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APHA, November, 2015Sr. Bat Baber, RSM

Janet Buelow, PhD, MSN, MPHSuzanne Cashman, ScD

Anita Nivens, PhD, RN, FNP-BCGreg Knofczynski, PhDPaula Tillman, DNP, RN

INTERPROFESSIONAL COLLABORATION IMPROVING

THE HEALTH OF URBAN POOR

Funding from HRSA, Grant UD7HP25051

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Disclosure No author has any relevant financial

relationships with any commercial interests.

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Session Objectives Explain strategies for developing an

interprofessional working culture

Compare selected collaborative team practices to prior practices and patient outcomes

Explain student patient advocacy teams

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St Mary’s Community Center, Health Clinic, Savannah, GA – and surrounding population

Population served: adults earning less than 200% federal poverty level;

uninsured

Nearly 70% of the households live in extreme poverty

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2014 Patient DataN=1168

Ages: 18-64 Gender:

Females 863 (74%) Males305 (26%)

Race: Black 857 (73%) White276 (24%) Asian 16 ( 1%) Other 19 ( 2%)

Hypertension Diabetes Obesity Tobacco Abuse Depression

Demographics Morbidity

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Overall Project Goals Expand existing St Mary’s Health Center to an

Interprofessional Collaborative Practice (IPCP) primary care home

Provide and coordinate primary care for underserved adults in Chatham County, GA

Implement quality improvement processes & monitor outcomes

Develop and Demonstrate effectiveness of nurse led IPCP team

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Strategies

Incorporate additional health care professionals

Create interprofessional team culture Hold bimonthly team meetings Identify specialist physician consultants Monitor patient outcomes Create student patient advocacy teams

St. Marys Community Center

Interprofessional Collaborative Practice Team

IPCPEvaluator:

Statistician/Data Analyst

Practice Partners

NephrologyCare

PodiatryCare

PsychiatryCare

Gynelogical Oncology

Care

General Surgery Care

DentalCare

Years 2 & 3

Core TeamPatient Advocacy Teams

Medical Director:

Admin Coordinator

Licensed Medical Social Worker

Nurse Practitioners2 Full time2 Part time

Informatics Coordinator

Quality Improvement Health Administrator

Health Educator

Program Director

Patient

Social Service Agencies

Nurse Resource Coordinator

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Should Teams Naturally Work?

Challenges

Valuing others’ contributions

Communication

Knowledge of roles

Coordination

Adding new team members

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Training Core Team Members

Five workshops 11/2012 - 4/2014 Background, mission, goals, objectives Achievements/challenges, roles Conflict competence, team norms Data, PDSA, QI groups Data, QI

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Team Mission

Mission-driven interdependent professionals working together to meet the holistic needs of our patient population

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Maintenance

Twice monthly Friday morning team meetings Updates/Burning issues Patient presentation New practice partner introductions

QI team work

Goal 1 Goal 1or

Goal 2

Cycle 1 Cycle 2 Cycle 3Goal 1

orGoal 2

orGoal 3

Plan

DoStudy

Act Plan

DoStudy

ActPlan

DoStudy

Act

Infuse Quality Improvement with PDSAs

1. How good? By when?2. Set up measures & monitor3. What change can we make?

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Quality Improvement Teams

Diabetes Mellitus Team

Hypertension Team

Depression Team

Interprofessional Teams - 3rd Fridays

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Measures – some are improving . . . Diabetes Mellitus Team (Yr 1 patients at Yr 3)

Microalbumin levels (n=15) HgA1C scores (n=68) LDL levels improved (n=57, p=.002)

Depression 1168 screened with PHQ 2 + PHQ2 screens followed-up PHQ 9 293 pts with active interventions

CVD Team (Yr 1 patients at Yr 3) LDL levels improved (n=106, p=.008) B/P (n=125)

No-Show Rates Improvement with 16% no-shows in Year 3

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Student Advocacy Teams

Sample Instructional ScheduleWeek Class Topics Assignments

1 Poverty Challenges - Poverty Simulation & Online Discussion

2 Overview of Uninsured

- Orientation at Clinical Sites; First Journal

3 Health Disparities - Clinical work; Week 2 Journal

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Evaluation & Outcomes

Agency Semester Reports

St Mary’s Community Center

Food Stamp ApplicationsHealth Insurance & Medical Bill Referrals

Eye Clinic – fitting for glasses

Emergency Room, Uninsured

Referrals to medical homesReferrals for social determinants

Percent of acceptance of medical home

St Mary’s Clinic

Telephone CallsSet up data bases; update information

Health Education Class Assistance

Student Pre & Post Scores

Interprofessional Socialization and Valuing Scale

Ability to Work with OthersValue in Working with Others

Comfort in Working with Others

Readiness for Interprofessional Learning Scale

Team ValueProfessional Identity

Roles & Responsibilities

Interdisciplinary Education Perception Scale

Competency & AutonomyNeed for Cooperation

Actual CooperationUnderstanding values of other disciplines

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Sample Student Services

Physical Assistance Vital signs, Depression screenings, Prepare exam rooms

Computer Updates Lab results, Provider requests

Telephone Calls Reminders regarding screening, medications & eye exams

Quality Improvement Program Calls & Classes Calls regarding B/P home monitoring, Exercise & Cooking

Class Research Assistance

Chart Check re: med. compliance

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Lessons Learned

Team training and meetings Communication—speaking, listening,

and understanding Power of data/informatics CQI confers ownership Value added of health

professions/advocacy students Nurse led IPCP can meet patient need

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Next Steps

Academic-Community Partner Model sustainability

Fiscal and funding considerations

Exploration of other ways to collaborate