UA Takes Collaborative Approach to Help Patients with Multiple Chronic Conditions
By Kim Eaton
University of Alabama students are learning the value behind the “two heads are better than one” concept when addressing the health-care needs of rural communities.
The Capstone College of Nursing received a $997,173 grant from the U.S. Department of Health and Human Services to implement a collaborative, team-based approach to working with patients who have multiple chronic conditions.
Chronic conditions are conditions that last a year or more and require ongoing medical attention. They include both physical conditions – arthritis, cancer, HIV infection – as well as mental and cognitive disorders, such as ongoing depression, substance addition and dementia. Multiple chronic conditions are two or more chronic conditions that affect a person at the same time.
“People are living longer, but they are getting sicker earlier,” said Dr. Leigh Ann Chandler Poole, UA assistant professor in nursing and coordinator of the Nurse Practitioner Concentration in Mental Health and Primary Care for Rural Populations. “What we’re doing is not working, so we’re moving to models that use interprofessional teams to provide quality, patient-centered care.”
The program is an innovative, interprofessional collaboration between the Colleges of Nursing, Community Health Sciences, Human Environmental Sciences and the School of Social Work, working closely with community partners Baptist Health Systems of Alabama and Zelia Baugh, its executive director of psychiatric services, and the University Medical Center.
The primary component of the three-year grant is the development of interprofessional grand round teams. These teams will be comprised of graduate-level students from the various disciplines, with nurse practitioner students in the Capstone College of Nursing taking lead on this project. Telemedicine equipment is used to facilitate data collection and sharing and provides the students with an opportunity to practice using the newest innovative technology in health care.
Each nurse practitioner student will be assigned patients, from rural areas, who have multiple chronic conditions, and they will follow those patients for up to a year. Nurse practitioner students will meet with their patients, do the initial workup and then present the patient to the interprofessional grand round team via telemedicine.
The team will meet on a weekly basis to come up with a plan on how to improve the patient’s quality of life and decrease problems associated with the multiple chronic conditions. That plan will then be presented to the patient’s primary care provider who will ultimately decide whether or not to implement the recommendations made by the team.
“This incorporates all disciplines, working together as a team and learning from each other and from the patient to develop best evidenced-based practice plans for the patient,” Poole said. “The patient needs to be part of the process in deciding what will work for them. The providers need to know their patient and their motivations and determine how we can best help the patient achieve their health-related goals.”
According to the Department of Health and Human Services, multiple chronic conditions are associated with substantial health-care costs in the United States. Approximately 66 percent of the total health-care spending is associated with care for over one in four Americans with multiple chronic conditions.
With the Affordable Care Act, health care providers have to prove what they’re doing works in order to get reimbursed, Poole said. For instance, if someone with congestive heart failure is readmitted to the hospital within 30 days, the hospital will not be reimbursed. But they still have to provide the care.
“We hope to provide quality, team-oriented care, and find evidence that this process works in improving the patient’s quality of life and health status and, at the same time, decreases the financial burden associated with multiple chronic conditions,” Poole said.