Public Health Nursing and Substance Abuse Services Team

State: MI Type: Promising Practice Year: 2014

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The Health Division has identified multiple health issues among the SUD population for many years. Recognizing missed opportunities to assess and educate clients about chronic health issues, risk reduction strategies, access to health care and activities to prevent illness was the motivation to address clients’ overall health and well-being. Incorporating a Public Health Nurse (PHN) with a clinical understanding of client health related needs and a working knowledge of community resources into the SUD treatment Access Center was identified as a viable solution to improving a client’s overall health.

Goals and objectives of the proposed practice:

  • Improve the assessment and identification of client health care needs
  • Support a holistic approach to recovery by engaging clients to formulate client centered health and wellness goals •
  • Increase access to health care
  • Reduce barriers to the utilization of Health Division services
  • Increase knowledge of pregnant clients and those of childbearing age about modifiable behaviors that reduce the risk of poor pregnancy outcomes
  • Reduce Infant Mortality
  • Increase client knowledge of community resources to promote healthy behaviors in the areas of nutrition, health maintenance, coping and safety
  • Increase knowledge related to child and adult immunization recommendations.
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Oakland County Health Division
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Public Health Nursing and Substance Abuse Services Team
The Oakland County Health Division (OCHD), through the Prior Authorization and Central Evaluation (PACE) program, is the Access Center for publicly funded substance use disorder (SUD) treatment. PACE is located within OCHD at 1200 N. Telegraph Rd., Pontiac, MI 48341.OCHD serves a jurisdiction of 62 villages, townships, and cities with a total population of 1,200,000. The Health Division has identified multiple health issues among the SUD population for many years. Recognizing missed opportunities to assess and educate clients about chronic health issues, risk reduction strategies, access to health care and activities to prevent illness was the motivation to address clients’ overall health and well-being. Incorporating a Public Health Nurse (PHN) with a clinical understanding of client health related needs and a working knowledge of community resources into the SUD treatment Access Center was identified as a viable solution to improving a client’s overall health. Goals and objectives of the proposed practice: Improve the assessment and identification of client health care needs Support a holistic approach to recovery by engaging clients to formulate client centered health and wellness goals • Increase access to health care Reduce barriers to the utilization of Health Division services Increase knowledge of pregnant clients and those of childbearing age about modifiable behaviors that reduce the risk of poor pregnancy outcomes Reduce Infant Mortality Increase client knowledge of community resources to promote healthy behaviors in the areas of nutrition, health maintenance, coping and safety Increase knowledge related to child and adult immunization recommendations. The SUD population was not fully utilizing the Health Division’s 30 programs/services and plethora of available community services. In an effort to better serve PACE clients, OCHD reviewed an existing program that incorporated a PHN into the WIC clinic. It was determined that incorporating a PHN into the Access Center’s screening process could be part of the solution to address the many health issues often impacting SUD clients. Results / Outcomes In March of 2012, a PHN was incorporated into the PACE Access Center. The nurse had 614 client contacts during the first three quarters of implementation and the following occurred during the contacts: 100% of all clients seen by the PACE PHN formulated health goals 271 (44%) clients were educated and connected to federal or state funded health insurance programs 331 (54%) clients were referred to a medical or dental provider for an identified health concern 151 (25%) clients received education about available Health Division services that would meet their identified needs, such as General Clinic, immunizations, WIC and Community Nursing Services 97 (16%) clients received a referral to the Health Division Clinic resulting in almost 55% of referred clients receiving clinic services Of the 68 satisfaction surveys completed by clients between October and December 2012, 93% (63) selected a “strongly agree” response to the question, “The services of the Public Health Nurse met my needs?” Currently all objectives are being met. Based on data, this program has had a significant impact on PACE clients. Prior to implementing this program, the SUD population most often did not follow through with PACE referred services. Currently an average of thirty percent of individuals screened in PACE receive services from the PACE PHN. What specific factors have led to the success of this practice? Having the PHN located in the Access Center Incorporating PHN services into the PACE screening process Collaboration with units within OCHD and community stakeholders. Public Health Impact of Practice The PHN has made a significant impact as a result of assisting PACE clients with formulating health goals, conducting health screenings and/or linking individuals with OCHD services such as, the clinic immunization program or communicable disease testing. The public health impact that has resulted includes: 18% increase in immunizations 109% increase in scheduled WIC appointments 68% increase in Hep C testing and treatment 5% increase in assistance with receiving Medicaid 5% increase in assistance with receiving other health care resources. The PHN has also had a strong impact on the SUD pregnant population by achieving a 46% increase in pregnancy confirmation among PACE clients. Each pregnant client is provided with pregnancy testing and clinical services and is linked to resources such as: Field Nursing, Nurturing Parent Program and Nurse Family Partnership. Each of these services provides support, education, self-sufficiency and home visits. This team works in a collaborative effort to promote successful parenting.
Brief description of OCHDOakland County’s Health Division is located at 1200 N. Telegraph Rd., Pontiac, MI 48341, serving a jurisdiction of 62 villages, townships and cities with a total population of 1,200,000. OCHD’s PACE program serves the SUD population who has Medicaid, no insurance or are underinsured. Problem statement Nationwide, nearly 25 % of stays in community hospitals are related to depression, bipolar disorder, schizophrenia, or other mental or substance use disorders, and addiction accounts for 2 million emergency room visits annually. Approximately 25 % of people who are homeless have serious mental illness, many of them with not only co-occurring mental health and substance use disorders but also serious primary health care needs such as diabetes, hypertension and other preventable or manageable health conditions. Many healthcare services and resources are available to the SUD population within the Health Division or among community service providers. However, many of these services are underutilized by the SUD population. What target population is affected by the problem? Clients who present in PACE seeking substance use treatment frequently have significant health and social concerns. These concerns include cardiovascular conditions, pregnancy complications, teenage pregnancy, HIV/AIDS, Hepatitis A, B and C, sexually transmitted diseases (STDs), domestic violence, child abuse, motor vehicle crashes, homicide and suicidal ideations. During the first eight months of incorporating the PHN into the Access Center, PACE Care Managers screened 1,797 clients Out of the 1,797 clients that presented in the PACE unit for screenings, during the first eight months of incorporating the PHN, there were 546 contacts. This is a little over 30 % of the SUD population seen in PACE. The PHN met with the clients at highest risk for other health problems, including injecting drug users, pregnant women, and women of childbearing age. What was done in the past to address the problem? Prior to incorporating the Public Health Nurse into the Access Center, Care Managers in the Access Center would make referrals to Health Division programs and outside community resources as part of the screening process. It was often found that follow-up to these referrals was not happening with most clients. Treatment has evolved and better serves individuals holistically to allow for greater opportunity to achieve successful recovery. Having a PHN to meet with clients and ask them to discuss their needs; actually guide them through the process or physically walk them to resources that are available and waiting to serve them has increased client follow through referrals and services. Why is current practice better? Having the Public Health Nurse in the Access Center provides a one-stop-shop to public health services allowing for better networking, referral processes and resources to meet the complex health-related needs of the uninsured, under-insured or indigent person with a SUD. Thus far, the addition of a PHN has significantly increased linkage to WIC, immunizations, treatment of communicable disease, Nurse Family Partnership program, early detection of pregnancy, and primary health care and other external resources. Is current practice innovative? For the first time, health assessment services are provided onsite to substance abuse clients. Oakland County’s creative use of existing resources has produced the only substance abuse Access Center in Michigan to incorporate the services of a Public Health Nurse on site. This unique model allows for improved collaboration with community stakeholders and enhances the referral process by expanding the delivery of direct services to SUD client. Tools utilized in this practice include: Recovery-Oriented Systems of Care SAMHSA’s Guiding Principles March of Dimes’ prematurity prevention toolkit Motivational Interviewing Is current practice evidence based? On a national level, the Substance Abuse and Mental Health Services Administration (SAMHSA), along with other professional agencies, have recognized the importance of wraparound services for all clients seeking mental health and substance abuse treatment. They have charged stakeholders with SUD clients to create multidisciplinary approaches to community based services. This approach supports the individual with a SUD pursuing recovery to not only achieve abstinence but also improved health, wellness and quality of life. The Health Division has a history of engaging in community collaboration because of the powerful outcomes that evolve for our local community. Hence, the concept of a PHN in the Access Center was well received by OCHD Administration and fell in line with SAMHSA wraparound approach. As noted in the references cited below, addressing the holistic needs of the client with SUD is vital to the short and long term goals of recovery. The Guiding Principles and Elements of Recovery Oriented System of Care (ROSC), (HHS, 2009) provides a framework of service model that includes a continuum of services and support for the SUD client. The framework suggests the person centered approach is vital. This includes a needs assessment that results in coordinated services and support to address housing, transportation, substance use, mental health, health care, child care, legal issues, and spiritual and cultural issues. Ensuring U.S. Health Reform Includes Prevention and Treatment of Mental and Substance Use Disorders describes studies that demonstrate that when client’s needs are assessed and met substance use outcome is improved and sustained (Hutchings and King.) Recovery-Oriented Systems of Care (ROSC) is a SAMHSA Initiative and Evidence-Based Best Practice that is being implemented throughout the United States. ROSC is a person-centered and self-directed approach to treatment to help sustain personal responsibility, health, wellness and recovery from alcohol and drug problems. As a result, it has been concluded that not only is substance use disorder treatment important but the complete well-being of a person before and after the treatment process is crucial to an individual’s recovery. Taking this into consideration and using the ROSC model, the Public Health Nursing system of treatment incorporates a holistic approach. Motivational Interviewing is used as a foundation for the interaction between the PACE PHN and the SUD client. It is an evidence-based treatment approach that addresses ambivalence to change, as identified on the SAMSHA’s national Registry of Evidence-based Programs and Practices website (http://nrepp.samhsa.gov/Motivational Interviewing.aspxt). Motivational Interviewing is a conversational approach intended to help people with the following: Discover their own interest in considering and/or making a change in their life Express in their own words their desire for change Look at their ambivalence about the change Plan for and begin the process of change Make use of their own change-talk Enhance their confidence Strengthen the commitment to change. This approach has been instrumental in assisting clients in understanding the importance of taking care of their health and engaging in preventative measures such as receiving immunizations and following up with primary care. Guiding Principles and Elements of Recovery-Oriented Systems of Care (ROSC): What do we know from the research? HHS Publication No. (SMA) 09-4439 August 2009. http://partnersforrecovery.samhsa.gov/docs/Guiding_Principles Whitepaper.pdf 09/26/2013 Hutchings, Gail P., and King, Kristen, Ensuring U.S. Health Reform Includes Prevention and Treatment of Mental and Substance Use Disorders -- A Framework for Discussion: Core Consensus Principles for Reform from the Mental Health and Substance Abuse Community, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857 SMA 09-4433 2009. http://www.samhsa.gov/healthreform/docs/HealthReformCoreConsensusPrinciples.pdf 09/26/2013 March of Dimes prematurity prevention toolkit: March of Dimes Healthy Babies are Worth the Wait: Preventing Preterm Births through Community-Based Interventions: Implementation Manual, 2011. Colocation and Coordination of Services Retrieved October 21, 2013, from https://www.prematurityprevention.org/portal/server.pt/community/prematurity_prevention_resource_center/461
Global Immunization|HIV in the U.S.|Nutrition, Physical Activity, and Obesity|Mother-to-Child Transmission of HIV and Syphilis|Teen Pregnancy|Tobacco
Goals and objectives of practice Improve the assessment and identification of client health care needs Support a holistic approach to recovery by engaging clients to formulate client centered health and wellness goals Increase access to health care Reduce barriers to the utilization of Health Division services Increase the knowledge of pregnant women and those of childbearing age about modifiable behaviors that will reduce their risk of poor pregnancy outcomes Increase the knowledge of pregnant women about community resources that will support a healthy pregnancy • Reduce Infant Mortality Increase client knowledge of community resources to promote healthy behaviors in the areas of nutrition, health maintenance, coping and safety Increase knowledge related to child and adult immunization recommendations. What did you do to achieve the goals and objectives? To achieve the proposed objectives, effective team work between the PACE PHN and Care Managers was critical. Attendance at team meetings and one-on-one discussions with each Care Manager provided an opportunity to orient PACE staff to the scope and service of a Public Health Nurse. The PHN also needed to acclimate with PACE staff, clients, and flow of the process. To ensure that the PHN had a better understanding of the screening process and the day to day operations of the unit, the PHN shadowed each Care Manager (Masters prepared Access workers that coordinate care for PACE clients) to learn about what they do and their perspectives of serving the SUD population. The PHN also met with the PACE Supervisor to discuss general policies and the client data base system. There were several meetings that took place with the PHN Supervisor, the PACE Supervisor, and the PACE PHN. In addition, the PACE Care Managers and Clerks were asked to provide feedback regarding the process. During these meetings protocols were developed for incorporating the services of the PHN into the PACE client screening process. The protocols for linking the PACE client with the nurse are as follows: Upon completion of the SUD screen, all injecting drug users and pregnant women would be escorted directly to the PHN All women of child-bearing age, regardless of the substance being used, would be escorted to the PHN to determine if pregnancy testing should be conducted All clients with an identified health need during the screening process would be referred to the PHN directly after the screening All others would be asked if they would like to formulate health goals with the PHN. As the program commenced, the PACE PHN identified clients that had a limited knowledge of community resources and the additional services available to them in the Health Division building where the PACE program is located. These services included pregnancy testing, STD assessment and treatment, immunizations, HIV counseling and testing, Women, Infant and Children Nutrition Program (WIC) and Community Nursing. To improve access and utilization of these Health Division services, excellent interdepartmental collaboration was required. The PHN Supervisor met with the OCHD General Clinic and WIC Supervisors to discuss a collaborative effort to provide services to PACE clients in an expedited manner. The PHN Supervisor provided an understanding of what the PACE PHN goals and role would be in the PACE unit. There was a need to increase the number of PACE clients seen, and give them immediate access to general clinic services due to the high risk behaviors and prevalence of public health issues seen within this population. The PHN Supervisor provided education on the SUD population to the General Clinic and WIC educating the supervisors regarding the importance of these services to the client’s health outcomes as well as the community. Through education and training, the supervisors were receptive to collaboration to meet the needs of the PACE clients. This collaboration resulted in the formulation of protocols in the General Clinic and WIC for clients referred from PACE. Protocols for General Clinic Services are: To improve the PHN’s ability to educate clients about their vaccine status, a clerk in the clinic looks for each scheduled client in the Michigan Care Improvement Registry (an electronic immunization registry). The immunization records are available to the PHN at the start of each business day and are a routine part of her client assessment Clients are also assessed for their risk of sexually transmitted infections and women of childbearing age are assessed for pregnancy status When it is determined clinic services are needed, the PHN assists the client with putting information into the intake kiosk located outside of the clinic registration office The PHN escorts the client to registration. The client is registered for clinical services and their file is marked with a green sticker to indicate that it is a PACE client The PHN accompanies the client to the clinic area to prompt expedited clinic services and serve as a verification to waive all service fees as approved by the Health Division Manager/Health Officer The PHN makes contact with clerical staff at the front desk. When possible, the client is immediately taken into an exam room. When this is not possible, the client is immediately placed next in line. If the client is ambivalent about waiting, the PHN sits with the client and takes this opportunity to provide further education until they’re called for services. Protocols for linking WIC services to PACE clients are: The PHN assesses the client for eligibility for WIC services The PHN escorts the client to WIC to expedite making an appointment The WIC standard of only making appointments by phone is waived, the PHN makes contact with the WIC clerk and an appointment is scheduled. Further collaboration occurred within the PHN unit including Field Nursing Services, Nurturing Parent Program and Nursing Family Partnership. The PACE PHN and PACE Supervisor met with the OCHD nursing unit staff to provide education about the SUD population and the services that the Access Center provides. Once educated, the nursing staff were receptive to collaborating within the Health Division to improve service delivery to PACE clients. Regular referrals are made to these departments by the PACE nurse and clients are linked with services. The thorough education and training of the numerous OCHD program staff and supervisors not only resulted in increased collaboration and services to clients, but also increased referrals from OCHD staff to the PACE Unit. For example, a Field PHN was providing services to a pregnant client with a history of heroin use. The client had recently relocated to Michigan from Florida. It was determined by the Field PHN that the client needed to follow-up with SUD treatment. The field PHN contacted the PACE PHN, resulting in the client being scheduled for an appointment to link the client with specialized SUD services for pregnant women the very next day. She met with the PACE PHN as part of the screening process. After conversing with the client, it was determined that the client was ambivalent regarding follow-up with SUD treatment. Although he client did not follow up with scheduled treatment initially, the Field PHN was able to contact the client and schedule a home visit to provide support, encourage follow up with the PACE Care Manager, and provide ante-partum guidance and teaching. The client eventually agreed that SUD treatment was important and engaged in specialized SUD treatment for pregnant women. This exemplifies PACE and Field Nursing cooperation, working together as a team for the well-being of the client. In fact, with the assistance from the PACE PHN and all other OCHD units, it ensures that PACE does not experience missed opportunities to provide much needed health services to the clients. The PHN plays a critical role in assessing pregnancy status of each woman seen at PACE. The female client may not recognize or may be in denial of known signs of pregnancy. The expertise of the PACE PHN has become invaluable while assessing and supporting women and during pregnancy testing in the clinic. Prior to the addition of the PHN in PACE there was no formal feedback mechanism to connect woman to critical services. The communication between programs is important so the Care Manager can make appropriate treatment referrals to Women’s Specialty Treatment Services. Positive pregnancy results also trigger important nursing interventions by the PACE PHN to support a positive pregnancy outcome. The PACE PHN assists pregnant women with the online application for the Maternal Outpatient Medical Services (MOMS) Letter if they are uninsured. This letter is an indication that the recipient has been approved for pre-natal medical services insurance coverage through the Michigan Department of Community Health. The PHN links clients to an Obstetrics/Gynecology physician in the community or assists clients with making an appointment if they already has a doctor. The PACE PHN is able to discuss with women the steps to support a healthy pregnancy. The rapport built between the client and the PACE PHN strengthens acceptance of a Field PHN who is available for guidance and education throughout the pregnancy and into the first year of the child’s life through home visits with the client. Another intervention that required interdepartmental collaboration was access to WIC. The PACE PHN assesses all clients for WIC eligibility and worked with the WIC Program Coordinator to modify the usual telephone only scheduling for appointments. The PACE PHN is able to coordinate directly with WIC intake staff to arrange scheduling of a WIC appointment in person and educates the client about the necessary documents for their first WIC appointment. This is very significant for the client because the PHN assists the client in organizing multiple pregnancy related appointments. Steps taken to implement the program- The PACE PHN utilizes several electronic systems in this project: CareNet, the Nurse on Call directory and Michigan Care Improvement Registry (MCIR). CareNet is a HIPAA-compliant vital records software used in the PACE Unit. CareNet software facilitates communication between treatment providers regarding authorization and treatment referrals from PACE. The PACE PHN utilizes the database to document pertinent health history, nursing interventions and referrals provided to the client. The PACE PHN has access to a secure internal resource directory. This electronic resource directory was initially designed for Nurse on Call hotline and was created using the Sharepoint server environment. Resource contact information can be updated by designated staff and it is immediately available to all users. The Sharepoint list feature allows for creating multiple views from one main list of resource contacts so information can be filtered based on a specific topic/category. In addition to the Nurse on Call database, the internet and cell phone are most frequently used. Incorporating the PHN into the Access Center also included additional training. During the first week, the PHN shadowed each Care Manager to become familiar with the screening process. The PHN was also acclimated to the process of PACE in the following areas: Confidentiality Familiarity with the flow of PACE SUD population CareNet Entering notes into the system Maintaining personal detailed notes. Any criteria for who was selected to receive the practice? PACE unit administrators regularly monitor data to determine needs of the SUD population. The data indicates that individuals with SUDs have a high prevalence of public health and health related issues. Therefore, the overarching goal is for all individuals receiving services through the PACE unit to be seen by the PHN. Further data review assisted in determining the most high risk populations seen at PACE. It was found that injecting drug users and pregnant women are at greatest risk of public health issues, such as engaging in unprotected sex, utilizing “dirty” needles and using substance while pregnant. As a result, the three priority populations referred immediately to the PACE PHN were pregnant women, women of child-bearing years and injecting drug users. This allows for the PACE PHN to encourage such interventions as pregnancy testing, communicable disease testing (STD/STI, Hep A, B, C) and immunizations against Hepatitis A and B. In addition, Care Managers continue to refer PACE clients to the PACE PHN in hopes of attaining the ultimate goal of all individuals seeking SUD services being assessed by the PHN and developing health related goals. What was the timeframe for this practice? This program has been fully functioning for the past year and a half. Working with the different units of the health division created a few challenges and there were lessons to be learned. For example: Some clinic staff were having difficulty understanding our PACE goals and the role of a PACE PHN collaborating with them. The goal was to fast track our clients and increase the number of PACE clients seen and give them immediate access to general clinic services due to high risk behaviors. The PHN worked to reduce the stigma attached to the SUD population by providing education to the clinic staff regarding the importance of decreasing the barriers for help and assistance. This helped the collaboration with our partners to understand our role and the services that are provided within the PACE unit. Several clinic staff reported feeling burdened and overwhelmed with extra duties. The clinic was already very busy. They did not think this collaboration was going to work. After the first year, it was noted by a clinic staff member that collaboration between PACE and the clinic has been very effective. Many more pregnant women were being identified, clients were being tested and immunization rates were increasing. This collaboration has also helped the clinic to achieve their goals. As previously stated, the PACE clients can be difficult to locate for follow-up. Now, with the PHN identified as a person of contact, the clinic is also able to locate these hard-to-find clients for STD treatment and follow-up. In the past, the client often would not have been found, tested or treated. Were other stakeholders involved? PACE engaged in a collaborative effort with other OCHD units, such as General Clinic, WIC, Field Nursing, Nurturing Parent Program and Nurse Family Partnership, to develop the protocols for referrals provided by the PHN to the internal services offered by OCHD. In addition, as the program evolved, services of the PHN began to expand. Clients presented in PACE with considerable health-related needs that required additional services beyond those available within OCHD. The PACE PHN began to communicate with community stakeholders in order to enhance linkages to external services. OCHD educated stakeholders on the PHN role in the referral process and established contacts in order to provide easier access to services. For example, OCHD developed relationships with low cost dental clinics, the local FQHCs and FQHC look a-like clinics. In addition, the PACE PHN created a process for assisting clients with scheduling appointments if the individual already had an established Primary Care Physician. The engagement of these stakeholders has resulted in better coordination of care and increased linkage to public health/health related services. How does OCHD foster collaboration with community stakeholders? In addition to assessing client health concerns that can be addressed by the Health Division, the PACE PHN is the bridge to access low or no cost clinics, federally qualified health centers, family planning resources, benefits of the Department of Human Services, food pantries and various other community agencies. OCHD has very strong relationships with community stakeholders that expand the resources available for its clients. OCHD convenes numerous collaborations and partnerships that share resources and ideas to effectively address community issues such as the Co-occurring Steering Committee, Outcomes Improvement Committee, Best Start for Babies, Homeless Healthcare Collaboration, and the Fetal and Infant Mortality Review Committee. The economic downturn has hit Michigan and Oakland County especially hard. With significant job loss, high unemployment and an increase in foreclosed homes, stressed people look for ways to cope. Ineffective coping strategies for some include using alcohol and other substances. So, for every client seen in the PACE program, it is important to recognize that substance abuse can be the tip of the iceberg. Therefore, our goal is to address substance use but also dive deeper and provide clients with an opportunity to address determinants known to improve individual and community health and wellness. Cost of the Program The total cost of the program was $101,060. One laptop computer at $2,800 per year One cell phone at $640 per year One Public Health Nurse at a yearly cost of $97,620 (full time salary and benefits) In-kind County resources related to existing Nurse on Call database.
What was found? Were objectives met?The Public Health Nurse (PHN) is a member of a multidisciplinary team that assist clients in the recovery process through which one strives to achieve greater balance of mind, body and spirit in relation to other aspects of life, including health, family, and community. The Access Center assists the individual in a complete process of building or rebuilding what a person has lost or never had due to his or her condition and its consequences. The PHN provides public health nursing services for PACE clients that include education, referral and resources and facilitation of direct services. Listed below are the goals and objectives and the measures for each practice that is evaluated. Data is collected by the PHN and reviewed by administration for improvements and effectiveness. In addition, PACE administration tracks measures from the electronic client and billing system CareNet such as the following: • 76 pregnant clients identified at PACE during FY13, an increase of 27% compared to FY12 • In the first eight months of incorporating the PHN into the Access Center, 1797 clients were screened by PACE Care Managers. The PHN was able to see 546 clients, representing 30% of all clients screened in PACE. Listed below are goals and objectives of the practice and how they are evaluated: Improve the assessment and identification of client health care needs. • Care managers refer all clients to the PHN for assessment and identification of the client’s needs. • In the event that the PHN is not available to meet with the client, Care Managers will utilize the PACE client PHN referral form to determine needs for PHN service. If needs are identified, the PHN will be given a written referral to request follow-up. Support a holistic approach to recovery by engaging clients to formulate client centered health and wellness goals. • PHN documents client centered goals on the PACE visit note. Increase access to health care. • PHN completes the data collection tool to track: 1. Number of health services applications completed. 2. Number of referrals to medical/dental provider. Reduce barriers to the utilization of Health Division Services. • PHN implements the “Access to Clinic Services for PACE Clients” procedure. • PHN provides ongoing evaluation of the above processes to the supervisor. • PHN completes data collection tool to tabulate: 1. Number of clients referred to Clinic services. 2. Number of clients referred to WIC services. 3. Number of Field Nursing referrals generated for home visit services. • PHN is able to utilize Insight, which is an electronic client system, to identify the number of clients that follow through with the referral to clinic services. Pregnant women and those of childbearing age have increased knowledge of modifiable behaviors that reduces their risk for poor pregnancy outcomes. Pregnant women have an increased knowledge of community resources that support a healthy pregnancy. Reduce Infant Mortality. PHN assesses and documents the client’s response to interventions related to the program goals, as well as completes the data collection tool to tabulate: Number of clients that receive AP/PP/Interconception education. Number of clients provided family planning education. Number of clients counseled on nutrition and BMI status. Number of clients referred to Clinic for pregnancy testing. Number of FN referrals and Maternal Outpatient Medical Services Letter (MOMS) applications. Number of clients referred to WIC. Number of clients referred to health care providers.Clients have increased knowledge of community resources to promote healthy behaviors in the areas of nutrition, health maintenance, coping and safety. PHN assesses and documents the client’s response to interventions related to the program goals, as well as completes data collection tool to tabulate: Number of clients referred to various community resources. Number of clients requiring additional contacts with the nurse to follow through with provided resources. Number of clients requiring referrals to receive case management from a contracted SUD provider.Clients have increased knowledge related to child and adult immunization recommendations. PHN assesses and documents the client’s response to interventions related to the program goals, as well as completes the data collection tool to tabulate: Number of clients that received immunization education . Number of clients referred to the Health Division’s immunization clinic. PHN is able to utilize Insight to identify the number of clients that follow through with the referrals to clinic service. PHN services have been added to the Satisfaction Survey used in the PACE Unit to assess the client’s perspective on the following: 1. Increase in knowledge related to the health need identified during PACE visit. 2. Outcome of referral source provided by PHN i.e., client received service, did not follow through, or was not eligible for service. 3. Overall satisfaction of PHN service. Did you evaluate the practice? The primary data sources are an excel spreadsheet capturing 47 components related to the PHNs contact with clients, a satisfaction survey and Insight (an electronic client record system) Data is also retrieved from CareNet, PACE’s client database All data is collected by the PHN. Each time she sees a client thorough notes are taken and entered into the excel spreadsheet, CareNet or Insight The data is reviewed by administration and compared to previous data to determine trends, progress or needed changes. Modifications were made based on the data; specific tracking of pregnant women and pregnancy testing was added to the data collected The process of recruiting clients was made more proactive resulting in the PACE PHN going to the PACE waiting area to offer services to friends and family members that accompany clients to the screening. When conducting follow-up services, through phone calls to clients and consultations with OCHD Field Nursing, the PACE PHN identified that clients were not following through with WIC and clinic referrals. This resulted in evaluating the WIC and clinic processes to identify opportunities to improve client follow through with referrals. For example, the improved process to link clients to WIC involved the PHN walking with them to the WIC clinic and connecting them to a WIC staff to schedule their appointment. The data showed that this simple change resulted in 110% increase in WIC appointments for PACE clients working with the PACE PHN. Data evaluation Review of the first eight months of data since incorporating the PHN into the Access Center from March to November of 2012 reveals the following: Client contacts 546 • Assisted with Immunizations 293 Linked to WIC 21 Assisted with Medicaid application 241 Linked to Healthcare Services 361 Referral for Hepatitis C Testing 142 The PHN has had contact with 30% of all of PACE’s clients in 2012 for these eight months. The first eight months of data from March to November of 2012 were compared to the first eight months of data from January to August of 2013. The sample of data collected concludes the following: Client contacts - 554- 1.5% increase from 2012 Assisted with Immunizations - 346 - 18% increase from 2012 Linked to WIC - 44 - 110% increase from 2012 Assisted with Medicaid application - 254 - 5% increase from 2012 Linked to Healthcare Services - 379 - 5% increase from 2012 Referral for Hepatitis C Testing - 238 - 68% increase from 2012 The PHN has had contact with 30% of all of PACE’s clients in 2013 for these eight months. The service of the PHN was added to the Access Center’s Customer Satisfaction Survey. There were 123 surveys completed in a three month time frame. The survey asks “Did the services of the Public Health Nurse meet my needs?” The clients reported the following responses: Strongly agreed 88 Agreed 11 Somewhat agreed 2 Disagreed 0 Strongly disagreed 1 N/A 21 Based on the data received, this program has been highly successful. Prior to implementing this program there was very little follow through of the SUD population with the referred services. Now an average of thirty percent of individuals seen in PACE are also assessed by the PACE PHN with referrals to public health and medical related services. The follow-up conducted by the PHN indicates that clients have increased following through with referrals provided. Examples of specific results from PACE PHN services include: Client #1 - Pregnancy Assessment Female client screened in the PACE Unit complained of weight gain due to beer consumption. As a consequence of the PACE PHN interventions, the client left aware of her pregnancy, enrolled in Medicaid, scheduled with OB/GYN and WIC. Although the client delivered a premature baby, the baby did not require medical follow-up beyond the usual post-delivery time and was discharged with mother free of Fetal Alcohol Syndrome. Client #2 – Dental Resources The client reported that he had received advice to remove all of his teeth and replace them with dentures. The PACE PHN is aware of community resources including a local church health fair that occurred the following weekend where the client received dental care. The client agreed to obtain a second opinion from a local dentist and reported that he only needed a partial denture. Client #3 – Immunization education extends to the entire family The mother of two pre-school age children was referred to PACE by Child Protective Services (CPS). The PACE PHN provided education regarding the importance of immunizations and the availability of the OCHD Immunization Clinic to provide the vaccines to the entire family. The mother returned with her two children prior to entering substance treatment to ensure that the entire family was up to date with all recommended vaccines. The CPS worker was delighted that the PACE program was able to provide services beyond facilitating substance abuse treatment for the client. OSAS has been able to determine that client engagement in health related services has increased by incorporating a PHN into the Access Center. Since the addition of a nurse in the resource center from March through December of 2012, the PHN saw 614 clients. From January 2013 to through August 2013 the PHN has seen 554 clients and is on track to seeing approximately 864 clients through December.
Lessons LearnedIn the Access Center the PHN is required to be flexible, assertive, creative, and take leadership to initiate or devise a variety of techniques to engage the PACE client to follow-up with the plan created to support their road to recovery. Many of our clients live in the moment; their lives are chaotic and disorganized. There is no accountability and lack of follow-through. Each person is unique. The PHN must engage in motivational interviewing to encourage the client to formulate health and wellness goals. The PHN interventions are customized and tailored based on the client’s needs at the time of the visit. The hope is that a seed was planted and clients remember that there are professionals that care about them and that they continue to explore the path to recovery. This collaboration has increased access and follow-up for SUD clients to OCHD services. Collaboration/integration is the way to success; breaking barriers within individual OCHD programs and communities can only be of benefit to clients who have a SUD. By providing a holistic approach, OCHD can effectively assist clients on the road to recovery and path of wellness. Is this practice better than what was done before? Having the PHN in the Access Center provides a one-stop-shop to public health services, allowing for better networking, referral processes and resources to meet the complex health-related needs of the uninsured, under-insured or indigent person with a SUD. Thus far, the addition of a PHN has significantly increased linkage to WIC, immunizations, primary health care, community resources, and treatment of communicable disease, Nurse Family Partnership programs, Nurturing Parent Program and early detection of pregnancy. OSAS has been able to determine that client engagement in health related services has increased by incorporating a PHN into the Access Center. Is there sufficient stakeholder commitment to sustain the practice? OCHD continues to have a strong commitment to its mission: To protect the community through health promotion, disease prevention and protection of the environment. OCHD fully supports providing a PHN to the Access Center and intends to continue that commitment. The Access Center is currently going through a transition which includes the plan to co-locate with the Community Mental Health Access Center in a building adjacent to the Health Division building beginning in 2014. This move will also include the PHN and related services. Continued data collection will be essential to monitoring and modifying the PHN program in PACE to ensure effective delivery of an enhanced holistic approach to recovery. In summary, the Access Center will continue to work with OCHD units and community partners to coordinate and improve a seamless process that includes the provision of health assessments, referrals and coordination of services. OCHD remains committed to improving the health of the SUD population and supporting expansion of the Recovery Oriented System of Care in Oakland County.
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