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

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 Organizational Chart

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

50% Male/50% Female

39% African American

46% White

6% Type 1 Diabetes

Patient Demographics

Mean Age – 46.45 (SD = 11.24)

Age Range – 21-78 years

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

Daily End-of-Clinic Survey

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

PATH Clinic: Challenges and Strategies

• PATH clinic exposed a Wicked Health Problem for Patients

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)

Questions?