Interprofessional Interagency Team Care at a Free
Diabetes Clinic: Year 2 Progress
Jennifer Frank, PhD, Brenda Iddins, DNP, FNP-BC, Michele Talley, MSN, ACNP-BC, Deepti Bahl, MD,
Heidi Beck, MS, Matt Fifolt, PhD, Lisle Hites, MS, PhD, and Cynthia Selleck, PhD, RN, FAAN
UAB School of Nursing
UAB School of Nursing
Institute of Healthcare Improvement
Triple Aim
• Improving the healthcare experience (quality
and satisfaction)
• Improving the health of populations
• Reducing healthcare costs
M-POWER Ministries
Literacy
Center
Education
Center
Health
Center
• Only free clinic in Birmingham; open
3 evenings/week
• UABSON opened PATH Clinic 1
morning/week in May 2011
Objectives
1. Implement a model in
which nurses and other
health professionals
become competent at
interprofessional
collaborative practice.
2. Demonstrate the efficacy
of the Chronic Care Model
in providing continuity of
care and chronic disease
management to a
medically underserved
population.
Objectives
3. Integrate nursing and other
health professions
students into the IPCP
model in order to gain
experience with teambased care and the
healthcare needs of
vulnerable populations.
4. Develop and implement a
plan for intermediate and
long-term success of the
IPCP model at the PATH
Clinic.
IPCP Staffing Plan
Tuesday Team
Endocrinologist
2 Nurse
Practitioners (NP)
Registered Nurse
(RN)
RN Care Manager
Dietitian
PAP Coordinator
Pharmacist
Students
Wednesday Team
Internist
2 NPs
Optometrist
1 Psych/MH NP
Psychiatrist
RN
RN Care Manager
Dietitian
PAP Coordinator
Pharmacist
Students
Thursday Team
Internist with
medical residents
1 NP
RN
RN Care Manager
Dietitian
PAP Coordinator
Pharmacist
Students
Total of 1,614 patient visits from 431 unique patients in 2014
Tuesday – 773 visits Wednesday – 559 visits Thursday – 282 visits
Data for Tuesday patients from December
2012 through December 2014
Project Innovations
• Collaboration and support
of an Academic Medical
Center
• Use of an Interprofessional
Coach
• Incorporation of multiple
disciplines, and students
from each discipline
• Use of daily team huddles
and post-conferences
• Recognition of need for RN
Care Manager and PAP
coordinator
Sweet Home Alabama
PATH Clinic: Pre-Huddle
• Each morning begins with a pre-huddle
• All providers, staff, and students attend
except triage nurses
• Patient list reviewed (time reduced to 15 min.)
– New patients versus established patients
• Discuss potential issues with flow (staffing
issues, dispensary issues, medication
availability)
PATH Clinic: Patient Appointment
• Enter clinic and sign in at front desk
• Complete demographic info
• Complete HIPAA and Patient Covenant with
M-Power and PATH clinic
• All new patients attend Diabetes Education
Class for 1-2 hours with Dietitian who is a CDE
• All established patients wait until called into
triage area
PATH Clinic: Patient Flow
• Patients called to triage area
• Triage nurse obtains height/weight, vital signs,
labs, and chief complaint
• Patient escorted to exam room by triage nurse
• Patient seen by provider
PATH Clinic: Patient Appointment
•
•
•
•
•
Provider (Nurse Practitioner or Physician)
reviews previous records
reviews glucometer, blood glucose trends, and
dietary log
conducts review of systems and physical exam
establishes a plan with patient
completes flow sheet with patient follow-up
information
Clinic Process
• After the visit is complete, patients receive a
flow sheet explaining other providers to be
seen before leaving the clinic
• Patients take the flow sheet to the next
provider (dietitian, nurse care manager,
pharmacist, social worker/pharmaceutical
patient assistance program manager)
• Follow-up appointment is made
Patient Instructions Form
PATH Clinic: Post-Huddle
• Post-huddle with all providers, staff, students
• Originally discussed each patient, now focus
on high priority patients
• Patient Assistance Program coordinator works
with providers so patients receive certain
meds that are expensive
• Nurse care manager follows up with any
missed appointments, necessary referrals, etc.
Tuesday Patient Demographics*
• 353 unique patients seen for a completed visit
• 1,826 visits scheduled
• 1,281 visits completed (1 – 20 per patient)
• 135 patients scheduled for a visit never came
Data for Tuesday patients from December
2012 through March, 2015
Tuesday Referral Demographics
Median Age at Referral = 47.02,
Range 19-78 years
Black/African
American
8.20%
32.20%
T1DM 15.8%
White
66.70%
Hispanic
45.70%
54.30%
Male
Female
Patient Referral Criteria
No Source for Care
80.20%
Financial Hardship
74.90%
Likely Readmit
61.43%
A1c>8.0
51.80%
Blood Glucose >300
51.10%
New Onset of DM
Frequent ED Visits
26.30%
11.00%
Outcome Measures
Resource Use
• Number of ED visits
• Number of Hospitalizations
• Total charges (costs)
Process Measures
• % clinic visits kept
• # clinic visits provided
• # services provided
Clinical Outcomes
• A1C, BP, BMI
• PHQ-9 Depression scale
Health & Social Outcomes
• Successful enrollment in
other care sites
• Obtaining health insurance
• Successful enrollment in PAP
Evaluation Instruments
• Alternating Monthly Provider Surveys
– Survey of Organizational Attributes of Primary Care (SOAP-C)
– Team Fitness Test Evaluation of Interprofessional Coaching sessions
• Structured interviews with providers on knowledge of
Interprofessional Collaborative Practice (IPCP)
• Annual Assessment of Interprofessional Team
Collaboration Scale survey
Results of Evaluation
Emerging Themes
–Knowledge of IPCP
–Interactions between providers
–Patient care
Knowledge about IPCP
• Providers had little knowledge of IPCP
before starting at the PATH clinic
• By the end of Year 2, could demonstrate
knowledge of the competency domains
with real world examples from the clinic
• Described model as “collaborative,
comprehensive, interactive”
Interactions between Providers
• Previous experiences were in physicianled hierarchical settings
• Indicated that their perceptions of other
disciplines remained high or improved
• Some reported an increased respect for
NPs
Patient Care
• Providers felt that IPCP model with direct
communication improved patient care
• Multiple perspectives reinforced
message to patients
• Model particularly effective with this
population who have trouble with
coordination of care
Clinical Outcomes (Tuesday)
Comparing the same 250 patients for one
year pre and post their first PATH visit
– Inpatient Admission Rate decreased 57%
(p<0.001)
– Diabetes related diagnoses are the most
frequent
– ED rate increased by 20%
(p<0.04)
Outcomes, continued
Comparing the same 250 patients for one
year pre and post their first PATH visit
– Median total hospital cost per patient (across all
admissions) increased ($9,403 versus $6,657)
– Assumption that patients are admitted for more
serious conditions
– Total hospital costs decreased by 60% with savings
of $1.5 million
Clinical Outcomes, 2014
Number Diagnosed
431
254
Total Patients 431
431
319
431
431
275
134
Clinical Outcomes, 2014
Diabetes (n=254)
Mean A1C on first clinic visit – 8.65 (SD=2.6)
On final measurement at patient’s most recent visit
A1c <8.0
(54.7%)
80
139
35
A1c 8.0-9.0
(13.8%)
A1c >9.0
(31.5%)
Hypertension
152/319 patients with BP < 140/90 on last measurement
Clinical Outcomes, 2014
Services Provided Across Days
•
•
•
•
•
•
Dilated Eye Exams – 141/431
Weight Screening and follow-up - 431/431
Patients Screened for Depression – 431/431
Patients treated for depression – 134/431
Flu Shots – 22/431
Tobacco cessation counseling - poor
Challenges to the Model
•
•
•
•
•
Staff turnover
Communication across clinic days
EMR
Lack of space/dispensary issues
Overcoming misperception of “leaderless”
model
• Sustainability
Lessons Learned
•
•
•
•
Education – to understand shifting leadership
Interagency cooperation - vital
Care management – crucial for our population
PAP Coordinator - essential for navigating
pharmaceutical company charity programs
• Reduction in hospital costs – difficult to assess
• Sustainability - start early
Questions?