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Richmond health and wellness program

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Richmond health and wellness program

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Richmond health and wellness program

  1. 1. 
 The Richmond Health & Wellness Program (RHWP)

  2. 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. 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. 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. 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. 6. R H W P The 
 “Value Added” of Linking Publicly Assisted Housing for Low-Income Older Adults with Enhanced Services RHWP Sustainability
  7. 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. 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. 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. 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. 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. 12. R H W P Canadian Interprofessional Health Collaborative RHWP Interprofessional Collaborative Practice (IPCP) Teams
  13. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 33. R H W P RHWP • Health Service Revenue • Research • Education RHWP Sustainability
  34. 34. R H W P • Health Service Revenue ➢Billable services ➢Shadow billing ➢Cost avoidance ➢MCO contracts ➢Medicare claims RHWP Sustainability
  35. 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. 36. R H W P RHWP Sustainability • Academic Value ➢ Icubed | http://icubed.vcu.edu/
  37. 37. R H W P • Research ➢Doctoral Students ➢Pre-Doc Awards ➢NIH ➢Foundation RHWP Sustainability
  38. 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
  39. 39. R H W P RHWP High Rise ED Visits
  40. 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
  41. 41. R H W P Questions?

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