Richmond health and wellness program

The Richmond Health & Wellness Program (RHWP)

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• Understand how methods and measures can be applied to IPE and IPECP and implications for advancements in education and practice

• Apply assessments to measure educational and treatment outcomes to your own settings

•

• Compare lessons learned with other attendees

Objectives: Integrating Theory, Frameworks, Models and Evidence

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Funding

This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UD7HP26044, The Richmond Health and Wellness Program (RHWP): Expanding Nurse-Led Interprofessional Collaborative Practice (IPCP) Teams for Community-Dwelling Older Adults, total award amount $1,488,584.00, 0% financed by nongovernmental sources. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

This project described was supported by a grant from Virginia Commonwealth University’s Council for Community Engagement. Its contents are solely the responsibility of the authors and do not necessarily represent official views of Virginia Commonwealth University and/or the Council for Community Engagement.

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The RHWP Experience

1. RHWP Background

2. Program Model

3. Highlight: Behavioral Health Clinic

4. Measures/Outcomes

5. Policy and Sustainability

RHWP Road Map

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• Need ➢1.8 million older adults live in federally

subsidized housing

➢> 50% limited in walking, climbing stairs

➢12% with mental or cognitive disability interfering with ability to perform IADL

➢Increased risk of institutionalization

Redfoot and Kochera 2004 ; Wilden and Redfoot 2002; 2002 American Community Survey; U.S. commission on Affordable Housing and Health Facility Needs for Seniors in the 21st Century 2002)

RHWP Sustainability

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The “Value Added”

of Linking Publicly

Assisted Housing for

Low-Income Older Adults

with Enhanced Services

RHWP

Sustainability

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Hypothesis

“Publicly assisted senior housing can act as an effective platform for organizing a system of coordinated health and long-term services and supports for low-income older adults”

U.S. Department of Health and Human Service Assistant Secretary for Planning and Evaluation Office of Disability, Aging and Long- Term Care Policy, January 31,2012-

RHWP Sustainability

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➢ Frank Baskind PhD

- Assistant Professor, School of Social Work

Steve Crossman, MD

- Associate Professor, School of Medicine

➢ Rachel Weiskittle, BA, PhD Student

- Behavioral Health Coordinator

RHWP Core Faculty

➢ Pamela L. Parsons PhD RN, GNP-BC

- Associate Professor, School of Nursing

➢ Kelechi C. Ogbonna PharmD, CGP

- Assistant Professor, School of Pharmacy

➢ Lana Sargent RN, MSN, FNP-C, GNP-BC

- Clinical Asst. Professor, School of Nursing

➢ Fay Parpart RN, MS, ANP-BC, AACRN

- Assistant Professor, School of Nursing

➢ Sierra Alewine, MS

- Clinic Coordinator

➢ Elizabeth Pohoreskey, FNP

- Assistant Professor, School of Nursing

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• Health Professional Shortage Areas (HPSA) ➢ Of 930,000 elderly residents in Virginia, approximately 50% live in

federally designated HPSAs

Joint Commission on Health Care, 2009

RHWP Identified Community Need

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• Healthcare Hotspots ➢ Population clusters with a high burden of chronic illness that can

benefit from targeted care delivery interventions

Gawande. The Hot Spotters. The New Yorker. 2011

RHWP Identified Community Need

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▪ Community & RHWP Concerns: ▪ Aging in place with high chronic disease burden

▪ Average # of medications taken per day = 9 [pilot data]

▪ Average # of chronic conditions = 5 [pilot data]

▪ High emergency room utilization

▪ Richmond Ambulance Authority ▪ Documented 138 transports to emergency department from DP in

2012 alone

▪ Of the 138 transports, 133 were deemed non-emergent

RHWP Background

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Canadian Interprofessional Health Collaborative

RHWP Interprofessional Collaborative Practice (IPCP) Teams

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The RHWP Experience

1. RHWP Background

2. Program Model




RHWP Road Map

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• Inter-professional Teams ➢ Nursing

➢ Pharmacy

➢ Social Work

➢ Medicine

➢ Psychology

• Care Coordination ➢ Link to appropriate care (liaison)

➢ Surveillance

- Diabetes – A1C monitoring

- Hypertension – BP monitoring

- Cholesterol

- Counseling & Education

- Triage

- Weight Management

RHWP Interprofessional Collaborative Practice (IPCP) Teams

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Team 2

Clinic Room 1 Clinic Room 2

Clinic Room 3

Team 1

Team 3

Faculty

Faculty

Faculty

RHWP Flow

NP Pharm SW NP Med Pharm

NP Med SW

House Calls

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• Company: ➢ DP is a Beacon Community

➢ Property housing management group

➢ Independently owned apartment complex for seniors

➢ Managed under the guidelines of Section 8 housing for low-income eligible elders

• Location: ➢ Located near the VCU Monroe Park Campus

• Building & Residents ➢ One bedroom apartments

➢ Approx. 247 residents living independently

Dominion Place Background

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• Company: ➢ RP is a Better Housing Coalition property

➢ Managed under the guidelines of Section 8 housing for low-income eligible elders

• Location: ➢ Located near the VCU Monroe Park Campus

• Building & Residents ➢ One bedroom apartments


Randolph Place Background

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• Company: ➢ CW is a Better Housing Coalition property

➢ Managed as a Tax-Credit property for low-income eligible elders

• Location: ➢ Located 5 miles from the VCU Medical Campus

• Building & Residents ➢ One bedroom apartments with 8-10 couples


Carter Woods Background

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• Company: ➢ Richmond Redevelopment Housing Authority

➢ Local HUD Contractors

• Location: ➢ Located 2 miles from the VCU Medical Campus

• Building & Residents ➢ One bedroom apartments with 200 and 105 apartments

Fay Towers and 4th Avenue Background

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Dominion Place

PCP

Pharmacy

ED Visits

Patient Improvement

Student PerformanceCommunity

Partners

Richmond Health & Wellness Program

Students

Psychology

Behavioral Health

DentalRandolph Place

Carter Woods

Partner Satisfaction

4th Avenue

Fay Towers

Medicine

Social Work

Pharmacy

Nursing

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The RHWP Experience

1. RHWP Background

2. Program Model




RHWP Road Map

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RHWP Behavioral Health Clinic

Services • Home Visits • Wellness Checks • Care Coordination • Referral Coordination • Wound Care • Medication Management • Patient Education • Blood Pressure • Glucose Check

Acute Care & Behavioral Health Services

Service Population • Overflow Home Visits • Urgent Care Walk-in’s • Crisis/Acute Needs • Care Coordination

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The RHWP Experience

1. RHWP Background

2. Program Model




RHWP Road Map

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• Patient Outcomes ➢ Care coordination (care coordination tool)

➢ Improved disease-state management

➢ Reduction in ER visits

• Student Outcomes ➢ Behavioral interventions

➢ Disease-state knowledge

➢ IPE principles/ Leadership

• Cost Savings/Cost Avoidance ➢ Decreased healthcare utilization

➢ Provision of services and associated cost

RHWP Measures/Outcomes

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RHWP Student Participation

Student Participation

Fall 2013

Spring 2014

Sum 2014

Fall 2014

Spring 2015

Sum 2015

Fall 2015

Spring 2016

PharmD 6 6 10 9 5 23 11 12

Medicine 6 7 4 6 - 2 2 4

Nursing (BSN) 10 9 10 18 18 13 29 25

Nursing (NP) 8 15 11 18 3 37 35 12

Nursing(Psych) - - - 2 5 - 7 7

Social Work 3 2 - - 4 2 2 3

Psych Doctoral - - - 2 7 2 0 1

Occupational Therapy

- - - - - - 1 41

Total 33 41 35 54 69 79 87 105

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RHWP Resident Clinic Visits

Resident Clinic Visits Fall 2015

Total

Carter Woods 99

Randolph Place 102

Frederic A. Fay Towers 85

1611 4th Avenue 92

1611 4th Avenue Behavioral Health 20

Dominion Place 265

Dominion Place Behavioral Health 48

Total 711

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➢ Adapted Care Coordination Tool1

o Care coordination activities/needs o Activity to fulfill needs o Outcomes prevented o Outcomes occurred o Notes

➢ CPT code list

➢ ICD-9 list ➢ Several pilot tests

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• Validated Screening Tools

➢ Geriatric Depression Scale-152

➢ Katz Activities of Daily Living Scale3

➢ Vulnerable Elders Survey-13 items4

➢ Assessing Care of Vulnerable Elders Quality Indicators5 ➢ Frail Questionnaire Screening Tool6

➢ Mini-Cog7

➢ Generalized Anxiety Disorder Scale-7 items8


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• Participant Experience

➢ Focus Groups o Impact on their health o Impact on understanding of health conditions o Communication with health care providers o Interaction with health care providers and students o Overall experience


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• Knowledge questions developed by faculty ➢ Communicating with older adults ➢ Health literacy ➢ Motivational Interviewing ➢ Diabetes ➢ Hypertension ➢ Cognition ➢ Falls ➢ Frailty ➢ Medications and polypharmacy


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• Brief post-survey

➢ How interprofessional care improves health

➢ Satisfaction

➢ Suggestions for improvement, strengths, and weaknesses

➢ Demographics

• Focus groups ➢ How the team worked

together for patient care

➢ Thoughts on interprofessional education

➢ Satisfaction with course


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The RHWP Experience

1. RHWP Background

2. Program Model



5. Sustainability and Policy

RHWP Road Map

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RHWP • Health Service Revenue • Research • Education

RHWP Sustainability

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• Health Service Revenue

➢Billable services ➢Shadow billing ➢Cost avoidance

➢MCO contracts ➢Medicare claims

RHWP Sustainability

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• Education

➢ VCU Quest for Distinction

➢ Service learning

➢ Community Based

➢ Interprofessional

➢ Team based care

➢ Competency based

➢ Prepared work-force

RHWP Sustainability

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RHWP Sustainability

• Academic Value

➢ Icubed | http://icubed.vcu.edu/

http://icubed.vcu.edu/

http://icubed.vcu.edu/

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• Research ➢Doctoral Students

➢Pre-Doc Awards

➢NIH

➢Foundation

RHWP Sustainability

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RHWP Sustainability

• Research/Funding Opportunities

➢ GWEP

➢ SAMSHA-Behavioral Health IPE and Substance Abuse

➢ P20 –NIH Nursing Center Grant – Symptom Management

➢ HRSA – BSN Training

➢ Student Focused Research ▪ Dissertation – Pharmacy ▪ UROP- Nursing- Community Engaged Fellowship

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RHWP High Rise ED Visits

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• Team Chemistry ➢ Don’t overlook

➢ Make decisions up-front (publication plan, etc.)

➢ Defer to better expertise

• Community Partnerships ➢ Research depends on strength of these relationship

➢ Needs to be revisited

• Funding Preference ➢ Goal and objectives more important than awardee

• Sustainability ➢ What will you do when funding runs out?

RHWP Take Home Points

Resident Approval

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Questions?