1. APHA, November, 2015 Sr. Bat Baber, RSM Janet Buelow, PhD, MSN, MPH Suzanne Cashman, ScD Anita Nivens, PhD, RN, FNP-BC Greg Knofczynski, PhD Paula Tillman, DNP, RN 1 INTERPROFESSIONAL COLLABORATION IMPROVING THE HEALTH OF URBAN POOR Funding from HRSA, Grant UD7HP25051

2. Disclosure  No author has any relevant financial relationships with any commercial interests. 2

3. Session Objectives  Explain strategies for developing an interprofessional working culture  Compare selected collaborative team practices to prior practices and patient outcomes  Explain student patient advocacy teams 3

4. St Mary’s Community Center, Health Clinic, Savannah, GA – and surrounding population 4 Population served: adults earning less than 200% federal poverty level; uninsured Nearly 70% of the households live in extreme poverty

5. 2014 Patient Data N=1168  Ages: 18-64  Gender:  Females863 (74%)  Males305 (26%)  Race:  Black857 (73%)  White276 (24%)  Asian 16 ( 1%)  Other 19 ( 2%)  Hypertension  Diabetes  Obesity  Tobacco Abuse  Depression 5 DemographicsMorbidity

6. Overall Project Goals 6  Expand existing St Mary’s Health Center to an Interprofessional Collaborative Practice (IPCP) primary care home  Provide and coordinate primary care for underserved adults in Chatham County, GA  Implement quality improvement processes & monitor outcomes  Develop and Demonstrate effectiveness of nurse led IPCP team

7. Strategies 7  Incorporate additional health care professionals  Create interprofessional team culture  Hold bimonthly team meetings  Identify specialist physician consultants  Monitor patient outcomes  Create student patient advocacy teams

8. St. Marys Community Center Interprofessional Collaborative Practice Team IPCP Evaluator: Statistician/Data Analyst Practice Partners Nephrology Care Podiatry Care Psychiatry Care Gynelogical Oncology Care General Surgery Care Dental Care Years 2 & 3 Core Team Patient Advocacy Teams Medical Director: Admin Coordinator Licensed Medical Social Worker Nurse Practitioners 2 Full time 2 Part time Informatics Coordinator Quality Improvement Health Administrator Health Educator Program Director Patient Social Service Agencies Nurse Resource Coordinator 8

9. Should Teams Naturally Work? 9 Challenges  Valuing others’ contributions  Communication  Knowledge of roles  Coordination  Adding new team members

10. Training Core Team Members  Five workshops 11/2012 - 4/2014  Background, mission, goals, objectives  Achievements/challenges, roles  Conflict competence, team norms  Data, PDSA, QI groups  Data, QI 10

11. Team Mission  Mission-driven interdependent professionals working together to meet the holistic needs of our patient population 11

12. Maintenance  Twice monthly Friday morning team meetings  Updates/Burning issues  Patient presentation  New practice partner introductions  QI team work 12

13. Goal 1 or Goal 2 Cycle 1Cycle 2Cycle 3 Goal 1 or Goal 2 or Goal 3 Plan DoStudy Act Plan DoStudy Act Plan DoStudy Act Infuse Quality Improvement with PDSAs 1. How good? By when? 2. Set up measures & monitor 3. What change can we make? 13

14. Quality Improvement Teams 14  Diabetes Mellitus Team Hypertension Team Depression Team Interprofessional Teams - 3 rd Fridays

15. Measures – some are improving...  Diabetes Mellitus Team (Yr 1 patients at Yr 3) Microalbumin levels (n=15) HgA1C scores (n=68) LDL levels improved (n=57, p=.002)  Depression  1168 screened with PHQ 2  + PHQ2 screens followed-up PHQ 9  293 pts with active interventions  CVD Team (Yr 1 patients at Yr 3) LDL levels improved (n=106, p=.008) B/P (n=125)  No-Show Rates  Improvement with 16% no-shows in Year 3 15

16. Student Advocacy Teams 16 Sample Instructional Schedule WeekClass TopicsAssignments 1Poverty Challenges- Poverty Simulation & Online Discussion 2Overview of Uninsured- Orientation at Clinical Sites; First Journal 3Health Disparities- Clinical work; Week 2 Journal

17. Evaluation & Outcomes 17 Agency Semester Reports St Mary’s Community Center Food Stamp Applications Health Insurance & Medical Bill Referrals Eye Clinic – fitting for glasses Emergency Room, Uninsured Referrals to medical homes Referrals for social determinants Percent of acceptance of medical home St Mary’s Clinic Telephone Calls Set up data bases; update information Health Education Class Assistance Student Pre & Post Scores Interprofessional Socialization and Valuing Scale Ability to Work with Others Value in Working with Others Comfort in Working with Others Readiness for Interprofessional Learning Scale Team Value Professional Identity Roles & Responsibilities Interdisciplinary Education Perception Scale Competency & Autonomy Need for Cooperation Actual Cooperation Understanding values of other disciplines

18. Sample Student Services  Physical Assistance  Vital signs, Depression screenings, Prepare exam rooms  Computer Updates  Lab results, Provider requests  Telephone Calls  Reminders regarding screening, medications & eye exams  Quality Improvement Program Calls & Classes  Calls regarding B/P home monitoring, Exercise & Cooking Class  Research Assistance  Chart Check re: med. compliance 18

19. Lessons Learned 19  Team training and meetings  Communication—speaking, listening, and understanding  Power of data/informatics  CQI confers ownership  Value added of health professions/advocacy students  Nurse led IPCP can meet patient need

20. Next Steps 20  Academic-Community Partner Model sustainability  Fiscal and funding considerations  Exploration of other ways to collaborate