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Bridging the Gaps
Enhancing Outcomes & Education Through Collaboration:
The Bridging the Gaps/St. Agnes LIFE CHF Protocol
Claudia Siegel, MA, MPA
Lucy Wolf Tuton, PhD
Elizabeth Barthmaier, MSN, CRNP
Emily Amerman, MSW
Bridging the Gaps
The Partnership
Bridging the Gaps
Bridging the Gaps
The Challenge
Can we collaborate on a project to teach students about interdisciplinary care that also will have a demonstrable benefit for the clients and the site?
Bridging the Gaps
The Outcomes
Project Year
# Clients in CHF
Protocol
Prevented CHF Adm.
# Clients w/ Prev. Hosp.
Est. Charges1
2003-04 27 10 10 $352,544
2004-05 492 21 16 $862,218
2005-06 442 24 15 $1,054,608
Tot. Est Savings
$2,269,370
1 Based on PA Health Care Cost Containment Council data for 2003-2005.
2 CHF group entry flexible, some variation possible
Bridging the Gaps
Bridging the Gaps Program
• Multi-disciplinary health professions education program in Philadelphia (also w/ UPitt, LECOM, Delaware)
• Pre-clinical, interdisciplinary, health-related community service (1991), Seminar Series (1997), and Clinical Rotation (2001)
• Collaboration among all Philly AHCs & other institutions
• Community partners serve as host sites
• Seventeen years old in 2007
Bridging the Gaps
BTG Model
Collaborative Service-Linked Partnerships w/
Community Orgs.
Continuity of contact
Didactic & Skill-building
components
AHC – Community Supervision Evaluation:
MUTUAL BENEFIT
Inform the community
Bridging the Gaps
St. Agnes LIFE, A PACE Program
• PACE = Program of All-Inclusive Care for the Elderly (BBA 1997, orig. in 70s in CA)– Goal: keep elderly in community, at home
• Clients: nursing home certified, typically Medicaid but others can participate
• Capitated program: provides all services, basic living, preventive, primary, acute and long-term
• Interdisciplinary team (physicians, RNs, NPs, SWs, OT, PT, dietitian, CNAs, etc.)
• Transportation
• Adult day care center (3X wk), w/ on-site clinic
Bridging the Gaps
PACE Participants
• 80 years old on average
• Mostly female
• 7.9 medical conditions, usually of chronic nature
• Only 7 percent nationally are in nursing homes
Bridging the Gaps
St. Agnes LIFE• Opened 1998 under St. Agnes Medical Center (SAMC),
Catholic community hospital in south Philadelphia
• 2001-04 served 378 people
• Very frail: average death rate 14% annually
• 65 FTE staff, relatively low turnover
• Now serves 10 zip codes in south and north Philadelphia
• Two PACE centers, one co-located with housing
• 2004: SAMC became St. Agnes Continuing Care Center
• 2005: 137 participants, dual capitation
Bridging the Gaps
BTG-St. Agnes LIFE Common Interests
• Vulnerable populations• Preventive health practice• Environmental factors impacting health
(broad definition of health)• Interdisciplinary care and training• Collaboration focused on client
population
Bridging the Gaps
BTG/St. Agnes LIFE Mutual Benefit
St. Agnes LIFE Benefit
• Special projects enrich program– BTG clin. rotation
requirement
• Encouragement of ID model/training
• Fresh ideas & stimulation
• Participant enjoyment of students
BTG Benefit
• IDT Experience• Community health
setting• Geriatrics/geriatric
philosophy• Managed care at its
best• Creative interventions• Big picture/small
picture
Bridging the Gaps
BTG-LIFE Clinical & Educational Cross-Fertilization
Medicine, Social Work, Clinical Psychology, Creative Arts/Dance Therapy, Occupational
Therapy, Pharmacy
STUDENT CHF PROJECT (2001-02)
CHF MULTI-DISCIPLINARY PROTOCOL
Bridging the Gaps
BTG/St. Agnes LIFE CHF ProtocolInterdisciplinary Responsibilities
Social Work
Assessment, Caregiver contact & support
Medicine
Assessment, wkly eval
monitoring, pharm. coord.
Pharmacy
Monitor drug therapy, consult
w/ med & nursing
Psychology
Assessment, decrease anxiety,
increase pain tolerance
Nursing-not in original stu IDT
Wkly evals (weights, etc.), monitor, report
to CRNP/Med Dir
Occupational Therapy
Evaluate/promote home safety, personal energy conservation
Creative Therapies
Increase well-being,
socialization, sense of self
Bridging the Gaps
BTG students intro to PACE and role of IDT
BTG students collaborate in researching CHF and designing potential CHF protocol
BTG students introduce protocol, discuss potential outcomes with LIFE IDT--“BUY IN”
Gradual IDT acceptance and implementation of protocol
Student role became ancillary
CHF Protocol Generation & Implementation
Bridging the Gaps
BTG/LIFE CHF Protocol
Chief intervention point:
WEEKLY MONITORING & WEIGHTS
Bridging the Gaps
BTG-St. Agnes LIFE Successes
• Prevented hospitalizations
• Integration of CHF protocol into LIFE SOP
• Student evaluations of experience
• Improvement of client quality of life
Bridging the Gaps
BTG/St. Agnes LIFE DifficultiesBTG/St. Agnes LIFE Difficulties
• Identifying and selecting participants with CHF for the protocol—flexibility based on site needs
• Managing logistics of completing weights weekly and bi-weekly; space, time, staff changes
• Covering staffing shortages
• Data collection: tools and continuity
• Coordinating disparate student schedules• Measuring quality of life
Bridging the Gaps
The Necessities
• Common goals
• Demonstrable mutual benefit
• Commitment to collaboration, no matter what– Flexibility & patience
• Willingness to admit mistakes, to discuss all details, and to problem-solve together
Bridging the Gaps
Would We Do It Again?
We would and we will:
• New partnership with New Courtland LIFE, also a PACE program
• Serves 12 Philly zip codes, co-located with housing
• Electronic medical record, emphasis on staff continuing education, quality of life and outcomes improvement