Interprofessional Collaborative Practice at the PATH Clinic

Transcription

1 Interprofessional Collaborative Practice at the PATH Clinic Jennifer Frank, PhD, Michele Talley, MSN, ACNP-BC, Phillip Berry, M.D. and Deepti Bahl, M.D.

2 UAB School of Nursing

3 UAB School of Nursing Offers BSN, RN Mobility, AMNP, MSN, DNP and PhD programs Enrollment of 2,450 Fall semester 2013 Ranked # 21 in overall graduate programs (among top 5% of nursing schools nationwide) by U.S. News and World Report Selected as a VA Nursing Academy Part of a larger health sciences campus that also includes Medicine, Dentistry, Optometry, Public Health, and Health Professions

4 M-POWER Ministries Literacy Center Education Center Health Center Only free clinic in Birmingham; open 3 evenings/week UABSON opened PATH Clinic 1 morning/week in May 2011

5 Objectives 1. Implement a model in which nurses and other health professionals become competent at interprofessional collaborative practice. 2. Demonstrate the efficacy of the Chronic Care Model in providing continuity of care and chronic disease management to a medically underserved population.

6 Objectives 3. Integrate nursing and other health professions students into the IPCP model in order to gain experience with teambased care and the healthcare needs of vulnerable populations. 4. Develop and implement a plan for intermediate and long-term success of the IPCP model at the PATH Clinic.

7 IPCP Organizational Chart

8 IPCP Staffing Plan Total of 1,600 completed appointments as of 11/1/2013 Total of 1,772 patient visits March Tuesday 552 visits Wednesday 493 visits Thursday 664 visits

9 Project Innovations Collaboration and support of an Academic Medical Center Integration of EMRs between a community-based free clinic and an AMC Use of an Interprofessional Coach Incorporation of multiple disciplines, including Informatics and Health Information Management Use of daily team huddles and post-conferences Sweet Home Alabama

10 PATH Clinic: Pre-Huddle Each morning begins with a pre-huddle All providers, staff, and students attend except triage nurses Patient list reviewed New patients versus established patients Discuss potential issues with flow (staffing issues, dispensary issues, med availability)

11 PATH Clinic: Patient Appointment Enter clinic and sign in at front desk Complete demographic info Complete HIPAA and Patient Covenant with M-Power and PATH clinic All new patients attend Diabetes Education Class for 1-2 hours with Dietician All established patients wait until called into triage area

12 PATH Clinic: Patient Appointment Patients go to triage area Triage Nurse obtains height/weight, vital signs, med list, and chief complaint Nurse escorts patient to room Provider enters (1 of 3 NPs with advanced diabetes expertise)

13 PATH Clinic: Patient Appointment NP reviews previous records NP reviews glucometer and log of blood sugars NP tracks and identifies trends NP conducts interview and physical exam NP establishes a plan with patient

14 PATH Clinic: Appointment After the provider-patient visit is complete, patients receive a flow sheet that explains who they need to see before leaving the clinic. Patients take the flow sheet to the next provider (dietician, nurse care manager, dispensary, social worker/pharmaceutical patient assistance program manager) Follow- up appointment is made

15 PATH Clinic: Post-Huddle Post-huddle conducted with all providers, staff, and students NPs typically discuss each patient to ensure continuity of care Patient assistance program manager works with providers for needs for the patient to receive meds Nurse care manager then follows up with any missed appointments, necessary referrals, etc.

16 Tuesday Patient Demographics 250 unique patients seen for a completed visit 500 return visits completed (0 12 per patient) 109 patients scheduled for a visit never came

17 Patient Demographics 50% Male/50% Female 39% African American 46% White 6% Type 1 Diabetes

18 Patient Demographics Mean Age (SD = 11.24) Age Range years

19 Patient Demographics No Source for Care 54.4% Financial Hardship 47.6% New onset of Diabetes 17.6% Blood Glucose > % A1C > % Frequent ED visits 7.6% Likely Readmission 39.6%

20 Outcome Measures Resource Use Number of ED visits Number of Hospitalizations Total charges (costs) Clinical Outcomes A1C, BP, BMI PHQ-9 Depression scale Mortality rate, amputation rate New/progressive retinopathy Process Measures % clinic visits kept # clinic visits provided # services provided Health & Social Outcomes Successful enrollment in other care sites Obtaining health insurance Successful enrollment in PAP.

21 Evaluation Instruments Assessment of Interprofessional Team Collaboration Scale Daily end-of-clinic surveys on team dynamics Evaluation of IP Coaching sessions Structured interviews with providers on knowledge of team dynamics Patient Experience Surveys

22 Daily End-of-Clinic Survey

23 Provider Survey Results Open communication between team members took place as decisions were made for patients. Mean=6.27 (SD=1.17) As decisions were considered, team members each actively represented their professional perspectives about patients needs. Mean=6.24 (SD=1.07)

24 Provider Survey Results Patient care activities were coordinated between team members. - Mean = 6.15 (SD=1.2) Overall, I was satisfied with the process in which decisions were made for patients. - Mean = 6.17 (SD=1.10) Overall I was satisfied with the decisions made for patients. Mean = 6.25 (SD = 1.07)

25 Patient Satisfaction Survey Paper Survey consisting of eight experiential items and five demographic questions completed just prior to checking out. 807 responses across the three clinic days through Dec Mean response scores all above 4.75

26 Patient Satisfaction Survey I was treated with respect at the clinic today. (Mean=4.80) The healthcare provider listened carefully to what I had to say. (Mean = 4.80) I am satisfied with the amount of time the healthcare providers spent with me during my visit. (Mean = 4.75) The problems I came to the clinic for were addressed. (Mean = 4.76)

27 Patient Satisfaction Survey I better understand how to take care of my health after today s visit. (Mean = 4.74) I am satisfied with the care I received at the clinic today. (Mean = 4.79) I am satisfied with the scheduling process to make appointments. (Mean = 4.77) I will probably use the clinic again. (Mean=4.82)

28 PATH Patient 1 28 yoaam referred from night clinic for DM and HTN management on 11/29/12 PATH clinic on 12/18/12: BP 158/106 A1c 11.1% History: Already on Metformin but was increased to 1000mg twice daily and Glipizide 5 mg a day was added 12/2012. Rx for Clonidine and Lisinopril for BP On 1/16/13 BP 128/88 Fasting BS 100mg/dL On 5/2/13 (next appt kept) BP 143/89 A1c 8.5% On 7/16/13 BP 147/103 On 11/5/13 BP 154/116 A1c 9.3%- Glipizide increased On 3/18/14 BP 165/112 A1c 7.1%

29 PATH Patient 2 52 yoaam referred from night clinic for DM and depression management on 7/30/13 PATH clinic on BP 158/106 A1c 9.9% History: Already on Novolin 70/30 at 25 units every am and 8 units every pm (had lots of lows). Night shift worker so needed adjustment in timing of insulin with meals. Novolin 70/30 at 23 units switched to 10:30pm and 8 units switched to 5:30 am (meals 11pm, 3am, 6 am) On 9/17/13 A1c 6.6 Lost to follow-up:? transitional housing, history of drug use, history of prison time

30 PATH Clinic: Challenges and Strategies PATH clinic exposed a Wicked Health Problem for Patients

31 Outpatient clinic or ED referral Hospital referral = Communication issues = Access issues -Lack of self care -Potential for: -non-compliance -poor outcomes - readmissions Referral form completed? - ED Visits no Potential lack of: Verbal communication to clinic? -Non-compliance -Knowledge Deficit: - routine care - nutrition - medication -Cultural Diversity Lack of: -transitional care -coordinated care G A P G A P G A P no no no no yes Supplies/ medications provided? yes yes Discharge teaching? yes Transportation available to clinic? yes Reminder call made? yes Total transitional care no no no Potential for: -inaccurate information -no reminder call -missed appointment -transitional care -coordinated care -poor outcomes Potential for: -non-compliance Lack of : -transitional care -coordinated care -resources G A P G A P G A P

32 Challenges Leadership issues Nurse Managed Clinic but the grant supportive of no identified leader Natural leaders emerged Interprofessional issues Communication, collaboration, and confusion of roles Interagency issues UAB School of Nursing Bureaucracy of the partnership UAB Hospital Additional funds Endocrinologist issues MPower Change in director Change in volunteers Difficulty with staffing dispensary

33 Strategies Patient Issues Hiring of an Nurse Care Coordinator (facilitates communication and access) Leadership Issues Coaching Sessions Interprofessional Issues Weekly Newsletter Interagency Issues Team Meetings at M-POWER at times convenient for M- POWER employees Hiring of Nurse Care Coordinator (act as a liaison between partners)

34 Questions?