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Interprofessional Collaborative Practice at the PATH Clinic
Jennifer Frank, PhD, Michele Talley, MSN, ACNP-BC, Phillip Berry, M.D. and Deepti Bahl, M.D.
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
M-POWER Ministries
Literacy Center
Health Center
Education Center
• Only free clinic in Birmingham; open
3 evenings/week • UABSON opened PATH Clinic 1
morning/week in May 2011
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.
Objectives
3. Integrate nursing and other health professions students into the IPCP model in order to gain experience with team- based 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.
IPCP Staffing Plan
Total of 1,600 completed appointments as of 11/1/2013
Total of 1,772 patient visits March 2013-2014 Tuesday – 552 visits Wednesday – 493 visits Thursday – 664 visits
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
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)
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
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)
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
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
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.
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
Patient Demographics
No Source for Care – 54.4%
Financial Hardship – 47.6%
New onset of Diabetes – 17.6%
Blood Glucose > 300 – 34.8%
A1C > 8.0 – 30.85%
Frequent ED visits – 7.6%
Likely Readmission – 39.6%
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.
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
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)
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)
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. 2013.
• Mean response scores all above 4.75
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)
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)
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%
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
Outpatient clinic or ED referral
Hospital referral
Discharge teaching?
Referral form completed ?
Transportation available to clinic?
Verbal communication to clinic?
Reminder call made ?
G A P
G A P
G A P
G A P
G A P
-Lack of self care -Potential for: -non-compliance -poor outcomes - readmissions - ED Visits
Potential lack of: -transitional care -coordinated care -poor outcomes
Potential for: -non-compliance Lack of : -transitional care -coordinated care -resources
-Non-compliance -Knowledge Deficit: - routine care - nutrition - medication -Cultural Diversity
Potential for: -inaccurate information -no reminder call -missed appointment Supplies/ medications
provided?
no
no
no
no
yes
yes
yes
yes
yes Lack of: -transitional care -coordinated care
no
no
= Access issues
= Communication issues
Total transitional care no no
G A P
yes
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
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)
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