Utah has a CMS waiver which allows the DGME funds flow through the Utah Medical Education Council and pass to the GME sponsoring institutions.  The receipt of the GME funds is link to the accomplishing of workforce goals and objectives.  This demonstration project was described in a report by the Federal Office of Rural Health Policy written by Pat Taylor .  The report is available on the ORHP web site at: http://ruralhealth.hrsa.gov/pub/UtahGME.asp.

Rural Focus 

The Utah Medical Education Council (UMEC) addresses the needs of rural Utah in its workforce reports shown by profession and job board, and through the Rural Graduate Medical Education (GME) program.

Rural GME  

In 2005 the UMEC obtained a $300,000 legislative annual appropriation for ten years to develop and support rural GME.  Our first initiative is to develop 30 day rural rotations for residents in the following specialties: family medicine, general pediatrics, general internal medicine, OG/GYN, general surgery, psychiatry, orthopedic surgery, and anesthesiology.  Rural rotations in pathology and radiology will follow as the next priority.  After the 30 day rural rotations are solidly established, the Council will work to establish a family practice rural training track (RTT) and variations of the RTT model for other specialties.

The development and allocation of funds is overseen by the Rural Residency Advisory Committee.  For committee make up and membership click this link: Rural Residency Committee. The committee helps establish policy and direction for the development of the rotations and allocation of resources.   

When practical, the rotations will be offered within Utah, but for some specialties rotations outside of Utah may be the only feasible option for a quality rural experience.  For both in-state or out-of-state rotations, the UMEC does all of the front-end development work.   

For in-state sites

• An initial assessment of all rural communities was conducted to determine:
  • community interest in having resident rotate at the local facilities,
  •  willingness of facility administrators to support rural rotations,
  • willingness of physicians to become preceptors and adjunct faculty to the program,
  • specialties in which the local physicians are board certified and able to met the RRC requirements for accreditation,
  • educational objectives which can be accomplished at the site
  • housing options for residents and their family members,
  • other resources that the community might contribute to the success of the rural rotations.
• The assessment also identified hospitals, public health systems, community mental health systems, clinics and community organizations willing to help support rural rotations.
•  When there is strong community support, but no local board certified physicians, alternate arrangement may be implemented.  For example, when faculty from the GME sponsoring institutions conduct clinics or provide services in rural facilities one or more days per week, they may be recruited to serve as the local preceptor. 
• After the initial assessment, a sequence of steps is followed to maintain an orderly process and assure that requirements of the accrediting body and Centers for Medicare and Medicaid Services (CMS) are met.  These steps are further explained in the Handbook for establishing rural rotations developed by UMEC. (Handbook General Requirement)
• Once a site is identified as having the necessary commitment and resources to make a rural rotation possible for a specialty, the residency’s program department is responsible for getting the rural physicians appointed as faculty and for obtaining approval of the respective RRC for the inclusion of rural rotations as part of the program.  The UMEC is responsible for developing a Memorandum of Understanding (MOU) between all the parties partnering to make the rural rotations a reality.  The MOU details the respective commitments and responsibilities of each partner.  Two examples can be viewed:  Internal Medicine Sample Agreement and Psychiatric Medicine Sample Participant Agreement. 

For out-of-state sites

• The UMEC identifies programs which offer rural training experiences not available in Utah and visits them to learn if they would be willing to accept residents from Utah programs.  Also identified are: terms for an agreement, possible time frames and locations, and the financial resources that will be required. 
• The UMEC also works with out-of-state programs to encourage their residents to do rural rotations in Utah.   For residents who choose to do a rural rotation in Utah, the level of financial support provided by the UMEC is the same as if they were in a Utah residency program.

MEC financial support

            Support for the Resident

·        To encourage residents and their families to participate in rural rotations, the UMEC covers housing, travel and per diem.  This may include:

o       Housing costs for resident and family members at the rural site in the most appropriate setting available includes motels, bed and breakfast, leased houses or apartments.  

o       Travel costs incurred by the resident are reimbursed at the federally established mileage rate. 

o       Per diem costs for the resident are paid at the state established rates.

·        If family members remain in the urban site, the UMEC will pay meals, lodging, and mileage for them to make two trips to the rural site during the rotation period.  The goal is to give the resident and family as much rural experience as possible during the 30 day period.   

Support for faculty  

·        The UMEC pays for department faculty to travel to rural sites to participate in the assessment, consult with the rural preceptor and others who become adjunct faculty, review with the resident the educational objectives and how they are being accomplished, and seek ways to enhance the quality and value of the rural rotations in the total educational experience.

·        Rural preceptors may spend a few days at the urban center working with department faculty to establish communications, and build trust and a collegial base for enhancing the shared responsibility of providing an good training experience for each resident.  The UMEC will pay the following costs for the rural preceptors to enable them to take advantage of this opportunity: travel, lodging, per diem, and a replacement locum tenens physician to provide services and maintain the revenue stream at the rural site.  

Handbook and agreements

A guidebook which lays out the steps, and sample documents required to establish a rural rotation is provided to each residency program director and the rural physicians and facility administrators.  This helps ensure that accreditation requirements are met and that CMS and Fiscal Intermediary audit documentation is in place to substantiate eligibility for GME payments.  

A Partnership Memorandum of Understanding is also prepared for each site for each residency program that has rotations at that site.  This document sets forth the educational objectives to be accomplished during rotations at the site. It also identifies what each party will do to facilitate a successful rural rotation and who must report what, when and to whom to assure that evaluation and feedback is obtained.   An example can be viewed by clicking Partnership Memorandum of Understanding: Internal Medicine and Psychiatric Medicine.

Faculty development and support

Few local physicians have had experience being preceptors for GME.  Many are concerned that mentoring a resident will negatively impact their practice by reducing both the number of patients seen and the associated revenue stream.  To help local physicians become more effective preceptors, the UMEC offers precepting assistance from a faculty mentor who is a teacher of residents with many years experience.  The link "A Syllabus for Community Preceptors" shows the range of training topics offered to rural faculty.  Additional topics and options will be provided if requested by rural preceptors.  This wide choice of topics helps ease the concerns of new preceptors and makes the process of learning pedagogical skills more user friendly.

The methods for mentoring preceptors are still being refined.  At present the following is being provided:

• The faulty mentor conducts at each rural site at least one interactive discussion about precepting before arrangements at each site are finalized.  During this session the principles of adult learning are reviewed.  A few examples of key concepts are presented.  The most frequently asked questions and topics of concern are raised and a few ideas about ways he and the UMEC may assist the rural preceptor are offered.  This promotes a partnership for developing the best educational experience possible for residents doing rural rotations.
• Face to face sessions are offered at the rural sites any time convenient to the rural physician or group of physicians.
• The local preceptors are given the contact information for the faculty mentor and UMEC so they may request materials on any precepting topics.  They are also offered telephone consultation with the faculty mentor after the materials are reviewed. 
• The development of marketing materials is being worked on.  These will be emailed to the rural preceptors and other physicians who may in the future serve as preceptors.  These will be brief messages that review some of the concepts and offer suggestions on ways to be an effective preceptor and at the same time reduce the impact on the practice’s operations from having residents in training in the practice setting.
• An annual retreat for adjunct faculty has been requested by some of the rural physicians and is being developed.  This may be offered in three or four rural locations to cover the geographic regions of the state.  Costs associated with the retreat will be paid by the UMEC.  
• Rural faculty physicians are encouraged to spend a few days in the residency program’s department interacting with faculty in a variety of settings such as attending lectures, observing regular faculty in the precepting role, and refreshing tutoring/mentoring skills.  The costs for the rural physician to do this are paid by the UMEC.  Some of the benefits of having rural preceptors spend a few days at the program are:

·        Rural physicians become known to the residents and a relationship is established prior to the local rotation.

·        A collegial relationship is established with the department which enhances communication and interface between urban academic and rural practicing physicians.

·        The rural physicians are viewed as a key part of the educational experience to be provided to residents.