2014 National Nursing Centers Consortium Conference. Interprofessional Collaborative Access Network (I-CAN)

Transcription

1 2014 National Nursing Centers Consortium Conference Interprofessional Collaborative Access Network (I-CAN)

2 Overview Introduction to the I-CAN Model The Client in Community Implications for Academic /Practice Models

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4 Goals of I-CAN Develop interprofessional collaborative practice and education partnerships Improve health outcomes and satisfaction with health care services Build capacity for leading interprofessional teams

5 Academic Partners OHSU School of Nursing OHSU School of Medicine OHSU/OSU College of Pharmacy OHSU School of Dentistry Global Health Center

6 Structure of I-CAN NCAPPs Neighborhood Collaboratives for Academic-Practice Partnership People in the neighborhood Health care organizations Community service agencies Academic partners

7 Year 1: Old Town, Portland Central City Concern Neighborhood House MacDonald Center

8 Year 2: West Medford La Clinica del Valle St. Vincent de Paul Family Nurturing Center

9 I-CAN Care Management (CM) and Follow Up Interprofessional student teams are placed at NCAPP agencies

10 I-CAN Care Management (CM) and Follow Up Nurse Faculty-in-Residence (FIR) coordinate interprofessional student teams

11 I-CAN Care Management (CM) and Follow Up NCAPP agencies identify most vulnerable clients Two or more non-acute EMS calls in the last 6 months More than three missed appointments in the last 6 months No primary care home No health care insurance More than 10 medications Older than 60 without stable housing Families with children without stable housing Five or more unexcused school absences for children Signs of child negligence More than one family member with a disabling chronic illness Developmentally delayed parent(s)

12 I-CAN Care Management (CM) and Follow Up Interprofessional student teams meet with clients in the community

13 Meeting Clients Where They Are Nearly half of client visits take place in the home, compared to an agency or clinic. 44% 42% 14% Client s Home Agency or Clinic Other The average client visit is 83 minutes.

14 I-CAN Care Management (CM) and Follow Up Interprofessional student teams huddle with staff at NCAPP agencies to develop care management plans to address social determinants of health

15 I-CAN Care Management (CM) and Follow Up Interprofessional student teams continue to follow clients to achieve health goals

16 Client Centered Health Goals 52% 51% 35% of visits include interactions about seeing a provider of visits include interactions about housing of visits include interactions about health insurance

17 I-CAN Care Management (CM) and Follow Up Population-based issues discussed with NCAPP agencies

18 I-CAN Population Impact Immunization clinics 90 people seen Blood Pressure clinics 75 people seen Housing assessments 10 buildings assessed, including interviews with the building managers

19 I-CAN Care Management (CM) and Follow Up Interprofessional student teams hand-off care managed clients to the next group of students

20 THE CLIENT IN COMMUNITY

21 I-CAN Project: Client Outcomes Short Medium Long Improve Health Literacy Increase Life Management Skills Improve Access Improve Satisfaction Improve Health Outcomes Improve Quality of Life

22 Client Profile (n=57) At initial assessment, clients are unable to identify the name or purpose of 25-50% of their medications. On a scale of 0-100, clients rate their overall quality of life at just Three-quarters of clients report problems with pain, mobility, and performing their daily activities.

23 Primary Care, Housing, and Insurance At time of referral, clients have poor access to care and experience high instability. 44% of clients lack a primary care home 37% of clients lack stable housing 27% of clients lack health insurance

24 High Utilization of Health Care In the six-month period prior to working with I-CAN: 57% 38% 37% 18% of clients visited the emergency department at least once of clients were admitted to the hospital at least once of clients used emergency medical services at least once of clients visited the ED three or more times

25 I-CAN Project: Aggregate Health Outcomes Short-Term Client Outcome Measures Increased number of clients with health insurance, primary care homes, & stable housing. Long-Term Client Outcome Measures Reduced EMS calls, ED visits, and hospitalizations, and increased satisfaction with health care services.

26 IMPLICATIONS FOR ACADEMIC/PRACTICE MODELS

27 I-CAN Project: Student Learning Outcomes Challenges facing the underserved Short Working in interprofessional teams Understanding community health systems Medium Providing interprofessional care to underserved populations

28 Number of Students Participating (n=146) Nursing 66 (45%) Pharmacy 62 (42%) Medicine 10 (7%) Dentistry 8 (5%)

29 Student Learning We were able to work with nurses and social workers to help a member of the community overcome challenges in his life. It was important to help him obtain the things that he valued, such as housing and food, before we can address his medical needs. By spending time with patients in their homes, hearing their stories, and observing their environment, we begin to connect the dots of health and sickness.

30 I-CAN Project: Community Outcomes Short Medium Long Improve networks & resources Increase collaboration Established navigation resources Improve community care coordination resources

31 I-CAN Project: Academic Partner Outcomes Short Build faculty interprofessional partnerships Medium Increase collaboration between academic & community partners

32 Our I-CAN Grant & Academic Team Project Director Project Manager Project Co-Manager Project Evaluator Project Evaluator Evaluation Coordinator Peggy Wros, PhD, RN Launa Rae Mathews, RN, MS, COHN-S Heather Voss, RN, MS Katherine J. Bradley, PhD, RN Tanya Ostrogorsky, EdD Nic Bookman, MPH Liaison to Provost s Office Liaison to SOM Liaison to SOD Liaison to COP GHC/iCHEE Program Faculty in Residence Jennifer Boyd, PhD, MBA Meg Devoe, MD Jill Mason, DDS Juancho Ramirez, PharmD Valerie Palmer Ann Beckett, PhD, RN

33 Our I-CAN NCAPP Partners Old Town Portland Central City Concern: Chuck Sve Macdonald Center: Kristrun Grondal & Sarah Knuth Neighborhood House: Donna Trilli West Medford La Clinica del Valle: Alma Elder St. Vincent de Paul: Ann Close Family Nurturing Center: Beth Jaffee-Stafford Disclaimer: This project is supported by funds from the Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS) under grant number UD7HP25057 and title Interprofessional Care Access Network. 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 the BHPr, HRSA, DHHS or the U.S. Government.