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Ambulatory Clinic Teaches Team Care

September-October 2017

By: Sonja Carberry


Ambulatory Clinic Teaches Team Care
Andrea Eberbach

At 9 a.m. on a Tuesday, when a patient sat down in an exam room at CHI Health Creighton University Medical Center–University Campus in Omaha, Nebraska, her care already was in motion. On the other side of the exam room door, an interprofessional team of care providers, along with students from various health professions, already had huddled to discuss the day. It's a quick and productive discussion, with input from faculty physicians, residents, nurses, physical and occupational therapists, dietitians, behavioral health specialists and learners. After talking about safety issues and recognizing individual successes, smaller teams gather to discuss the patients they will see that morning.

This smaller team — a resident, medical assistant, preceptor and learners from medicine, nursing or pharmacy — go over the patient's lab results and discuss the patient's care.

A typical scenario, according to Amy McGaha, MD, a CHI Health primary care physician and chair of the Department of Family Medicine at the Creighton University School of Medicine, might go like this:

"Before we see the patient, we might see that her diabetes is a little improved but still needs help, and also her cholesterol is elevated," said McGaha. "We know she is going to need a different glucose monitor and maybe some nutritional counseling."

A resident sees the patient for an exam and discusses the care plan and follow-up. A dietitian stops in to provide some nutritional counseling. Then a team member walks the patient to the on-site pharmacy to see about a different glucose meter. When she leaves to catch the bus home, the patient has tools and information she needs to better control her diabetes and make gains in her health.

As that patient is leaving, another arrives at the University Campus emergency department with a cough and a fever. Rather than endure a long wait, patients arriving at the emergency department are screened, and those who can be treated in the outpatient clinic are sent directly there for the appropriate and less costly level of care. The goal is to get patients screened and up to the outpatient clinic within 15 minutes.

Those with a clinic-level complaint who arrive at the emergency department after clinic hours are routed to a "vertical flow" area off the emergency department. There they are treated and released — with a prescription in hand, if needed — in 30 minutes or less. More serious emergencies — from chest pain to gunshot wounds — are triaged and moved to stabilization or resuscitation rooms, where the patients receive care from emergency department physicians, residents and students, who also do rotations at the nearby Level I trauma center.

This is what care looks like at CHI Health University Campus. The 86,000-square-foot, $36.5 million ambulatory care facility has family medicine, pediatrics, internal medicine and women's health clinics, occupational and physical therapy services, a retail pharmacy and a full-service emergency department.

This also is what learning looks like at CHI Health University Campus. As the primary clinical partner for Creighton, a Jesuit Catholic university, the facility is where more than 600 medical students, residents and fellows, and 1,000-plus nursing, occupational therapy, physical therapy, pharmacy and emergency medical services students learn how interprofessional, collaborative patient-centered care works in an ambulatory setting.

Throughout University Campus, the magic is in the interaction among patients, faculty, residents and students.

"Everybody teaches, and everybody learns," said Michael White, MD, CHI Health chief academic officer. "It's a phenomenal care environment for our patients and learning environment for our learners."

Medical student Sarah Turner Pietruska, Class of 2018, worked at a variety of clinics before her rotation at University Campus. The latter experience stood out, she said.

"There is a pretty sizeable difference just because of the access you have to all the various specialists and health care professionals," she said. "I think it helps you realize the value all these health care professionals have to offer."

What also stood out was the approach of the attending faculty member she worked with.

Mark Goodman, MD, "is a person who set an example of being a humble leader, taking input from all of the members of the health care team," she said.

When it opened in 2017, University Campus became the largest and most comprehensive CHI Health clinic in the Omaha metropolitan area that was accompanied by a fully licensed and accredited community-based emergency department.

The opportunity to design and build a forward-looking facility that maximizes teaching and care environments came out of what — on the surface — sounded like bad news for the local urban neighborhood.

In 2013, CHI Health decided to move from Creighton University Medical Center. The sprawling 334-bed hospital had a long history of serving northeast and downtown Omaha, and it was the primary clinical partner for Creighton University's 125-year-old School of Medicine and various health professions programs.

The decision was driven by the same market forces affecting major cities throughout the U.S. Too many hospital beds in metropolitan areas decrease efficiency and raise health care costs.

CHI Health — a health care system with 14 hospitals throughout Nebraska and Western Iowa — made the strategic decision, with community input, to build an ambulatory facility to best serve the local population while shifting its inpatient academic medical center to an existing hospital 6 miles away — the newly renovated and enhanced Creighton University Medical Center–Bergan Mercy.

"Looking to the future, we have to be willing to change and even anticipate where health care is going. With University Campus, we're now able to blend our innovative academic organization with ever-increasing clinical care being delivered in an ambulatory setting," said Cliff Robertson, MD, CEO of CHI Health.

As a fourth year medical student, Chris Salvatore found the layout of University Campus uniquely practical. The future pediatrician appreciated how the design provided easy access to everything a clinician needs.

"Radiology is right on site, and there's a lab facility for things like rapid strep tests," Salvatore said. "There's a surgical procedure room where you can remove stitches and perform minor procedures. It just makes it so much more convenient."

He also liked how the exam rooms surround a dedicated space for clinicians and students.

"The design of the facility is so collaborative," he said. "I've never seen a clinic where they have the patient rooms around the outside."

Inside that center area, he might be sitting next to a nurse, a radiology tech, an attending physician or an occupational therapist. 

"Every day they're talking as a team," Salvatore said. "Being able to communicate with each other made for a seamless work flow that was really beneficial for the patients and the care providers."

That enhanced communication extended to the patient experience, he added. If a patient was being referred to a psychologist, for example, "the psychologist can come into the room and introduce themselves at that time, so the patient has met the person they'll be talking to," Salvatore said. "It's really powerful, and I saw it all the time."

Creighton University's move toward the interprofessional education model brings together students from two or more health professions to learn a collaborative approach to patient-centered health care. The World Health Organization has called interprofessional education "a necessary step in preparing a 'collaborative practice-ready' health workforce that is better prepared to respond to local health needs."1

In fact, Creighton University's family medicine residency program had earned a National Committee for Quality Assurance-certified residency for a patient-centered medical home, which means it includes multidisciplinary care and an interprofessional approach.

"We started this effort even before the idea of University Campus came about," said McGaha. "But this partnership has been essential and has really ignited our transformation."

EVOLVING BUSINESS MODELS
The two institutions — CHI Health and Creighton University — are accustomed to being on parallel and often entwined paths.

Long before Creighton University Medical Center became a CHI Health facility, it was known as St. Joseph Hospital — the teaching hospital operated by Creighton University. It served as the educational stomping grounds for decades of Creighton University students and fellows in medicine, nursing, dentistry, pharmacy, occupational therapy, physical therapy and emergency medical services.

Times change and business models evolve — particularly in health care.

In 2012, Creighton University and Tenet Healthcare Corporation sold the teaching hospital to CHI Health, then called Alegent Health, and initiated a strategic affiliation to transfer Creighton University School of Medicine physician faculty to CHI Health employment and to give Creighton University students access to CHI Health clinics and hospitals as teaching sites.

The partnership relieved Creighton University of the financial burden and complexities of operating its own health system while joining the academic institution to a health care organization with mirror-image values.

"As a Catholic organization, our mission is incredibly well-aligned with Creighton's," said Robertson. "Our real purpose is to serve those who are in need and particularly those in the most need. That's a unique and distinctive position in our faith-based mission that ties back to our founders and aligns perfectly with Creighton's mission to serve. It's a marriage made in heaven."

Once the decision to close Creighton University Medical Center was made, both institutions committed to exploring how they could target needs for the community they long had served.

"There's an energy that occurs when well-aligned partners get behind an ambitious plan, and that's been the case with our academic partner Creighton University," said Robertson. "We have two stakeholders. Feedback from students and residents, and the community and patients will determine our success."

A thorough discovery process pointed the way forward.

"Long before [Creighton University Medical Center] closed, we had a two-day session with the different stakeholders," said Todd DeFreece, CHI Health vice president of operations. The meeting included representatives from the north Omaha community, clergy, employers from downtown Omaha and Creighton University administrators and faculty.

"It was a broad spectrum of stakeholders," DeFreece said. "What we found out is they wanted three things: primary care, an emergency department and specialty care access."

An ambitious plan was initiated to create a unique and comprehensive clinic and learning environment which accommodated the interprofessional education approach taking root at Creighton University.

"There's a ton of talk, but not a lot of people yet are incorporating IPE into care environments, and even less so designing and building an entire facility around interprofessional education," Robertson said.

Having interprofessional education requires space, and plans for the facility expanded by about 30 percent.

"When you have learners, you are going to need extra space," McGaha said. "When you have lots of different care providers, they have to have space to work together. The space helps us to be able to discuss patients and still protect patient confidentiality."

The resulting two-story facility features pods for each of the four separate clinics. Each pod has 17 exam rooms and one procedure room, plus diagnostic equipment such as ultrasound, X-ray and cardiology stress test. The exam and procedure rooms ring a central collaboration space for care providers, fellows, residents and students. That's where the huddle happens twice daily.

"It's the Disney onstage, offstage concept," DeFreece said. Just as Disney visitors never see Mickey Mouse out of character, patients at University Campus never see or hear a physician and a student discussing other patients or consulting about a case.

The dedicated space includes a meeting room with video conferencing, so students, residents and faculty can participate in grand rounds and conferences happening in other facilities — or even sit in on a grand rounds occurring in Phoenix, where Creighton University's School of Medicine has a long-standing affiliation with Dignity Health St. Joseph's Hospital and Medical Center to accept a group of Creighton students for their third and fourth years of medical school.

Tailoring the space for a forward-thinking approach to care also is evident in the emergency department, which contains 11 traditional rooms, four behavioral health rooms, two stabilization and resuscitation rooms, an isolation room and a room specifically designed for OB/GYN and use by a Sexual Assault Nursing Examiner. Having a SANE-dedicated space is unique for the region.

"It's a separate room away from prying eyes," DeFreece said. "It has a table for a police interview, so patients don't have to go to the police station, and it has an adjacent private bathroom and shower."

Lab and diagnostic services are located within the emergency department, rather than somewhere within a hospital.

"Patients who require overnight hospitalization or inpatient care are transferred from this facility to one of the other facilities in town at the choice of the patient," said Dr. White.

Throughout University Campus, residents and students learn how different team members work together and when it's appropriate to refer.

Take a 90-year-old patient with symptoms of dementia. The resident learns how to diagnose dementia and when it's appropriate to get an occupational therapy assessment to evaluate fall risk and ability to perform daily living activities.

Faculty have "Aha! moments" right along with students.

McGaha had one while caring for a young cerebral palsy patient who had a rash. During evaluation, the physician found that the child needed new leg braces and asked an occupational therapist to stop in.

"When discussing the patient's care, Dr. Joy Doll — an OT faculty member — recommended that OT could also assess for sensory issues that would be an underlying issue related to the rash," McGaha said. "Before our interprofessional model of care, I would not have even considered that OT might also be able to help with more than just the patient's mobility needs."

This is how the collaborative environment helps break down the silos that traditionally have separated health professionals.

"Some of the best care is done by your professional colleagues who may not be clinicians," said Robertson.

"How do we take the hierarchy out of our care teams? Physicians have traditionally been at the top of the hierarchy because that's the way it's been set up. But a physical therapist has just as much to say, or a medical assistant — they are just as responsible and insightful," DeFreece said.

That collaborative approach is at the center of a clinical research study launched at University Campus that will focus on patients deemed at highest risk of rehospitalization.

A total of 262 patients were identified as meeting three criteria: having high hemoglobin A1C; having a likelihood of being rehospitalized, according to a hospital metric; and having had three emergency room visits in the past six months. The interprofessional teams are reaching out to those patients to determine how to offer appropriate services to improve their overall health.

"We will go through those patients and make sure we are planning for their care appropriately. It's a proactive model rather than reactive disease management," said study co-investigator Thomas Guck, PhD, a health psychologist and professor in the Department of Family Medicine at Creighton University School of Medicine.

Barriers can be as simple as language — many of the patients in the family medicine program are refugees — or lack of transportation.

"Sometimes medications were not being filled," Guck said. "We've got a pharmacy right here in the building, so they can get a prescription filled before they go home."

Results of the study will guide how interprofessional education teams act on the core philosophy underlying efforts at University Campus: Care improves when patients are at the center.

"If we can teach the next generation of health care providers this care model of collaborative and collegial care, we create a better work environment and a better care environment," DeFreece said.

It's a model in motion as care and reimbursement practices evolve.

"As we're training students and residents, we tell them: You may not encounter this kind of care team wherever you land," McGaha said. "What I want is for Creighton University graduates to go out into their communities and build this, to be change agents. We're preparing them to be leaders in the health care system and to be part of transformational change."

Meanwhile, the local community is receiving care that is ahead of its time.

"We've made the investment into patient-centered care for the underserved with the same investment as clinics in other areas. We really provide the best," Robertson said.

SONJA CARBERRY is a writer in the marketing department at CHI Health in Omaha, Neb., an affiliate of Englewood, Colo.-based Catholic Health Initiatives .

NOTE

  1. John H.V. Gilbert et al., Framework for Action on Interprofessional Education and Collaborative Practice (Geneva: World Health Organization, 2010), 7. http://apps.who.int/iris/bitstream/10665/70185/1/WHO_HRH_HPN_10.3_eng.pdf.

 

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