title of presentation network (i-can) · 10/1/2018 · nexus innovators network i-can is a nexus...
TRANSCRIPT
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Subtitle for Presentation
Title of Presentation
DATE: MONTH 22, 2015 PRESENTED BY: NAME LAST NAME, TITLE
Interprofessional Care Access Network (I-CAN)
Peggy Wros, Heather Voss, Claire McKinley-Yoder, Katherine Bradley, Kate LaForge
2013-2017
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The I-CAN Model
Client, Student, & Population Impact
Community Partner Perspectives
Questions and Discussion
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The I-CAN Model
Client, Student, & Population Impact
Community Partner Perspectives
Questions and Discussion
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I-CAN is a model for healthcare delivery and
interprofessional practice and education.
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Core Elements of I-CAN
• Disadvantaged and underserved people and populations
• Faculty practice model
• Long-term commitment to community partners
• Neighborhood/community academic-partnerships
• Interprofessional student teams
• Focus on social determinants of health
• Home visitation
• Population health interventions
• Continuous quality improvement
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What can an I-CAN client expect?
ReferralCommunity
partners identify potential I-CAN
clients
Intake
Faculty-in-Residence and student teams conduct intake
Home visitsStudent teams
meet regularly with clients, often in
their homes
Care coordination Students address
social determinants of health using local resources
TransitionClients transition
out of I-CAN when client-set goals are
met
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Community Partnership Networks
People in the Neighborhood
Community Service Agencies
Healthcare Organizations
Neighborhood/ Community Academic-
Practice Partnership (NCAPP)
Health Profession Academics
Coordinated Care Organizations
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Monmouth
West MedfordKlamath Falls
Reaching Rural Residents in IPE (R3)
Southeast Portland
La Grande (2018)
Gresham CARES
Rockwood
I-CAN and Partner Sites
I-CAN
Partner sites
Old Town
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I-CAN Benefits…
Academic partners
Students
Clients
Community partners
Populations
5
4
1
3
2
individualized care
interprofessional learning
increased capacity
student project dissemination
via
rigorous evaluation
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I-CAN clients
I-CAN clients include families, refugees, the elderly, and veterans — who may be sociallyisolated, poor, and facingmultiple chronicconditions.
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I-CAN clients
Over
800students
Clients from all over the world:Korea, China, Myanmar, Congo, Mexico, Vietnam, Somalia, Iraq, Cuba, Canada, Eritrea, Afghanistan, Burundi, Bhutan, Nepal, Burma, Ethiopia, France, Iran, Ireland, Switzerland
Speaking 21 languages:English, Cantonese, Farsi, Karen, Korean, Spanish, Swahili, Vietnamese, ASL, Arabic, Burmese, Hindi, French, Kinyarwanda, Nepali, Pashtu, Dari, Somali, Tigrinya, Toisanese, Taishanese
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I-CAN clients
1 in 2of I-CAN clients are between the ages of 40-64
1 in 4of I-CAN clients have 8years or less of formal education
0 – 4
5 - 8
9 - 12
13 - 16
17+
25
21
73
47
5
20 – 39
40 - 64
65 - 79
80+
50
40
10
90
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I-CAN clients
1 in 5 live with a partner/spouse
1 in 4 live alone
1 in 4 live with children
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I-CAN clients
Over
800students
Tobacco:Clients smoke daily or most days
Alcohol:Clients drink daily or most days
At intake…
Substances:Clients report substance use
36% 30%13%
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I-CAN clients
On intake, 89% of I-CAN clients had public insurance
89
8
3
Public
Uninsured
Private
%
%
%
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Referral: Partners Identify Clients
Healthcare Utilization2+ non-acute EMS calls in 6 months3+ missed healthcare appointments in 6 months10+ medications
Social DeterminantsLack of primary care homeLack of healthcare insuranceLack of stable housing
Family Contributors5+ unexcused school absences2+ family members with a disabling chronic illnessDevelopmentally delayed parent(s)Signs of child negligence
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Intake: Students Conduct Assessment
Churn Rate: System Cycling in the Past 6 Months• EMS calls• ED visits• Hospitalizations
Stabilizing Factors in the Past 6 Months• Employment/income• Food security/nutrition• Insurance changes• Housing changes
Demographics, Health Screening, Medication Review
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Top Health ConcernsMusculoskeletal issues/painMental/behavioral healthDental/oral healthEndocrine issues (e.g., diabetes)
Client Self-Reported Concerns
Top Social ConcernsMedication managementHousing stabilizationAddiction controlPersonal hygieneSafety and securitySocial Isolation
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Types of Students & Courses
NursingChronic Illness, Population Health, & Leadership
MedicineFamily Medicine & Rural Health
Physician AssistantClinical Projects and Placements
Nutrition & DieteticsCommunity-Based Practice & Internship
PharmacyTransitional Clerkship
DentistryCommunity Dentistry
1092students
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The I-CAN Model
Client, Student & Population Impact
Community Partner Perspectives
Questions and Discussion
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Case study: Lucy
SOCIAL
MEDICAL
Has five childrenReferred to I-CAN because she has missed multiple healthcare appointments Recently came to Oregon from the CongoSpeaks only SwahiliHas no formal education
Recently diagnosed with hepatitis BHas underlying sickle cell anemia
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Consolidated assigned payers and providers
Read health insurance renewals
Reinstated lapsed healthcare insurance
Referred one child for urgent dental care
Turned off smoke alarm
Provided medication safety teaching
Provided follow-up teaching after an ED visit
Case study: Lucy
STEPS
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The I-CAN program has demonstrated
success in improving health outcomes.
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Of clients increased their medication literacy
Improvement in Healthcare Domains
Of clients improved their ability to manage pain
51% 45%Of clients increased their ability to manage chronic disease
50%
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Of clients increased their access to food
Of clients improved their housing status
38% 35%Of clients improved their mobility
30%
Improvement in Social Domains
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The percentage of clients without insurance and unstable housing dropped after participation in the I-CAN program.
Unstable housing7.4%
Pre Post
2.4
1.6
No insurance6.6%
Aggregate Health Measures
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18%
33%
14%
35%
51%
34%
EMS callouts
ER visits
Hospitalizations
Clients saw decreases in recent hospitalizations, ER visits, andEMS callouts after participating in the I-CAN program.
Pre
Post
Reducing Resource Demand
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The rate of emergency and inpatient healthcare utilization decreased after I-CAN participation*, compared to the rate prior to joining I-CAN, for 71 clients with pre/post data.
Reducing Resource Demand
*Rates adjusted and standardized for number of occurrences per 6 month period.
42
35
EMS callouts
70
67
ED visits
31
21
Hospitalizations
Estimated
$185kin cost savings
per 6 mo.
0
100 per 6 months
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Student Learning
0
1
2
3
4
5
6
SPRING 2016
SUMMER FALL WINTER 2017
SPRING SUMMER
Team-based decisions Skills development Team functioning
The I-CAN program has seen consistently high scores in student team-based decision-making, skills development, and team functioning.
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Student Learning
I-CAN was an incredibly valuable experience for me as a future nurse. I learned more about myself and how to
work as a team member than I ever imagined. I am beyond grateful for this opportunity and will value it as
I move forward with my career.
“
”
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The I-CAN Model
Client, Student, & Population Impact
Community Partner Perspectives
Questions and Discussion
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Community Partners
Our community partners consider
I-CAN a valuable resource for agencies working with complex
clients that extends the reach of
the agency, engages clients with health and social systems, and
identifies and addresses systems barriers and population level problems.
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1.0Acute Care
Healthcare System
2.0Coordinated
Seamless Healthcare
System
3.0Community Integrated Healthcare
System
Source: Halfon, N., Long, P., Chang, D.I., Hester, J., Inkelas, M., & Rodgers, A. (2014). Applying a 3.0 transformation framework to large scale health system reform. Health Affairs, 313(11), 2003-2011.
OutcomeAccountableCare
Community IntegratedHealth Care
Episodic Non-IntegratedCare
Healthcare System Transformation
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Nexus Innovators Network I-CAN is a NEXUS Innovation Incubator Project for the National Center for Interprofessional Practice and Education.
HRSA Funded This project was supported in part by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UD7HP25057 and title “Interprofessional Care Access Network” for $1,485,394 from 2012-2016. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.
Carl in the Nexushttps://nexusipe.org/engaging/learning-system/carl-nexus
Acknowledgements
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Acknowledgements
I-CAN Core teamPeggy Wros, Heather Voss, Claire McKinley-Yoder, Katherine Bradley, Kate LaForge
FacultyLinda Callahan, Ginny Elder, Patti Warkentin, Beth Doyle, Kristen Beiers-Jones, Karla Reinhart, Tamara Rose, Carla Hagan, Angela Docherty, Jane Hagan, Basilia Basin, Linda Paul
Community PartnersCascade Health Alliance, Klamath & Lake Community Action Services, Klamath Open Door, Sky Lakes Outpatient, Capitol Dental, Northwest Human Services, Polk County Family & Community Outreach, Polk County Health Department, Salem Health West Valley Hospital, Willamette Valley Community Health CCO, Home Forward, Maybelle Center, Neighborhood House, Housing with Services, Gresham Fire & Emergency Services, Reynolds School District-Alder Elementary, The Wallace Medical Concern, Asian Health & Service Center, Catholic Charities, Lutheran Community Services, Multnomah Mid-County Clinic, OHSU Richmond Clinic, AllCare Health, Family Nurturing Center, Head Start, La Clinica