Transcript Trends in Community-Engaged Translational Research at Duke

Healthy-in-Place (HIP)-Seniors:
A Durham Health Innovations
Project
Eleanor S. McConnell, RN, PhD, GCNS, BC
Duke School of Nursing &
Durham VA Geriatric Research, Education and Clinical Center
On behalf of the HIP-Seniors Team
The Cost of a Long Life
U.S.
UC Project for Global Inequality
Slide Courtesy of Rob Califf, Durham Health Summit, 2009
Durham County Health Status
• The US is approximately equal to Cuba
(and worse than several dozen other countries)
in terms of the health of its citizens
• North Carolina is in the bottom half of US states
in survival and functional status
• Durham County is average for North Carolina in
almost every health statistic
– except significantly more doctors and dentists per
population
Slide Courtesy of Rob Califf, Durham Health Summit, 2009
Opportunity to partner with community as
never before to improve important public
health outcomes in Durham
CDC Definition of Community
Engagement
• “ the process of working
collaboratively
• with and through groups of people
affiliated by:
– geographic proximity,
– special interest, or
– similar situations
• to address issues affecting the
wellbeing of those people.”
DHI Planning Grants: $100K each
• Life stage
1. Maternal/Fetal
Health
2. Adolescent Health
3. Seniors’ Health
• “Hard medical”
4. Cardiovascular
5. Cancer
screening/survivors
6. Asthma/COPD
• Behaviors
7. Substance
abuse/pain
management
• Medical/behavioral
8. Obesity
9. Diabetes
10.STDs
Slide modified from Rob Califf, Durham Health Summit, 2009
Unique Features of DHI Projects
Access to:
• GIS mapping
• Data Support
Repository
• Durham stakeholders
– Agency heads
– Senior leaders at
Duke
Intention to change
systems of care
Timeline for The Process
• Sept – Nov 2008: Stage 1 proposals
• Jan – Mar 2009: Stage 2 planning
• April – Dec 2009: Stage 3 planning
• Monthly Team Meetings with >75 stakeholders from
DUHS and Durham Community
• Work Groups Meeting regularly to gather data,
summarize & explicate evidence-based models
• Ongoing Focus Groups & Social Marketing to:
– Define the problems with seniors & their health care
– Develop an innovative model of care for seniors
Process
• Propose an evidence-based concept responsive
to public health need of Durham County
• Build a team
– Community & University co-leadership
• Think big
• Collaborate across teams
• Focus quickly
Aging in Place with Dignity
Falls Prevention &
Physical Activity Promotion
Improved
Care Transitions
Outreach to
Socially Isolated
Medication
Management
Where is the sweet spot?
A protypical scenario….
•“I would get scared –
I didn’t even realize I had
been to the ER 19 times”
Themes:
•Doctors are too busy
•Misses…
•Diagnosis
•Medications
•Information on phone
•Family caregiver frustrated
Courtesy: AARP:
http://www.aarp.org/research/ppi/articles/faces_of_chronic_care.html
Expanded Chronic Care Model
VISION
By 2020, Durham County will be the
community where seniors safely age
in place supported by collaborative
efforts of a community-university
health system that empowers them
with the information and resources
to make choices on the quality of
their own lives.
MISSION
HIP Seniors is a collaborative, community-based
planning process bringing stakeholders from the
community and university health systems
together to design a streamlined, comprehensive
and innovative model of care for seniors.
Thismodel will provide seniors a person-centered,
evidence-based, cost-effective, responsive
system of care by building upon existing
services and offering seamless transitions, no
wrong door access, and full coordination of care.
Model Outcomes
• Decrease return visits to hospital/ED
• Decrease EMS calls, ED visits &
hospital admissions due to falls or
med-related issues
• Increase in seniors who report at least
30-minutes of physical activity per day
• Increase in seniors receiving
immunizations
Core Components
• USA – Universal Senior Assessment
– Tool to identify risks and strengths, shared information
• Navigation
– Various strategies:
•
•
•
•
Self-management,
Family-caregiver support,
Lay navigators in community agencies or neighborhoods, or
Senior Support Nurse
• Link & Support to Key Interventions
– Specific programs or services that address identified risk
• Coordination of Services HUB
– Information, access, follow-up, follow-through and linkage to existing
community and health system services
Coordination & Navigation HUB
Nonprofit
Organizations
Durham City &
County Agencies
HUB
of
Coordinatio
n
Seniors
Duke University
Health System
Community Resource Connection
as a Hub?
HIP Seniors Model: Navigation
Process
PHASE 1:
Assessment
PHASE 2:
Identify Care Navigator Type
PHASE 3:
Identification of Potential Interventions
Falls Risk
Self
Referrals & Linkages
POINT OF CONTACT:
Universal Senior
Assessment (USA)
Completed*
Family/
Significant
Other
CORE
*Completed
by RN in
ER or hosp.
setting
Medication Mgmt
Wellness Practices
Lay Care
Navigator
Assessment includes:
•Falls risk assessment
•Cognition assessment
•Medication assessment
•Wellness practices
•Social support
Referrals & Linkages
HEALTH
ER, Hospital Admission,
PCP, or Community Agency
Senior
Support
Nurse
Social Needs
Complex Health
Care Coordination
**Each care navigator would consult
and collaborate with discharge planner (PRM) as is
current practice.
New Discharge checklist to be revised/added
consistent with Coleman’s Model
Referrals for vaccines, or to
community or health system
resources re physical activity
Such as transportation,
meals on wheels, utility
assistance, personal
care service referrals
Coordination
Coordination of
of care
care &
&
assistance
assistance with
with multiple
multiple cocomorbidities,
morbidities, multiple
multiple health
health
care
care providers,
providers, lack
lack of
of
social
social support
support to
to assist,
assist,
facilitates
facilitates communication
communication
and
and assesses
assesses ongoing
ongoing
needs,
needs, both
both health
health &
& social
social
Personal Electronic Health Record to be made available to the care navigator and health care providers
across the care continuum.
Next Steps
Time
Step
Now..
Durham Health Innovations Oversight Team reviews reports, and
finds commonalities to create a Close-Connected-Care model
Limited support for ongoing project management to coordinate
team activities
Publish articles on our experience, ideas, findings
Ongoing
•Uniform Senior Assessment (USA): Pilot recently funded to
support development of transitional care module
•Medication Reconciliation & Therapy Management Pilot:
seeking funding
•Improved Discharge Processes Pilot: GEC funded
•Lay navigator
•Coordination hub – preparing CRC proposal