HANDBOOK FOR AHEC TRAINING IN COMMUNITY PSYCHIATRY
The purpose of this handbook is to serve as a guide for the training of UNC Psychiatry residents in AHEC sponsored community training sites. It is intended for both trainees and community based trainers. The documents contained within should provide the bulk of information, both background and detailed, needed during the course of the training year.
Thanks to the combination of several unique resources, the North Carolina based psychiatric resident receives one of the best introductions to community based psychiatric treatment available anywhere. The NC AHEC program. one of the earliest and best established programs of its type in the nation, links the UNC Department of Psychiatry with over half of the State Area Programs, covering all geographical regions and both urban and rural populations.
Section I of this handbook describes further the big picture of the AHEC mission, and the 'why' of community based medical training. (see also Dr. Bridges article in the appendix). UNC's training in community psychiatry is set aside not only by the diversity and depth of the experience offered, but by its design as well, which includes 2 separate one year exposures, one in the PGY2 training year and the second in the PGY4 year. This allows the progressive development of first basic(clinical) and then advanced(administrative) skills (see AACP training objectives in appendix). The overall Community Psychiatry training plan, including specific training goals of the PGY2 and PGY4 rotations, is delineated further in the remainder of Section I.
Section II contains detailed policies and instructions on the logistics of the AHEC rotation, including resident and training site expectations, training site assignment procedures, travel arrangements and evaluation procedures.
Section III deals with the specific AHEC sponsored training opportunities available to UNC residents. It is subdivided: a) a descriptive catalog of training sites and b) a listing of specific training selection slots available for selection in the current year. This list will be retailored each year to match residency class size and to address needs for geographic balance. Additional background material on training sites will be kept of file in Ms. Daniel's office.
The appendix contains several key references; some of these will serve as background reading for beginning of the rotation orientation seminars.
The UNC Community
Psychiatry Training Goals:
Undergraduate Training
While the training objectives highlight residency training, the task of developing community oriented psychiatrists begins in medical school. UNC and AHEC have developed successful advanced undergraduate training rotations in community psychiatry at the VGFW and Charlotte Area Programs. These sites were approved in 1991 to be included in the required MSIV ambulatory care selective, and are now among the most popular of rotations. Currently 19 MSIV students/year select one month rotations at these sites. Those who are now passing through our residency training program appear to have heightened interest in public sector practice.
PGY1-Year
Early and thorough immersion in public sector psychiatry has long been a strength of the UNC program. DDH and UNC were awarded the Gold Award of the H&CP Institute for their groundbreaking work establishing an integrated training program in the early 1970's. Residents now spend 3/4 of their first year at DDH and 1/4 on the inpatient units of UNC Hospitals. The main training thrust of the state hospital experience is to establish early competence and comfort working with patients who have chronic, multiple, and severe disabilities. At the UNC inpatient site, we have developed the additional PGY1 goal of providing early and intimate exposure to the programs of our local Area Program , which shares in the management of 60% of UNC inpatients. To this end we have been working to improve significantly our service and training integration with the local area program. Representatives of both institutions now meet monthly to develop innovative programming for continuing care of seriously disabled patients. Fruits of this labor so far include a highly collaborative psychotic disorders unit, routine integration of area program personnel in inpatient treatment planning, and a community oriented crisis service. We are banking on the idea that vicarious exposure to a respectfully interdigitated academic/community care system in the first year will help community oriented practice to seem like something worth learning when the resident begins formal community psychiatry training in the PGY2 year.
PGY-2 Year
The community oriented goal of the second training year is for the resident to become comfortable and competent providing direct and continuous clinical care to severely disabled patients in a community based setting ; there is a secondary goal of giving the resident a 'first look' at non office based mental health center programs. The centerpiece of the PGY2 introduction to community psychiatry is a year long AHEC rotation (1 day/week) in one of 16 mental health centers spread across the state (Appendix 1). Although the details of the placement vary according to specific interests of resident and site, the common theme of all placements at this stage is direct patient assessment and treatment planning skills within the framework of a multidisciplanary team. A designated psychiatrist supervisor works with the resident at each site, offering at least one hour of weekly of direct supervision (reimbursed by AHEC). At the onset of the PGY2 community psychiatry rotation we conduct orientation seminars in which CMC medical directors, staff psychiatrists, and area directors discuss the history , goals, and structure of the mental health center program and the evolving role of psychiatrists in this system. At this time residents read the AACP training goals and the NCPA report on psychiatrists in the NC system. During the course of their placement, we follow the development of the residents experience with several half day workshops in which the residents and supervisors process in a group format what they are learning at their training sites. In parallel with this, their community based supervisors meet several times during the course of the year to refine goals and share teaching methods.
PGY-3 Year
During the PGY3 year the residents stay 'at home'. The training focus at this stage is to provide a didactic 'bridge' between the direct care focus of the PGY2 experience and the programmatic orientation of the PGY-4 community experience. PGY 1, 2, 3 and 4 residents participate in a weekly Community Psychiatry Seminar Series. Other didactic courses offered during the PGY3 year cover additional topics related to community psychiatry including forensic issues and the treatment of substance abuse.
PGY-4 Year
PGY4 residents
and PGY5 Child Fellows return to community training sites for a second required
year long AHEC placement The
PGY4 resident is expected to take a relatively more
active role in exploring the system and
negotiating the terms of his or her 'employment'. Time is invested in one or more non direct service activities
including working on an administrative team, developing a consultative role, helping to plan new
services, or researching an issue
related to the operation of the area program or a treatment need of the
community. PGY4 residents join PGY2 residents in the group process
workshops. In addition to the required
AHEC placement we offer additional
community psychiatry electives that allow allow more thorough
development of special interests (e.g., community substance abuse treatment,
SPMI programming, divisional administration, etc.).
Additional Approaches
Additional 'islands' of community psychiatry training are spread through the fabric of psychiatry department life. Several major PGY 2/3 teaching clinics at UNC Hospitals, which have been developed in concert with the local area program, provide training in community management techniques; these include psychotic disorders program, and a crisis clinic. Residents run a weekly clinc at the Chapel Hill Homeless Shelter. Through our commitment to the continuing education arm of the AHEC Mental Health Initiative, faculty of all divisions teach and consult in area programs across the state; our department contributed a total of 560 AHEC teaching hours last year.
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Training Site Assignment Procedure:
In early spring of each year (February-March), rising PGY2 and PGY4 trainees will be provided a catalog listing and describing in depth the training sites that will be available the following year. The selection of choices available in a given year will be determined by the Psychiatry Department Liaison in consultation with the AHEC regional Mental Health Coordinators and clinical supervisors. It will be such a size that each site listed for that year can expect to have at least one trainee. The composition of the catalog will balance needs to provide geographical balance, teaching excellence and program diversity. The number of training slots offered at each participating site will be prearranged by the departmental liason -generally being in the vicinity of 2 residents/site. Trainiees will have approximately one month to 'research' their choice. They are encourgaged to contact and possibly visit sites, speak with residents who have trained there (contact Ms. Daniel for names), and speak with Dr. Haggerty. Training sites will also be givin the opportunity to express prefences, should they have them. By mid-April, residents will be asked to submit their 3 top choices to Ms. Daniel. Trainees and sites will be matched using standard and neutral procedures, and assignments will be announced by mid -May. Every effort will be made to maximize choice, but residents should be prepared to accept their matched assignment, even if it is not their first choice.
Residents will need to provide the
site with the following:
1)
Photocopy of your North Carolina medical training or
regular license.
2)
DEA number
3)
Social Security Number
Please furnish these to your site prior to the beginning of your assignment, preferably on your initial visit, so that necessary paper work can be completed before your first training day.
Within several weeks of beginning the assignment, the resident is expected to develop in conjunction with his or her supervisor a more or less detailed work plan that concisely describes how the resident will spend his/her time, learning focuses, supervision arranagements, and other mutual expectations. This work plan is required by the residency training office, and becomes a permanent part ot the residents training file in . Samples are attached.
The work plan should be:
1) typed (or legibly written)
2) signed by you and your supervisor at the AHEC site
3) returned to Myra Daniel:
Psychiatric Education Office
10625 Neurosciences Hospital
CB 7160, Psychiatry
Attendance
Residents are expected to observe the regular working hours at the assigned AHEC site. (Travel time is not counted as part of your work day). An average working day at a mental health center would probably be 8 AM to 4:30 PM or 8:30 AM to 5 PM. If your assignment is 1 day per week for a year, you should be at your site at least 42-45 days, allowing for holidays and vacations. Residents doing bloc assignments should have an equivalent number of days. Please schedule on call, moonlighting and other activities to avoid conflicts with your AHEC assignment.
You are expected to follow the site's requirements & procedures for patient care, follow-ups, reports, etc. You should discuss these with your supervisor at the beginning of your work to make certain you have a clear understanding of expectations. Your supervisor will complete an evaluation form on you for the Director of Residency Training at the end of each 4-month period just as your training supervisors within the department do.
Reporting of Vacation Days & Other Absences:
You should inform the following persons in advance of all planned vacation days or other absences:
1) The AHEC Site: Your supervisor and other personnel should have as much notice as possible of all planned absences so that they will not schedule patients for you on those days. If you are sick or unavoidaly cannot attend as scheduled, you should call the site as soon as you know you cannot come so they can reschedule your appointments, etc. Failure to inform the site of any absence planned or unplanned is bad for the public image of the department and disruptive to the site.
2) Myra Daniel (6-6997): Myra needs to keep an accurate and up-to-date count of actual days worked at AHEC sites by all residents in order to complete reports required by Central AHEC, make certain travel reimbursements are processed in a timely fashion and help the program run smoothly.
Training Site Criteria and Responsibilities:
AHEC's general goals are first to provide excellent training in communitybased psychiatry, and secondly to have this training be decentralized as much as possible among the communities of North Carolina. To this end AHEC encourages the establishment of training sites in all regions being served. With approximately 20 residents to place each year, it should be theoretically possible for each AHEC region to have at least one active training site. The ideal number of active training sites operating in any given year would probably be in the range of 10-12, including both sites that maintain an ongoing training contract with AHEC and developing or rotating sites that would accept trainees on a periodic basis. AHEC will pay particular attention to maintaining a balance between urban and rural sites, and developing sites that expose trainees to unique populations and innovative approaches to treating the underserved.
The ideal training site is one that can provide the trainee a variety of training opportunities that include traditional clinical work, community outreach, and involvement in community mental health administration. It is desirable that the site have some flexibility to tailor different training opportunities for different trainees. For sites accepting second year residents, the training focus should emphasize basic clinical skills; sites accepting fourth year residents should have the capacity to involve them in activities related to program administration and development. The presence of enthusiastic faculty and of a cordial and well functioning interdisciplinary milieu are definite pluses.
Specific Requriements
for Training Sites Include:
1) The Mental Health Center and Area Program formally agrees to support a training slot. This decision should be made with the approval and support of both administrative and clinical staff, including at a minimum the medical director, the clinical director, and the area director. These individuals will make an effort to understand the goals of training, and the staffing commitments necessary to support training. In particular, there will be an understanding that the purpose of being a training site is education, and that having a trainee will not necessarily result in an overall reduction in the work load of clinical staff. (Having stated this, it should be noted parenthetically that in the long run, the presence of residents does make a positive contribution to resources; some service is provided, the educational atmosphere of a clinic is enhanced, and recruitment prospects are increased.)
2) The MHC is willing to make a commitment to being a training site for a period of not less than one year, providing appropriate space, clerical support, and supervision for at least one resident for at least one day/week.
3) The training site is committed to the concept of interdisciplinary teamwork, and is willing to include and expose the trainee to team functions.
4) The site will specifically provide an MD supervisor who will set aside time on a weekly basis. The supervisor will be responsible for developing an educational plan for the trainee ,providing formal and informal instruction, and in participating in various meetings related to training on and off site. The time spent by the supervisor in these functions will be reimbursed by AHEC.
5) In general the training site should be prepared to have at least 20% of the trainee's on site time be considered educational time--to be spent with the supervisor or his designee, or engaged in other educational activities aside from direct clinical service.
6) The training site agrees to participate, along with the UNC departmental liaison, in regular evaluations of the trainees progress and of the overall efficacy of its training program.
THE
BASIC POLICY:
Travel to
and from AHEC training sites will either be provided or reimbursed by Central
AHEC. The choice of transportation type is largely determined by
distance and geography: by car for sites reached within about 90 minutes
driving time, otherwise by air. For car travel, the resident uses his or her
personal car, and is reimbursed for milage.
For sites requiring air transportation (currently Charlotte, Roanoke
Rapids, Wilmington, Asheville), AHEC's
medair operation will provide flights from Horace Williams Airport in Chapel
Hill; this is the preferred arrangement.
Occassionally, AHEC will recommend
that the resident use comercial carriers out of RDU if comercial rates
happen to be cheaper. AHEC limits travel reimbursement to two
trips per week per individual - those residents planning “block” aassignments.
FLIGHTS TO AHEC SITES:
Unless AHEC indicates that commercial carrier is preferable for your destination, you should plan to use Med-Air. To use Med-Air, you must commit to flying with them on a regular basis and make your reservation for days/places for the year in advance and no later than the first of June.. Until that time, you will have a "priority" status. Should you decide after June to fly Med-Air, you may not be able to work out the schedule you need. You make your own reservations for the Med-Air flights by calling Gerri Wright at 2-5207, identifying yourself as a Psychiatry resident scheduling flights for your AHEC rotation, and giving her all the details (day of week, place you need to go, times you need to arrive and depart, etc.) she will need to work you into the flight schedule. Med-Air will confirm names of residents with Myra Daniel, Psychiatry AHEC Coordinator, before they confirm your seating.
Ground transportation between the airport and the AHEC training site will be worked out by the regional AHEC office linked to your training site. The specifics of this arrangement vary from site to site, so check with your local contact person about details before your first visit.
The process:
Details on filing for travel reimbursement and a sample form are outlined in the following memorandum. Travel reimbursement forms which are illegible or incorrectly completed will be returned by travel! BE SURE TO READ THIS MEMO CAREFULLY AND FOLLOW INSTRUCTIONS.
Training Site Evaluation Form (Completed by Resident)
Available Selections for 1999 -
2000 Training Year
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