Care Coordination Program Fills Gaps in Social Determinants of Health
Goal is to reduce ED visits
An interprofessional care coordination program helps train college students while helping vulnerable communities.
The Richmond Health and Wellness Program (RHWP) began in 2012 with the three prongs of education, research, and service, says Katherine Falls, NP, operational director of RHWP and clinical instructor at Virginia Commonwealth University (VCU) School of Nursing.
The idea of the health and wellness program was to provide care to people to fill their gaps from social determinants of health, she says.
“That would, hopefully, prevent emergency department [ED] visits, help shorten hospital stays, and help provide care so that people don’t end up in the ED or hospital,” Falls says. “It was started at Dominion Place, one of our sites in Richmond. “It’s an older adult apartment building complex that’s federally subsidized and is for people with disability.”
Its target population includes older adults with multiple chronic illnesses and outcomes that are affected by social determinants of health.
“RHWP was started to fill those gaps with education, case management, and health and wellness services that help to provide some of the things that are difficult for them to access because of where they live,” Falls explains.
Since the program began, it has served five different apartment buildings and includes a freestanding health and wellness building.
“VCU and VCU Health, our health system entity, have partnered to build a freestanding community health center in one of our highest poverty areas of Richmond,” says Pamela Parsons, PhD, GNP-BC, FNAP, associate dean for practice and community engagement, and associate professor at VCU School of Nursing. “The highest concentration of public housing is also in that area and would have easy access to the building. RHWP is one of the programs offered within that building site.”
Bridge Between Community, System
In the winter of 2019-20, VCU partnered with a local health system to create a position for a nurse case manager, employed by the health system and working under the VCU Health care management team, Parsons says. The goal is for the case manager to serve as a liaison for people with unmet needs. The case manager coordinates their care and is a bridge between community health workers and the health system.
“We’re just implementing that right now and putting that person in place,” Parsons says.
Although the COVID-19 pandemic interrupted progress with the RHWP’s mission and caused the facility to be locked down for several months, the organization continued to serve people through telehealth, Falls notes.
“We were unable to connect with some people because of a lack of telephone services,” she adds. “But we were persistent, and were able to connect with a lot of the folks we do serve in these buildings.”
They also put together an interprofessional group of pharmacy, nursing, nurse practitioner, medical, physical therapy, occupational therapy, and psychology students to meet through Zoom calls and Google Meet, Falls explains.
“We go over what’s going on and call patients to discuss whatever is important to them,” she adds. “It’s always a participant-led conversation.”
The team follows the Institute for Healthcare Improvement’s 4Ms, an age-friendly model: What matters most to the person, medication, mentation, and mobility. (More information is available at this link: http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/Resources.aspx.)
“We’ve continued to use that 4Ms model and structure to organize our calls and address needs pertinent to our population,” Falls adds.
Each student contributes through his or her personal expertise; for example, mobility can be addressed by physical and occupational therapy students. They also are encouraged to step out of their normal area.
“A nurse practitioner might lead the discussion on medication, and the pharmacy student can jump in and help where needed, and they all talk about what matters to the patient,” Falls explains.
Much of the focus during the early months of the pandemic was on how people were coping with COVID-19. They could talk about their experiences and how they felt. “Having someone to connect to is very important from a nursing perspective,” Parsons says.
The team observed that people with no mental health challenges managed well during the pandemic. They could rely on their coping skills. Other people have developed new symptoms of anxiety and depression, and are struggling more than they did pre-pandemic, Falls says.
“We’re moving into a new phase where people are recognizing that this is here to stay for a while, and they have to figure out how to adapt and make their life work,” she adds. “We were talking to a participant who has an autoimmune disease and is worried about contracting the virus. She has to take a bus to get her medications, and worries about bus transfers and how long it takes to get this medication that she didn’t have delivered.”
Through motivational interviewing and focusing on what mattered most to this patient, the team learned she did not want her medication delivered because she wanted to get out of her house with these trips to the pharmacy. She wanted to be safe, but she also wanted to exercise, see people, and have some in-person interaction.
“For this patient, her biggest concern was to find a closer CVS. A student looked at the area transportation system’s website and found a bus that would not require a transfer,” Falls says.
The woman met her personal goals, stayed safe, and obtained her medication. “Goal-setting is the way we help people figure out how to solve some of these problems and how to make some steps toward living their best COVID life,” Falls says.
Worrying about these sorts of pandemic-era challenges creates stress. People need endurance to deal with it, and the interdisciplinary team can help them navigate these challenges and troubleshoot some of their problems, Falls explains.
The team takes a holistic approach to helping people, including advance care planning, falls prevention, and addressing food insecurity, housing stability, and literacy issues, Parsons says.
“We plan to do more and connect over to the health system with continuum of care,” she adds.
- Winship JM, Falls K, Gregory M, et al. A case study in rapid adaptation of interprofessional education and remote visits during COVID-19. J Interprof Care 2020. doi: 10.1080/13561820.2020.1807921. [Online ahead of print].
An interprofessional care coordination program helps train college students while helping vulnerable communities. The Richmond Health and Wellness Program began in 2012 with the three prongs of education, research, and service. The idea of the health and wellness program was to provide care to people to fill their gaps from social determinants of health.
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