Key Messages Identified by Individual Speakers and Participants
- The growing popularity of community colleges for education—both in the United States and globally—represents an opportunity for introducing interprofessional education (IPE) to students, health workers, and health professionals. (Meyer)
- It is a responsibility of faculty who are working in student-engaged volunteer clinics to publish research and outcome data so others can learn from their successes and failures. (Kolasa)
- Improving communication between law enforcement and health providers through a common curriculum could benefit the health and welfare of communities. (Adams)
- Meeting the needs of people and communities might be considered a primary goal of health professional education. (Cox, Palsdottir)
The second day of the workshop focused on outcomes of interprofessional education (IPE) in and with communities with the ultimate goal, as Newton put it, of improving outcomes in communities. He then introduced Afaf Meleis, Co-Chair of the Global Forum on Innovation in Health Professional Education, who would be making some personal observations about how to improve community outcomes. In his introduction, Newton recollected asking Meleis how she became interested in IPE. And while
she admitted there are many routes for one to be engaged in IPE, for her, a major influence was work she did at Linköping University in Sweden, where she assisted in developing a new health discipline called the caring sciences. With almost 3 decades of experience in IPE, Linköping University’s Faculty of Health Sciences employs a problem-based learning curriculum that integrates theory and practice and makes community orientation and health promotion key concepts for learning (Linköping University, 2011). Their integration of future doctors, nurses, and caring science professionals is what helped Meleis to really understand the potential and excitement of a new way of thinking about care.
WAYS TO IMPROVE COMMUNITY OUTCOMES
Afaf Meleis, Co-Chair, Global Forum on Innovation in Health Professional Education
According to Meleis, outcomes and effects of community-based involvement come in many forms, and her remarks were an attempt to broaden the workshop participants’ thinking about outcomes. Meleis acknowledged the importance of community-based involvement of learners, educators, and health professionals for obtaining improvements, but she added that outcomes and effects of community-based involvement influence and impact research as well as health professionals’ practices. To explain her thinking about how research affects community outcomes, Meleis cited two examples from her own experiences.
University of California, San Francisco
The first example involved her work at the University of California, San Francisco (UCSF) that started in the 1970s. At that time, she and others were beginning to recognize the lack of culturally competent care at health facilities. Having been born in Egypt and educated in various schools in Egypt and the United States, Meleis was singled out as the consultant for health care professionals caring for Middle Eastern immigrants. She and her colleagues quickly realized the lack of culturally competent care given to immigrants in the United States. According to Meleis, one cannot discuss community-based education/practice outcomes without also discussing culture.
Through her consultancy, Meleis came to realize that immigrant populations from the Middle East have not been identified as a group needing special kinds of care and culturally competent care, and that little knowledge existed about this group. To address the gap, Meleis and her UCSF colleagues developed the Study of Immigrant Health and Adjustment (SIHA).
SIHA means health in Farsi and Arabic, which resonated well with their target community who spoke these languages.
Meleis began by inviting students and faculty to participate in developing a framework for culturally competent care. One outcome that came from this effort was that immigrants from Middle Eastern countries became defined as a minority group. By designating them as minorities, they became eligible for special funding for care through the mayor’s office and then by the governor’s office. Another outcome was that care for this immigrant population became sustainable. To create sustainability, Meleis’s office took on new roles as a referral office, as a health assessment office, and as an advocacy office that helped Middle Eastern immigrants navigate the health care system. Much of this work was undertaken by students, so another outcome Meleis acknowledged was the experiential learning of students whose introduction into community education actually involved providing care. In addition, this work provided a variety of research opportunities for Ph.D. candidates on such topics as pain management, hypertension, exercise, and sociological activities and behaviors of this unique population. In total, 33 dissertations came from the office Meleis and her colleagues set up at UCSF. The final outcome Meleis noted was to increase the published literature about the population.
University of Pennsylvania
The second example was from her work at the University of Pennsylvania (Penn) School of Nursing. In setting up her remarks, Meleis noted there was an aging population in West Philadelphia that required intervention to keep them at home as long as possible for social and financial reasons. She described developing a program called LIFE (Living Independently for Elders), based on the Program of All-Inclusive Care for the Elderly (PACE) program from California, which was taking care of Chinese immigrants. Meleis pointed out that, again, the product drew from work with immigrant populations.
The LIFE program in Philadelphia is owned by the Penn School of Nursing (http://www.lifeupenn.org). In that program, 430 elderly people in West Philadelphia receive care to prevent them from being institutionalized. The program staff administers to all their clients’ health care needs, including their nutritional and cognitive requirements, as well as their transportation to and from the center in 1 of the 22 center-owned microbuses.
Outcomes in this example focus on training and research. The center provides opportunities for multidisciplinary and interprofessional training for 400 students. Additionally, there are multiple research projects going on simultaneously at the center that, once published, are translated by the
Ruth Lubic: Nurse Midwife, Educator,
Administrator, Crusader, and Advocate
Ruth Lubic stated that the Developing Families Center in Northeast, Washington, DC, is the third freestanding birth center in which she has been involved. The first one, sponsored by the not-for-profit Maternity Center Association (MCA), was located on 92nd Street in the Carnegie Hill section of Manhattan. According to Lubic, that center did not attract low-income people, so she and her MCA colleagues opened the Morris Heights center in the Southwest Bronx. After receiving the MacArthur Fellowship award, Lubic took what she learned in the Bronx and decided to try to open a clinic in the city with poorest birth outcomes in the country at that time, as well as a poor education system—Washington, DC. She wanted the clinic to provide not only birthing services but also social supports and early childhood education to the members of the community.
Lubic networked for 6 years before opening the DC Developing Families Center in a building and on land donated by a local businessman, John Hechinger, Sr., through Hechinger Enterprises in Ward 5 (Northeast DC). After opening
faculty researchers into practice. In this way, the published faculty research does not sit on shelves but is translated for use out into the community, which connects education to care to communities.
Meleis closed by reminding the participants of the broader focus of outcomes stemming from work and education with, from, and within communities. This led to her introduction of Ruth Lubic, who at the age of 87 continues her life’s work on improving women’s health outcomes through midwifery care. According to WHO (2014), roughly 800 women die every day from preventable causes related to pregnancy and childbirth. Meleis pointed out that the estimate includes not only developing countries in Africa and Southeast Asia but also developed countries where pockets of poverty and poor access to health care exist today.
That is why Lubic—a nurse midwife, educator, administrator, crusader, and advocate—has spent decades working tirelessly to find ways to help low-income pregnant women connect to the prenatal care they might oth-
the clinic in 2000, Lubic began collecting data that showed that between 2003 and 2005 rates for Cesarean sections, preterm birth, and low birth weight all decreased in the African-American population served by her birthing center (RWJF, 2010). She estimated that the clinic saved the health system more than $1 million.
Lubic’s goal was to prove that through good midwifery practice, such centers could improve outcomes and strengthen families in poverty-stricken neighborhoods. The DC Developing Families Center demonstrated that this was in fact possible. But the true outcome of success for Lubic was that although the clinic was in one of the most dangerous areas of Washington, DC, the clinic remained without graffiti and was never broken into. The reason is that members and leaders of this DC community viewed the clinic as their own and made sure no harm came to the building where the work took place.
Lubic explained that because of the community connection at the DC Developing Families Center, the center has had success in recruiting members of the community into the health professions, specifically nursing and midwifery. Lubic has seen several women who came to them as clients continue on to get their GEDs and go into nursing. Because of their positive experience at the birthing center, women modeled what they wanted to do for their careers on what they saw and how they were treated at the center.
Although the clinic does provide education to some students who seek to learn in Lubic’s community-based midwifery clinic, there are too few, according to Lubic, who would welcome the opportunity to establish a more formal academic connection. When asked to provide advice to learners seeking to better engage communities, her response was simple; she said, “I think you need to take the time to do it, and when you do, make the community your friend.”
erwise not have received. This is where Lubic has had the greatest impact. In 1983, she cofounded the National Association of Child-Bearing Centers. From there, Dr. Lubic ignited a movement and established more than 200 freestanding birth centers across the nation and the world, serving families at all social and economic levels. Lubic was honored for her work by the membership of the Forum at this workshop (see Box 4-1 for a summary of some of Lubic’s remarks).
OPPORTUNITIES FOR IPE IN COMMUNITY SETTINGS
Also on day 2 of the workshop, members of the Forum and other workshop participants gathered in one of three rooms to hold focused discussions on increasing the number of available interprofessional, community-based learning experiences, which for the purposes of the workshop was called “scale-up.” They also considered how interprofessional experiential learn-
ing might be “spread” to include more professions interested in serving and helping marginalized or vulnerable communities.
The first two groups looked at spread and scale-up of successful community-based, IPE programs, while the third group considered a new opportunity for community-based, experiential, interprofessional learning. Each group had a leader who was assisted by at least one person who could provide greater context around the innovation. The three groups were
- Community colleges: A model for spreading community-based IPE
- Scaling up community-based, interprofessional, faculty-run and faculty-assisted student-run clinics
- IPE: Preparing law enforcement and health professions together
For each of these innovations, workshop co-chair Warren Newton from the American Board of Family Medicine asked the leader of the group to present one innovation within their prescribed area of community education to the larger audience. He was most interested in learning what each leader felt was important to spreading and scaling up of their innovation.
Next, Newton asked the group leaders to explain (1) how their innovation works; (2) when possible, what might drive a successful spread and scale-up of the innovation; and most important (3) how the innovation might be sustained. For the third question, he requested that the leaders address the opportunities and challenges of each innovation. The following are the reports from each of the group leaders to the participants of the workshop. These comments are a summary of the group discussions presented by the group leaders, and they should not be viewed as consensus.
A Model for Spreading Community-Based IPE
Leader: Donna Meyer,
National Organization for Associate Degree Nursing
Assisted by: Poonam Jain,
Southern Illinois University School of Dental Medicine
Forum and workshop planning committee member Donna Meyer is the Dean of Health Sciences at Lewis and Clark Community College and the president of the National Organization for Associate Degree Nursing, which represents roughly 945 community college nursing programs in the United States. She led the breakout group on community colleges and their
untapped potential for spreading and scaling up interprofessional health education. Her views about the discussions that took place were then presented to the workshop participants and began with Meyer describing the value of community colleges.
Value of Community Colleges
Meyer explained that almost half of all undergraduate students in the United States are enrolled in a community college (AACC, 2014). Often considered the gateway to higher education for low-income and minority students, community colleges are deeply rooted in many communities through tax dollar support. In fact, health professions often rely upon community colleges for continuing education and for training of the health workforce. This is particularly relevant for nurses, for 60 percent of the nursing workforce begin their education through 2-year community colleges (RWJF, 2014).
A Model for Community College IPE
The growing popularity of community colleges for education—both in the United States and globally—represents an opportunity for introducing IPE to students, health workers, and health professionals. However, as Meyer pointed out, few community colleges take advantage of this opportunity. The Lewis and Clark Family Health Clinic is one exception. Since the clinic’s inception in 2006, the Lewis and Clark Community College’s School of Nursing has been pursuing IPE within its on-campus, community health clinic. The clinic has been steadily growing in size and scope and now includes students and providers from nursing, occupational therapy, exercise physiology, dentistry, and mental health. In her breakout session, Meyer drew upon lessons learned from this robust model of IPE—at a community-based clinic on the campus of a community college—to consider how IPE in this setting might be spread to more professions and scaled up to more geographical locations.
Meyer began by describing her desire in 2006 to establish an interprofessional community-based clinic and her concerns over the lack of clinical sites for placing her nursing students. At that time, Lewis and Clark had a health services clinic, staffed by two registered nurses, that was somewhat limited in health issues it could address. Meyer approached the president of the college with an idea for transitioning the health services clinic into
a nurse-managed center. The president became a strong ally and supported Meyer in her attempts to get such a clinic funded.
Meyer secured a grant from Health Resources and Services Administration (HRSA) to start what is now a robust, nurse-managed center providing health care and supervised student experiences to a variety of different learners for experiential, interprofessional education at a community college.
Lewis and Clark Family Health Clinic
The clinic is open to the community and serves between 10,000 and 12,000 patients each year. It is operated by three nurse practitioners, two of whom have faculty practice arrangements that allow them to teach while maintaining their clinical skills. One nurse practitioner works full-time in the clinic along with two registered nurses and two administrative staff people. The state of Illinois requires that its clinics have a collaborating physician, although the physician does not have to be on-site and does not monitor their patient records. It is structured so that if one of the nurse practitioners has questions regarding the management of a difficult case, the physician will be consulted.
In keeping with the mentality of accessibility of community colleges, Meyer wanted to ensure that services at the Lewis and Clark Family Health Clinic were accessible to the community. In this way, the clinic accepts public and private insurance and keeps out-of-pocket costs for services very low.
According to Meyer, 285 nursing students rotate through the clinic, but all of their students work collaboratively. Learners from dental hygiene, nursing, occupational therapy, exercise science, and on certain occasions (like health fairs) emergency medical technician students join the collaboration.
Lewis and Clark Mobile Health Unit
Like the health clinic, the Lewis and Clark Mobile Health Unit serves the communities of Southern Illinois. Meyer was assisted in her small group session by Poonam Jain from the Southern Illinois University (SIU) School of Dental Medicine, who explained the interprofessional work of the mobile clinic to their breakout group participants. The mobile unit has two private rooms, a reception area, and space for patient education. It is staffed by dental hygienists and nurse practitioners and provides interprofessional experiential learning to nursing and dental students from the Lewis and Clark Nurse Managed Center and College of Nursing. It is set up to pro-
vide a variety of preventive dental and health services like blood pressure screening and routine cholesterol or glucose monitoring (Lewis and Clark Community College, n.d.).
The community-based educational innovation Meyer reported on was community colleges. Her reasoning was simple: community colleges are embedded in the community, are taxpayer supported, and draw their board of trustees from the community. More specifically, her innovation leverages community college–based health clinics for IPE. As far as Meyer knows, the Lewis and Clark Family Health Clinic is the only one of its kind offering experiential IPE at a community college.
Opportunities and Challenges
Meyer identified a number of challenges to scaling up the model she presented. These include collaborations with universities, understanding IPE, economic viability, turf battles, leadership support, and accreditation.
Collaborations with universities Improving collaborations between universities and community colleges was cited by Meyer as a challenge and an opportunity. Her very positive experience with SIU may be an exception to what can be major barriers owing to the physical separation between campuses and the academic “cultural” divides between the two educational systems.
Understanding IPE Faculty who truly understand IPE are better equipped to provide educational experiences that are not simply putting different health professional students in a classroom together for lectures.1 Meyer believed this could be facilitated through faculty development efforts.
Economic viability Meyer said that often administrators are looking for a monetary profit or demonstration that an intervention saved money, which can be difficult for clinics such as hers that are open to the community. One advantage Meyer pointed out about nurse-managed centers is that, from her experience, they are less expensive and therefore more economically viable than other more expensive models, and thus more sustainable. In
1 See the Institute of Medicine workshop summary Interprofessional Education for Collaboration: Learning How to Improve Health from Interprofessional Models Across the Continuum of Education to Practice for information about interprofessional education (IOM, 2013).
this regard, her nurse-managed clinic may be particularly attractive when considering scale-up.
Turf battles At a previous workshop addressing professionalism, the workshop participants identified turf battles as struggles over who gets paid or reimbursed for their work (IOM, 2014). Meyer pointed out that such battles still exist.
Leadership support Meyer felt strongly that buy-in from the presidents of the universities and community colleges is extremely important and was key to the success of her program. In addition, faculty development and getting faculty support are also important.
Accreditation Meyer noted the extensive discussion that ensued in her breakout group over the issue of accreditation. Accreditation is a process that, in the case of The Joint Commission, aims to assist organizations in identifying and resolving safety, quality of care, treatment, and service issues (The Joint Commission, n.d.). To maintain their accreditation status, organizations must comply with the standards. For example, the Accreditation Council for Pharmacy Education is now including IPE as one of their educational outcome standards (ACPE, 2014). However, as was brought up by a participant in the breakout group, even if IPE is part of an accreditation standard, such a requirement does not necessarily translate into an institutional culture of collaboration.
In closing, Meyer repeated that as far as she knows, Lewis and Clark is the only community college in the United States to offer an interprofessional, community-based educational experience. Her students learn clinical skills while truly engaging with other professions in the clinic.
Knowing the extraordinary skill and commitment Meyer and the community college’s leadership have put toward its success, Jain questioned whether such a model would be replicable at other community colleges. For Meyer, the question was not if but how. How might this model of IPE training at a community college be scaled up to other locations? And how might universities and community colleges take advantage of opportunities to work together? After all, said Meyer, so many of the health programs begin at the community colleges that it makes sense to build the workforce together.
Scaling Up Community-Based, Interprofessional,
Faculty-Run and Faculty-Assisted Clinics and Student-Run Clinics
Leader: Kathy Kolasa, Academy of Nutrition and Dietetics
Assisted by: Eileen Moore, Georgetown University;
Riva Touger-Decker, Nutritional Sciences/Rutgers University; and
Rick Valachovic, American Dental Education Association
In laying the foundation for discussions in her breakout group, Forum and workshop planning committee member Kathy Kolasa described looking at IPE in faculty-run clinics and faculty-assisted, student-run clinics. These are excellent opportunities for health professional students and trainees to learn about the unique needs of special populations while engaging in real and rewarding work in community settings, she said. These clinics typically provide care to those most in need of assistance (i.e., homeless and uninsured). They can also provide opportunities for different health professional students to learn from and with other professions.
Participants who attended this breakout session heard perspectives from those who are knowledgeable about and actively engaged in health clinics that use the expertise and enthusiasm of health professional students. This led to a variety of discussions about the value of volunteer health clinics and required health clinics, how more professions might be included in them, and how they might be scaled up to more geographical locations.
The innovation Kolasa described included IPE in volunteer clinics that directly involve students in the running and management of the clinic. Initially, she believed there were only two types of these clinics that were either faculty run and student operated or faculty assisted and student run. The first would offer students credit toward graduation, while the other might be strictly voluntary and occur after regular business hours. Although this may be indicated by the literature, discussions with her breakout group uncovered a much wider variety of clinics that engage students and a wider array of interprofessional pairings than were noted in the literature. However, the true depth of interprofessional training may vary from one clinic to another.
IPE in Student-Assisted or Student-Run Clinics
Based on her small group discussions, Kolasa made the observation that many student clinics do not engage in purposeful IPE. Although it
might occur in some instances, students from differing health professions are often placed in the same space without necessarily working together as a truly interprofessional team. Kolasa also noted that in settings where the IPE is effectively implemented, students report tremendous value in the experience. This is because in their view, it is the only setting where they train interprofessionally, because it is not routinely part of their clinical rotation experience. Students mentioned learning about IPE in a classroom but not seeing it in action outside of their clinic. Without a properly trained faculty, the likelihood of experiential IPE becomes ever more remote, said Kolasa, adding that experiential IPE in volunteer clinics may be an area where faculty might want to focus their energy. Identifying clinics where purposeful IPE is working may be a source of information for scaling up IPE in volunteer clinics.
Variety of Student-Engaged Voluntary Clinics
Kolasa’s background research for this session uncovered a fairly large number of medical and dental student-run and student-assisted clinics; however, through the discussions with her group, she realized the number of professions engaging with students in volunteer clinic settings is much larger than just medicine and dentistry. It includes nursing, dietetics, social services, physical and occupational therapy, speech language and hearing, ophthalmology, pharmacy, and probably others who were not represented in the room. This discussion led to conversations about other health and nonhealth professions that could be engaged in volunteer clinics, like the veterinarians who were represented in the breakout session. Providing free animal care may be a way to bring patients into a medical clinic who possibly care more about their pets’ health than their own. Kolasa used the veterinarians as an example of how the student clinics might spread to new areas of expertise such as informatics, administration, law, or engineering.
One model that was mentioned in the breakout session was the nurse-led clinic that engages students in interprofessional work. Another model, presented by a pharmacy representative, involved the students administering the clinic by seeking funding for the clinic, running the services, developing the formulary, and dispensing the medications. They are also responsible for setting up the policies and procedures for the work they undertake. This was similar to one model described by a representative from medicine, which also included an application process to screen students before they become the leaders who would undertake the components for creating a system of community-based patient care for vulnerable and marginalized populations. A faculty-driven, student-engaged model was described by the representative from dentistry. The person representing nutrition and dietetics also used a faculty-driven, student-assisted model.
Their clinic was revitalized by funding from HRSA and with space on the medical school campus to bring different health professional students together in a community-based clinic.
Opportunities and Challenges
Published data Through discussions with her small group, Kolasa came to realize why her literature search did not reveal the true depth of work involving students in volunteer health clinics. Often, the clinics are written about in informal sources such as newsletters and annual reports. In her opinion, it is a responsibility of faculty who are working in these clinics to publish research and outcome data so others can learn from their successes and failures. One attempt to do that, said Kolasa, is the Society of Student-Run Free Clinics. This is an interprofessional platform where those interested in starting, scaling up, or spreading student-run clinics can learn from others’ best practices, research, and experiences.2 Although it is only focused on the United States, some of the lessons could be applicable to other countries.
Cost An important point discussed in the breakout session and brought to the attention of the workshop participants by Kolasa involved the term free clinic. Although the student experiences in volunteer clinics are called free and involve no cost to the patient, a number of expenses are incurred. Faculty time, supplies needed to run the clinic, and the facility itself are not free. This raised the issue of sustainability for these types of clinics and educational opportunities.
Sustainability The topic of sustainability created a host of reactions from the members of Kolasa’s breakout group. One reported opinion was that, for such clinics to be sustainable, the school should embrace the idea to ensure they remain after the volunteers staffing the clinic (faculty and students) are no longer with the institution. It would be termed a university- or school-run clinic rather than a faculty- or student-run clinic.
A counterargument was proposed to institutionalize volunteer student/faculty clinics in an effort to maintain staffing by those who are truly motivated to make a difference in the lives of their patients. But by formalizing the clinic and mandating who must work in them, the clinic would no longer be driven by people who want to be there. This sentiment was echoed by another participant, who felt the issue being discussed revolved around sustaining student engagement rather than sustaining care for a vulnerable
and marginalized population. In agreement with this view, one participant believed that volunteer clinics are for giving back to the communities and for building social responsibility and accountability in students. One possible model might combine a tuition stream, to support faculty time in the clinic, and a fee-for-service payer system. This way, the clinic could take clients regardless of their ability to pay. This model has been used in dentistry. In exchange for patients coming into the clinic, dedicating their time, and being part of an educational process, there is at least a 50 percent reduction in the costs versus other community-based dental services. That fee basically covers the facility and other minor expenses. And although none of the dentistry clinics are showing great profits or surpluses, they are mostly able to sustain their operations.
Following the discussion on sustainability, an interesting comment was expressed that for the most part, these clinics are not designed to provide sustainable care. They are opportunities to engage people in the health system and then hopefully move them into a more stable care system. Expecting more may be creating something the volunteer safety-net clinic was not set up to do. This comment resonated with speaker Eileen Moore, the director of the Hoya Clinic (see Box 4-2), who felt strongly that it is incumbent upon the faculty and the students to create the connectivity between their volunteer clinic and more sustainable care beyond what they can offer. At the Hoya Clinic, a student is assigned the responsibility of linking patients to additional or sustained care and for lowering barriers, such as transportation, to better ensure the patients’ care is not an episodic one-time visit without any follow-up.
Kolasa finished her report by noting that many faculty- and student-run clinics were started out of altruism to provide safety nets for the community. For reasons of sustainability, these same volunteer clinics are now evolving into educational establishments that go beyond the social mission on which they were founded. In pondering this shift, Kolasa asked how the specialness of the voluntary clinics might be retained as the institutional support is built into the framework of the clinics to better ensure sustainability. And with this new sustainable structure, how might the clinic remain a place where students can express creativity to finding solutions to real-life challenges of patients and vulnerable populations?
Building upon the origins of most volunteer health clinics, Kolasa called on academic institutions to value the range of clinics established by faculty and students. They are more than just a nice promotional piece for the university, she said—they are opportunities to give back to the community
The Hoya Clinic, Georgetown University
Eileen Moore, Director
The Hoya Clinic, which opened its doors in September 2007, is a collaboration between Georgetown University School of Medicine and Georgetown Med-Star Hospital. The clinic is located in what used to be the DC General Hospital, which was turned into an emergency family shelter. The Hoya Clinic is a freestanding, ambulatory care site that is accredited by The Joint Commission. The clinic is open in the evenings, usually from 6:00 PM to 11:00 PM, but often later. The clinic includes primary care specialties and some subspecialties, including psychiatry, OB/GYN, otolaryngology, orthopedics, and nursing medicine. The services are free for patients, and everyone who works at the clinic is a volunteer. There are more than 400 medical students, 27 doctors and nurse practitioners, and 24 registered nurses involved.
Though the structure of medical education in the United States is typically 2 years of preclinical experience, followed by 2 years of rotations in clinical practice, the Hoya Clinic offers all students an opportunity to engage with patients. The first-year student greets the patients, brings them to the appointment room, and takes their vitals. The second-year student records the patients’ history of present illness. Then a student clinician, a third- or fourth-year student, will conduct a visit, and the faculty will see each patient. The supervision model is very direct; the students see each patient, then the faculty member learns about the patient and staffs the case. The Hoya Clinic uses the electronic medical health records to document all information. The clinic also has a fairly full pharmacy and dispenses directly (supervised by a faculty member).
To maximize the value of the patient, the Hoya Clinic respects the patient’s time by aiming for a 1-hour visit with patients (from when they enter the clinic to when they leave the clinic) without compromising quality or any of the visit metrics. To facilitate this, the volunteers will often have an educational roundup at the end of the night to discuss an interesting case and talk about the educational aspects.
Moore sees two important key values of the clinic: the educational value to the students, and the service to the community and to the patients. Seeing health disparities firsthand is far more educational than being lectured about health disparities in a classroom, she believes. And the sense of community is strong because the volunteers are essentially practicing in the home of the patients. The Hoya Clinic has also worked hard over the past several years to gain the trust of the community.
Moore also identified the challenge of faculty burnout, because the Hoya Clinic is a 100 percent volunteer organization. The clinic started with only two physicians supervising, but it now has more than 20 providers. To add context to this challenge, Moore added, “Every time I go to Hoya Clinic—and I go pretty frequently—I receive so much more than I give. I actually find it rejuvenating, edifying, and sustaining. I would submit that precepting in a volunteer clinic of this sort is more rejuvenating than it is energy consuming.”
and to role-model social accountability and true interprofessionalism for the next generation of faculty and health providers.
IPE: Preparing Law Enforcement and Health Professions Together
Leader: Virginia Adams, National League for Nursing
Assisted by: Joseph Morquecho, DC Metropolitan Police Department
Gay and Lesbian Liaison Unit; and
Marsha Regenstein, George Washington University
To set the stage for her breakout session, workshop planning committee member Virginia Adams explained that jails are community organizations where the majority of detainees and inmates (73 percent) have mental health and/or substance use disorders (CASA, 2010). Of the 1.5 million jail inmates in the United States, only about 11 percent receive any professional treatment for substance use disorders while admitted (CASA, 2010). Adams made the distinction between jails, which are at the local level and part of the community, and prisons, which function at the federal level and have access to greater financial resources. However, in both jails and prisons, there are evidence-based treatments that could be used but are rarely employed. This is particularly true in jails, mainly because of the short amount of time inmates and detainees typically stay in the correctional facility. The result is an unacceptably high recidivism rate of almost 45 percent, some of which can be prevented (Pew Center on the States, 2011).
Sensitivity Toward Marginalized Populations
Adams said that there has been an attempt through officer training to sensitize police officers to the needs of vulnerable and marginalized populations such as the LGBT (lesbian, gay, bisexual, and transgender) community. The District of Columbia police force now provides liaisons to LGBT persons and other marginalized groups. An objective of this effort is to strengthen positive communication with special populations. In this way, she said, officers’ communication with vulnerable and marginalized persons can potentially keep LGBT individuals (who come in contact with law enforcement) out of jails by directing them to appropriate community-based intervention services.
Adams explained that health providers, who may not typically receive similar sensitivity training as that provided during officer training, could benefit from collaborative education with law enforcement officers. The
breakout session, she said, explored how the health professions’ and police officers’ training in a community setting could create a more sensitized and effective health professional workforce. It might also identify other unique opportunities for improving collaborations between law enforcement training and health professional education.
For her breakout group, Adams was assisted by police officer Joseph Morquecho. Morquecho is a full-time member of the Washington, DC, Gay and Lesbian Liaison Unit (GLLU) of the police department (see Box 4-3 for more information on GLLU). His unit focuses on the public safety needs of the LGBT community and their allied communities. They conduct public education campaigns on issues related to hate crimes and public safety.
The primary focus of GLLU is to gain the trust of the community and to seek out information that leads them to the closure of hate crime and violent crime within the LGBT community. They conduct patrol functions and respond to all citizen complaints. Morquecho is a first responder, especially if teenagers are involved who might be arrested but should not be in jail.
In addition to Morquecho, Adams had input in her breakout group from Marsha Regenstein, a professor of health policy at George Washington University (GW). The focus of Regenstein’s work is on the availability, the quality, and the cost of care for underserved individuals. Regenstein also directs the research and evaluation for the National Center for Medical Legal Partnership and provided a unique perspective that combines policy with law for the protection of incarcerated patients.
Jails as Community Organizations
In her report to the entire audience of workshop participants, Adams pointed out that there are a number of organizations that make up a community. Jails are one of these organizations that temporarily house many of the community’s members. These members are part of families that make up the community, and many of them have serious mental and physical health issues. These include mental health and substance use disorders as well as chronic and infectious diseases. In trying to better care for the vulnerable populations that reside in the jails, Adams explored with her group how to better coordinate the work of those in law enforcement with health professionals and how to educate students using this model.
In looking at the value of law enforcement and health professionals working together, Adams was struck by how little those who work in the health field know about law enforcement issues, and vice versa. Given the lack of mutual understanding between police and health care providers, Adams wondered how each group could maximize the work of the other to benefit those who are part of the revolving door into and out of jail.
DC Metropolitan Police Department
Gay and Lesbian Liaison Unit
Joseph Morquecho, Officer
In 1999, two openly gay female officers in the police department read an article noting that in the past 4–5 years there had been zero reported hate crimes in the DC metropolitan area, despite the fact that DC had a large gay, lesbian, bisexual, and transgender (GLBT) community. The officers wondered why hate crimes had not been reported—they thought maybe it involved a lack of training, a lack of education, or officers and/or the public not knowing how to handle the situations. The police department already had several liaison units (such as the deaf and hard of hearing liaison, the Asian liaison, and the Latino liaison), and so the officers proposed the creation of the DC Metropolitan Police Department’s Gay and Lesbian Liaison Unit (GLLU). According to Joseph Morquecho, police officer with GLLU, no other law enforcement agency in the United States had a gay and lesbian liaison unit at the time.
Gaining Trust and Developing Partnerships
Community policing is meant to be all-encompassing, said Morquecho, and everyone in the community should partner to work toward a healthier, safer community—including health care, law enforcement, and schools and universities. To do this, GLLU reached out to the most vulnerable of the GLBT community—African American GLBT youth and people from the transgender community. There was a large part of the GLBT community that distrusted law enforcement, so GLLU worked to break down barriers and overcome this challenge through outreach programs. They partnered with the Department of Health, Child and Family Services, and nongovernmental organizations (NGOs) that had experience in health care. GLLU aimed to gain the trust of the community and to help community members improve their health so they would reduce their risk of later becoming victims.
Before GLLU existed, there were not many places where people could go to get help in difficult situations. Morquecho told a story of parents calling 911 because they found a dress in their son’s room, knew he was possibly transgender, and thought he was therefore mentally ill and needed to be taken away. GLLU officers receive training, and they understand what services exist for people in need. They are in communication with psychiatrists, doctors, and mental health services, including many who are openly gay or lesbian and want to help in emergency situations. They also have contact information for most people in DC government services. Morquecho said that because of the support of the DC health department, DC mayors Vincent Gray and Adrian Fenty, and the management of the DC police department, GLLU is able to succeed.
Work with Marginalized Communities
The transgender community is at great risk of sexual assaults, robberies, domestic violence, and engagement in survival sex. For some of GLLU’s outreach to this community, they brought in doctors from Johns Hopkins Hospital (which
does sexual reassignment surgery) to learn from the medical perspective about a transgender person’s experiences. Morquecho made an important distinction that many low-income or black transgender persons face significantly different challenges that transgender persons who have accepting families, have health care, or are Caucasian. Despite the fact that the DC government has implemented some progressive changes for the transgender community, stigma continues to exist. GLLU works to decrease the stigma by doing trainings about the transgender community with various groups, such as other police officers, the National Park Service Police, parole and corrections workers, DC government employees, and bus drivers.
DC also has one of the highest HIV/AIDS rates in the country, and GLLU works to promote safe sex among the DC population, especially DC youth. GLLU also works with universities’ public safety officers and trains the universities’ resident assistants on how to identify club drugs, how to identify domestic violence, and how to reach out to vulnerable GLBT students.
The police department has also taken initiatives to learn how to handle cases involving people with mental illness. In the past, a person who was behaving strangely would be handcuffed and sent to jail or to DC General Hospital. Now, the police department trains critical incident officers (CIOs), who do an evaluation on a first-responder level of what needs to happen in a given situation. They also contact the proper facilities; for example, the Department of Mental Health 24/7 response team or the police emergency crisis team (they bring a psychologist to the scene). The police department partners with GW Hospital and the Psychiatric Institute of Washington to help the person in need receive proper care.
Morquecho noted that his officers heard language used or questions asked in hospital settings that were inappropriate or offensive. In these situations, a person who is very sick might shut down and not let providers help. GLLU works with hospitals to do sensitivity trainings with a specific GLBT focus to help providers understand what is appropriate or inappropriate, and how to communicate with people who are vulnerable and need help. GLLU also engages students through internships and ride-alongs; some participating groups include GW students studying medical health and American University students studying criminal justice. This helps students understand marginalized and vulnerable populations in a new way and helps students to be sensitive to the issues these individuals face.
Scale-Up and Spread
Morquecho described GLLU as an innovative program that redefined community policing for the GLBT community. In fact, people from outside the GLBT community began approaching GLLU because of the services they offered. The DC police department combined law enforcement, outreach, and training into one initiative using every resource available, and created a replicable program. In Morquecho’s opinion, this is what makes something truly innovative. GLLU, which won the Harvard Innovation in American Government award in 2006, has advised the governments of Cleveland, Toronto, Montreal, Scotland, Haiti, and Queensland, Australia, to help them develop similar units and trainings.
Adams then described the major innovation that she envisioned: Provide joint educational opportunities for trainees in law enforcement and the health professions. The training materials would be modeled on the mental health facilitation curriculum that is described in Chapter 3 of this summary report. As such, the curriculum would use a common language that is easily understood by all students and would employ a set of educational materials that are simple and flexible.
Experiential learning for gaining a better understanding of the vulnerabilities of community members could be undertaken through police car ride-alongs and specific training designed to create greater sensitivity toward vulnerable populations in service settings, such as emergency care situations. Adams believed much of the training could be done through shadowing. A component of the curriculum might also address the language used with the prisoners or detainees in the jails.
Adams also pointed out that people with a history of substance abuse and mental health problems often have a multitude of social challenges, including homelessness. These are the same people who are repeatedly jailed. Many people in society fear them and do not know how to deal with them because of their unfamiliar behaviors. The training would educate law enforcement and health professionals on how to deescalate a potentially dangerous situation in order to keep all community members safe, regardless of whether the threat is real or perceived.
Adams reported that a major focus of the training could be on improvements in communication—more specifically, communication between law enforcement and health professionals, particularly for training around a more centralized intake process that better informs police officers and health providers. But, said Adams, that raises the question of how much information can be shared without violating HIPAA or a patient’s confidentiality. For example, if a health professional suspects a client with mental health issues may have tendencies toward violence, how might the health professional safely share that information with an agency that is in the business of enforcing the law, especially when his or her prediction could be wrong?
Assuming this obstacle can be overcome, an advantage to a coordinated intake system is the potential cost savings of not having to input the same information and data from separate sources. Making the system available electronically allows for real-time information that can be turned into alerts for either the health worker or the police officer. Interprofessional training
on such a system could be used as the communication bridge between law enforcement and health.
Facilitating a Return to the Community
Many inmates in the criminal justice system occupy jails for very short periods but do so repeatedly. Given this, Adams wondered whether a more coordinated system could be in place between jails and the community services that could help provide inmates with the sorts of support systems they need to prevent further recidivism. In this way, communities become safer places for everyone, including the inmate. Adams proposed that the innovative curriculum could start relationships between law enforcement officers and health providers from social services.
Challenges and Opportunities for Scale-Up and Spread
Resources One challenge Adams identified is the lack of resources available to initiate the interprofessional curriculum. That said, the DC Metropolitan Police Department is already providing sensitivity training to their officers. Morquecho made the comment during the breakout session that his training has already been scaled up to other sites in the world. Based on that, he was confident his program could be replicated. Adams agreed with Morquecho but recognized there would be differences in the populations of trainees that would require bridging. Although this could be a challenge, Adams also considered this an asset; for example, law enforcement resources could be leveraged with social service training resources in an effective manner.
Newly available resources that Adams highlighted were discussed by Marsha Regenstein during the breakout session. Regenstein talked about the Patient Protection and Affordable Care Act and how more of the young men, especially young black men, who do not have services while they are incarcerated will now have access to health care. This may be a way of providing health care services to recently released inmates. It might also be an opportunity for interprofessional training to police candidates and health professional students or trainees. However, Adams wondered how these resources might be sustained.
Electronic curriculum Adams pointed to the availability of short-term, interactive modules that can be used or adapted for sensitivity training with police and health professionals and their students. If done well, it might be possible to scale up parts or the entire curriculum electronically, she said. However, in designing the virtual curriculum for scale-up and spread, considering cross-cultural messaging and differences in geographical target
areas would likely increase the reality of the situations presented to the trainees. To make the learning more active, Adams suggested the electronic curriculum could involve case modules as well as interactive chat rooms for discussions that engage law enforcement and health professionals in active dialogue.
Leadership Another challenge Adams identified is leadership. Most successful endeavors are pushed by a champion, who in this case would bridge the divide between law enforcement and the health professions. For this curriculum to succeed, she said, joint leadership from both sides—law enforcement and health care—would more likely drive the agenda.
Measuring success The final challenge is knowing how and when to measure success. Adams indicated that the ultimate desired outcome is reduced recidivism. The other way to measure success is to look at the number of inmates who connect with the right services, the number of inmates who successfully transition into the community, and the number of inmates who remain out of jail.
In laying out the need for improved communication between health professionals and law enforcement, Adams cited the recent example of the 56-year-old Marine veteran who was arrested for trespassing. However, the real motivation for his arrest was an attempt by the police to keep him safe and warm during a freezing cold New York winter night. The veteran was homeless and on antipsychotic and antiseizure medication, which can increase one’s vulnerability to heat. When the jail cell he was retained in reached more than 100 degrees, the veteran died from excessive heat in a facility that was ill-equipped to handle his health condition (CBS New York, 2014).
Had a system of communication been established between police and health professionals, this death and other similar incidents could potentially be avoided, suggested Adams. Members of Adams’s group identified a communication tool that could possibly be adapted for these purposes. Called the Blue Button, this tool facilitates easy access to and sharing of electronic health records.3 Blue Button is currently being used by some health care providers and insurance companies as well as a number of federal agencies, including the Departments of Defense, Health and Human Services, and Veterans Affairs. Adams proposed that maybe Blue Button could be scaled
3 For more information, please visit http://www.healthit.gov/patients-families/blue-button/ about-blue-button (accessed October 3, 2014).
up and spread through interprofessional training efforts that engage more than just the health professions. A strategy such as this, said Adams, could initiate thinking and movement toward a common curriculum that would improve communication for the benefit of communities.
Warren Newton led the final session, in which he asked the workshop participants to reflect upon lessons learned based on the discussions that took place throughout the course of the workshop. He welcomed general observations as well as specific comments related to the scale-up and spread of community-based education of health professionals.
Broadening the Definition of Health
Malcolm Cox from the University of Pennsylvania observed how the Global Forum has evolved since its inception more than 2 years ago. To him, the tone of the discussions had changed. He noted that members were finally talking about health and communities, and making education the process for how to attain those goals or outcomes. This workshop was emblematic of that shift, said Cox.
In his opinion, this shift is important because scale-up and sustainability are about the return on investment. He said that it is important to influence the people who control the resources and the people who are most interested in health. It is up to the educators to inform workforce development to bring about system changes that result in the desired health outcomes.
Bjorg Palsdottir from Training for Health Equity Network (THEnet) agreed with Cox that education has to change in order to meet the health needs of people and communities, and she built on this point by encouraging workshop participants to look at a broader set of outcomes than just health. This could mean talking about the justice system, like what Virginia Adams addressed in her small group, or possibly the social determinants of health. Such topics are embedded in health but move the conversation into other areas. Some examples Palsdottir offered were economic opportunities that could improve health, the social capital that could be built through community clinics, the empowerment of people to take charge of their lives through health-based community outreach, and the creation of jobs through the establishment of health clinics. Palsdottir believes that the Global Forum can look at outcomes in a broader way that retains the “return on investment” that Cox mentioned.
In building on this discussion, workshop speaker Sarah Freeman from the Alaska Native Tribal Health Consortium made a concrete suggestion to bring the payers into the conversation. It would be exceedingly valuable, she
said, for groups like insurance companies, Medicare, and Medicaid to hear about health-related work and education from an outcomes perspective.
Roles of the Community Health Workers
Patricia Hinton Walker from the Uniformed Services University of the Health Sciences (USUHS) expressed her view that this particular workshop on communities has pushed the participants to think more carefully about the roles of community health workers. Having been joined at the table by Malual Mabur and Siyad Ahmed—community health outreach workers in Maine and originally from Sudan and Somalia, respectively—and hearing from Daveda Hudson and Marjorie Cooper-Smith from the Care Center in southeast Washington, DC, Walker was moved to rethink her traditional definitions of health care providers.
In addition, reflecting on the talk by Scott Hinkle, who spoke about the Mental Health Facilitator program, Walker described greater sensitivity to what she termed “connections.” Health professionals are often more separated than they should be from the community, she said, but if the definition of a health provider were to include the links to the community through patient navigators and other community outreach workers, health professionals would not as separated from their communities.
Including Education with Broadly Defined Outcomes
Pamela Jeffries from Johns Hopkins University School of Nursing agreed with the previous comments that there should be a focus on health, but she also felt that education has been neglected and would benefit from greater attention, not less. Jeffries mentioned that she recently attended a conference sponsored by Coursera, which is an education platform for massive open online courses (MOOCs). At that conference, Jeffries interacted with more than 450 attendees from around the world who were teeming with excitement about MOOCs being a catalyst for academic excellence in education. Jeffries wondered, how might the conversation include both education and health?
Jan De Maeseneer from Ghent University in Belgium agreed with Jeffries’ perspective. De Maeseneer is chairing the European Union Expert Panel on Effective Ways of Investing in Health.4 One of the conclusions of its report was that education of health professionals should be seen as an investment. This reinforces the opinions expressed earlier—and in particular Jeffries’ opinion—about having a global perspective for keeping education and outcomes within the same sphere.
4 For more information, visit http://ec.europa.eu/health/expert_panel/index_en.htm (accessed October 3, 2014).
Evaluating Education with Health Impacts
Zohray Talib, who is a member of the Medical Education Partnership Initiative (MEPI) Coordinating Center at GW, pursued comments about education and health but from the perspective of evaluation.
Having listened to the different examples and interpretations of community-based education, Talib suggested that an interesting and informative objective might be to try to connect strategies to outcomes through evaluation. For example, how much time does a student need to spend in a community setting in order to have the desired impact as defined by their educators, while also demonstrating an impact on the communities they serve? In answering this and other similar questions, Talib reflected on the debates session of the workshop that focused on longitudinal versus block education. She asked if it would be possible to set up a coordinated effort that looks at different models to determine which ones are having the agreed-upon effect. Those outcomes could involve improving quality, quantity, or retention of the health workforce. It would be good, she said, to compare the different types of community-based education models to see which ones achieved the desired outcome.
One complication Talib acknowledged to using health outcomes as an evaluation tool is it often takes time to demonstrate patient or community impacts, which are different from student impacts that can be assessed relatively quickly. But, said Talib, there may be surrogates that can be used for short-term evaluations when students are brought to the community for experiential learning. The students not only are being trained to be competent providers for serving their communities better in the long term, but the students are also improving the health of the target community and the facility’s performance during their experiential learning opportunity. Talib wondered whether that data could be captured in a way that sustains funding for community-based initiatives; this could be a powerful message to bring to ministries of health and finance for funding, she added.
Leveraging a Full Global Oversight Framework: Accreditation, Licensure, and Certification5
Given that accreditation is a voluntary process involving self-regulation, Newton wondered why more professions in the United States do not make community-based education part of their accrediting standards. John
5 According to the Institute of Medicine report Health Professions Education: A Bridge to Quality (IOM, 2003, p. 7), “It is imperative to have [such] linkages among accreditation, certification, and licensure; it would mean very little, for example, if accreditation standards set requirements for educational programs, and these requirements were not then reinforced through testing on the licensing exam.”
Finnegan from the Association of Schools and Programs of Public Health widened the discussion and commented that two accreditation agencies he knows of in the United States—public health and veterinary medicine—also accredit internationally, although there are others. Linking this to Newton’s question, Finnegan asked whether community-based education accrediting standards might be expanded to recognize that the United States is part of a global community. He acknowledged that there may not be agreement on one unified design theory and that regional differences would have to be considered. But Finnegan still felt that if this is a serious social movement that includes but does not stop with education, one must ask how it might be scaled up to demonstrate a worldwide impact. In his opinion, there is a relatively substantial global interest for undertaking this.
Palsdottir confirmed Finnegan’s point, citing several global initiatives and activities under way in this area. For example, the World Health Organization recently published guidelines on transforming education for health professionals for health equity (WHO, 2013). Both she and De Maeseneer are involved in a follow-up activity to this report addressing social accountability. Palsdottir believes the Global Forum can contribute substantially to the major world conferences and international networks that also occur. The greatest value of the Global Forum, said Palsdottir, is its interprofessional membership and approach to Forum-related activities. As someone who works primarily outside of the United States, Palsdottir encouraged her fellow Forum members to seek opportunities for sharing lessons learned on a more global platform. Finnegan agreed with Palsdottir about the large amount of activity currently under way around the world, but he expressed a desire for more specificity on how to actually move the global accreditation–licensure–certification framework agenda forward.
Envisioning the Future
Joanne Schwartzberg, a scholar in residence at the Accreditation Council for Graduate Medical Education, commented about a forward-looking issue involving home-based health services. Currently, many of these services and interventions are provided through home health and community agencies. She noted that training programs for nurses, therapists, and social workers make use of these services as an entrance into the community. In her opinion, many other health professions could similarly work with the home-based agencies for more experiential learning and training opportunities. In this way, more health professional students might explore such topics as how families live with chronic illnesses and what that means to the patient and those around them. Schwartzberg was involved with such an educational program many years ago that went beyond the health professions and engaged urban planners and architects. In looking
at health more broadly, Schwartzberg felt that nonhealth professions are a resource with whom health educators might work more closely.
De Maeseneer’s final remark encouraged participants to look at new challenges that emerge not only from societal evolutions but also from scientific evolutions. How might society, and thus education, deal with future innovations coming from such fields as genomics, proteomics, and microbiomics, and what effect might discoveries in these areas of research have on the way health care is delivered? How might the health professions anticipate changes and integrate them in a meaningful way through an educational process that is more responsive to—and in sync with—the health care delivery process? If innovations trigger significant changes, how might the aims of equity and social justice be maintained and safeguarded? And, how will accountability of universities, both in their research and in their educational component, be determined? His last question explored whether innovations meant to improve lives will lead to greater inequity, or whether such advancements will be integrated in a way that brings about better health for everybody on the planet.
With that, Newton thanked the audience, and the workshop was adjourned.
AACC (American Association of Community Colleges). 2014. Community college trends and statistics http://www.aacc.nche.edu/AboutCC/Trends/Pages/default.aspx (accessed July 30, 2014).
ACPE (Accreditation Council for Pharmacy Education). 2014. Accreditation standards and key elements for the professional program in pharmacy leading to the doctor of pharmacy degree: Draft standards 2016. Chicago, IL: Accreditation Council for Pharmacy Education.
CASA (Center on Addiction and Substance Abuse). 2010. Behind bars II: Substance abuse and America’s prison population. New York: National Center on Addiction and Substance Abuse at Columbia University.
CBS New York. 2014. Officials: Mentally ill homeless veteran “baked to death” in overheated jail cell. CBS New York. http://newyork.cbslocal.com/2014/03/19/officials-mentally-ill-homeless-veteran-baked-to-death-in-overheated-jail-cell (accessed September 23, 2014).
IOM (Institute of Medicine). 2003. Health professions education: A bridge to quality. Washington, DC: The National Academies Press.
IOM. 2013. Interprofessional education for collaboration: Learning how to improve health from interprofessional models across the continuum of education to practice: Workshop summary. Washington, DC: The National Academies Press.
IOM. 2014. Establishing transdisciplinary professionalism for improving health outcomes: Workshop summary. Washington, DC: The National Academies Press.
The Joint Commission. n.d. Accreditation process overview. http://www.jointcommission.org/assets/1/18/Accreditation_Process_Overview_factsheet.pdf (accessed July 30, 2014).
Lewis and Clark Community College. n.d. Lewis and Clark mobile health unit. http://www.lc.edu/Mobile_Clinics (accessed July 30, 2014).
Linköping University. 2011. Linköping University Practical Guide. Linköping, Sweden: LTAB.
Pew Center on the States. 2011. State of recidivism: The revolving door of America’s prisons. Philadelphia, PA: The Pew Charitable Trusts.
RWJF (Robert Wood Johnson Foundation). 2010. Program results report: Helping mothers and children with a families center in Washington, D.C. Princeton, NJ: Robert Wood Johnson Foundation.
RWJF. 2014. Summary of the 2013 community college presidents’ meeting and progress in the year since it was convened. http://www.rwjf.org/content/dam/files/rwjf-web-files/Resources/2/Community_Colleges_Paper_4-3-14_FINAL.pdf (accessed July 30, 2014).
WHO (World Health Organization). 2013. Transforming and scaling up health professionals’ education and training: World Health Organization guidelines 2013. Geneva, Switzerland: World Health Organization.
WHO. 2014. Maternal mortality. Fact sheet No.348. http://www.who.int/mediacentre/factsheets/fs348/en (accessed September 2, 2014).