HEROs in Rural Health: Q&A with Art Kaufman

by Beth Blevins

Arthur Kaufman, MD, is the vice chancellor for community health at the University of New Mexico (UNM) Health Sciences Center and is a distinguished professor of family and community medicine in the UNM School of Medicine (SOM). Kaufman launched educational innovations that placed medical students in clinical roles in underserved areas. Kaufman also helped create UNM's Health Extension Rural Offices (HEROs) program, based on the agricultural extension model, which assigns HERO agents throughout the state to serve as community liaisons with the UNM Health Sciences Center. In addition, Kaufman helped spearhead the "Beyond Flexner" movement, a national effort to change how academic health centers address social determinants that play a pivotal role in health risks and outcomes. In 2015, he was elected a member of the National Academy of Medicine, formerly the Institute of Medicine. Recently, UNM SOM recognized Dr. Kaufman as its 2018 Living Legend, creating the Arthur and Ellen Kaufman Endowed Chair in his honor. He has written four books and authored over 70 publications and has received numerous federal and private foundation grants. Kaufman's wife, Ellen, and their two children are also physicians.

Recently, we spoke about the role that HERO agents have played in his state and beyond, how he is helping push the visibility and use of community health workers, and his work with UNM's World Health Organization Collaborating Center.

What sparked the idea for Health Extension Rural Offices (HEROs)?

"Health extension" is an idea we borrowed from the agricultural Cooperative Extension Service. There were two appealing aspects of the Extension Service – they addressed social determinants of disease and they were a model of the diffusion of innovation from land grant universities to frontline farmers and farm families. For example, Cooperative Extension agents help increase nutrition education through its Family and Consumer Sciences, help youth with school success via its 4-H clubs, and help farmers increase crop yields though university science labs. Further, if an agricultural college discovers a better growing technique or a new way to treat fruit tree infestations, community-based Cooperative Extension agents can move that knowledge quickly to frontline farmers. And if an extension agent in a community sees one farmer devise an innovative best practice, the agent can promptly share that practice with other farmers in the region or state. That was our role model and it's how we started putting HERO agents all over the state. It's a model that has now been emulated in many states.

Beyond adopting the Cooperative Extension idea into health, we now have a growing partnership with agricultural extension in New Mexico. This is facilitated by the major changes in the U.S. agriculture industry. With mechanization, the agricultural workforce is shrinking, so Cooperative Extension is seeking to redeploy much of their workforce toward health – and we need them.

What do HERO agents do?

Their role is to connect the priority health needs of their regions with university resources. We started with UNM Health Sciences Center resources, but we learned in the last couple of years that we have many more resources in the university that can help communities – for example, the colleges of engineering and of architecture and planning. We have developed a model that is driven by community needs rather than university needs – that's what health extension facilitates.

What does the day in the life of a HERO agent look like? It varies with the geographic area. It's designed around what communities want. Some HERO agents are tackling the deficit in behavioral health services in the state by putting on Mental Health First Aid classes for laypeople. Some are helping communities write grants, and some are working on changing health policies. Many are helping in primary care practice transformation to meet the Affordable Care Act goals. One agent just helped start the first school-based clinic in the southeast corner of the state, near west Texas.

HEROs help move the locus of control from the university to the community.

HEROs help move the locus of control from the university to the community. HERO agents are instructors and receive faculty appointments at UNM. People recognize the value of having this resource and access to the resources of the university right at their front door.

We currently have 10 HERO agents but are looking to eventually hire 20 to cover the state adequately. New Mexico is the fifth largest state in size, but it's sparsely populated. With too few agents, they spend too much time on the road.

How have HEROs evolved and how will they evolve in the future?

Our work is in three mission areas: education, service, and research. We spent much of our initial years focused on educational innovation to get more medical graduates into rural and underserved areas because of the desperate access issues in our state. Over time, it became clear that that effort is not sufficient. You can train very eager, well-prepared health providers for rural and underserved areas, but they might enter healthcare systems that are inhospitable to a focus on primary care and community health, incented more to build subspecialty referral bases. So that's the first big shock – we'd better expand our focus to innovations in clinical service. The second major issue was that, when you look at the healthcare system, you realize it has so little impact on health. A major reason the U.S. lags so far behind all the other Western countries in quality of service and health outcomes is we spend so much more on clinical services and so much less on social services.

Adverse social determinants play a major role in health, and that would be served by the social services component of a health system. The question was whether we could take some of that "downstream" clinical service money and re-allocate it "upstream" to address social needs like transportation, nutrition, poverty, and housing. HEROs were one answer to this question.

What other resources are you using to address social determinants of health?

Our biggest and newest program that is expanding rapidly is around community health workers (CHWs). They address social determinants at the individual level, whereas HEROs address them at a regional or county level. HERO agents are more masters-level trained, and CHWs only need to have a high school education. Their skill is defined not by degrees on their wall but by their intimate knowledge of their communities, their cultural and linguistic competence, and the trust their communities have in them. They can also quickly identify social needs in their patients, they know a myriad of resources, and they have the ability to screen for and address adverse social determinants. We've now linked them so that we have HERO agents training CHWs in different areas of the state, bringing these two important systems together.

How have HEROs been funded?

When the ACA was being written, our UNM Office for Community Health and the Department of Family and Preventive Medicine at the University of Oklahoma wrote Section 5405 of the ACA, entitled Primary Care Extension Program. The Senate Health, Education, Labor and Pensions (HELP) Committee, chaired at the time by Senator Ted Kennedy, was interested in the concept of health extension. We already had been developing health extension for a number of years before the ACA. The committee writing the ACA thought we might use extension to help improve the quality and efficiency of primary care practices and also help those practices to improve community health.

The Agency for Healthcare Research and Quality (AHRQ) at the time put $4 million into the IMPaCT grant to pilot primary care extension, with New Mexico receiving one of these grants. After the success of IMPaCT, AHRQ invested $112 million into the next grant, EvidenceNOW, creating seven cooperatives all over the country, each supporting primary care transformation for at least 200 small to medium-sized practices involving eight million patients.

…if health extension is going to be successful, it has to be sustained by state and local funding. Federal and private grants are important in helping test innovations, but they're only a start.

The idea of health extension is growing, partly through federal grants, but private foundations also have contributed. The dissemination was given a big boost by the Commonwealth Fund, which funded development of the online Health Extension Toolkit, a vehicle for showcasing the health extension work of 16 programs. For me, if health extension is going to be successful, it has to be sustained by state and local funding. Federal and private grants are important in helping test innovations, but they're only a start. Institutionalization usually requires sustained funding by those who receive benefit from the innovation—health systems, public agencies, governments.

What is the Health Extension Toolkit and how does it tie in with HEROs?

The Toolkit was a way for us to update our partners and present evidence with the material we've used. We want to share what we have and needed a universal perspective of looking at data. How do you mobilize an academic center to address social determinants? You hire agents around the state and mobilize around this vision, deploying resources a different way. Health extension is our cutting edge to get there. When you have agents in the community telling you, "You don't have enough nurses in the community, mental health problems here are horrendous…" all of these were addressed community by community. That's the genesis of an online, freely accessible toolkit to offer different approaches to implementing health extension, with lessons learned from different states.

Do you collaborate with other groups besides Cooperative Extension? And has there been any resistance to HEROs from other organizations?

Each step of the way there was resistance because we were treading on other people's area of expertise. Whether it's the Area Health Education Center (AHEC) or Cooperative Extension, they feared we would receive funding and notoriety that rightfully belonged to them. But, as we worked together, fear subsided and our mutually supportive and complementary strengths became apparent. AHEC was originally, primarily, an educational pipeline development program. But the newest iterations of AHEC grants nationally included expectations of greater connection with clinical service, a role more in line with health extension. In addition, both the HEROs program and the AHEC program are now under our office. We have three AHECs in New Mexico, and those three AHEC directors wear a second hat so that they are also HERO agents. The overlap and collaboration is so high that it works very well.

Early on, some in the Department of Health were also skeptical of HEROs, seeing them as little different than the Department's Health Promotion Specialists. Over time, we iterated that HEROs had a special connection with the resources of the University of New Mexico, just as Promotion Specialists accessed resources of the State Department of Health. Today, public health is becoming a stronger ally as we both struggle to address health inequities in our state.

How are community health workers forging a stronger relationship with HEROs and other organizations in your state?

CHWs are known, trusted, and able to move nimbly in different community circles based in part on their cultural and linguistic competence. To complement their role in communities, when you put CHWs in the middle of clinics and hospital services, it allows the health service system to understand firsthand the importance of screening for and addressing adverse social determinants affecting the health of patients. This strategy is linked to health extension, for HERO agents train and work collaboratively with CHWs in their region.

Having CHWs embedded in clinical settings has been transforming for our clinics. CHWs are a popular new addition there because they take the most difficult problems off the plates of providers. They help get patients into the social services they need, for example, getting new mattresses for patients who have bed bugs or getting people enrolled in GED classes. In the past, we would never have asked about adverse social determinants since we didn't have the resources to address them. Clinic-embedded CHWs have brought great cost savings to the clinical enterprise. Now that we have this model, many organizations are adopting it. Besides hospitals and clinics, Medicaid managed care organizations all over the state now have CHWs working with their highest-risk patients and are reducing costs. The state's largest county jail is employing them to reduce recidivism. And they are populating nonprofit social service agencies.

Today, we screen every patient who comes into primary care clinics at UNM and at the county's largest Federally Qualified Health Center, First Choice Community Healthcare. We've screened over 25,000 already. We found that one of patients' top unmet needs was for help in paying their utility bills. While CHWs have easy ways to get utilities paid for, their greatest challenge is finding housing for needy patients.  When you are in Santa Fe or Albuquerque, you might have a wide array of resources. But in a rural or frontier community, you have to be in the business of generating those resources if they don't exist. In bigger cities, CHWs might be differentiated – some working in hospitals, others in community agencies. But in smaller towns, our CHWs are broadly trained and not differentiated.

What does the WHO Collaborating Center do, and how does it draw on your other interests such as social determinants of health?

New Mexico is one of the poorest states. Ours is a public academic health center that has tried to mobilize its programs in education, service, and research to address state priority needs. This was of enormous interest to the World Health Organization (WHO), for the vast majority of schools in developing countries train physicians who leave their countries or serve wealthier clients in bigger cities – very few go into rural or underserved areas. In the U.S., you see the large research institutions that also don't adequately address priority community health needs. So WHO became interested in sharing UNM's model with other countries. One component of that interest was our designation as a WHO Collaborating Center focused on health workforce development for local needs.

The designation leads to an expectation that WHO and its regional Pan American Health Organization would send leadership from schools in developing countries to look at models we've created here and have us put on workshops on our models and also on how to create institutional change. In addition, members of our team visit interested institutions in other countries. We are also a beneficiary of this designation, as we are able to adapt important innovations we see abroad to our own institution and state. These models include community-based learning, recruitment into the health professions from rural and underserved ethnic communities, and broader use of CHWs as a tool for improved community health and economic development.

There was a study done in South Africa that showed if a doctor is trained in a developing country but leaves to work in North America or Western Europe, that developing country lost the $150,000 investment they made in training that doctor. But as a recipient of that doctor, North American or Western European countries save $450,000 that they didn't have to invest in their training. Such a brain drain represents a massive subsidy of the wealthy by the poor.

What led you to leave NYC, where you grew up and where you received your medical training, for New Mexico? Did you always want to live in the Southwest?

It changed my life. I … saw the devastation wrought by adverse social circumstances on my Native American patients, and I changed my career to primary care and community health.

I sought an alternative to the draft as a Vietnam War protester and was selected to work in the Indian Health Service in South Dakota, then New Mexico. It changed my life. I planned to become a NYC psychiatrist but saw the devastation wrought by adverse social circumstances on my Native American patients, and I changed my career to primary care and community health. My wife, also a physician, and I fell in love with New Mexico. We've been here 43 years.

Opinions expressed are those of the interviewee and do not necessarily reflect the views of the Rural Health Information Hub.