RN SYSTEM WIDE EDUCATION

PRESENTED BY S. FERGUSON, T. DILLON,

L. LOCK, J. HASBUN, S. SHAH & R. GAINES

Shepherd’s Hope

Shobha Shah and Ruth Gaines

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).

Lora Lock and Tessa Dillon

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)

Who we serve

Any person needing care.

Uninsured.Family income at

or below 200% of poverty level.

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.

PCAN Clinics

• 11 Locations

• In Orange County

• 1 location in Seminole County

Sherri Ferguson

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

Janina Hasbun

Questions?

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