Title of Presentation I-CAN · 2017. 8. 24. · Subtitle for Presentation Title of Presentation DATE: MONTH 22, 2015 PRESENTED BY: NAME LAST NAME, TITLE Community Partnerships for

Subtitle for Presentation

Title of Presentation

DATE: MONTH 22, 2015 PRESENTED BY: NAME LAST NAME, TITLE

Community Partnerships for Interprofessional Clinical Education & Population Health: An interactive workshop

I-CAN

PEGGY WROS, PhD, RN; KATHERINE BRADLEY, PhD, RN; KATE LAFORGE, MPH

AUGUST, 2017

The National Center for Interprofessional Practice and Education is supported by a Health Resources and Services Administration Cooperative

Agreement Award No. UE5HP25067. The National Center is also funded in part by the Josiah Macy Jr. Foundation, the Robert Wood Johnson

Foundation, the Gordon and Betty Moore Foundation, The John A. Hartford Foundation and the University of Minnesota. © 2015 Regents of the

University of Minnesota, All Rights Reserved.

This activity has been planned and implemented by the National Center for Interprofessional Practice and Education.

In support of improving patient care, the National Center for Interprofessional Practice and Education is jointly accredited by the Accreditation Council for Continuing Medical

Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the

healthcare team.

Physicians: The National Center for Interprofessional Practice and Education designates this live activity for a maximum of 1.5 AMA PRA Category 1 Credits™.

Physician Assistants: The American Academy of Physician Assistants (AAPA) accepts credit from organizations accredited by the ACCME.

Nurses: Participants will be awarded up to 1.5 contact hours of credit for attendance at this workshop.

Nurse Practitioners: The American Academy of Nurse Practitioners Certification Program (AANPCP) accepts credit from organizations accredited by the ACCME and ANCC.

Pharmacists: This activity is approved for 1.5 contact hours (.15 CEU) UAN: 0593-0000-17-021-H04-P





Disclosures

The National Center for Interprofessional Practice and Education

has a conflict of interest policy that requires disclosure of financial

interests or affiliations of organizations with a direct interest in the

subject matter of the presentation.

Peggy Wros and Katherine Bradley

do not have a vested interest in or affiliation with any corporate

organization offering financial support or grant monies for this

interprofessional continuing education activity, or any affiliation with

an organization whose philosophy could potentially bias her/his

presentation.





Interprofessional continuing education credit will be awarded to

participants that paid the continuing education credit fee while registering

for the Summit.

All workshop participants are asked to scan their barcode (from nametag)

upon entrance to session and complete the evaluation distributed at the

end of the workshop. Those who registered to receive continuing

education credit will also receive a certificate of completion following the

Summit.

Workshop Objectives

Describe academic-community partnerships for supporting underserved communities

Explain collaborative clinical practice model for preparing an interprofessional healthcare workforce

Provide examples of value-based learning and community service

2

1

2

3

Workshop Format

Please keep the following in mind in order to get the most out of today’s workshop:

Spread Out! Make sure that there are at least three different professions represented at each table.

Identify Roles! Each table will need a scribe, a reporter, and a discussion facilitator.

Don’t Peek! Please wait to open the case study envelopes until instructed to do so. There will be two rounds, each with a separate envelope. Each table has 1 of 3 different cases.

The I-CAN Model

Case Studies – Round 1

Learning How to Zoom


The I-CAN Model




I-CAN is a model for healthcare delivery and

interprofessional practice and education

Core Elements of I-CAN

Focus on social determinants of health

Long-term commitment to community partners

Neighborhood academic-partnerships

Faculty practice modelInterprofessional student teams

Population health interventionsHome visitation

What can an I-CAN client expect?

ReferralCommunity

partners identify potential I-CAN

clients

Intake

Faculty and student teams conduct intake

Home visitsStudents meet regularly with

clients, often in their homes

Care coordination Students address

social determinants of health using local resources

TransitionClients transition

out of I-CAN when client goals are met

Types of Students

NursingChronic Illness, Population Health, & Leadership

Medicine & Physician AssistantFamily Medicine & Rural Health

Nutrition & DieteticsCommunity-Based Practice & Internship

PharmacyTransitional Clerkship

DentistryCommunity Dentistry

Over

800students

Six Communities, Six Populations

Old Town Portland (Urban) - Homelessness, mental health, disability, low-income, veterans, seniors.

Southeast Portland (Urban) - Immigrants and refugees from Sub-Saharan Africa, the Middle East, Southeast Asia, and Syria.

West Medford (Rural) - Low-income families, homelessness, seasonal and migrant farm workers.

Klamath Falls (Frontier) - Socially isolated, low-income, disability, comorbidity, mental health.

Monmouth (Rural)Socially isolated, low-income, comorbidity, mental health.

Rockwood/Gresham (Urban) - Homelessness, mental health, frequent EMS callers, low-income, seniors, ex-convicts, families with school-aged children.

Community Partnership Networks

People in the Neighborhood

Community Service Agencies

Healthcare Organizations

Neighborhood/ Community Academic-

Practice Partnership (NCAPP)

Health Profession Academics

Accountable Care Organizations

NCAPP Refers Vulnerable Clients

Healthcare Utilization2+ non-acute EMS calls in 6 months3+ missed healthcare appointments in 6 months10+ medications

Social DeterminantsLack of primary care homeLack of healthcare insuranceLack of stable housing

Family Contributors5+ unexcused school absences2+ family members with a disabling chronic illnessDevelopmentally delayed parent(s)

Client Intake Assessment

Churn Rate: System Cycling in the Past 6 Months• Provider calls and provider visits• EMS calls• ED visits• Hospitalizations• Healthcare appointment adherence

Stabilizing Factors in the Past 6 Months• Employment/income• Level of social support• Food security/nutrition• Insurance changes• Housing changes

Demographics, Health Screening, Medication Review

Students• Work with clients and community

partners• Review client issues to identify

population-level issues

Faculty-in-residence• Long-term commitment to

community-based practice• Supervise student learning and

safety

Teams

of clients increased their ability to manage chronic disease

I-CAN Outcomes

of clients improved their health insurance status

of clients improved their housing status

58% 31%38%

18%

32%

16%

35%

51%

35%

EMS callouts

ER visits

Hospitalizations

Aggregate Health Measures

Clients saw decreases in recent hospitalizations, ER visits, and EMS callouts after participating in the I-CAN program.

Pre

Post

The I-CAN Model




Round 1

Please open the envelope marked “Round 1” and read over the full case summary assigned to your table.

Discuss among yourselves the case summary and consider the following questions:

What are the issues related to lifestyle and social determinants of health?

What would you bring to the case based on your professional perspective/lens?

1

2

A 34-year-old single mother She has five children and was referred to I-CAN because she has missed multiple healthcare appointments. She has recently come to Oregon from the Congo, speaks only Swahili, and has no formal education.

She has recently been diagnosed with hepatitis B

She has underlying sickle cell anemia

Lucy

A 40-year-old male from the MidwestHe has been blind since birth, reads Braille, and has highly developed cell phone skills. He is referred by the community service agency because of his health needs.

He has a very strong unpleasant body odor

He has an underlying seizure disorder and depression

Mark

A 38-year-old male refugeeHe has come to Oregon from Burma by way of several refugee camps, speaks Cantonese, and has 12 years of education.

He has painful facial swelling and a foul odor from his mouth

He has underlying hypertension and a family history of high blood pressure

Kian

The I-CAN Model




Lucy, Mark, & Kian

Find a partner and zoom out on the case assigned to your table. Zoom as far as you can!

What new insights does this bring to the case? Discuss with others at your table.

Share with the full group what you discussed and what you learned from your discussion.

Applying Zoom

The I-CAN Model




Round 2

Open the “Round 2” envelope and read the additional information about your case, then consider:

Are there any surprises in the case you didn’t anticipate?

How does the level of “zoom” refocus your intervention and practice?

What resources do you need to address the client’s SDH?

What community or professional partners did you include as you zoomed in/out?

What should be included in a client-centered plan of care?

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2

3

4

5

Round 2 Discussion

Each table share with the full group a summary of your discussions.

What new information did you learn about your case?

What might different community agencies bring to this case?

What resources would you engage in your community?

1

2

3

The I-CAN Model




1.0Acute Care

Healthcare System

2.0Coordinated

Seamless Healthcare

System

3.0Community Integrated Healthcare

System

Source: Halfon, N., Long, P., Chang, D.I., Hester, J., Inkelas, M., & Rodgers, A. (2014). Applying a 3.0 transformation framework to large scale health system reform. Health Affairs, 313(11), 2003-2011.

OutcomeAccountableCare

Community IntegratedHealth Care

Episodic Non-IntegratedCare

Healthcare System Transformation

Nexus Innovators NetworkI-CAN is a NEXUS Innovation Incubator Project for the National Center for Interprofessional Practice and Education.

HRSA FundedThis project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UD7HP25057 and title “Interprofessional Care Access Network” for $1,485,394. 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.

Acknowledgements

Acknowledgements

I-CAN Core teamPeggy Wros, PHD, RN; Katherine Bradley, PHD, RN; Launa Rae Mathews, MS, RN; Heather Voss, MS, RN; Kate LaForge, MPH

Faculty-In-ResidenceLinda Callahan, Darcy Mize, Virginia Elder, Patti Warkentin, Beth Doyle, Claire McKinley, Mary Pesch, Kristen Beiers-Jones, Karla Reinhart

Community PartnersCascade Health Alliance, Klamath & Lake Community Action Services, Klamath Open Door, Sky Lakes Outpatient, Capitol Dental, Northwest Human Services, Polk County Family & Community Outreach, Polk County Health Department, Salem Health West Valley Hospital, Willamette Valley Community Health CCO, Home Forward, Maybelle Center, Neighborhood House, Gresham Fire & Emergency Services, Phoenix Rising Transitions, Reynolds School District-Alder Elementary, The Wallace Medical Concern, Human Solutions, Asian Health & Service Center, Catholic Charities, Lutheran Community Services, Multnomah Mid-County Clinic, OHSU Richmond Clinic, AllCare Health, Family Nurturing Center, Head Start, La Clinica

Thank You

www.ohsu.edu/i-can

[email protected]

Documents

Title of Presentation I-CAN · 2017. 8. 24. · Subtitle for Presentation Title of Presentation DATE: MONTH 22, 2015 PRESENTED BY: NAME LAST NAME, TITLE Community Partnerships for