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.

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.

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.

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.

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.

Using Data Analytics as Evidentiary Support for Financial Outcome Success in Nurse-Led Population-Based Clinics.

Achieving the highest quality in health care requires organizations to develop clinical improvements that result in measurable outcomes for success. The purpose of this article is to demonstrate an example of clinical quality improvement through the use of data analytics to generate evidence for financial return on investment in two nurse-led, population-based clinics.

The Implementation of a Patient Assistance Program in a Free Clinic Setting: A Case Report.

This article describes the implementation of a pharmaceutical Patient Assistance Program in a free clinic, including issues such as navigating complicated pharmaceutical company requirements, obtaining documentation for income verification, engaging healthcare providers, tracking and re-ordering medications, and developing clear expectations for patients. Successes, challenges, and lessons learned are also discussed.

Parental smoking and children undergoing anesthesia: Is there a role for pediatric hospitals in smoking cessation?

PURPOSE: Pediatric hospitals within the Children's Hospital Association were surveyed to determine their tobacco cessation efforts for parents/patients. DESIGN AND METHODS: Electronic surveys were sent to 75 anesthesia providers and/or preoperative surgery specialists at 41 facilities. RESULTS: A total of 52 completed surveys were returned. The majority (97%) of facilities were smoke-free, and 68% included preoperative questions about parental smoking and secondhand smoke (SHS) exposure. Few offered cessation assistance. PRACTICE IMPLICATIONS: Pediatric hospitals have a role in parental smoking cessation. This article provides recommendations for pediatric hospitals to assist parents to overcome their addiction to tobacco as they strive to provide the best possible healthcare services for children.

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.

Veteran Competencies for Undergraduate Nursing Education.

Military Veterans comprise approximately 10% of the US population. Most Veterans do not receive their health care through Veterans Affairs facilities, are seen across the health care system, and their prior military service and associated health issues often go unrecognized. In this study, a modified Delphi design was used to develop a set of 10 Veteran Care Competencies and associated knowledge, skills, and attitudes for Undergraduate Nursing Education: Military and Veteran Culture, Post Traumatic Stress Disorder, Amputation and Assistive Devices, Environmental/Chemical Exposures, Substance Use Disorder, Military Sexual Trauma, Traumatic Brain Injury, Suicide, Homelessness, and Serious Illness Especially at the End of Life.