The Interprofessional Care Access Network (I-CAN): achieving client health outcomes by addressing social determinants in the community

Practice Perspectives on Care Coordination in Rural Settings

PURPOSE

Social needs and nonmedical health determinants are increasingly incorporated into care coordination models. However, little is known about the practice of operationalizing enhanced care coordination, particularly in rural settings. The objective of this study was to determine care coordination practices in rural settings that integrate social services with health care.

PRIMARY PRACTICE SETTINGS

Staff and administrators in rural Missouri health and health care settings were interviewed about their organization's implementation of enhanced care coordination practices.

METHODOLOGY AND SAMPLE

This is a mixed-methods study; 16 key informant structured interviews were conducted across 14 organizations.

RESULTS

Organizations reported a median care coordination population of 800 (range: 50-21,500) across a median of 11 case managers (range: 3-375). The percentage of organizations reporting social determinants of health services included the following: 100% transportation, 86% mental health, 79% food, 71% housing, and 50% dental. Implementation of the essential indicators of care coordination quality ranged from 41.7% to 100%. We report organizations' innovative solutions to care coordination barriers.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

This study contributes to a very limited literature on the practice of rural care coordination by assessing the quality of care provided compared with a recommended standard. This study also contributes an in-depth reporting on the variety of service models being implemented. Finally, this study uniquely contributes innovative interprofessional examples of enhanced care coordination initiatives. These examples may provide inspiration for rural health care organizations. As the care coordination landscape evolves to include social determinants of health, there remain important fundamental barriers to ensuring quality of care.

Financial strain across 25 years and women's bladder health: a life course perspective

BACKGROUND

A small number of cross-sectional studies have found that financial insecurity-a social determinant of health-is associated with lower urinary tract symptoms.

OBJECTIVE

This study aimed to examine (1) whether women in the Coronary Artery Risk Development in Young Adult Study with higher levels of financial strain, assessed at 7 time points across 25 years beginning in 1985-1986, were more likely to report lower urinary tract symptoms and impact after the 2010-2011 financial strain assessment and (2) whether healthcare access and comorbidities mediated potential associations.

STUDY DESIGN

This prospective cohort study recruited Black and White participants aged 18 to 30 years at baseline (1985-1986) from the populations of 4 US cities. The analytical sample was composed of women with complete data for analyses involving financial strain trajectories across 7 assessments (n=841) and mediation tests of data collected at 4 assessments (n=886). The outcome variable was previously developed through a cluster analysis of urinary incontinence severity, urinary incontinence impact, other lower urinary tract symptoms severity, and their impact in 2012-2013, which yielded 4 lower urinary tract symptoms and impact cluster categories: women with no symptom or very mild symptoms and no impact vs women with mild, moderate, or severe symptoms and impact. Financial strain was defined as finding it "very hard," "hard," or "somewhat hard" (vs "not very hard") to pay for the very basics, such as food, heating, and medical care. Using proportional odds logistic regression, cluster categories were regressed on the financial strain trajectory group, adjusting for age, race, education, and parity. For mediation analyses, separate financial strain variables (difficulty paying for the very basics, such as food and heating, and difficulty paying for medical care) were created by combining 1995-1996 and 2000-2001 values. Two healthcare access variables (difficulty receiving care and underutilization of care) and a single comorbidity index (smoking, physical inactivity, body mass index, hypertension, diabetes mellitus, and depressive symptoms) were created by combining 2005-2006 and 2010-2011 values. Regression analyses and structural equation modeling were used to test whether healthcare access and comorbidities mediated associations between financial strain and lower urinary tract symptoms and impact cluster categories.

RESULTS

In comparison to women who were consistently not financially strained, women who were consistently strained (odds ratio, 2.10; 95% confidence interval, 1.13-3.91), shifted into being strained (odds ratio, 2.00; 95% confidence interval, 1.29-3.10), or experienced >1 shift in strain (odds ratio, 1.99; 95% confidence interval, 1.46-2.71) had roughly twice the odds of reporting greater lower urinary tract symptoms and impact. Underutilization of healthcare and comorbidities mediated the association between difficulty paying for medical care and lower urinary tract symptoms and impact. In the structural equation model, difficulty paying for medical care and underutilization of care were associated (β=.31; P<.01), as was underutilization of care and greater lower urinary tract symptoms and impact (β=.09; P<.01). Moreover, difficulty paying for medical care and the comorbidity index were associated (β=.34; P<.01), as was the comorbidity index and greater lower urinary tract symptoms and impact (β=.24; P<.01). Collectively, these mediation pathways eliminated a direct association between difficulty paying for medical care and lower urinary tract symptoms and impact.

CONCLUSION

Underutilization of healthcare and comorbidities explained an association between financial strain (difficulty paying for medical care) and lower urinary tract symptoms and impact. Research is needed to confirm the findings and examine other mechanisms that may further explain the association. Accumulated evidence may inform future policies and practices.

Social justice attitudes of undergraduate nursing students: The impact of praxis

BACKGROUND

Social justice is a foundational concept in nursing, yet studies on how best to impact change in nursing students' attitudes toward social justice are few.

OBJECTIVES

The intent of this work was to quantify the impact on attitudes of undergraduate nursing students toward social justice, after extended interactions with adults living in poverty.

METHODS

Undergraduate nursing students from three programs, university medical center, private university, and community college were given a validated survey of social justice attitudes before and after a clinical rotation with low-income adults in an inner-city neighborhood. All students did home social visits through the same social service agency. Students from the medical center were also involved with active care coordination for assigned clients.

RESULTS

Each group showed significant increases in social justice attitudes following their experience. Students doing care coordination did not have significantly greater changes in overall scores but did show significant improvement in subtests others did not.

CONCLUSION

Clinical opportunities placing nursing students in direct interaction with marginalized populations are recommended to increase social justice awareness.

From the Nexus vision to the NexusIPE™ learning model

The Nexus vision of simultaneously transforming health professions education and healthcare delivery to achieve Triple (now Quadruple) Aim outcomes was first articulated in the 2012 proposal and funding of the National Center for Interprofessional Practice and Education (National Center). Over the past decade, the National Center has worked with over 70 sites implementing large scale and practice-based interprofessional practice and education (IPE) programs. Because what is needed to implement the Nexus to achieve Quadruple Aim outcomes was not well understood in 2012, the National Center took a social innovations and developmental evaluation approach. This iterative method led to the development of the National Center NexusIPE™ Learning Model that adapts the 3-P high-level stages (Presage, Process, and Product), proposed as a framework for IPE by Barr and colleagues. National Center collaborators' lessons learned about the Nexus vision are highlighted in this issue and provide real-world examples of elements of the NexusIPETM Learning Model. Reflecting on ten years of experience, the National Center leaders recognize the need for Nexus transformation and the relevance of the NexusIPETM Learning Model today as education and health systems grapple with mounting workforce challenges. The model provides opportunities to address growing workforce shortages, provide equitable care that leads to health, and support the well-being of practice teams in the face of challenges such as the COVID-19 pandemic.

Feasibility study of student-led fall prevention care management: Reducing fall risks in assisted living facilities

Falls are common in Assisted Living Facilities (ALFs). We evaluated the feasibility, acceptability, and preliminary impact of student-led Fall Prevention Care Management (FPCM) on reducing fall risks in ALFs. Residents who were age ≥65, had a fall in the previous year Or considered high fall risk at the facility, and who had a MoCA cognition score>15 were enrolled. The FPCM interventions were semi-structured to facilitate students' learning while addressing participants' unique fall risks. Twenty-five older adults in the U.S. completed the study (recruitment rate: 55%; retention rate: 64%). Participants rated the study as 87.16 (100 = excellent), and likelihood to recommend the study to others was 80.85 (100 = most likely). Participants were 84% female, mean age 88.6 years old. Fall risks such as fear of falling decreased from 16.05 to 15.12 (p = .022), fall prevention behaviors increased from 2.94 to 3.07 (p = .048), and the level of confidence to prevent falls increased from 63.38 to 78.35 (p = .015). Students commonly provided education and coaching on fall prevention strategies, and addressed emotional and behavioral aspects of fall prevention. With improvement with recruitment and retention, student-led FPCM intervention is a promising approach for fall prevention in ALF.

Improving the Health of Rural Communities Through Academic-Community Partnerships and Interprofessional Health Care and Training Models

Health disparities between rural and urban areas are widening at a time when urban health care systems are increasingly buying rural hospitals to gain market share. New payment models, shifting from fee-for-service to value-based care, are gaining traction, creating incentives for health care systems to manage the social risk factors that increase health care utilization and costs. Health system consolidation and value-based care are increasingly linking the success of urban health care systems to rural communities. Yet, despite the natural ecosystem rural communities provide for interprofessional learning and collaborative practice, many academic health centers (AHCs) have not invested in building team-based models of practice in rural areas. With responsibility for training the future health workforce and major investments in research infrastructure and educational capacity, AHCs are uniquely positioned to develop interprofessional practice and training opportunities in rural areas and evaluate the cost savings and quality outcomes associated with team-based care models. To accomplish this work, AHCs will need to develop academic-community partnerships that include networks of providers and practices, non-AHC educational organizations, and community-based agencies. In this commentary, the authors highlight 3 examples of academic-community partnerships that developed and implemented interprofessional practice and education models and were designed around specific patient populations with measurable outcomes: North Carolina's Asheville Project, the Boise Interprofessional Academic Patient Aligned Care model, and the Interprofessional Care Access Network framework. These innovative models demonstrate the importance of academic-community partnerships to build teams that address social needs, improve health outcomes, and lower costs. They also highlight the need for more rigorous reporting on the components of the academic-community partnerships involved, the different types of health workers deployed, and the design of the interprofessional training and practice models implemented.

Primary care-based interventions to address the financial needs of patients experiencing poverty: a scoping review of the literature

BACKGROUND

It is broadly accepted that poverty is associated with poor health, and the health impact of poverty has been explored in numerous high-income country settings. There is a large and growing body of evidence of the role that primary care practitioners can play in identifying poverty as a health determinant, and in interventions to address it.

PURPOSE OF STUDY

This study maps the published peer-reviewed and grey literature on primary care setting interventions to address poverty in high-income countries in order to identify key concepts and gaps in the research. This scoping review seeks to map the tools in use to identify and address patients' economic needs; describe the key types of primary care-based interventions; and examine barriers and facilitators to successful implementation.

METHODS

Using a scoping review methodology, we searched five databases, the grey literature and the reference lists of relevant studies to identify studies on interventions to address the economic needs-related social determinants of health that occur in primary health care delivery settings, in high-income countries. Findings were synthesized narratively, and examined using thematic analysis, according to iteratively identified themes.

RESULTS

Two hundred and fourteen papers were included in the review and fell into two broad categories of description and evaluation: screening tools, and economic needs-specific interventions. Primary care-based interventions that aim to address patients' financial needs operate at all levels, from passive sociodemographic data collection upon patient registration, through referral to external services, to direct intervention in addressing patients' income needs.

CONCLUSION

Tools and processes to identify and address patients' economic social needs range from those tailored to individual health practices, or addressing one specific dimension of need, to wide-ranging protocols. Primary care-based interventions to address income needs operate at all levels, from passive sociodemographic data collection, through referral to external services, to direct intervention. Measuring success has proven challenging. The decision to undertake this work requires courage on the part of health care providers because it can be difficult, time-consuming and complex. However, it is often appreciated by patients, even when the scope of action available to health care providers is quite narrow.

Context, complexity and cross-pollination: Nursing leaders' views of the role of the voluntary and community sector in nurse education

BACKGROUND

Placements in voluntary and community sector (VCS) organisations have long played an important part in student nurses' education in several countries. New standards for nurse education published by the Nursing and Midwifery Council in the United Kingdom include significant changes to practice supervision arrangements that enable students to spend more time in VCS organisations.

OBJECTIVES

To assess nursing leaders' views on the role of the VCS in nursing education and benefits of VCS placements for students and organisations.

DESIGN

Qualitative interview study.

PARTICIPANTS

Twenty-four nursing leaders from academic (n=15), practice (n=4) and regulatory (n=5) sectors.

METHODS

Semi-structured interviews were conducted face-to-face (n=21), by telephone (n=2) or Skype (n=1). Interviews were transcribed and analysed, using interview questions as structural themes, followed by inductive thematic analysis.

RESULTS

Nursing leaders identified three key roles for the VCS in nursing education: (1) determining knowledge needs; (2) developing curricula; (3) providing placements. Five key benefits of VCS placements for students were shared: (1) understanding the contribution of the VCS to care; (2) seeing the context and complexity of people's lives; (3) challenging attitudes and perceptions; (4) gaining confidence, knowledge and skills; and (5) supporting career decisions. Three benefits for VCS organisations were found: (1) cross-pollinating knowledge, skills and networks; (2) changing organisational cultures; (3) promoting careers in the VCS.

CONCLUSIONS

Changes to practice supervision models enabling closer relationships with the VCS were welcomed. Nursing leaders thought that VCS placements had potential to cross-pollinate ideas and harness the role of student nurses as knowledge brokers in increasingly integrated health and social care systems. Nurse educators should embrace opportunities offered through collaboration with the VCS for student learning and deeper partnerships across health and social care settings to enable students to gain deeper insight into the context and complexity of people's lives.

Using community pharmacies and team observed structured clinical encounters (TOSCEs) for interprofessional education and training

INTRODUCTION

Collaborative practice improves patient outcomes and is a needed student skill. An interprofessional education and collaborative practice (IPECP) program was developed using community pharmacies, clinics, and emergency departments. This study's purpose was to assess student pharmacists' team attitudes and skill development after the IPECP using team observed structured clinical encounters (TOSCEs).

METHODS

Nineteen pairs of fourth-year pharmacy and second-year physician assistant students practiced together in a community pharmacy (two days) and clinic or emergency department (two days). They completed TeamSTEPPS training and two team modules. Assessments included TOSCEs and pre/post attitude surveys.

RESULTS

Students significantly increased all TOSCE domain skills with pre- to post-mean score (SD) of: team communications 3.0 (0.5) to 4.1 (0.5), collaboration 2.8 (0.6) to 4.0 (0.5), roles and responsibilities 2.4 (0.4) to 3.8 (0.5), patient-centered care 2.8 (0.5) to 4.1 (0.6), conflict management 2.8 (0.5) to 4.1 (0.6), team functioning 2.7 (0.6) to 3.9 (0.6), and global performance 2.8 (0.6) to 4.0 (0.5). Afterwards, students reported positive attitudes about team-based patient care. All students stated the experience increased patient and healthcare professional communication skills and understanding of patient problems, and decreased errors. Most students (84%) agreed team care increased interventions compared to individually provided care. Most students (84%) thought the experience was worthwhile, and 68% agreed the IPECP program should be continued.

CONCLUSIONS

This study supports that IPECP can be conducted in a community pharmacy and clinic or emergency department to improve student team skills as evidenced by documented team skills development during TOSCEs.

Prescribing Housing: A Scoping Review of Health System Efforts to Address Housing as a Social Determinant of Health

US health systems have begun to address housing instability within a larger effort to address social determinants of health. To explore existing themes within efforts by health systems to reduce housing instability and improve health, the authors conducted a scoping review supplemented with key informant interviews. Twenty-two articles were analyzed and 7 participants from 6 health systems were interviewed. Themes identified from the literature and interviews included intervention strategies and funding, access, coordination, and administrative processes and evaluation. As more health systems integrate housing-related interventions, findings from this study highlight the need for more upstream focus, consistent funding, and reliable evaluation strategies.

Feasibility of Interprofessional Education in a Community Pharmacy

OBJECTIVE

To evaluate student learning, preceptor opinions, and feasibility of conducting interprofessional education in a community pharmacy.

METHODS

Six pharmacy and 6 physician assistant students from 2 universities were paired to practice together in a community pharmacy for 1 day and clinic or emergency department for 1 day. Investigator-developed surveys were completed anonymously by students and preceptors. Students self-assessed learning and team attitudes. Preceptors evaluated team functioning and provided feedback. Students and preceptors attended separate focus groups to discuss their experiences.

RESULTS

Students reported improved understanding of discipline-specific roles. Students stated shared learning would improve future ability to work on a team (n = 9), helped with understanding patients' clinical problems (n = 8), and improved professional communications (n = 8). Students thought teams avoided healthcare delivery errors (n = 12), improved patient care (n = 11), increased efficiency (n = 8), and increased interventions (n = 7) compared to solo practice. Some students (n = 6) felt preceptors did not provide enough feedback. Students and preceptors stated the project should be continued. Students suggested improving orientation by including team functioning expectations and insuring patient availability for medication therapy management reviews. Preceptors wanted more training on providing team feedback and thought the experience should be longer to accommodate physician assistant student orientation to pharmacy operations.

CONCLUSIONS

Interprofessional education in a community pharmacy was feasible and resulted in students learning about discipline roles, team functioning, and team care. Additional training and orientation for both students and preceptors are needed. More than 1 day at each practice site is needed to enhance interprofessional learning and skills.