Tomorrow s Coordinated Health Care System-Today

Transcription

1 Tomorrow s Coordinated Health Care System-Today Breakout Session III. Innovative Interprofessional Collaborative Practice Models Dr. Marilyn Crumpton Dr. Kelly Bohnhoff Mr. Larry Bauer

2 Session Objectives 1. Discuss impact of interprofessional practice teams on patient care outcomes. 2. Explore health care needs of diverse populations. 3. Discuss preparation of next generation of health care providers to work in interprofessional practice teams.

3 Brief Overview of the Grant The Nurse Education, Practice, Quality and Retention (NEPQR) Program-Interprofessional Collaborative Practice (NEPQR-IPCP), HRSA , CFDA No was awarded to the XU School of Nursing in July, Year Grant

4 Purpose The overarching purposes of this project are to create new and expand existing IPCP environments through academic-practice IPCP partnerships capable of being replicated nationally through three key aims: 1) support a paradigm shift to IPCPs environments by training increased numbers of nurse leaders and other health professionals in IPCP core competencies so they can work in a culture of welltrained interprofessional teams; 2) oversee, monitor and evaluate the creation and expansion of innovative IPCP environments; and 3) provide improved patient/family experiences and health outcomes with reduced per capita costs through increased access to comprehensive, culturally competent, holistic preventive and primary health care services for patients, families, and communities.

5 Partners Cincinnati Health Department Clinics (5) School-Based Health Centers (9) Black Stone/Episcopal Retirement Communities (5) National Church Residencesworking on adding 3 local sites

6 Research Tools Xavier University Multi-Site IPCP Health Care Collaborative Project IPCP Team Collaboration Survey Xavier University Multi-Site IPCP Health Care Collaborative Project IPCP Evaluator Collaboration Survey North Carolina Family Assessment Scale for General Services (NCFAS-G); [High-Risk Families] Power School/EPIC (SBHC s) Uniform Data System (UDS)-CCPC Health Centers only Patient Activation Measure (PAM) [ERS Centers only] Vulnerable Elders Survey (VES-13) [ERS Centers only]

7 Research #15-081, Xavier University Multi-Site IPCP Health Care Collaborative Project: Engaging High Risk Families Principal Investigator: Dr. Kelly Bohnhoff XU IRB Approved April 7, 2016 The purpose of the study is to engage high-risk families in the community setting utilizing the IPCP teams located in SBHC s in order to provide improved student/family experiences and health outcomes with reduced per capita costs through increased access to comprehensive, culturally competent, holistic preventive and primary health care services.

8 NEPQR-IPCP Current Results Table 1. Baseline and 3-month IPCP Team Surveys by Partner Site Before you get started, please let us know the name of the group that was meeting. Please only enter one of the following options: AWL, Blackstone/ERH, Millville Clinic, Mt. Airy, Roberts Academy Roberts AWL Blackstone/ERS Mt. Airy Academy Total Assessment Baseline Count % within Assessment 18.2% 39.4% 21.2% 21.2% 100.0% 3-Month Count % within Assessment 21.9% 43.8% 18.8% 15.6% 100.0% Total Count % within Assessment 20.0% 41.5% 20.0% 18.5% 100.0%

9 Xavier University Multi-Site IPCP: Operational Definitions and Measures Survey for School-Based Health Centers (SBHCs) Results Summary Question 1. Where is your school-based health center? Academy of World Languages (AWL) 8 (50.0%) Mt. Airy 2 (12.5%) Roberts Academy 6 (37.5%) Total Responses 16 Question 2. From your perspective as an IPCP team member, what top 3 factors would you consider when identifying a family as high risk? #1 Categories #2 Categories #3 Categories Poverty/Income Level Food insecurity Communication barriers Mental health issues Complex health needs/stress School attendance and performance Instability at home Abuse/neglect Neighborhood violence Transportation Alcohol/Drug abuse Unstable housing/homeless

10 Social Determinants of Health Healthy People , 2, 3 What is Healthy People 2020? Healthy People provides science-based, 10-year national objectives for improving the health of all Americans. For 3 decades, Healthy People has established benchmarks and monitored progress over time in order to: Encourage collaborations across communities and sectors. Empower individuals toward making informed health decisions. Measure the impact of prevention activities. Goal: Create social and physical environments that promote good health for all. The Office of Disease Prevention and Health Promotion reported, Nearly everyone is impacted by the social determinants of health in one way or another. Healthy People 2020 organizes the social determinants of health around five key domains: (1) Economic Stability, (2) Education, (3) Health and Health Care, (4) Neighborhood and Built Environment, and (5) Social and Community Context.

11 Adverse Childhood Experiences (ACEs) The Adverse Childhood Experiences Study (ACE Study) is a research study conducted by Kaiser Permanente health maintenance organization and the Centers for Disease Control and Prevention (CDC) in 1998 that included 17,000 adult participants recruited to the study between 1995 and 1997 and have been in long-term follow up for health outcomes. 4 Adult patients were asked about any exposure they had as a child to the following: Recurrent physical abuse Recurrent emotional abuse Contact sexual abuse Alcohol and/or drug abuser in the household An incarcerated household member Someone in the household who is chronically depressed, mentally ill, institutionalized or suicidal Mother is treated violently Parents are separated or divorced Emotional neglect Physical neglect

12 What is the NCFAS-G? North Carolina Family Assessment Scale-General 5 Assists workers to assess families in eight domains of family functioning: Environment (7 subscales) Parental Capabilities (8 subscales) Family Interactions (8 subscales) Family Safety (8 subscales) Child Well-Being (7 subscales) Social and Community Life (6 subscales) Self-Sufficiency (6 subscales) Family Health (8 subscales) Likert Scale: +2 (Clear Strength); +1 (Mild Strength); 0 = Baseline/Adequate; -1 Mild Problem; -2 Moderate Problem; -3 Serious Problem. Also includes N/A or Unknown.

13 Mt. Airy Family Assessment This family (single parent with 3 boys ages 15, 12, and 6) was chosen by the Mt. Airy IPCP Team due to concerns about neighborhood violence, complex health needs/stress, school attendance and performance of the 6 th grader, poverty/income level, communication barriers, and mental health issues. The overall goal is to improve family well-being so that the younger son will not be exposed to the same risk factors as he grows up. NCFAS-G Outcomes Measures 10 X Initial NCFAS-G (5/26/2016) 3-Month NCFAS-G (8/26/2016) 6-Month NCFAS-G (11/26/2016) 12-Month NCFAS-G (5/26/2017) NCFAS-G Domains/Overall Score A. Environment B. Parental Capabilities C. Family Interactions D. Family Safety E. Child Well-Being F. Social/Community Life G. Self-Sufficiency H. Family Health Scale: +2 (Clear Strength) to -3 (Serious Problem)

14 Mt. Airy Family Assessment The goal is to leverage the family s strengths in order to decrease the impact of family risk factors on the overall well-being of the family. Family Assets, Strengths, and Protective Factors 1 (Domain/Subscale) A. Housing stability X E. Children s relationship with parent B. Supervision, discipline, and developmental opportunities for children C. Promotes children s education D. Absence of domestic violence, family conflict, and/or physical abuse of children. X X X NCFAS-G Protective/Risk Factors Identified F. Relationship between caregiver, school, and other providers; parent initiative and acceptance of available help/support; connection to spiritual/religious community G. Self-sufficiency related to financial management; transportation H. Parent and children s physical health adequate Family Risk Factors 1 X Poverty (low income) X Current family dysfunction/violence 9 X X Low level of parental education Large number of children History of trauma/abuse/violence (Adverse Childhood Events) 3,4,7,11 Parental mental illness/substance abuse 6 X Not owning a home X Family discord or illness 5 Single parenthood 2 X Welfare Dependence X X

15 Mt. Airy Family Assessment Goals identified by parent/primary caregiver during the assessment process included: Goal Statement #1 Time Frame Target Date Parent/primary caregiver will relocate her family to a safer living environment. 180 days 11/26/2016 Measurable Objective(s) 1) Parent and children will actively participate with the IPCP Team in the search for a safer home environment near Mt. Airy Elementary School. 2) Parent and children will move into a safer home environment near Mt. Airy Elementary School. Goal Statement #2 Time Frame Target Date Parent will explore opportunities for additional education and employment 60 days 7/26/2016 assistance through CitiLink. Measurable Objective(s) 1) Parent will actively participate with the IPCP Team to obtain information related to CitiLink. 2) Parent will explore CitiLink resources and begin additional educational opportunities and/or job placement. Goal Statement #3 Time Frame Target Date Parent will explore opportunities for summer camps, mentorship programs, 30 days 6/26/2016 and summer youth employment program for her children.

16 Mt. Airy Family Assessment Goals identified by parent/primary caregiver during the assessment process included: Goal Statement #3 Time Frame Target Date Parent will explore opportunities for summer camps, mentorship programs, 30 days 6/26/2016 and summer youth employment program for her children. Measurable Objective(s) 1) Parent will actively work with the IPCP team to utilize resources for summer camp program, mentorship programs, and summer youth employment programs. 2) Children will participate in summer camp programs (12 y/o son; 6 y/o son). 3) Youth will participate in mentorship program and summer youth employment program (15 y/o son). Goal Statement #4 Time Frame Target Date Parent will complete activities related to the physical and mental health care of 180 days 11/26/2016 the family. Measurable Objective(s) 1) Parent will actively participate with the IPCP Team to obtain information resources related to family physical and mental health. 2) Parent will make an appointment to see her primary care provider, and dentist. 3) Parent will explore additional resources for mental health symptoms (as needed). 4) Parent will make a MEDSOM appointment for her 12 y/o son to follow-up with medication management. 5) Parent will continue to ensure that children are up-to-date on their immunizations, eye care, dental care, and primary care.

17 High Risk Family Assessment 6 HP 2020: Goal-Create social and physical environments that promote good health for all. LENS NCFAS-G Assessment

18 Parent/Primary Caregiver Role in the SBHC-IPCP Team SBHC-NP Resource Coordinator Medical School Nurse Administration Social Worker Mental Health Provider Teacher Family Peer Support

19 References 1. Office of Disease Prevention and Health Promotion (ODPHP) [2016]. Healthy People 2020: Social determinants of health. Retrieved June 1, 2016, from 2. Office of Disease Prevention and Health Promotion (ODPHP) [2016]. Healthy People 2020: Interventions and resources. Retrieved June 1, 2016, from 3. Office of Disease Prevention and Health Promotion (ODPHP) [2016]. Healthy People 2020: About healthy people. Retrieved June 1, 2016, from People 4. Shelly, P. (2014). ACES (Adverse Childhood Experiences) Basics. Retrieved June 1, 2016, from 5. National Family Preservation Network (2016). NCFAS-G :Research report. Retrieved June 1, 2016, from 6. National Center for Family Professional Partnerships (2016). Family-centered care assessment. Retrieved June 1, 2016, from

20 Next Steps 1. Continue to work with High Risk Families identified by SBHC s prior to the end of the school year. 2. Formalize the referral process from SBHC s to CHD-Home Health. 3. Continue NCFAS-G Assessment Training with CHD-Home Health Social Worker. 4. Continue working with SBHC s to identify high risk families in grant YR 2 and 3.

21 Introduction: Larry Bauer