Sustainability of an Interprofessional Collaborative Practice Model for Population Health.

Sustainability is an important concept in implementation science, yet little about sustainability is published in leadership journals. Leaders are charged on a daily basis with initiating programs that make a difference; however, they are often not well prepared to design effective strategies to sustain their efforts. In a value-based health care industry where facilitating access to care, enhancing the patient experience, improving health outcomes, and reducing the cost of care are imperative, creating sustainability strategies that achieve these results is key. In this article, we describe the successful efforts within an academic-practice partnership to implement a sustainable interprofessional collaborative practice model emphasizing transitional care coordination in chronic disease management for advancing population health with underserved populations. A sustainability framework is presented along with lessons learned.

Evaluating Patient Navigation to Improve First Appointment No-show Rates in Uninsured Patients with Diabetes.

Free clinics increase access to care, however, patients frequently miss appointments. The purpose of this quality improvement project was to determine if providing patient navigation affects first appointment no-show rates and hemoglobin A1c (HbA1c) in uninsured patients with diabetes at a free clinic. For 6 months, all patients scheduled for new appointments received weekly patient navigation calls. First appointment no-show rates decreased by 17.7% (p = 0.01). Among patients who received at least one patient navigation call, a significantly greater proportion attended their first appointment (72%) compared to the show rate for those who did not receive a completed call (43%) (p = 0.004).

Transforming veterans health care through academic-practice partnerships.

The Veterans Health Affairs Office of Academic Affiliations (OAA) has invested in the creation of academic-practice partnerships to transform the care of veterans and their families. This article details how a long-standing relationship between the University of Alabama at Birmingham School of Nursing and the Birmingham Veterans Affairs Medical Center grew into such a partnership. The three programs that now exist within the Birmingham Veterans Affairs Nursing Academic Partnership (VANAP) umbrella are described, including an undergraduate VA nurse scholars program that has sustained beyond OAA funding, a VANAP graduate education program for psychiatric mental health nurse practitioners (NPs), and a Mental Health NP Residency. Key features of the programs are noted as are outcomes and lessons learned for building mutual goals and a sustainable academic-practice partnership. With the recent passage of the Veterans Choice Program, the importance of educating all nurses about veterans and veterans' health is stressed.

The Impact of Smoking and Smoking Cessation on Wound Healing in Spinal Cord-Injured Patients With Pressure Injuries: A Retrospective Comparison Cohort Study.

PURPOSE: The purpose of this study was to evaluate the impact of implementing evidence-based guidelines on smoking cessation in persons with spinal cord injuries and pressure injuries. We also evaluated the impact of smoking on pressure injury healing in this population. SUBJECTS AND SETTING: The sample population included 158 spinal cord-injured patients with pressure injuries (29 females and 129 males). There were 83 in the control group and 75 in the intervention group, with a mean age of 44 years in both groups. The research setting was an outpatient wound clinic located in a large medical center in the southeastern United States. METHODS: A retrospective chart review was completed. Data were reviewed 6 months before and 6 months after implementation of the US Department of Health and Human Services Clinical Practice Guidelines for Treating Tobacco Use and Dependence. We evaluated the number and size of wounds, achievement of smoking cessation, and demographic information. RESULTS: Forty-eight percent of the control group participants and 57% of the intervention group participants smoked cigarettes at baseline. Smoking cessation doubled with the use of the clinical practice guidelines (P = .03). Smokers presented with a greater number of pressure injuries than nonsmokers. They experienced a mean increase rather than reduction in wound size. Nearly half (45.5%) of the intervention group participants who desired to have surgery had it performed, compared with only 34.9% of the control group participants (P = .35). CONCLUSIONS: Our findings demonstrate a positive influence with use of clinical practice guidelines to help individuals stop smoking. Results also confirm findings of previous studies supporting the negative impact of smoking on pressure injury healing in persons with spinal cord injuries.

Implementation of an electronic health records system within an interprofessional model of care.

Implementation of electronic health records (EHR) systems is challenging even in traditional healthcare settings, where administrative and clinical roles and responsibilities are clearly defined. However, even in these traditional settings the conflicting needs of stakeholders can trigger hierarchical decision-making processes that reflect the traditional power structures in healthcare today. These traditional processes are not structured to allow for incorporation of new patient-care models such as patient-centered care and interprofessional teams. New processes for EHR implementation and evaluation will be required as healthcare shifts to a patient-centered model that includes patients, families, multiple agencies, and interprofessional teams in short- and long-term clinical decision-making. This new model will be enabled by healthcare information technology and defined by information flow, workflow, and communication needs. We describe a model in development for the configuration and implementation of an EHR system in an interprofessional, interagency, free-clinic setting. The model uses a formative evaluation process that is rooted in usability to configure the EHR to fully support the needs of the variety of providers working as an interprofessional team. For this model to succeed, it must include informaticists as equal and essential members of the healthcare team.

Evaluation of Team-Based Care in an Urban Free Clinic Setting.

This article reports the experiences of a school of nursing, academic health center, and community-based organization working via an interprofessional collaborative practice model to meet the mutual goal of serving the health care needs of an indigent, largely minority population in Birmingham, Alabama. The population suffers disproportionately from chronic health problems including diabetes, obesity, cardiovascular disease, asthma, and mental health disorders. The program emphasizes diabetes management because the academic health center recognized the need for transitional and primary care, including mental health services, for the increasing numbers of uninsured patients with diabetes and its comorbidities. Half of the clinicians involved in this project had no prior experience with interprofessional collaborative practice, and there was confusion regarding the roles of team members from the partnering institutions. Activities involving care coordination consistently received low scores on weekly rating scales leading to the creation of positions for a nurse care manager and pharmaceutical patient assistance program coordinator. Conversely, shared decision making and cooperation ratings were consistently high. Evaluation identified the need for reliable, accessible data and data analysis to target clinically effective interventions and care coordination and to assess cost effectiveness. The strengths, challenges, lessons learned, and next steps required for sustainability of this alignment are discussed.

Caring for America's Veterans: The Power of Academic-Practice Partnership.

Veterans receive care across the entire health system. Therefore, the workforce needs knowledge and awareness of whether patients are Veterans and the impact of their military service on their physical and mental health. Recent reports of limitations in access for Veterans seeking health care have highlighted this need across all health care settings. Academic-practice partnerships are one mechanism to align the need for improved health care services within the Veteran population while advancing nursing practice in the Veterans Health Administration and surrounding communities. The key to strong partnerships and sustained collaboration is shared goals, mutual trust and respect, the development of formal relationships, and support of senior leadership that fosters the joint vision and mission to improve nursing care for Veterans. This article describes the evolving partnership between one Veterans Health Administration Medical Center and a School of Nursing, which aligned strategic goals across both organizations to increase the capacity and capability of services provided to Veterans.

Rural, Underserved, and Minority Populations' Perceptions of COVID-19 Information, Testing, and Vaccination: Report from a Southern State.

The purpose of this project was to survey rural, minority, and underserved Alabamians regarding their perceptions of COVID-19 information, testing, and vaccination. Community health workers surveyed 3721 individuals from October 20-December 31, 2020. Participants came from 46 of Alabama's 67 counties (35 rural and 11 urban counties) and were largely Black (69.6%), female (56.5%), and between the ages of 40-59 years (34.8%). The majority of respondents reported that recommendations from public health agencies were easy to understand, information on COVID-19 was easy to find, and they felt confident in keeping themselves safe from infection. Most also reported they would get tested for COVID-19 if they had been exposed to someone who tested positive. Hesitancy to receive a COVID-19 vaccine was very high among all respondents; only 38.7% said they would be vaccinated. Significant differences by sex, race/ethnicity, age, and/or rural/urban status were seen for all survey items. Findings from this survey differ from other published studies and will be of interest to states with large rural, underserved, and minority populations as they tailor messaging for those most vulnerable. Findings also are now validated by Alabama's poor response to vaccine administration, which falls far short of the national vaccination rate, putting Alabamians at even greater risk. Building vaccine confidence among low vaccine populations remains challenging yet is imperative, especially for those populations with preexisting economic, social, and physical conditions that place them at continued high risk for COVID-19 infection.

Use of a Screening Protocol to Identify Asymptomatic COVID-19 in a Free Community Health Clinic in Shelby County, Alabama, October 2020-February 2021.

OBJECTIVE: Community of Hope Health Clinic (CHHC), a free and charitable clinic in Shelby County, Alabama, developed a screening protocol to identify patients with asymptomatic COVID-19 with the goal of minimizing infection risk for other patients, health care providers, and staff. We sought to determine whether the use of the CHHC screening protocol identified asymptomatic carriers of SARS-CoV-2 before their scheduled clinic visits. METHODS: The CHHC screening protocol included the use of an adapted Centers for Disease Control and Prevention questionnaire via telephone 48-72 hours before a scheduled clinic appointment, coupled with a second administration of the questionnaire and a temperature check immediately before the patient's scheduled visit. Patients with positive responses to any questions or whose temperatures were greater than 100.4 °F were refused entry to the clinic, their appointments were rescheduled, and a SARS-CoV-2 test was recommended. SARS-CoV-2 laboratory testing was conducted on all patients with an appointment from October 26, 2020, through February 18, 2021, to verify whether the screening protocol was effective. RESULTS: Of 298 patient encounters, 20 patients screened positive on the SARS-CoV-2 patient screen. Another 278 patients screened negative, were seen for patient care, and received a SARS-CoV-2 test via nasal swab; 274 (98.6%) patients received a negative test result, and 4 (1.4%) patients received a positive test result. CONCLUSIONS: The CHHC SARS-CoV-2 screening protocol, as validated by SARS-CoV-2 assay, was effective in screening out asymptomatic patients infected with SARS-CoV-2 before they were seen in clinic. As clinics and office practices return to prepandemic volumes, the use of such a screening protocol can help mitigate the risk of serious COVID-19 infection, especially for unvaccinated patients, health care providers, and staff.

Interprofessional Collaborative Practice Model to Advance Population Health.

The purpose of this paper is to describe the development, implementation, and lessons learned associated with an interprofessional collaborative practice (IPCP) care delivery model initiated at the University of Alabama at Birmingham (UAB). The model emphasizes transitional care coordination in chronic disease management for underserved and vulnerable populations. The model operates within a clinic environment with care providers from a variety of disciplines who integrate individual case management and actualize leadership taken by the appropriate discipline based on the needs of each patient. Two clinics will be discussed - Providing Access to Healthcare (PATH) and Heart Failure Transitional Care Services for Adults (HRTSA) - both of which leverage the resources of an existing academic-practice partnership between the UAB School of Nursing and UAB Hospital (UABH) and Health System. Clinic target patient populations are uninsured adults with diabetes (PATH Clinic) and uninsured or underinsured adults with heart failure (HRTSA Clinic) who are discharged from UABH with no source for ongoing care. The model uses a nurse-led, team-based approach that involves multiple professions working together to provide care for high-need, high-cost patients. Clinics use 4 simultaneous bundles of care that include evidence-based treatment guidelines, transitional care coordination activities, patient activation strategies, and behavioral health integration. Engaged patients indicate very high levels of satisfaction with care and improved physical and mental health outcomes resulting in significant cost savings for the health system. Finally, IPCP team members report joy in their work within the clinics.

Food Link: A Partnership Providing Healthy Foods to Food Insecure Patients.

BACKGROUND: Defined as an economic and social condition characterized by uncertain access to adequate food, food insecurity (FI) is associated with negative health outcomes and higher health care costs. OBJECTIVES: The purpose of this article is to discuss the implementation and results of Food Link, a population-based FI program serving vulnerable populations in Birmingham, Alabama. METHODS: Academic, clinical, and community partners implemented Food Link in two free clinics serving patients with diabetes and heart failure. Patients identified as FI using the Hunger Vital Signs Screener receive dry goods and produce, food pantry referrals and benefits education. RESULTS: During the first 18 months of Food Link, more than one-half of the patients (n = 466) screened as FI and received food, with a total of 1,179 food distributions. CONCLUSIONS: Academic, clinical, and community partners working together can help meet the FI needs of vulnerable populations with the goal of improving health and decreasing costs.

Expanding Data Reporting Capacity of Free and Charitable Clinics: A Quality Improvement Project.

BACKGROUND: In 2018, member clinics of the Virginia Association of Free and Charitable Clinics (VAFCC) provided over 235,500 visits to un/underinsured patients. A survey of VAFCC members found that only 67% report on clinical outcome measures and 56% do not collect social determinant of health (SDOH) data. OBJECTIVE: The purpose of this project was to determine if the provision of web-based technical assistance toolkits and peer mentoring improve quality and data reporting capacity of VAFCC member clinics. METHODS: Clinics that self-selected were provided with 16 weeks of customized interventions including SDOH Data Reporting Toolkit, CMS Quality Data Reporting Toolkit, Electronic Health Record Implementation Toolkit, and peer mentoring. RESULTS: Post-implementation, 100% of participating clinics reported that the resources provided benefited their organizations and increased their capacity to report. CONCLUSIONS: The provision of technical assistance, tangible resources, and customized peer mentoring can better equip Free and Charitable Clinics (FCCs) to tell the story of their patients' social barriers and clinical outcomes. IMPLICATIONS FOR NURSING: DNP prepared nurses working with vulnerable populations are positioned to assist FCCs in documenting their relevance in the safety net system. Enhancing the ability of FCCs to collect and report data will allow them to demonstrate the provision of high-quality care, despite limited resources.

Partnering to Educate Nurses in Long-Term Care.

Despite a 2008 national call to retool a health care workforce for an aging America, the geriatrics-trained workforce is declining while the U.S. population continues to age. Formalized academic-practice partnerships between long-term care facilities and schools of nursing are one response to strengthening the work-force caring for older adults. This article details the activities of an intentional, synergistic, 3-year partnership between National HealthCare Corporation (NHC) and University of Alabama at Birmingham (UAB) School of Nursing. The partnership focused on providing continuing education and leadership development for NHC nurses while also providing nursing faculty with access to clinicians and patients in long-term care for the purposes of education, research, and quality improvement. The ultimate goal for both partners was improved patient outcomes. [J Contin Educ Nurs. 2020;51(2):75-81.].

Development of an academic practice partnership to improve maternal child health.

This manuscript describes one nursing school's innovative community-based partnership with community organizations and Nurse-Family Partnership (NFP), an established nurse home visiting program for first-time, low income mothers and infants. The aim of this academic nursing endeavor with the community and NFP is to improve the health and well-being of low-income, first time mothers and their children while also providing comprehensive, population-based nursing experiences for students and service leadership and scholarship opportunities for faculty. The academic-practice community partnership described here makes a case for utilizing the expertise and capacity of a nursing school to implement and administer an NFP program and serves as an exemplar for the recommendations described in the New Era for Academic Nursing report (AACN, 2016). The value of forming partnerships between a public health department, the philanthropic community and an academic nursing institution is highlighted. In this case, the three organizations partnering together around a common purpose of improving birth outcomes enabled the partnership to accomplish more than any individual organization could have accomplished alone.

Effectiveness of Diabetes Self-Management Education in Community Health.

BACKGROUND: Diabetes self-management education (DSME) programs utilize a multidisciplinary, skills-based approach allowing participants to make self-management choices and follow a comprehensive plan of care, improving their glycemic control. OBJECTIVE: The purpose of this quality improvement project was to evaluate the effectiveness of DSME on the reduction of hemoglobin A1c (HgbA1c) and body mass index (BMI) in overweight/obese community health center patients. METHODS: The free program met 2 hours weekly for 6 consecutive weeks. A retrospective chart review was conducted to compare baseline to post-session HgbA1c and BMI 12 weeks after completion of the program. Pre- and post-session surveys were also conducted to assess improved diabetes knowledge and confidence. RESULTS: Mean HgbA1c decreased by 1.6% (p = .003) 12 weeks after completion of the program; however, BMI remained unchanged (p = .582). Diabetes knowledge and confidence also improved significantly following DSME (p = .000 and p = .001, respectively). CONCLUSIONS: The study demonstrated that a reduction in HgbA1c levels and an increase in diabetes knowledge and confidence can occur in low income, community health center patients following participation in DSME. IMPLICATIONS FOR NURSING: Community health center patients who have access to free DSME can improve their health, self-efficacy, and diabetes self-management practices.

Strengthening universal health: development of a nursing and midwifery education quality improvement toolkit.

OBJECTIVE: to present the development of a toolkit for education quality improvement in universal health and primary health care, targeting schools of nursing and midwifery in Latin American and Caribbean countries. METHODS: an expert work group conducted a systematic literature review, selected key content and completed toolkit drafting, using an iterative consensus approach. International partners reviewed the toolkit. Cognitive debriefing data were analyzed, revisions and new tools were integrated, and the final version was approved. RESULTS: twenty-two articles were identified and mapped as resources. The Model for Improvement, a data-driven approach to performance analysis, was selected for its widespread use and simplicity in carrying out the following steps: 1) organize a team, 2) assess improvement need regarding universal health and primary health care education, 3) set an aim/goal and identify priorities using a matrix, 4) establish metrics, 5) identify change, 6) carry out a series of Plan-Do-Study-Act learning cycles, and 7) sustain change. CONCLUSIONS: the Education Quality Improvement Toolkit, developed through stakeholder consensus, provides a systematic, and potentially culturally adaptable approach to improve student, faculty, and program areas associated with universal health coverage and access.

Designing Large-Scale Improvement: Using an Academic-Practice Partnership to Enhance Care Transitions.

This department column highlights translation of research into healthcare quality practice. Achieving the highest quality in healthcare requires organizations to understand care delivery and to develop and design process efficiencies. The improvement process may be enhanced through a partnership between the healthcare facility and an affiliated school of nursing. The purpose of this article was to describe the process for developing a large-scale improvement project focused on enhancing care transitions within an academic medical center using an academic-practice partnership model.

Meeting Health Care Needs in Rural Alabama: The Power of Partnerships.

Recruiting and retaining rural primary care providers is challenging. The Graduate Nursing Education Primary Care Scholars (GNEPCS) is a partnership between a philanthropic organization and a school of nursing to recruit, educate, train, and retain primary care advanced practice registered nurses (APRNs) for practice in rural Alabama with a focus on improving the state's health outcomes. In its initial four years, the GNEPCS partnership has been successful in identifying 60 registered nurses interested in becoming rural primary care APRNs. These students have received mentoring, individualized content on rural health, preceptorships with rural providers, and opportunities for professional and leadership development. Pilot philanthropic funding has allowed us to develop sustainable curricula, attract additional complementary federal funds, and create a critical mass of practice-ready APRNs who are improving primary care access for some of the state's most rural and underserved populations.

Improving Population Health Among Uninsured Patients with Diabetes.

Diabetes is a leading cause of morbidity and mortality; prevalence of diabetes is especially high in the southeastern United States among minority populations and those from lower socioeconomic sectors without access to health care services. The purpose of this project was to evaluate the clinical and financial outcomes of a nurse-led, interprofessional collaborative practice model that provides care coordination and transitional care for uninsured patients with diabetes. Data for this study were collected and evaluated from medical records of patients seen at the Providing Access to Health Care (PATH) Clinic between August 1, 2015, through May 30, 2017. Clinical outcomes were evaluated by comparing hemoglobin A1c (HbA1c) values before and after referral to the PATH Clinic. Cost savings to the academic medical center were evaluated by comparing costs associated with inpatient or emergency department encounters before and after referral to the PATH Clinic. A significant decrease in HbA1c (P < .0005) was noted for patients attending the PATH Clinic. In addition, financial analyses revealed a 55% decrease in pre to post PATH Clinic patients' direct costs. Similarly, a 42% decrease in the pre to post PATH Clinic patients' direct cost per encounter was noted. Average length of stay also was reduced when these patients were readmitted to the academic medical center. Results from this study support the effectiveness of the PATH Clinic model in caring for uninsured patients with clinically complex medical and social needs, often with behavioral health problems, who incur high health care spending and are often readmitted.

Providing primary care using an interprofessional collaborative practice model: What clinicians have learned.

This article details a nurse-led, interprofessional collaborative practice (IPCP) model that was developed to provide primary care to a medically indigent population in Birmingham, Alabama. Funding to develop and implement this project came from a federal Nurse Education, Practice, Quality and Retention award to the University of Alabama at Birmingham (UAB) School of Nursing, with additional support coming from the UAB Hospital and Health System. The clinic is housed within a local community-based, non-profit organization and all services, including supplies and pharmaceuticals, are provided free of charge to this vulnerable population. The IPCP model that was developed includes three primary care teams and incorporates faculty clinicians from a variety of disciplines, including nursing, medicine, optometry, nutrition, mental health, social work and informatics. Evaluation of the project has included annual structured interviews of project personnel, a variety of survey instruments completed electronically at various intervals, and assessments by students as well as patients experiencing team-based care. The focus of this article is the qualitative data collected from structured interviews of clinician faculty annually over the three years of the funded project. The learning, understanding and growth that have taken place by the experienced clinicians from multiple disciplines regarding IPCP are detailed.