Find out how a rheumatology educational program for primary care providers in the Navajo Nation may be improving care.
Despite high rates of rheumatoid arthritis prevalence and associated morbidity, the Navajo Nation, the largest American Indian reservation in the United States, only has one rheumatologist providing care for 250,000 tribal members. As a result, the responsibility of rheumatology care has shifted to the primary care providers on the reservation. But are they getting adequate training?
Research presented at the annual American College of Rheumatology’s (ACR) Convergence took a look at the first rheumatoid arthritis training program called the Rheumatology Access Expansion initiative, or RAE for short, developed for primary care providers in the Navajo Nation.
This research was presented by Dr. Jennifer Mandal, an Assistant Professor at the University of California, San Francisco (UCSF), Director of the RAE Initiative, and the study’s lead author. Dr. Mandal began sharing the primary barrier to rheumatology in the Navajo Nation: the physical distance to the nearest rheumatologist. She explained that this barrier makes it crucial to train primary care providers on providing care for rheumatic conditions and help primary care physicians feel more confident in being able to provide this level of care.
To help prepare primary care providers, the RAE initiative is a 12-week training program designed by a team of rheumatologists, pharmacists, and Navajo cultural interpreters. It’s formatted based on the Project ECHO, or Extension for Community Healthcare Outcomes, educational model and uses videoconferencing to conduct seminars with community members.
The rheumatoid arthritis Navajo Nation curriculum included weekly interactive seminars incorporating the nurse practitioner, physician assistant, and community health worker. These seminars consisted of a didactic and a case discussion.
Primary care providers also completed a pre- and post-training knowledge test, which covered the diagnosis and management of rheumatoid arthritis and other rheumatic conditions, and completed pre- and post-training surveys about their confidence in three areas: diagnosis of rheumatoid arthritis, treatment with conventional disease-modifying anti-rheumatic drugs, and treatment with biologics. They were also asked to rate the usefulness of each session.
Among those who complete the knowledge and confidence surveys:
- 22 percent saw improved performance on their knowledge test
- The mean session usefulness rating of 4.52 of our 5
- In the self-reported survey, researchers saw a little under a 20% increase in confidence for the diagnosis of rheumatoid arthritis and a little over a 20% increase in confidence for the management of rheumatoid arthritis
“We successfully designed and implemented a 12-week RA training program for Navajo Nation primary care providers,” said Dr. Mandal. “The curriculum, now in its third cohort, has been very well received and has improved the providers’ knowledge of evidence-based RA guidelines and their confidence in disease management.”
Future plans to develop the program to include more disease states, such as spondyloarthritis, and expand to other Native American communities are in the works. Researchers are hoping to get a better understanding of the program through patient outcome data but are planning to wait a few years to establish a strong track record of trust and reliability in the Navajo community before they do so.
For now, Dr. Mandal believes we’re on the right track when it comes to improving rheumatology care.
“This model is cost-effective, logistically feasible, even in very rural communities, and easily scalable,” she explained. “We hope our work can serve as a blueprint for other rheumatology providers who may be interested in launching similar remote training programs in other underserved communities across the United States and beyond. By providing high-quality rheumatology training and mentoring to front-line primary care providers in vulnerable communities, this program could have a positive impact on many thousands of patients suffering from rheumatic diseases.”