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Enhancing Outcomes & Education Through Collaboration:

Enhancing Outcomes & Education Through Collaboration: The Bridging the Gaps/St. Agnes LIFE CHF Protocol. Claudia Siegel, MA, MPA Lucy Wolf Tuton, PhD Elizabeth Barthmaier, MSN, CRNP Emily Amerman, MSW. The Partnership. Bridging the Gaps.

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Enhancing Outcomes & Education Through Collaboration:

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  1. Enhancing Outcomes & Education Through Collaboration: The Bridging the Gaps/St. Agnes LIFE CHF Protocol Claudia Siegel, MA, MPA Lucy Wolf Tuton, PhD Elizabeth Barthmaier, MSN, CRNP Emily Amerman, MSW

  2. The Partnership Bridging the Gaps

  3. Can we collaborate on a project to teach students about interdisciplinary care that also will have a demonstrable benefit for the clients and the site? The Challenge

  4. The Outcomes 1 Based on PA Health Care Cost Containment Council data for 2003-2005. 2 CHF group entry flexible, some variation possible

  5. Multi-disciplinary health professions education program in Philadelphia (also w/ UPitt, LECOM, Delaware) Pre-clinical, interdisciplinary, health-related community service (1991), Seminar Series (1997), and Clinical Rotation (2001) Collaboration among all Philly AHCs & other institutions Community partners serve as host sites Seventeen years old in 2007 Bridging the Gaps Program

  6. BTG Model Didactic & Skill-building components Continuity of contact Collaborative Service-Linked Partnerships w/ Community Orgs. AHC – Community Supervision Inform the community Evaluation: MUTUAL BENEFIT

  7. PACE = Program of All-Inclusive Care for the Elderly (BBA 1997, orig. in 70s in CA) Goal: keep elderly in community, at home Clients: nursing home certified, typically Medicaid but others can participate Capitated program: provides all services, basic living, preventive, primary, acute and long-term Interdisciplinary team (physicians, RNs, NPs, SWs, OT, PT, dietitian, CNAs, etc.) Transportation Adult day care center (3X wk), w/ on-site clinic St. Agnes LIFE, A PACE Program

  8. 80 years old on average Mostly female 7.9 medical conditions, usually of chronic nature Only 7 percent nationally are in nursing homes PACE Participants

  9. Opened 1998 under St. Agnes Medical Center (SAMC), Catholic community hospital in south Philadelphia 2001-04 served 378 people Very frail: average death rate 14% annually 65 FTE staff, relatively low turnover Now serves 10 zip codes in south and north Philadelphia Two PACE centers, one co-located with housing 2004: SAMC became St. Agnes Continuing Care Center 2005: 137 participants, dual capitation St. Agnes LIFE

  10. Vulnerable populations Preventive health practice Environmental factors impacting health (broad definition of health) Interdisciplinary care and training Collaboration focused on client population BTG-St. Agnes LIFE Common Interests

  11. St. Agnes LIFE Benefit Special projects enrich program BTG clin. rotation requirement Encouragement of ID model/training Fresh ideas & stimulation Participant enjoyment of students BTG Benefit IDT Experience Community health setting Geriatrics/geriatric philosophy Managed care at its best Creative interventions Big picture/small picture BTG/St. Agnes LIFE Mutual Benefit

  12. Medicine, Social Work, Clinical Psychology, Creative Arts/Dance Therapy, Occupational Therapy, Pharmacy BTG-LIFE Clinical& EducationalCross-Fertilization STUDENTCHF PROJECT (2001-02) CHF MULTI-DISCIPLINARY PROTOCOL

  13. BTG/St. Agnes LIFE CHF ProtocolInterdisciplinary Responsibilities Social Work Assessment, Caregiver contact & support Medicine Assessment, wkly eval monitoring, pharm. coord. Creative Therapies Increase well-being, socialization, sense of self Pharmacy Monitor drug therapy, consult w/ med & nursing Psychology Assessment, decrease anxiety, increase pain tolerance Nursing-not in original stu IDT Wkly evals (weights, etc.), monitor, report to CRNP/Med Dir Occupational Therapy Evaluate/promote home safety, personal energy conservation

  14. CHF Protocol Generation & Implementation BTG students intro to PACE and role of IDT BTG students collaborate in researching CHF and designing potential CHF protocol BTG students introduce protocol, discuss potential outcomes with LIFE IDT--“BUY IN” Gradual IDT acceptance and implementation of protocol Student role became ancillary

  15. Chief intervention point: BTG/LIFE CHF Protocol WEEKLY MONITORING & WEIGHTS

  16. Prevented hospitalizations Integration of CHF protocol into LIFE SOP Student evaluations of experience Improvement of client quality of life BTG-St. Agnes LIFE Successes

  17. BTG/St. Agnes LIFE Difficulties • Identifying and selecting participants with CHF for the protocol—flexibility based on site needs • Managing logistics of completing weights weekly and bi-weekly; space, time, staff changes • Covering staffing shortages • Data collection: tools and continuity • Coordinating disparate student schedules • Measuring quality of life

  18. Common goals Demonstrable mutual benefit Commitment to collaboration, no matter what Flexibility & patience Willingness to admit mistakes, to discuss all details, and to problem-solve together The Necessities

  19. Would We Do It Again? • We would and we will: • New partnership with New Courtland LIFE, also a PACE program • Serves 12 Philly zip codes, co-located with housing • Electronic medical record, emphasis on staff continuing education, quality of life and outcomes improvement

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