To engage healthcare stakeholders in creating a public-private funding program that will support foreign-trained medical professionals in securing medical residency
What has been most instrumental to your progress?:
Inclusivity and diversity of stakeholder membership of the International Medical Graduate (IMG) Task force of 15 members, and the subsequently established IMG Assistance Program Advisory Group of 21 members, were instrumental to making progress. These groups brought together those who were crucial to making the intended changes and included not only supporters but also skeptics of increasing the number of medical residency slots for IMGs. At each meeting, IMG Program participants were also welcome to participate. This permitted meaningful engagement of key stakeholders and IMGs. This was important because it permitted supporters and opponents to share ideas and increase understanding of each other’s rationale, which facilitated discussions and promoted ownership of plans of action. These plans included the IMG Taskforce Report recommending the establishment of the IMG Assistance Program as an integral part of the MDH, Office of Rural Health and Primary Care, with the following components: career guidance and support; clinical assessment with preparation; dedicated residency slots; and creation of a revolving fund at the State to collect and manage the public and private funds.
Sustained collaboration through monthly engagement of selected stakeholders, supporters and opponents over an entire year was another activity that was instrumental to making progress. Each stakeholder’s interest was sustained over the month, as they actively researched issues raised in the task force or advisory council. It was very helpful that the sessions of the task force had a preset timeline of commitment and that meetings were scheduled well in advance, thus increasing participation. A rewarding collaborative activity was the participation in the White House National Credential & Skills Institute by the Minnesota program leadership team, including: the Director of MDH Rural Health & Primary Care; the Coordinator of the IMG Assistance Program, the Director of WISE/NAAD Partnership, and the Chair of the IMG Taskforce and the IMG Assistance Program Advisory Group. Minnesota’s IMG Program was recognized, at this June 2016 White House gathering of health related federal and state agencies, as the most advanced program in the country and it has become a model for other states to duplicate.
Prior to this grant cycle, WISE/NAAD Partnership was committed to a specific solution: “supporting IMGs (formerly termed foreign trained medical professionals) in securing medical residency.” This hindered discussion with other stakeholders and therefore progress toward our intended outcomes. With this grant cycle, WISE became committed to the process versus a specific outcome. The acquired commitment to the process resulted in ownership by all stakeholders, which eventually led to broad consensus. We soon learned that the process is slow and must be intentional, engaging stakeholders in discussions over the barriers to accessing medical residency, making the best collective decisions and testing ideas for their benefits to the IMG participants affected by these barriers. In addition, it is also necessary to consider several solutions to ensure we meet the needs of all IMG participants, since alternative professional pathways are now acceptable options for some.
Key lessons learned:
One key lesson learned doing work during the grant period was that it was important to identify all the needs and unanswered questions across a variety of stakeholder groups related to addressing the identified barriers. At the beginning in the IMG Task force we thought we had enough needs and unanswered questions. However, when we recruited additional stakeholders for the IMG Assistance Program Advisory Council we were able to identify additional unanswered questions. We knew the issues and concerns of IMGs but we were not aware of the issues and concerns of residency program directors, for example. Thus, diversifying the stakeholders with known supporters and opponents is necessary to get a broad enough spectrum of needs and unanswered questions to be able to generate a variety of ideas that can be tested or evaluated to discover the ones most favorable to removing the barriers to accessing medical residency.
Another key lesson learned during the grant term was that all stakeholders, opponents and supporters, valued the goal of integrating and diversifying the healthcare workforce. However, the process of achieving the goal needed to be fleshed out. Special working groups had to be established for researching licensure options in different western countries and alternative medical pathways. These groups required recruiting additional representative stakeholders. The ideas and research findings of groups were summarized and presented to the IMG Assistance Program Advisory Group. Some of these proposals have been looked upon favorably already. For example, medical employer stakeholders, such as Fairview Hospital, which has personnel shortages, and St. Catherine University, which needs to diversify its student pool for new credentialing requirements, are looking forward to collaborating with IMGs, who would benefit from training in alternative primary care careers such as Physician Assistant, Physical Therapist, Advanced Practice Nursing, Occupational Therapist and the corresponding licensure.
A third key lesson learned was that increased financial resources to fund residency slots for doctors was not the only necessary ingredient for success. The most significant catalyst was finding a champion who would be a trailblazer. Even with resources, without a champion for progress, the progress would be very slow. In this process we had several champions; Dr. Wilhelmina Holder, the co-founder and Director of the WISE/NAAD partnership; Yende Anderson - who led the legislative effort for the establishment if the IMG Assistance Program; Mark Schoenbaum, the Director of the MDH Rural Health Program & Primary Care- who provided staff for the task force without additional funding; and Dr. Pitt – who was the first and only applicant for the first state funded dedicated residency program for IMGs. Dr. Pitt accepted the applications of 36 IMG applicants, thus opening the door for the IMGs’ applications to be reviewed. 15 of these IMGs received interviews while 4 were found qualified to match and be recipient of medical residency, two of these were in Minnesota. With the second round of funding for dedicated residency slots, two more residency programs submitted applications.
Reflections on the community innovation process:
Now that the MN Legislature has created a state funded program, we have the opportunity to implement the solutions generated by the task force and evaluate their efficacy. As we begin this process, we are noticing that the coalition is reacting in various ways. Many IMGs had extremely high expectations and are discouraged that change is not coming as fast as expected. It is now important to make sure that we manage expectations appropriately so that the perfect does not become the enemy of the good
Progress toward an innovation:
The major progress toward achieving innovation to diversify the MN health workforce by integrating IMGs was the legislatively created, state funded IMG Assistance Program now housed in the MDH Office of Rural Health and Public Affairs. The program provides career guidance and support, including alternative paths for those unlikely to become licensed physicians, and a six-month clinical preparation course at a teaching hospital; created an assessment process and certificate to document immigrant physicians’ qualifications to enter residency; and established a revolving fund that will support 3 -5 residency positions. The Bill provided one million dollars annually of public funds for the Public Private Funding Initiative for medical residencies. The public-private funding will be housed with MDH and has rules, regulations and policies governing the funds and a process for accepting funds from private donors. We now need to turn our attention to obtaining private funding for this Initiative. We plan to develop a fundraising plan and implement the process of identifying donors, educating them, soliciting funds and continuing to update them about the Initiative.
What it will take to reach an innovation?:
WISE/NAAD Partnership, although close, has not yet achieved the innovation we are envisioning. We now need to turn our attention to obtaining private funding beginning with developing a fundraising plan.
One additional step toward achieving innovation is to identify, through outreach and education, 21 committed community leaders/stakeholders from the private sector - major healthcare institutions, businesses, insurance companies, corporations, and banks to form a Taskforce or Community Action Committee that would meet monthly for a year to establish a consortium of private sector funders committed to investing in the revolving fund to increase medical residencies for IMGs.
Another important step will engage the state and federal Departments of Labor, Education and Employment and Economic Development; Office of Refugee Resettlement; Office of Minority and Multicultural Health in finding state and federal solutions to the barriers IMGs face. In addition, we should apply for public grant funding for the Initiative from the above government agencies for residency funding as well as to fund the WISE/NAAD partnership to maintain the necessary support of IMGs.
The current program being implemented at MDH is promising and positioned to assist Minnesota to address issues of health equity and diversifying the health workforce. However, the program will have limited impact due to limited funding. When the bill was proposed, we asked for 7 million dollars, we received 1 million dollars. We are very grateful for these funds but more are needed. Therefore, we plan to begin the process of engaging additional stakeholders committed to collaborating with WISE/NAAD partnership to invest in the public private partnership Funding initiative (PFI). We will establish a Fundraising Committee that will meet monthly to plan a Forum to launch the PFI and get pledges from key funders. We next plan to develop and implement a long-term funding raising plan that includes a policy that IMGs who benefit from the dedicated residency program pay $15,000 into the revolving fund for five years post-residency and commit to working for five years in rural or medically underserved areas of the state.
If you could do it all over again...:
One intervention we would have added at the beginning of the program, in hindsight, would be focusing more on empowering IMGs to realize and believe that they are not beggars looking for a handout, instead they are medical assets available to fill existing workforce vacancies/shortages and to provide the culturally and linguistically appropriate health care services that are currently needed in Minnesota's health workforce, giving the increasing diverse population of the state.
This would have been important because we would have framed the issue differently and we would have broadened our stakeholders to include health care providers, rural health systems;
health demographers and other federal government offices, such as the US Department of Health and Human Services, Department of Health Research and Services Administration; Department of Labor; and the Department of Education
One last thought:
WISE/NAAD partnership cannot adequately express their gratitude for this valuable Bush Foundation Community Innovative Grant funding. It provided legitimacy for the partnership and open doors for us to reach stakeholders and be recognized in the community. This funding also provide support for staff time to do advocacy and outreach activities. Thirdly, it provided ample training, capacity building and information sharing opportunities at Bush Foundation Forum, Webinars, and the Minnesota Council of Non-Profits Annual Conference, Duluth, MN.