SDC # 1
Updated Project Abstract for NEPQR Grant
Project Title: Interprofessional Collaborative Practice Enhancing Transitional Care Coordination in Heart Failure Patients Applicant Organization: University of Alabama at Birmingham School of Nursing
Project Director: Maria R. Shirey, PhD, MBA, RN, NEA-BC, ANEF, FACHE, FAAN Address: NB 426, 1720 2nd Avenue South, Birmingham, AL 35294-1210 Phone/Fax: (205) 996-6110 (W); (205) 996-6585 (F)
Email Address: [email protected]
Organizational Website: www.uab.edu/nursing
The purpose of this project is to implement an innovative, interprofessional (IP) collaborative practice (IPCP) model around transitional care coordination to reduce 30-day hospital readmissions in heart failure (HF) patients. Building on an ongoing academic/practice partnership with the University of Alabama at Birmingham Hospital (UABH), the project expands services at UABH to establish a Nurse Managed Heart Failure Center for an underinsured and/or medically underserved population. Recent closure of the regional indigent hospital, Cooper Green, has created a critical access to care issue for this vulnerable population. Through this cooperative agreement, establishing HF services to an underserved population in a previously underutilized physical location of UABH involves implementation of an IPCP model that includes nurses, physicians, social workers, health services administrators, and health information technology professionals to offer a 3-day/week clinic with round the clock transitional care support for HF patients.
Innovations of this project include: (a) collaboration and support of an Academic Medical Center; (b) utilization of an integrated electronic medical record to optimize information exchange, care transitions,
and population health care quality, cost, and patient/family engagement consistent with the Triple Aim;
(c) use of a Transitional Care Coach; (d) addition of a palliative care expert; (e) incorporation of multiple disciplines addressing clinical and health system sustainability issues; (f) use of “bundled” approaches in collaborative practice including daily team huddles, evidence-based HF guidelines, coordinated patient handoffs, and clinic post conferences along with patient/family home visits and team-focused, scenario- based decision making simulation; (g) creation of IP patient dashboards and a HF registry to assist the team in providing a quality patient experience in a safe, efficient, equitable, and cost effective manner.
A funding preference is requested as this project will substantially benefit an underserved population.
The new heart failure clinic at UABH is located within Jefferson County (Birmingham), Alabama and is situated in a Medically Underserved Area/Medically Underserved Population and Health Professional Shortage Area for primary care, mental health, and dental health.
Through this collaborative effort, four objectives will be accomplished: (1) Implement a model in which nurses and other health professionals become competent at IP collaborative practice; (2) Demonstrate efficacy of the Chronic Care Model in providing continuity of care and chronic disease management to a medically underserved population of HF patients/families; (3) Integrate nursing and other health
professions students into the IPCP model to gain experience with team-based care and the healthcare needs of vulnerable populations; and (4) Develop and implement a plan for intermediate and long-term success of the IPCP model at the Russell Clinic at UABH.