Oregon Health & Science University: Community-Based Interprofessional Care Access Network

Member since: July 2014

Intervention: A Community-based Interprofessional Care Access Network

Partners:

Oregon Health & Science University (OHSU) Schools of Dentistry, Medicine, and Nursing, and the OHSU/Oregon State University College of Pharmacy
OHSU Richmond Clinic
Billi Odegaard Dental Clinic
Maybelle Center for Community
Neighborhood House
Home Forward
La Clinica
Southern Oregon Head Start
Family Nurturing Center
Lutheran Community Services NW
Asian Health and Service Center
Russell Street Dental Clinic
Multnomah County Health Department’s Mid-County Health Center
Klamath Open Door
Sky Lakes Outpatient Care Management
Cascade Health Alliance (Coordinated Care Organization [CCO])

Occupations represented: Students and professionals including case managers, community health workers, dentists, dental hygienists, dieticians, drug and alcohol counselors, mental health professionals, nutritionists, nurses, nurse practitioners, pharmacists, physicians, physician assistants, psychologists, public health professionals, and social workers.

Overview: The Interprofessional Care Access Network (I-CAN) is a community-based interprofessional health care delivery and education program that addresses Triple Aim outcomes for vulnerable populations in urban neighborhoods and rural communities. The purpose of I-CAN is to establish an evidence-based model of care delivery demonstrating the impact of interventions focusing on social determinants of health. Goals are achieved through community-based partnerships and development of a healthcare workforce prepared for competent practice in emerging models of care. As a robust clinical model for interprofessional education, I-CAN teaches collaboration and accountability within a population health context. The continuity of a community-based nurse faculty-in-residence provides for sustained engagement with clients over multiple terms with rotating students, and long-term engagement results in sustainable changes in health behaviors among participating clients, committed community partnerships, and expansion of neighborhood resources.

I-CAN provides care coordination for individuals and families with two or more non-acute EMS calls or missed medical appointments in six months; lack of a primary care home; lack of health insurance; elders and families lacking stable housing; and children with family members with a disabling chronic illness or developmentally delayed parent(s). The common factor among I-CAN clients and families is that they are poor and have significant barriers to achieving health; many are socially isolated. Clients are often resistant to traditional approaches to health care or have distrust or lack of understanding of the healthcare system. Interprofessional student teams visit clients weekly to address barriers to engagement in health care. Outcomes measured include housing status, health insurance, access to and use of primary care, food security, health literacy, emergency department visits, EMS calls and hospitalizations.

Intervention study question: