, Executive Director, University of Louisville Institute ...
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Transcript of , Executive Director, University of Louisville Institute ...
Anna C. Faul, PhD, Executive Director, University of Louisville Institute for Sustainable Health & Optimal Aging
Joseph G. D’Ambrosio, PhD, Director of Health Innovation and Sustainability, University of Louisville Institute for Sustainable Health & Optimal Aging
Barbara Gordon, MA, Director Social Services, KIPDA Area Agency on Aging
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This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under U1QHP28732 titled Kentucky Rural & Underserved Geriatric Interprofessional Education Program and is a 3 year grant of $2.55 million. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.
The “Business Institute”
The mission of the Aging and Disability Business Institute (Business Institute) is to successfully build and strengthen partnerships between community-based organizations (CBOs) and the health care system so older adults and people with disabilities will have access to services and supports that will enable them to live with dignity and independence in their homes and communities as long as possible.
aginganddisabilitybusinessinstitute.org
Partners and Funders
Partners:
• National Association of Area Agencies on Aging
• Independent Living Research Utilization/National Center for Aging and Disability
• American Society on Aging
• Partners in Care Foundation
• Elder Services of the Merrimack Valley/Healthy Living Center of Excellence
• The National Council on Aging (NCOA)
• The Evidence-Based Leadership Council (EBLC)
• Meals on Wheels America (MOWA)
Funders:
• Administration for Community Living
• The John A. Hartford Foundation
• The SCAN Foundation
• The Gary and Mary West Foundation
• The Colorado Health Foundation
• The Marin Community Foundation
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“We believe that the U.S. health care system would benefit greatly from more integration between population-oriented and individual patient care systems.” Sloan et al, American Medical Association, 2009
University of Wisconsin Population Health Institute, 2015
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Population HealthAccess to Care and Qualityof Care
Health Behaviors (tobaccouse, diet and exercise,alcohol and drug use,sexual activity)
Social and EconomicFactors (education,employment, income,family and social support,community safetyPhysical environment (airand water quality, housingand transit)
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University of Louisville Geriatric Workforce
Enhancement Program
University of Louisville Geriatric Workforce
Enhancement Program
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University of Louisville Geriatric Workforce Enhancement Program Interdisciplinary Curriculum for the Care of Older Adults
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Didactic Online Modules
Explores ways to work effectively with colleagues of multipleprofessions, across multiple settings.
https://www.softchalkcloud.com/lesson/serve/dayHh5OqrJ8kRw/html
Focus on care of an older patient with Alzheimer’s disease andsupport for caregivers
https://www.softchalkcloud.com/lesson/serve/T9uf2goDR0CWhA/html
Didactic Online Modules
Explores an older Hispanic undocumented worker with diabetes, congestive heart failure and periodontoal disease
https://www.softchalkcloud.com/lesson/serve/Z61PwF5vBornxm/html
Didactic Online Modules
Explores care of an older patient with advanced cancer cared for athome by her elderly husband
https://www.softchalkcloud.com/lesson/serve/C4x6XRVnA97iBd/html
Didactic Online Modules
Instructs the learner in a basic understanding of motivationalinterviewing
https://www.softchalkcloud.com/lesson/serve/ptG95JbVi3lrx0/html
Didactic Online Modules
Interdisciplinary Case Management Experience
Jim Thomas (Diabetes
Focused, Dental)
https://youtu.be/xO-_0qMpXh0
Mary Hamilton (ADRD Focused)
https://youtu.be/4GUNlGvtJgA
Jerry Freeman (Cancer)
https://youtu.be/WV1HenYBAIc & https://youtu.be/tmi5zl3sBoM
Shadowing health care sites with reflective writing
Rural primary care site infusion
Glasgow, Hart, Metcalfe Counties, KY
Shelby County, KY
Latino Community Clinic, KY
Henry County, KY
Bullitt County, KY
500 learners (36% nursing, 32% dentistry, 7% pharmacy, 7% social
work, 7% community health partners)
Learners reported mean satisfaction score of 4 on
a scale from 1 to 5
Learners showed a significant increase from
pre-to post test with a mean post knowledge
score of 84%
65% earned at least a mean of 8 on the self-efficacy scale from 1 to
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Online Modules
330 learners (33% medical students, 27% nursing, 11%
dental, 8% pharmacy, 8% social work, 12% community
health partners)
Learners showed a significant difference from pre-to post assessment on
interprofessional self-efficacy
Interdisciplinary Case Management Experience
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University of Louisville Geriatric Workforce Enhancement
Program – Flourish Care Coordination Model
University of Louisville Geriatric Workforce Enhancement Program – Flourish Care Coordination Model
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Marketing and Initial Referral
In-Home Geriatric Assessment by
Health Care Navigator
Case Conceptualization
Team Meeting
Clinical Care Plan meeting with
Doctor
Community Care Plan
Follow-up Health Care Navigation
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Our Referral Sources
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In-Home Geriatric Assessment
In-Home Geriatric Assessment
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In-Home Geriatric Assessment
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In-Home Geriatric Assessment
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In-Home Geriatric Assessment
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In-Home Geriatric Assessment
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In-Home Geriatric Assessment
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In-Home Geriatric Assessment
Case Conceptualization Meeting
Community OrganizerArea Agency on Aging
CHN with SW supervisor
Geriatrician Pharmacy consult (remote)/in person (fellow)
Law consult (remote) if applicable
PCP absent
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Clinical Care Plan Meeting
Community Organizer
CHN
Patient Clinical Social Worker (if needed)
MD/Nurse Practitioner
Caregiver/ Family
Community Care Plan
Community Organizer
CHN
Patient Clinical Social Worker (if needed)
Area Agency on Aging
Caregiver/ Family
Care Coordination Plan in Action
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CHN
EHR/ Navigation system
Follow up Health Navigation Meetings
Community OrganizerArea Agency on Aging CHN with SW
supervisor
Nurse Practitioner/ Geriatrician
Pharmacy consult (remote)/in person (fellow)
Law consult (remote) if applicable
PCP consult
Mean number of chronic conditions = 4.5 (range
between 2 and 9)
Most common chronic conditions were high blood pressure, heart disease and
diabetes
Patients perceive the involvement of primary care
offices in their self-management of chronic
diseases as low
ADL that presents the biggest challenge is ability to bend; IADLs show middle of the
range dependency
Patients show moderate risk of falling, relatively frail and
losing muscle, with a significant risk of losing
weight. Also showing mild cognitive impairment
Mean number of medicines taken at baseline = 11 (range 5-18) with 65% taking 10 or
more meds
Flourish patient data Biological determinants of health
Rate health as fair.Show moderate
levels of depression
Only moderately confident that they can manage their
chronic conditions.
Flourish patient dataPsychological determinants of health
On average patients have 11.5 years of education
(just below a high school education)
Average income $1,700 per month
Two thirds of patients do not own a car and
experience transportation issues
Patients experience loneliness and social
isolation. Those wo are providing care to a spouse,
experience role strain
Patients in need of home repairs with significant fall
hazards in the house
Flourish patient data Social determinants of health
Only a third of patients exercise. On average
those who exercise, do it 4 times a week.
Patients do not report problem drinking
10% of patients smoke
Flourish patient data Individual determinants of health
Patient Needs
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0 10 20 30 40 50 60 70
Personal home care
Chronic care education
Nutritional support
Guidance advanced directives
Home repair assistance
Transportation services
Mental health services
Medication management
Caregiver support services
Services Received
Percentage
Patients lower extremity muscle
strength improved
Patients muscle density and muscle
tissue quality improved
Home hygiene improved
Fall hazards in the home greatly reduced
Patients feeling of satisfaction with PCPs engaging with them in goals of care improved
Polypharmacy issues greatly improved
(prescription, over the counter and dosage)
Flourish patient data Main Outcomes After Six Months
University of Louisville Geriatric Workforce Enhancement Program – Flourish Care Coordination Model: Client Testimonials
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University of Louisville Geriatric Workforce Enhancement Program – Kentucky Coalition for Healthy Communities
University of Louisville Geriatric Workforce Enhancement Program – Memory 360
Where our last three years of work has led us…
Development of the Flourish Index
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Working closely with AAAs are important
Transforming primary care practices are complicated; EHR
difficult to manage
Volunteers are needed to help fill the needs for
addressing the social determinants of health
There is not a good reimbursement system
to support social determinants of health
Very important to train students to do health
navigation
Interdisciplinary home visits are crucial and should include the
health navigator and pharmacist
Lessons Learned
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Thank you for tuning in!
Anna C. Faul, PhD, Executive Director, University of Louisville Institute for Sustainable Health & Optimal [email protected]
Joseph G. D’Ambrosio, PhD, Director of Health Innovation and Sustainability, University of Louisville Institute for Sustainable Health & Optimal [email protected]
Barbara Gordon, MADirector Social Services, KIPDA Area Agency on Aging [email protected]
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Box
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