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
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.
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.
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.
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
Case Studies – Round 2
The I-CAN Model
Learning How to Zoom
Case Studies – Round 1
Case Studies – Round 2
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
Learning How to Zoom
Case Studies – Round 1
Case Studies – Round 2
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
Learning How to Zoom
Case Studies – Round 1
Case Studies – Round 2
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
Learning How to Zoom
Case Studies – Round 1
Case Studies – Round 2
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?
1
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
Learning How to Zoom
Case Studies – Round 1
Case Studies – Round 2
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