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.

Leaders have identified a need to enhance knowledge about roles, scope of practice, and training of professions at the clinic. Leaders are concerned that lack of knowledge is reducing interprofessional collaboration and contributing to inappropriate, over-, or under-utilization of services.

The main objective of this project is to improve quality of care, increase interprofessional collaboration, and increase efficiency in utilization of resources by: 1) increasing knowledge about roles, scope of practice, and training of the professions at the clinic and 2) assembling an interprofessional team to screen patients on admission to the clinic and make recommendations for collaboration across professions.

This intervention project takes place in Sheridan Health Services’ School Based Health Center. There are two patient cohorts for testing the impact interprofessional care teams. One cohort contains 80 pediatric patients with asthma, and the other contains 85 pediatric patients with a body mass index (BMI) at or above the 85th percentile. The care teams aim to increase the number of patients with controlled asthma and decrease the number of patients with high BMIs. They also plan to increase patients’ knowledge of healthy habits and access to preventive health care.

This intervention project centers on interprofessional care to support approximately 80 adults with chronic pain. Many of the individuals in this patient cohort have not experienced regular preventive care, and so increasing access to preventive care is part of the intervention. Education about the health risks of opioids is also part of the project, and it is delivered via shared medical visits and a six-week course. Pre-intervention data about preventive care use were collected through the health system’s 2014 quality care indicators. Additionally, emergent nurse leaders will develop and demonstrate skills in interprofessional team building, collaborative problem solving, shared decision making models, and care coordination.

This intervention project centers on care of approximately 120 diabetic adults via an interprofessional care team. Most of the individuals in this patient cohort have experienced uncontrolled Type 2 diabetes. Self-management education and a group visit model are components of the intervention. The care team also incorporates shared decision making models that include the patient in decisions. Better preventive care and enhanced self-management are intended outcomes, and pre-intervention data were collected through the health system’s 2014 quality care indicators.

With the goal of improving health care outcomes, this intervention supports collaborative practice in community-based primary care clinics that serve underserved populations. In Phase 1 of the project, an interdisciplinary group of preceptors will complete the IPE Faculty Development: Train-the Trainer CoP program, and develop lesson plans. In Phase 2, these preceptors will supervise students who are part of interprofessional teams at El Rio Community Health Center and HealthPoint Community. In Phase 3, the effects of these collaborative practice efforts will be assessed. The intervention thereby creates a nexus between ATSU-SOMA and the community clinics.

The “Community Health Mentor Program” (CHMP) reflects the alignment of health professions education where the students learn from their assigned community health mentor who has a chronic disease and/or disability about their experience as a patient within the healthcare system and their community, as well as their role within an interprofessional team. The students meet with their assigned mentor eight times over the course of the one year. This project collectively forms a ‘nexus’ partnership between two state academic institutions, interprofessional student teams, and a defined population of residential community-based consumers of healthcare.