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Jane Calhoun, M.S.Director of Clinical and Field Services
The Medical Home Workforce:Creative Medical Home Team
Building in the Mississippi Delta
Presenter Disclosures Jane Calhoun
The following personal financial relationshipwith commercial interests relevant to this presentation existed during the past 12 months:
No relationships to disclose
Links the three major Delta universities with the University Medical Center and the Delta Council.
Applies the latest findings to create programs with local partners.
Delta Health Alliance
What is Delta Health Alliance?
Our goal is simpleOur goal is simple……
…to improve the health of the men, women, and children who call the Mississippi Delta their home.
Delta Challenges: Socio-economic and geographic barriers to c
• Underserved by primary care providers
• Lack of access to preventive care and education
• Reduced motivation for healthy lifestyle choices
• Working uninsured wages lost for healthcarevisits
• Estimates of uninsured rate vary from 18% -35%
• Approximately 39% population at poverty level
• Little or no access to public transit
• Low literacy level
Obesity
All higher than their national counterparts
Delta Challenges: Not Enough Physicians
Source: MSU Social Science Research Center
Generalist Patient Loads
Not enough Nurses and Nurse Practitioners
Source: Mississippi Office of Nursing Workforce
21st
Century Primary Care
Model for Chronic Disease
•
Transforming primary care practices in rural health clinics and free clinicsin target counties
•
Measuring impact on access to care,treatment outcomes, and provider/patient satisfaction
21st
Century Primary Care
Model for Chronic Disease
•
Assisting affiliated rural clinics in transitioning to a patient-centered medical home model using a systematic approach developed by TransforMED.
•
Utilizing an interdisciplinary team approach
•
Improving clinic quality and efficiency
•
Adopting new technologies
21st
Century Primary Care Model -
Project Goals
Goal 1: Improved Health Outcomes for people with Diabetes and Hypertension
Goal 2:
Increased Access to Care
Goal 3:
Increased Community Awareness
Goal 4:
To evaluate the effectiveness of the process and the outcome of a PCMH model in the Delta and itsimpact on overall health outcomes.
21st
Century Primary Care Model -
Interdisciplinary TeamAt each clinic site:•
CFNP
•
Nurse •
Patient Navigator
•
Community Health Worker
Supporting 3-4 clinics:•
Clinical Pharmacist
•
Registered Dietician
Interdisciplinary Team: Family Nurse Practitioner
Assigned duties/services in the Clinic
Serves as clinical “executive”
to the team of health
care professionals that includes both medical and non-medical personnel.
Spends time with new patients and those with medically complex conditions.
Assists with care coordination.
Ensures adherence to clinical best practices, and promotes the adoption of appropriate P&Ps by the clinic.
Leads team in adoption of new technology.
Nurse Practitioner challenges
1) Lack of experience in leading a clinical team■
Failure to delegate and fully utilize skills of team
■
Implementing too many changes at one time, resulting in overwhelmed staff
2) Challenged by volume of medically complex conditions among high uninsured population.
3)
Challenged by issues surrounding implementation of EHR.
Interdisciplinary Team: Clinical Pharmacist
Education and Training–
Medication Therapy Management (MTM) certification through APhA (American Pharmacists Association)
–
Pharmaceutical Care for Patient with Diabetes
certification through APhA
–
Certified Asthma Educator
–
US Diabetes Conversation Map®
Facilitator Training through Healthy Interactions and the American Diabetes Association
Interdisciplinary Team: Clinical Pharmacist (cont’d)
Assigned duties/services in the Clinic
•
Medication access services for patients
•
Preventive Care Programs
•
Medication Reconciliation
•
Retrospective Drug Utilization Review
•
Medication Therapy Management
•
Disease State Management
Clinical Pharmacist challenges
1)
Acceptance from providers (MDs, NPs) of the PharmD’s role in the clinic, and failure to fully utilize services in one clinic.
2)
Uncertainty from other clinic staff of PharmD’s role, and hesitancy to accept recommendations.
Interdisciplinary Team: Registered Dietician
Education & Training
Bachelor’s degree-
Nutrition/Dietetics
Registered Dietitian through American Dietetic Association
Licensed Dietitian through the State of MS
US Diabetes Conversation Map®
Facilitator Training through Healthy Interactions and the American Diabetes Association
Working towards obtaining Certified Diabetes Educator (CDE) certification
Interdisciplinary Team: Registered Dietician (cont’d)
Services in the Clinic
Individual & group education regarding diet and disease management
• DASH(Dietary Approaches to Stop Hypertension) diet for hypertension
• Heart Healthy diet for patients with heart disease, high cholesterol, high triglycerides, etc.
• Carbohydrate counting and diabetes diet for patients diagnosed with diabetes mellitus
Interdisciplinary Team: Registered Dietician (cont’d)Delta Slim Down , a successful strategy to help patients
reduce the risk factor of obesity, has been utilized by Will Rowland, 21st
Century Registered Dietician.
Registered Dietician’s challenges
1)
No challenges regarding acceptance by otherstaff or utilization of technology (EHR).
2)
Challenges center around working with a mostly uninsured, low-income, low literacy patient population.
3) Residents lack access to fresh foods.
Interdisciplinary Team: Patient Navigator
Education & Training
Licensed Bachelor’s level Social Worker
Trained in use of Motivational Interviewing
Trained on The Pharmacy Connection (TPC)
Services provided
Facilitate patient-provider communication
Psychosocial assessment and referral
Coordinate the available resources to serve patients, including follow up and referral processes.
Promoting patient self-efficacy
Group education and group support facilitation
Patient Navigator (BSW) challenges
1)
PN role not fully utilized by
some providers.
2)
Number of pharmaceutical assistance applications.
3)
PN’s lack of supervisory experience.
Interdisciplinary Team: Community Health WorkerCHWs provide outreach services to link patients to the medical
home.CHWs initially worked under the direction of the Patient Navigator,
but now report to NP.
Services provided
•
Reinforcing chronic disease education (EMMI Solutions)
•
Encouraging disease self-management•
Encouraging compliance with appointments•
Assisting with application procedures for social, financial, and governmental services (i.e., pharmaceutical assistance, Medicaid, energy assistance, transportation assistance);
Interdisciplinary Team: Community Health Worker
Core skills training module (35-hours)Training provided by Susan Mayfield Johnson, PhD, of the University of Southern Mississippi’s Center for Sustainable Health Outreach.
Curriculum supports skills training in areas recommended by the federal Patient Navigator Act.
Orientation training at assigned clinicHIPAA compliance, patient confidentiality, use of HIT with regards to patient privacy and security of data
Skills Training prepares CHWs to provide:Skills Training prepares CHWs to provide:
Community Health Worker challenges1)
Uncertainty among staff about CHW role.
2)
Environmental pressures in the clinic
tend to result in CHWs not being fully
functional in their role.
3)
Current level of training offered may
not be adequate.
4)
Past job experience and individual
character traits appear to influence
effectiveness.
Results for the MHIQ Assessment
Overall MHIQ Assessment Scores over time for Good Samaritan and Gorton Rural Health Clinics.
Total possible score is 341.
MHIQ: Module 5 (Practice-based Team Care)
The team care module addresses the essential elements of a physician led
care management team. Total possible score: 13
Preliminary Clinical Outcomes
■
Assessed change in clinical outcomes: HbA1c, Blood pressure, LDL levels
■
Data is collected at baseline, 3 months, 6 months, and 12 months following enrollment in the study.
■
The results to date are encouraging, and suggest that improvements in clinical outcomes are associated with the adoption of the medical home model.
Decrease in HbA1c levels
■
One-third of the patients (36.6 or n=49) maintain or achieve excellent control over the study period.
■
Twenty-seven patients (61.4%) whose glycemic
control was considered “poor”
at baseline experienced no change.
■
These differences are statistically significant at p<.001.
Baseline
Followup Total
Excellent % (n) Good/Fair% (n) Poor % (n)
Excellent Control 69.4^(n=25)
27.8^(n=10)
2.8^(n=1)
26.9*(n=36)
Good/Fair Control 36.4^(n=20)
56.4^(n=31)
7.3^(n=4)
41.0*(n=55)
Poor Control 9.1^(n=4)
29.6^(n=13)
61.4^(n=27)
32.6*(n=44)
Total 36.6(n=49)
40.0(n=54)
23.7(n=32)
100(n=135)
Baseline
Followup Total
Not Under Control % (n)
Under Control % (n)
% (n)
Not Under Control
52.4^(n=65)
47.6^(n=59)
46.1*(n=124)
Under Control 23.5^(n=34)
76.6^(n=111)
53.9*(n=145)
Total 63.7(n=99)
36.3(n=170)
100(n=269)
Improvement in B/P Control using <140/90 as the cut-off for “Under Control”
The percentages reported reflect row percentages. *The percentages reported reflect column percentages. A chi-square test was performed.
Improvement in B/P Control
Values Given for 215 Patients
Analysis of 269 patients. Paired samples t-test, p<.001
Changes in LDL Cholesterol
Patients’
mean LDL level decreased from 112 at baseline to 110 at follow-up. This mean differencedid not achieve statistical significance at p<.05.
Lessons learned, as reported by staff….
•
Plan before diving into a new activityPDSA (Plan, Do, Study, Act)
•
Define team member responsibilities for change
•
Address one change at a time
•
Clearly define the responsibilities of team members with realistic expectations of workload
Lessons learned, as reported by staff….
•
Know when to let go of something that doesn’t work, no matter how well you
envisioned it would work.
•
When small changes are made rather than trying to fix everything at once, more progress
is made over time.
Lessons learned, as reported by staff….
•
The addition of community health workers to the healthcare team requires staff time for supervision and coordination of referrals.
•
The level of training provided has not proven adequate for the community health workers to be effective health advisors. More comprehensive, targeted training is needed.
.
The Delta Health Alliance is gratefully acknowledged for supportof this project through HRSA Grant Number U1FRH0741. The Delta Health Alliance is a non-profit organization based in Stoneville ,MS that advocates, develops, and implementscollaborative programs to improve the health of citizens in the Deltathrough the support of partnerships that increase access and availability of health care, conduct and apply health research, or offer health education programs that foster healthy lifestyles for Deltans. For more information about the Delta Health Alliance visit www.deltahealthalliance.org.
