Nexus Innovation Network

Member since: March 2015

Intervention: Interprofessional Student Teams Develop Comprehensive Care Plans

Partners:

• University of Southern Indiana (USI) College of Nursing and Health Professions (CNHP)
• USI Community Health Centers at Glenwood, Cedar Hall, and Lodge
• Marion Veterans Affairs Medical Center and Community Clinics in Evansville and Vincennes (IN) and Owensboro (KY)

Occupations represented: Students and professionals including dietitians, nurses, occupational therapists, occupational therapy assistants, respiratory therapists and social workers.

Overview: Students engage with the Veteran’s Administration (VA) Patient Aligned Care Teams (PACT), as well as nurse practitioners and support staff from the USI Community Health Centers, to develop comprehensive care plans and provide patient care. The teams are charged with developing a plan of care that addresses an individual’s primary health care needs.

Resources for the plan include individual, family and community assessments, and it is developed in collaboration with the IPE team, the individual and the family/support system. The teams also integrate technology such as telehealth to assist and support the patients for better self-management of their health. USI faculty members serve as Interprofessional Clinical Coaches (ICC) at each location. Intended intervention outcomes include improved management of chronic conditions and reduced hospital admissions.

The Marion VA Medical Center and its community-based outpatient clinics serve veterans in the tristate area of southwestern Indiana, southeastern Illinois and western Kentucky. The area is comprised of 35 counties that are predominantly rural, and 80% of the area is designated as a health professions shortage area (HPSA).

The USI Community Health Centers are located in schools with the Evansville Vanderburgh School Corporation. The health centers serve a racially diverse population in a designated health professions shortage area (HPSA). In 2014, the percentage of residents in this community with income below the poverty level was three times greater than the statewide percentage. 

Intervention study questions:

• In a primary care patient population, what is the effect of an interprofessional educational clinic model on pre-established patient level outcomes for hypertension, diabetes mellitus, depression and chronic obstructive pulmonary disease, compared to baseline data over a 28-month timeframe?
• In a health professional student population, what is the effect of an interprofessional educational clinical model on student-level measurements of team structure, leadership, situational monitoring, mutual support and communications, compared to baseline data over a 28-month timeframe?
• In health care professionals, what is the impact of a formal leadership program on leadership competency and management skills, compared to baseline data over a 12-month timeframe?