doing for"(4) Guided by the vision that more could be accomplished by working together, trust and team were central to community academic institutional partnership. Rather than duplicating community health initiatives, the University chose to work with community in enhancing the existing programs.
During the five years of the CPHPE our evaluation team has monitored trends and characteristics of Partnership leaders. Initially the project directors could best be characterized as positional leaders deans and vice provosts most commonly. Approximat t t tely two years into the program we noticed a different type of leader emerging. We labeled them "boundary spanners" as they were perceived by their constituents as having their allegiance to the partnership structure more than to a parent institution suc c c ch as nursing, medicine or social work. For the most part these leaders developed skills that allowed their boards to mature from fledging loosely organized boards to more sophisticated functioning partnerships. Initial findings from the leadership stud d d dy suggest successful partnership leaders engage in participative governance, build effective coalitions, evidence high commitment to the partnership and use a human resource approach in their leadership approach.(5) Further observations of leaders indica a a ates that the work of a single leader is giving way to broader leadership in which a core group of individuals representing different interests, give direction to the partnership.
Admissions and Faculty Multi- Students Curriculum Roles disciplinary Total 18 52 19 14 103
Institutional Policy Change
Policy changes made by the health professions schools are important indicators that the institutions are preparing to engage in long-term change. Institutional policies address the most important missions and functions of a school and ultimately define i i i its purpose. To describe the character of the policy change at the seven partnerships, the changes were divided into four broad categories those related to admissions and students, curriculum, faculty roles and responsibilities and multidisciplinary efforts. The number of policy changes across the seven partnerships is identified above in Table 1.
Admissions policies might include appointing a community health center faculty to the admissions committee or giving priority to an eligible student who resides in a targeted community. Curriculum policies are frequently aimed at modifying required core coursework to include experiences in a community health center. Faculty policies challenge old notions of what efforts and products may be used to build a faculty portfolio for tenure and promotion. Finally multidisciplinary policies are most likely to address ways in which different academic institutions can cooperate on shared course offerings, faculty appointments and service. Collectively, institutional policy change can reveal much about the organization's willingness to engage in meaningful reform.
After five years of challenging and exciting educational reform we have discovered that much of the real significant reform is not always measured in numbers of students and changed courses. For the Community Partnerships in Health Professions, education change has meant involving community in decisions about student experiences in and out of hospital settings and modifying traditional institutional policies. If academe is to be successful in providing a relevant curriculum for health professions student faculty and administrators must be prepared to examine many of our traditional roles and responsibilities.
1. Bulgar, RJ. Generalism and the need for health professional educational reform. Academic Medicine. 1995; 70 (1 suppl): S31-34.
2. Goldman, L. The academic health care system: preserving the missions as the paradigm shifts. JAMA. 1995; 273: 1549 - 52.
3. Richards, RW. Building Partnerships: Educating Health Professions For The Communities They Serve. San Francisco: Jossey-Bass, 1996.
4. Maurana, C. and Goldenberg, K. A successful academic community partnership to improve the public's health. Academic Medicine. 1996; 71:425-431.
5. Bland, C., Starnaman, S., Hembroff, L., Perlstadt, H., and Henry, R. Characteristics of leadership associated with successful curriculum reform. Manuscript in progress (available from the author).
Dr. Henry is a Professor in the Office of Medical Education Research and Development in the College of Human Medicine at Michigan State University. She can be reached via e-mail at firstname.lastname@example.org.
Henry C. Community partnerships: Going beyond curriculum to change health professions education. MEO 1996;1:4.