Bridging the Gaps

Enhancing Outcomes & Education Through Collaboration:

The Bridging the Gaps/St. Agnes LIFE CHF Protocol

Claudia Siegel, MA, MPA

Lucy Wolf Tuton, PhD

Elizabeth Barthmaier, MSN, CRNP

Emily Amerman, MSW

Bridging the Gaps

The Partnership

Bridging the Gaps

Bridging the Gaps

The Challenge

Can we collaborate on a project to teach students about interdisciplinary care that also will have a demonstrable benefit for the clients and the site?

Bridging the Gaps

The Outcomes

Project Year

# Clients in CHF

Protocol

Prevented CHF Adm.

# Clients w/ Prev. Hosp.

Est. Charges1

2003-04 27 10 10 $352,544

2004-05 492 21 16 $862,218

2005-06 442 24 15 $1,054,608

Tot. Est Savings

$2,269,370

1 Based on PA Health Care Cost Containment Council data for 2003-2005.

2 CHF group entry flexible, some variation possible

Bridging the Gaps

Bridging the Gaps Program

• Multi-disciplinary health professions education program in Philadelphia (also w/ UPitt, LECOM, Delaware)

• Pre-clinical, interdisciplinary, health-related community service (1991), Seminar Series (1997), and Clinical Rotation (2001)

• Collaboration among all Philly AHCs & other institutions

• Community partners serve as host sites

• Seventeen years old in 2007

Bridging the Gaps

BTG Model

Collaborative Service-Linked Partnerships w/

Community Orgs.

Continuity of contact

Didactic & Skill-building

components

AHC – Community Supervision Evaluation:

MUTUAL BENEFIT

Inform the community

Bridging the Gaps

St. Agnes LIFE, A PACE Program

• PACE = Program of All-Inclusive Care for the Elderly (BBA 1997, orig. in 70s in CA)– Goal: keep elderly in community, at home

• Clients: nursing home certified, typically Medicaid but others can participate

• Capitated program: provides all services, basic living, preventive, primary, acute and long-term

• Interdisciplinary team (physicians, RNs, NPs, SWs, OT, PT, dietitian, CNAs, etc.)

• Transportation

• Adult day care center (3X wk), w/ on-site clinic

Bridging the Gaps

PACE Participants

• 80 years old on average

• Mostly female

• 7.9 medical conditions, usually of chronic nature

• Only 7 percent nationally are in nursing homes

Bridging the Gaps

St. Agnes LIFE• Opened 1998 under St. Agnes Medical Center (SAMC),

Catholic community hospital in south Philadelphia

• 2001-04 served 378 people

• Very frail: average death rate 14% annually

• 65 FTE staff, relatively low turnover

• Now serves 10 zip codes in south and north Philadelphia

• Two PACE centers, one co-located with housing

• 2004: SAMC became St. Agnes Continuing Care Center

• 2005: 137 participants, dual capitation

Bridging the Gaps

BTG-St. Agnes LIFE Common Interests

• Vulnerable populations• Preventive health practice• Environmental factors impacting health

(broad definition of health)• Interdisciplinary care and training• Collaboration focused on client

population

Bridging the Gaps

BTG/St. Agnes LIFE Mutual Benefit

St. Agnes LIFE Benefit

• Special projects enrich program– BTG clin. rotation

requirement

• Encouragement of ID model/training

• Fresh ideas & stimulation

• Participant enjoyment of students

BTG Benefit

• IDT Experience• Community health

setting• Geriatrics/geriatric

philosophy• Managed care at its

best• Creative interventions• Big picture/small

picture

Bridging the Gaps

BTG-LIFE Clinical & Educational Cross-Fertilization

Medicine, Social Work, Clinical Psychology, Creative Arts/Dance Therapy, Occupational

Therapy, Pharmacy

STUDENT CHF PROJECT (2001-02)

CHF MULTI-DISCIPLINARY PROTOCOL

Bridging the Gaps

BTG/St. Agnes LIFE CHF ProtocolInterdisciplinary Responsibilities

Social Work

Assessment, Caregiver contact & support

Medicine

Assessment, wkly eval

monitoring, pharm. coord.

Pharmacy

Monitor drug therapy, consult

w/ med & nursing

Psychology

Assessment, decrease anxiety,

increase pain tolerance

Nursing-not in original stu IDT

Wkly evals (weights, etc.), monitor, report

to CRNP/Med Dir

Occupational Therapy

Evaluate/promote home safety, personal energy conservation

Creative Therapies

Increase well-being,

socialization, sense of self

Bridging the Gaps

BTG students intro to PACE and role of IDT

BTG students collaborate in researching CHF and designing potential CHF protocol

BTG students introduce protocol, discuss potential outcomes with LIFE IDT--“BUY IN”

Gradual IDT acceptance and implementation of protocol

Student role became ancillary

CHF Protocol Generation & Implementation

Bridging the Gaps

BTG/LIFE CHF Protocol

Chief intervention point:

WEEKLY MONITORING & WEIGHTS

Bridging the Gaps

BTG-St. Agnes LIFE Successes

• Prevented hospitalizations

• Integration of CHF protocol into LIFE SOP

• Student evaluations of experience

• Improvement of client quality of life

Bridging the Gaps

BTG/St. Agnes LIFE DifficultiesBTG/St. Agnes LIFE Difficulties

• Identifying and selecting participants with CHF for the protocol—flexibility based on site needs

• Managing logistics of completing weights weekly and bi-weekly; space, time, staff changes

• Covering staffing shortages

• Data collection: tools and continuity

• Coordinating disparate student schedules• Measuring quality of life

Bridging the Gaps

The Necessities

• Common goals

• Demonstrable mutual benefit

• Commitment to collaboration, no matter what– Flexibility & patience

• Willingness to admit mistakes, to discuss all details, and to problem-solve together

Bridging the Gaps

Would We Do It Again?

We would and we will:

• New partnership with New Courtland LIFE, also a PACE program

• Serves 12 Philly zip codes, co-located with housing

• Electronic medical record, emphasis on staff continuing education, quality of life and outcomes improvement