Medical School Hotline

It is customary that faculty members of health sciences schools, especially medical schools, collaborate to form practice groups to provide high quality clinical services. The services provided by these groups help to realize community expectations that health sciences schools not only train the next generation of clinicians, but also provide excellent patient care. In State schools, such as the University of Hawai‘i, the health sciences schools are also expected to provide community service, especially in areas and in specialties of greatest need. The faculty practice plan helps to meet all of those expectations.

UCERA is the main faculty practice plan of the John A. Burns School of Medicine (JABSOM). A previous article about UCERA was published in August, 2010.¹ Unlike many medical schools in the United States, by design of its founders, JABSOM does not have its own University hospital. Rather, it bases its clinical education activities in many different practice sites, such as community medical centers and clinics. Hence, faculty members who are part of UCERA provide services to patients and clinical teaching at many different places throughout the community. These private sector and State facilities are critical to providing the sites of training and financial support, especially for residency programs. The school also depends on the large number of voluntary faculty members who give of their time and efforts.

UCERA is a 501(c)(3) organization established for charitable purposes. While a few departments had department-based services, the major growth of the faculty practice started in 2003, mainly as a result of a strong recommendation by the Liaison Committee on Medical Education (LCME), the medical school's accrediting organization. UCERA is governed by a voluntary board composed of both medical school department chairs and community members. As a charitable non-profit organization, the faculty practice participates with a wider variety of insurers, including Medicare and Medicaid. However, the clinical services are not underwritten by the university or a medical center, and must be financially sustainable on its own. The revenues help to support faculty and staff salaries, department expenses, and academic enhancement. UCERA also provides the legally compliant infrastructure for research involving patients' protected health information; and provides the infrastructure support for other UH health sciences schools to develop their faculty practice activities.

Faculty Practice Group Plan

The faculty members who are clinicians may join UCERA for their clinical practice. An increasing number of physician faculty members are choosing not to develop their own private practices. A faculty practice organization provides the greatest opportunity and flexibility to adapt their activities as their professional interests change over the years. In joining a faculty group practice, they do not make a financial investment for space and equipment, or make a commitment of full-time clinical service. It is expected that, in addition to providing excellent clinical care, they will also teach and develop other academic pursuits. Thus, they may more easily change the focus of their activities, especially in developing their interests in academic medicine or research. Many faculty members express an interest in “giving back” to the medical school by focusing their attention on medical student and resident education, more readily accomplished in a faculty practice plan than in private practice or private sector employment.

Currently, there are approximately 120 faculty clinicians in the various hospitals, clinics, and nursing homes who are members of UCERA. Clinicians include primary care and specialty physicians, psychologists, speech therapists, audiologists and nurses. In the medical school, they include members of the departments or programs in Communication Sciences and Disorders, Geriatric Medicine, Family Medicine & Community Health, Hyperbaric Medicine, Internal Medicine, Native Hawaiian Health, Obstetrics and Gynecology, Psychiatry, and Surgery. Faculty members of the Department of Pediatrics have a separate organized faculty practice called Kapi‘olani Medical Specialists (KMS), associated with Kapi‘olani Medical Center for Women and Children.

Examples of UCERA Clinical Services

Communication Sciences and Disorders

UCERA operates a Speech and Hearing clinic in the Gold Bond Building at 677 Ala Moana Boulevard, in Honolulu. (808-692-1580) The Speech Services include comprehensive evaluations, training for augmentative devices, accent and dialect modification, individual and group therapy for speaking and singing voice, and communication, speech, stuttering, language and swallowing assessments, and treatment. The Hearing Evaluation and Treatment services include aural rehabilitation, comprehensive evaluation, fitting and dispensing of hearing aids, customized ear protection, and other assistive hearing technologies.

Family Medicine and Community Health

Faculty members in this department provide clinical services and training for medical students and family medicine residents at the Physician's Center at Mililani. The center is located at 95-390 Kuahelani Avenue, Mililani, Hawai‘i. (808-627-3200) This clinic is owned by Wahiawa General Hospital. Working through UCERA, this department also developed a family medicine clinic in Hilo which has now become a part of Hilo Memorial Hospital in support of the hospital's rural family medicine residency program.

Geriatric Medicine

Kuakini Medical Center is the home of the Department of Geriatric Medicine. UCERA faculty physicians now provide all of the physician care at Kuakini Geriatric Care, Kuakini's nursing facility. The practice plan has now expanded the Teaching Nursing Home Program to include patients at many of O‘ahu's nursing homes. Physicians willing to provide nursing home services are in very short supply in Hawai‘i and nationally because many office-based primary care physicians no longer provide inpatient hospital or nursing home services. While the number of hospitalists has rapidly increased to provide hospital inpatient services, the number of nursing home specialists has not grown in proportion to the need. Geriatric medicine is considered a critical shortage specialty nationally. In the Teaching Nursing Home Program, faculty physicians provide attending physician care to nursing home residents and also serve as medical directors and associate medical directors to help meet this critical need. The department also serves as the medical school's center for Palliative Medicine. Many of the faculty members provide palliative consultative services and serve as medical directors for several Hospice programs in Hawai‘i. The department also operates an outpatient primary care geriatric medicine service, the Leahi Outpatient Geriatrics Clinic. This clinic is located at Leahi Hospital on the slopes of Diamond Head, at 3675 Kilauea Avenue, Honolulu, Hawai‘i. (808-732-9907)

Hyperbaric Treatment Center

Faculty members and staff operate this center located on the ground floor of Hale Pulama Mau at Kuakini Medical Center, 347 N. Kuakini St, Honolulu, Hawai‘i. (808-587-3425) The services are available all day every day for emergency treatment of diving injuries. Treating with hyperbaric oxygen has increasingly been shown to result in dramatic wound healing. Hyperbaric oxygen can improve healing in 80% of diabetic ulcers, half of which could have been fatal in 5 years. This treatment can prevent amputations. Hyperbaric oxygen also can heal radiation injury and severe infections of the skin and bone. This center has state-of-the-art large multi-patient equipment capable of providing a greater pressure of oxygen into the tissues than smaller single patient units. Moreover, the equipment is large enough for staff members to accompany patients into the unit during treatment. The availability of staff during treatment is especially important with some medically fragile or anxious patients.

Internal Medicine

The Department of Medicine operates two clinics. Department faculty members working in the clinic located in the Physicians Office Building III, 550 S. Beretania St., Honolulu, Hawai‘i at the Queen's Medical Center (808-536-3773) provide both primary and specialty care, including endocrinology, interdisciplinary diabetes care, pulmonology, neurology, and rheumatology.

The Clint Spencer Clinic located in the Gold Bond Building at 677 Ala Moana Blvd, Honolulu, Hawai‘i (808-806-8208) is a multi-specialty clinic focusing on the care of individuals infected with the HIV virus and its complications. The Clinic provides state-of-the-art HIV-related primary care as well as consultative care for all of Hawai‘i's HIV-infected population. This clinic also helps patients enter clinical trials with the latest therapeutic or diagnostic tests associated with HIV-related disease.

Native Hawaiian Health

The Department of Native Hawaiian Health operates the Lau Ola primary care clinic in the Gold Bond Building, at 677 Ala Moana Blvd, Honolulu, Hawai‘i (808-469-4380). The clinic provides interdisciplinary medical and behavioral health services in a culturally knowledgeable and sensitive manner. The department also works with Native Hawaiian communities and community organizations to improve the general health of Native Hawaiians.

Obstetrics and Gynecology (OB-GYN)

The Department of OB-GYN operates five clinics providing a wide range of primary and specialty obstetric and gynecological services. There are two clinics at Kapi‘olani Medical center at 1319 Punahou Street, Honolulu, Hawai‘i. The Maternal-Fetal Medicine Clinic is in suite 808 (808-203-6580), and the Obstetrics and Gynecology clinic is in suite 990 (808-946-1481). There are two department clinics at the Queen's Medical Center. The clinic at the Queen's Physicians Office Buildings II provides services in gynecologic oncology at 1329 Lusitana Street, Honolulu, Hawai‘i (808-526-2477), and there is a multidisciplinary OB-GYN clinic in the Queen's Physicians Office Building III at 550 S. Beretania Street, Honolulu, Hawai‘i (808-218-7900). The department also operates a clinic for OB-GYN and GYN oncology in Waipahu at 94-235 Hanawai Circle (808-671-0090). The department's services include a full spectrum of obstetrical care, gynecology, urogynecology, maternal-fetal medicine, and reproductive endocrinology and infertility. Faculty members in OB-GYN also provide services at several federally qualified health clinics. Additionally, faculty members provide on call services at Kapi‘olani Women and Children's Hospital.

Psychiatry

Faculty members in the Department of Psychiatry provide specialized diagnosis and treatment of mental illness, including disorders of emotions, thoughts, moods, perceptions, motivations, interpersonal relationships, acculturation, work, sexuality, addiction, and socialization. The majority of the outpatient services are provided at the Queen's Counseling Services at Kaheiheimalie at 1374 Nuuanu Avenue, in Honolulu (808-691-4401). The department also provides the majority of the inpatient psychiatric services at the Queen's Medical Center, both on the inpatient wards and in the emergency department.

Surgery

The faculty practice services of the Department of Surgery are in a rebuilding phase. Currently, the department provides some of the trauma surgical services at the Queen's Medical Center. There are a large number of clinical faculty members who provide a wide range of surgical services and who contribute to the teaching and supervision of the surgery residency program.

UCERA's Infrastructure

UCERA sustains this wide array of widely dispersed clinical services through cost-efficient centralized management, finance, legal, compliance, human resources, medical billing, contracting, information management functions, including a single electronic medical record system. In addition to clinical providers, UCERA also employs over 100 staff members who work either alongside the faculty members in the clinical departments or in the central offices. Department based staff members include practice managers, nurses, medical assistants, coders, and clerical personnel.

UCERA'S structure is evolving from a mainly department run operation to a multi-group practice. In the United States the majority of faculty practice plans were established after 1960. The first plans were department based. As practices and organized care systems evolved, along with the increasing complexity of medical billing and contracting, and compliance with an increasing number of regulations, departments worked more closely together to form “federated” structures. These structures are made up of multiple, relatively independent departments, with cross-departmental shared management systems and some common governance. By 2011, independent department-based faculty practices accounted for only 8% of all plans in the United States. The trend for faculty practice plans is for further evolution into multi-specialty group practices, such as with UCERA, which are better suited to provide a continuum of care and to contract to provide clinical services in population based organizations.²

Conclusion

As UCERA evolves, the opportunity for, and presence of, interdepartmental collaboration in a multi-specialty group practice is also growing. Another trend is for UCERA to provide a home for the developing faculty practices of the university's other health sciences schools, such as those in the College of Health Sciences and Social Welfare. The faculty practice is also well suited to develop and test new models of prevention and care, such as population based care, insurance funded demonstration projects, and accountable care organizations. UCERA is also well suited for clinical research aimed at identifying issues that lead to poorer health outcomes despite high utilization of health care services. As such, JABSOM's faculty practice is a stronger potential partner in the evolving trends in preventive medicine and in health care delivery.