Nurse Education, Practice, Quality and Retention Project: The MHC’s Perspective

Introduction

The Health Resources and Services Administration (HRSA) awarded a Nurse Education, Practice, Quality and Retention (NEPQR) grant to the Michigan Department of Health and Human Services (MDHHS) in partnership with Grand Valley State University (GVSU), Wayne State University (WSU), Michigan Area Health Education Center (MI-AHEC), and the Michigan Health Council (MHC). The three-year award totaled $1,474,347 and began on September 1, 2012 and ended June 30, 2015.

The main goals of the project were to allow emergent nurse leaders to demonstrate interprofessional collaborative practice (IPCP) leadership, incorporate training opportunities for nursing and other health professional students into the IPCP practice environment, and develop the long term sustainability of the IPCP clinic-based innovation through a statewide initiative. The IPCP teams used the Midwest Interprofessional Practice, Education and Research Center’s (MIPERC) model of interprofessional education (IPE) to help reduce Michigan’s 2012 adult obesity rate of 31.7% by supporting team-based care delivery, health promotion activities, and other wellness measures in an IPCP framework. The MIPERC modules focused on:

• Faculty development • Preceptor manual overview • Introduction to IPE and IPCP • Patient Safety • Team dynamics • Tips for implementing health care behavioral change

Disciplines involved in the project included: undergraduate nursing, graduate nursing, undergraduate and graduate social work, dietetics, and movement science. Total individuals served as of May 2015 included: 14 staff/faculty members, 59 students and 291 patients at two pilot sites. This report details the Michigan Health Council’s NEPQR deliverables described below in order to document how MHC and its grant partners came together, identified challenges, and disseminated findings:

• Site visits—identify new and emerging clinical placement locations that can implement interprofessional models • Consulting committee—convene and support a consulting committee to ensure buy-in to sustain interprofessional models • Pilot sites—participate in the NEPQR pilot site facilitation in order to disseminate lessons learned • Systematize rotations—identify ways to systematize interprofessional clinical site rotation certification and scheduling using MHC’s existing online rotation system • Evaluation activities—assist Project Director in practice environment tracking and evaluation activities

The project’s objectives that align with the deliverable are:

• Objective 2.2-facilitate IPCP student learning experiences through community projects • Objective 3.1-convene consulting committee to ensure the IPCP can deliver a return on investment • Objective 3.3-advance the number of IPCP practice environments across Michigan by 10% each year

Site visits

The Michigan Health Council investigated the current use of IPCP in Michigan in order to find out what leads to teamwork implementation, whether or not two or more professionals learning about, from, and with each other have positive impacts, and how teamwork can be improved. MHC completed 22 site visits to a variety of settings, including:

• Long term acute care hospital • Retirement community • Critical access hospital • Health department • VA medical center • Community health network • Program of All-Inclusive Care for the Elderly • Health center • Health system

One particular question the Michigan Health Council faced was how IPCP came to fruition. Smaller hospitals, such as Harbor Beach Community Hospital, have found that living in a rural area requires more innovative thinking. The need for creative thinking combined with a small, adaptable staff led the hospital in Harbor Beach to utilize IPCP process improvements through a program called Adaptive Design ®. However, IPCP also works in larger hospitals and care centers. Veterans, for example, receive care from Patient Aligned Care Teams (PACTs). The PACTs provide patient-driven, proactive, personalized team-based care, focusing on preventative care and improved healthcare outcomes. The MHC noted that this program has been successful in its implementation largely due to the structure provided by government requirements. Another successful IPCP program is the Program of All-inclusive Care for the Elderly (PACE). PACE is a Medicare & Medicaid program that helps elderly men & women meet their health care needs in the community instead of going to a nursing home or other care facility. Healthcare teams focus on and coordinate around the patient in need. This program was born out of a need for better health care and lower costs. This program has thrived because of the improved health outcomes, patient satisfaction, and financial incentives to use the program. Another question the MHC sought to answer was whether implementing IPCP in Michigan had negative, neutral, or positive results. The Harbor Beach Community Hospital has attributed several incidents of success to their collaborative practice process. For example, when a diagnostic machine stopped working, the various members of the team took the initiative to step up and fix the error before any patient harm could be done. In cases where teams fail to communicate or work together efficiently, problems may be left unresolved, as everyone may assume it is someone else’s responsibility to address. Team-based care supports personal responsibility among team members, which leads the MHC to believe that the results have been positive.

Other common activities completed by the variety of sites MHC visited include:

• Using teamwork ice-breaker activities to build camaraderie • Developing a single care plan created by multiple health professionals • Completing regular team huddles/rounds • Overcoming conflict by focusing on patient need • Making organizational culture explicit in order orient everyone toward promoting the Triple Aim and reducing medical errors • Using teamwork to compensate for a limited supply of health professionals in more remote areas • Using clinical process information/data (e.g. patient emergency department use) to calibrate team performance • Beginning to practicing teamwork on specific friction points (e.g. increasing patient activation) • Involving community/population health professionals to prevent/manage chronic conditions before emergency care is required

The main challenge sites faced was a lack of awareness and/or understanding of team based care. In the early stages of implementation, several hospitals were not aware of standards to follow or how to improve their processes in a specific way. In order to get a team to work together effectively, every member should understand why and how IPCP improves care. Without motivation or instruction, IPCP programs are not likely to develop. MHC developed customized requests for meetings when scheduling site visits in order for each organization to better understand why teamwork is directly relevant to their work.

Consulting committee

The consulting committee dialogued with members regarding implementation issues at potential settings, and explored ways to sustain interprofessional interventions. In addition to the grant-funded partners, organizations participating in the committee included:

• Michigan Center for Rural Health • Michigan Primary Care Association • Ferris State University • Traverse Health Clinic • University of Michigan School of Dentistry

MHC convened nine meetings with these partners and discussed the following topics:

• Long period of time needed for institutional review board (IRB) approvals • Challenges recruiting and retaining necessary provider staff (e.g. part-time nurse practitioner, dietician) • Ways to increase patient retention (e.g. gift cards used mid-way through project as incentive) • Balancing provider productivity with the need to train students in IPE and IPCP • Producing brochures to advertise IPE and IPCP experiences to schools, sites, and students • Identifying community “pockets of innovation” and the broader penetration of teamwork in Michigan

Pilot sites

MHC participated as a member of the evaluation team in the project’s second year after completing Human Research Review Committee (HRRC) Collaborative Institutional Training Initiative (CITI) requirements for the Michigan Department of Health and Human Services, Wayne State University and Grand Valley State University. All partners were involved in the monthly meetings hosted by Michigan Department of Health and Human Services to provide current updates and feedback on how each partner was meeting the study objectives.

Systematize rotations

In 2013, the Indiana Rural Health Innovation Collaborative (RHIC) contacted the Alliance for Clinical Experience (ACE), a service of the Michigan Health Council, in search of a web-based scheduling tool that would allow them to schedule and arrange interprofessional clinical rotation experiences. The RHIC is dedicated to offering educational opportunities for teams of future health care providers, particularly those in rural areas. Colleges and universities included in the collaborative offer diverse academic programs, including physician assistant, occupational therapy, recreational therapy, applied health science, behavioral health, social work, medicine (MD), and psychology.

After exhibiting the MHC’s clinical rotation tool (ACEMAPP) to the group, the RHIC agreed to engage in a formal pilot of ACEMAPP in the summer of 2013. The RHIC has a proposed start date of fall 2015 and plans to fully implement ACEMAPP to facilitate clinical rotation scheduling at a regional level. Due to the RHIC’s commitment to integrating interprofessional education and collaborative care into each program’s educational curriculum, ACE integrated a feature into ACEMAPP that allows educational coordinators to detect when the clinical rotation schedules of students from different educational programs overlap with their own students’ schedules. This feature allows two or more schools to coordinate an interprofessional clinical education experience for their students at a common clinical site. The MHC plans to connect with more universities that may be interested in utilizing ACEMAPP to train and encourage teamwork during clinical rotations.

MHC was unable to test ACEMAPP’s teamwork scheduling component at the NEPQR pilot sites. MIPERC staff assessed the costs and benefits of ACEMAPP and felt the tool was not appropriate for the project. MHC is hopeful that other partners in Michigan are interested in using ACEMAPP to schedule teamwork rotations. A recent survey of 45 ACEMAPP users finds that 54% of school users and 33% of site users are interested in using ACEMAPP to schedule interprofessional rotations.

Evaluation activities

The Project Director and MHC staff worked together to balance an inherent challenge between ensuring the validity of all data collected, while also maintaining a commitment to communicate lessons learned in a timely manner as a project financed by the federal government. MHC began participating in monthly evaluation committee calls at the beginning of the third and final year of the project (July 2014). The Project Director and her staff expressed a need for time in the first two years to collect and vet data that may be used in future journal publications. MHC believes the National Center for Interprofessional Practice and Education’s Resource Exchange at https://nexusipe.org/resource-exchange offers an expedited avenue for researchers, clinicians, students, and other stakeholders to share information about what works and why in IPE and IPCP.

Next steps

The Michigan Health Council intends to move forward with promoting team-based care as part of its mission to create a culture of health with health professionals at the heart of the delivery system. Next steps involve continued systematic site outreach, sharing customized information regarding IPCP and IPE, and building relationships with those within the healthcare community that can support practice transformation. The MHC also plans to promote its Education to Practice (E2P) initiative as a vehicle to simultaneously deliver these messages to multiple stakeholder groups. This will help to overcome the barrier of lack of accessible information for health care providers and organizations searching for ways to implement team-based care.

This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UD7HP25052, Nurse Education Practice, Quality, and Retention—Interprofessional Collaborative Practice. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

Contact Drew Murray at the Michigan Health Council at 517-347-3332 or[email protected] if you want to learn more about MHC’s NEPQR experience or next steps.

Education to Practice is a service of the Michigan Health Council

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