The Richmond Health & Wellness Program (RHWP)
The Richmond Health & Wellness Program (RHWP)
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
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.
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
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
R H W P
The “Value Added”
of Linking Publicly
Assisted Housing for
Low-Income Older Adults
with Enhanced Services
RHWP
Sustainability
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
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
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
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
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
R H W P
Canadian Interprofessional Health Collaborative
RHWP Interprofessional Collaborative Practice (IPCP) Teams
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
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
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
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
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
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
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
R H W PYear 3
Dominion Place
PCP
Pharmacy
ED Visits
Patient Improvement
Student PerformanceCommunity
Partners
Richmond Health & Wellness Program
Students
Psychology
Behavioral Health
DentalRandolph Place
Carter Woods
Partner Satisfaction
4th Avenue
Fay Towers
Medicine
Social Work
Pharmacy
Nursing
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
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
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
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
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
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
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
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
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
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
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
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
R H W P
RHWP • Health Service Revenue • Research • Education
RHWP Sustainability
R H W P
• Health Service Revenue
➢Billable services ➢Shadow billing ➢Cost avoidance
➢MCO contracts ➢Medicare claims
RHWP Sustainability
R H W P
• Education
➢ VCU Quest for Distinction
➢ Service learning
➢ Community Based
➢ Interprofessional
➢ Team based care
➢ Competency based
➢ Prepared work-force
RHWP Sustainability
R H W P
RHWP Sustainability
• Academic Value
➢ Icubed | http://icubed.vcu.edu/
R H W P
• Research ➢Doctoral Students
➢Pre-Doc Awards
➢NIH
➢Foundation
RHWP Sustainability
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
R H W P
RHWP High Rise ED Visits
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
R H W P
Questions?