2. R H W P
• Understand how methods and measures can be applied to
IPE and IPECP and implications for advancements in
education and practice
• Apply assessments to measure educational and treatment
outcomes to your own settings
•
• Compare lessons learned with other attendees
Objectives: Integrating Theory, Frameworks, Models and Evidence
3. R H W P
Funding
This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S.
Department of Health and Human Services (HHS) under grant number UD7HP26044, The Richmond Health
and Wellness Program (RHWP): Expanding Nurse-Led Interprofessional Collaborative Practice (IPCP) Teams
for Community-Dwelling Older Adults, total award amount $1,488,584.00, 0% financed by
nongovernmental sources. This information or content and conclusions are those of the author and should
not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA,
HHS or the U.S. Government.
This project described was supported by a grant from Virginia Commonwealth University’s Council for
Community Engagement. Its contents are solely the responsibility of the authors and do not necessarily
represent official views of Virginia Commonwealth University and/or the Council for Community
Engagement.
4. R H W P
The RHWP Experience
1. RHWP Background
2. Program Model
3. Highlight: Behavioral Health Clinic
4. Measures/Outcomes
5. Policy and Sustainability
RHWP
Road Map
5. R H W P
• Need
➢1.8 million older adults live in federally
subsidized housing
➢> 50% limited in walking, climbing stairs
➢12% with mental or cognitive disability
interfering with ability to perform IADL
➢Increased risk of institutionalization
Redfoot and Kochera 2004 ; Wilden and Redfoot 2002; 2002 American Community
Survey; U.S. commission on Affordable Housing and Health Facility Needs for Seniors
in the 21st Century 2002)
RHWP
Sustainability
6. R H W P
The
“Value Added”
of Linking Publicly
Assisted Housing for
Low-Income Older Adults
with Enhanced Services
RHWP
Sustainability
7. R H W P
Hypothesis
“Publicly assisted senior housing
can act as an effective platform for
organizing a system of coordinated
health and long-term services and
supports for low-income older
adults”
U.S. Department of Health and Human Service Assistant Secretary for Planning and Evaluation Office of Disability,
Aging and Long- Term Care Policy, January 31,2012-
RHWP
Sustainability
8. R H W P
➢ Frank Baskind PhD
- Assistant Professor, School of
Social Work
Steve Crossman, MD
- Associate Professor, School of
Medicine
➢ Rachel Weiskittle, BA, PhD Student
- Behavioral Health Coordinator
RHWP
Core Faculty
➢ Pamela L. Parsons PhD RN, GNP-BC
- Associate Professor, School of Nursing
➢ Kelechi C. Ogbonna PharmD, CGP
- Assistant Professor, School of Pharmacy
➢ Lana Sargent RN, MSN, FNP-C, GNP-BC
- Clinical Asst. Professor, School of Nursing
➢ Fay Parpart RN, MS, ANP-BC, AACRN
- Assistant Professor, School of Nursing
➢ Sierra Alewine, MS
- Clinic Coordinator
➢ Elizabeth Pohoreskey, FNP
- Assistant Professor, School of Nursing
9. R H W P
• Health Professional Shortage Areas (HPSA)
➢ Of 930,000 elderly residents in Virginia, approximately 50% live in
federally designated HPSAs
Joint Commission on Health Care, 2009
RHWP
Identified Community Need
10. R H W P
• Healthcare Hotspots
➢ Population clusters with a high burden of chronic illness that can
benefit from targeted care delivery interventions
Gawande. The Hot Spotters. The New Yorker. 2011
RHWP
Identified Community Need
11. R H W P
▪ Community & RHWP Concerns:
▪ Aging in place with high chronic disease burden
▪ Average # of medications taken per day = 9 [pilot data]
▪ Average # of chronic conditions = 5 [pilot data]
▪ High emergency room utilization
▪ Richmond Ambulance Authority
▪ Documented 138 transports to emergency department from DP in
2012 alone
▪ Of the 138 transports, 133 were deemed non-emergent
RHWP
Background
12. R H W P
Canadian Interprofessional Health Collaborative
RHWP
Interprofessional Collaborative Practice (IPCP) Teams
13. R H W P
The RHWP Experience
1. RHWP Background
2. Program Model
3. Highlight: Behavioral Health Clinic
4. Measures/Outcomes
5. Policy and Sustainability
RHWP
Road Map
14. R H W P
• Inter-professional Teams
➢ Nursing
➢ Pharmacy
➢ Social Work
➢ Medicine
➢ Psychology
• Care Coordination
➢ Link to appropriate care (liaison)
➢ Surveillance
- Diabetes – A1C monitoring
- Hypertension – BP monitoring
- Cholesterol
- Counseling & Education
- Triage
- Weight Management
RHWP
Interprofessional Collaborative Practice (IPCP) Teams
15. R H W P
Team 2
Clinic Room 1 Clinic Room 2
Clinic Room 3
Team 1
Team 3
Faculty
Faculty
Faculty
RHWP
Flow
NP Pharm SW NP Med Pharm
NP Med SW
House Calls
16. R H W P
• Company:
➢ DP is a Beacon Community
➢ Property housing management group
➢ Independently owned apartment complex for seniors
➢ Managed under the guidelines of Section 8 housing for low-income
eligible elders
• Location:
➢ Located near the VCU Monroe Park Campus
• Building & Residents
➢ One bedroom apartments
➢ Approx. 247 residents living independently
Dominion Place
Background
17. R H W P
• Company:
➢ RP is a Better Housing Coalition property
➢ Managed under the guidelines of Section 8 housing for low-income
eligible elders
• Location:
➢ Located near the VCU Monroe Park Campus
• Building & Residents
➢ One bedroom apartments
➢ Approx. 50 residents living independently
Randolph Place
Background
18. R H W P
• Company:
➢ CW is a Better Housing Coalition property
➢ Managed as a Tax-Credit property for low-income eligible elders
• Location:
➢ Located 5 miles from the VCU Medical Campus
• Building & Residents
➢ One bedroom apartments with 8-10 couples
➢ Approx. 150 residents living independently
Carter Woods
Background
19. R H W P
• Company:
➢ Richmond Redevelopment Housing Authority
➢ Local HUD Contractors
• Location:
➢ Located 2 miles from the VCU Medical Campus
• Building & Residents
➢ One bedroom apartments with 200 and 105 apartments
Fay Towers and 4th Avenue
Background
20. R H W P
Year 3
Dominion Place
PCP
Pharmacy
ED Visits
Patient Improvement
Student Performance
Community
Partners
Richmond Health &
Wellness Program
Students
Psychology
Behavioral
Health
Dental
Randolph Place
Carter Woods
Partner Satisfaction
4th Avenue
Fay Towers
Medicine
Social Work
Pharmacy
Nursing
21. R H W P
The RHWP Experience
1. RHWP Background
2. Program Model
3. Highlight: Behavioral Health Clinic
4. Measures/Outcomes
5. Policy and Sustainability
RHWP
Road Map
22. R H W P
RHWP
Behavioral Health Clinic
Services
• Home Visits
• Wellness Checks
• Care Coordination
• Referral Coordination
• Wound Care
• Medication Management
• Patient Education
• Blood Pressure
• Glucose Check
Acute Care & Behavioral Health Services
Service Population
• Overflow Home Visits
• Urgent Care Walk-in’s
• Crisis/Acute Needs
• Care Coordination
23. R H W P
The RHWP Experience
1. RHWP Background
2. Program Model
3. Highlight: Behavioral Health Clinic
4. Measures/Outcomes
5. Policy and Sustainability
RHWP
Road Map
24. R H W P
• Patient Outcomes
➢ Care coordination (care coordination tool)
➢ Improved disease-state management
➢ Reduction in ER visits
• Student Outcomes
➢ Behavioral interventions
➢ Disease-state knowledge
➢ IPE principles/ Leadership
• Cost Savings/Cost Avoidance
➢ Decreased healthcare utilization
➢ Provision of services and associated cost
RHWP
Measures/Outcomes
25. R H W P
RHWP
Student Participation
Student Participation
Fall
2013
Spring
2014
Sum
2014
Fall
2014
Spring
2015
Sum
2015
Fall
2015
Spring
2016
PharmD 6 6 10 9 5 23 11 12
Medicine 6 7 4 6 - 2 2 4
Nursing (BSN) 10 9 10 18 18 13 29 25
Nursing (NP) 8 15 11 18 3 37 35 12
Nursing(Psych) - - - 2 5 - 7 7
Social Work 3 2 - - 4 2 2 3
Psych Doctoral - - - 2 7 2 0 1
Occupational
Therapy
- - - - - - 1 41
Total 33 41 35 54 69 79 87 105
26. R H W P
RHWP
Resident Clinic Visits
Resident Clinic Visits Fall 2015
Total
Carter Woods 99
Randolph Place 102
Frederic A. Fay Towers 85
1611 4th Avenue 92
1611 4th Avenue Behavioral Health 20
Dominion Place 265
Dominion Place Behavioral Health 48
Total 711
27. R H W P
RHWP
Measures/Outcomes
➢ Adapted Care Coordination Tool1
o Care coordination activities/needs
o Activity to fulfill needs
o Outcomes prevented
o Outcomes occurred
o Notes
➢ CPT code list
➢ ICD-9 list
➢ Several pilot tests
28. R H W P
• Validated Screening Tools
➢ Geriatric Depression Scale-152
➢ Katz Activities of Daily Living Scale3
➢ Vulnerable Elders Survey-13 items4
➢ Assessing Care of Vulnerable Elders Quality Indicators5
➢ Frail Questionnaire Screening Tool6
➢ Mini-Cog7
➢ Generalized Anxiety Disorder Scale-7 items8
RHWP
Measures/Outcomes
29. R H W P
• Participant Experience
➢ Focus Groups
o Impact on their health
o Impact on understanding of health conditions
o Communication with health care providers
o Interaction with health care providers and students
o Overall experience
RHWP
Measures/Outcomes
30. R H W P
• Knowledge questions developed by faculty
➢ Communicating with older adults
➢ Health literacy
➢ Motivational Interviewing
➢ Diabetes
➢ Hypertension
➢ Cognition
➢ Falls
➢ Frailty
➢ Medications and polypharmacy
RHWP
Measures/Outcomes
31. R H W P
• Brief post-survey
➢ How interprofessional care improves health
➢ Satisfaction
➢ Suggestions for improvement,
strengths, and weaknesses
➢ Demographics
• Focus groups
➢ How the team worked
together for patient care
➢ Thoughts on interprofessional education
➢ Satisfaction with course
RHWP
Measures/Outcomes
32. R H W P
The RHWP Experience
1. RHWP Background
2. Program Model
3. Highlight: Behavioral Health Clinic
4. Measures/Outcomes
5. Sustainability and Policy
RHWP
Road Map
33. R H W P
RHWP
• Health Service Revenue
• Research
• Education
RHWP
Sustainability
34. R H W P
• Health Service Revenue
➢Billable services
➢Shadow billing
➢Cost avoidance
➢MCO contracts
➢Medicare claims
RHWP
Sustainability
35. R H W P
• Education
➢ VCU Quest for Distinction
➢ Service learning
➢ Community Based
➢ Interprofessional
➢ Team based care
➢ Competency based
➢ Prepared work-force
RHWP
Sustainability
36. R H W P
RHWP
Sustainability
• Academic Value
➢ Icubed | http://icubed.vcu.edu/
37. R H W P
• Research
➢Doctoral Students
➢Pre-Doc Awards
➢NIH
➢Foundation
RHWP
Sustainability
38. R H W P
RHWP
Sustainability
• Research/Funding Opportunities
➢ GWEP
➢ SAMSHA-Behavioral Health IPE and Substance Abuse
➢ P20 –NIH Nursing Center Grant – Symptom Management
➢ HRSA – BSN Training
➢ Student Focused Research
▪ Dissertation – Pharmacy
▪ UROP- Nursing- Community Engaged Fellowship
40. R H W P
• Team Chemistry
➢ Don’t overlook
➢ Make decisions up-front (publication plan, etc.)
➢ Defer to better expertise
• Community Partnerships
➢ Research depends on strength of these relationship
➢ Needs to be revisited
• Funding Preference
➢ Goal and objectives more important than awardee
• Sustainability
➢ What will you do when funding runs out?
RHWP
Take Home Points
Resident Approval