RN SYSTEM WIDE EDUCATION
PRESENTED BY S. FERGUSON, T. DILLON,
L. LOCK, J. HASBUN, S. SHAH & R. GAINES
Shepherd’s Hope
Goals of Community Project
Ensure that a system to educate volunteer staff is in place at Shepherd’s Hope clinics that reinforces the aim of the organization which is to provide:
1. Basic acute nonemergency care.2. Appropriate timely referral to a
permanent medical home.
Objectives of Community Project
Volunteer will have a referral procedure available that is sustainable and consistently transferable.
Volunteer trainer(s) from a pilot location will train volunteers at other Shepherd’s Hope locations in the use of referral process.
Review of Literature
Studies have shown that a lack of healthcare access causes increased mortality and morbidity.
There is a need to use community resources to fullest capacity to mitigate this mortality and morbidity.
Inadequacies in existing community referral processes need to be explored.
Knowledge regarding availability of community referral resources are lacking.
Shepherd’s Hope Survey
Considerable gap in nurse’s knowledge regarding role of other community resources.
Lack of knowledge and information regarding process.
Lack of clear referral criteria.
Survey Cont’d
Formalized patient pathway to PCAN is likely to:
1. Improve clinical management.2. Minimize frequent hospitalization.3. Reduce mortality and morbidity.4. Increase recommended referrals.
Barriers of community referral
Inability of healthcare system to meet consumers’ demand
Diminished access to care due to low socioeconomic status
Lack of insuranceLack of adequate transportationCultural and language barriersLack of informationLack of awareness among primary care
providers regarding the role and availability of community resources
Barriers Continued
Less access to preventative health services (Not having primary care available to primary care results in more specialty referrals)
Disabling physical mobility limits visitation to resources. Some include: Chronic health conditions Diabetes Musculoskeletal Cardiac and respiratory diseases
Possible Interventions
Development of new patient referral process.
System to support volunteers in implementing referral process.
Potential clinic monitoring system to ensure patients receive appropriate follow up after referral to PCAN.
Possible Interventions
Possible telephone or follow up appointments with PCAN referrals
Providing accurate information of referral location (PCAN clinic) such as name, address and phone number.
Providing information to patients on documentation requirement for referral services (PCAN clinic).
What is Shepherd’s Hope
Free Clinics for the uninsured.Part of PCAN Network.Provides services found in primary
practice setting.Not designed to be permanent medical
home.
What you do
Provide access to care.Via case management at Shepherd’s Hope,
provide referrals to specialists.Provide medication treatment.Provide competent care.But today we are talking about how you assist
in finding a medical home in Orange County.
Who we serve
The 14% uninsured Seminole County residents.The 19% uninsured Orange County Residents.Individuals, families, and children of multi-
ethnic and multi-cultural origin.
(Garvan, Duncan & Porter, 2005)
What else is offered
Medications at no cost (when available).Low or no cost labs at local participating
facilities.Low or no cost selected diagnostic tests
and stress tests.
Logistics for PCAN Referral Process
1. Health Center manager to designate trained volunteers to handout referral to PCAN slip(Remaining will be piloted at Tazkiah location)
2. Volunteers to use the “New Patient Referral Process Flowchart” to complete the PCAN Referral Process
3. Return chart to front desk and have volunteer: Insert copy of Referral Slip into patient’s chart Verify that Referral Log filled out for that patient
Patient Referral to PCAN slip
Date _______________
Patient’s Name: ________________________________________ Diagnosis: _____________________________________________ Referred to PCAN: ____________________________________________ Address: _______________________________________________ Phone Number: _________________________________________ Call to set up eligibility appointment with selected clinic. Plan to arrive at Health Center at least 30 minutes before your appointment. Plan to bring the following to your appointment:
Identification such as photo I.D. and Social Security Card (if available). Insurance Card (Prior to appointment, call the phone number on your card to determine
your assigned primary care doctor.) If you are applying for sliding scale, proof of income for everyone in family is needed (at
least four pay stubs or most recent W2 form) For children, must be accompanied by a parent or legal guardian and bring proof of
guardianship (such as birth certificate) Medications are not provided free, but patients can usually get prescriptions
filled at a discounted cost. A sliding fee scale is used for the uninsured patients in order to receive a
discount for health care services based on household income and family size.
Patient's Name
Patient Phone
Number
Date of Visit
Center Referred
to
Call # 1 / Date Appt
Made
Call # 2 / Date Appt
Made
If Appt Made
Document Time and
Date
Reason For Not
Making Appt After
Second Call
Sample patient A
407-555-5555 3/16/2011
Eatonville Family Center No No
4/5/2001 @ 130pm
Logistics for Referral Continued
4. Once referral is verified, stamp PCAN at the left upper hand front of chart cover.
5. Document outcome of each callNext Clinic Session
1. Health center volunteer to call patients listed on log from previous week
2. Documented outcome of each call in front inner cover of chart and referral logAfter two calls, if appointment not made, patient is discharged from Shepherd’s Hope Health Center and advised of the same
3. Document discharge in chart
Plan Implementation
PCAN Referral Procees – Initial Training Location:
Tazkiah Shepherd’s Hope Health Center
PCAN Referral Process – Initial Training for:
Tazkiah Shepherd’s Hope Volunteers
Classes Provided by:
University of Central Florida Graduate Nursing Students
Plan Evaluation
Evaluation of “New Patient PCAN Referral Process” will include ascertaining:
1.% of patients referred to PCAN Medical Homes who follow through with referral
2.Compatibility between PCAN Referral Process with health center resources i.e., available man-power, ability to complete follow-up phone calls during clinic sessions, cost-effectiveness
3.Barriers that prevent patients from establishing PCAN Medical Home
Long-Term Goals
Implement Tazkiah Shepherd’s Hope clinic pilot for at least three months
Tweak PCAN Referral Process at the Tazkiah clinic to facilitate compatibility with it’s resources
Depending on pilot outcomes, train all new volunteers in the PCAN Referral Process
Consistently refer all patients to PCAN Medical HomesUsing volunteer trainers, train new volunteers at other
Shepherd’s Hope Health centers in the PCAN Referral Process
References
Garvan, C., Duncan, R.P. and Porter, C. (2005, August). The Florida health insurance study 2004: County estimates of people without health insurance. Retrieved from, http://www.statecoverage.org/files/County%20Estimates%20of%20People%20Without%20Health%20Insurance%20from%20the%202004%20Florida%20Health%20Insurance%20Study.pdf