Sacred Heart University has forged a partnership with Western Connecticut Health Network (WCHN) who, along with other health care agencies and community service providers, is focused on using a team-based approach to partner with high risk patients and improve their health care access and outcomes.
The collaboration has resulted in an interprofessional student “health-care hotspotting” program—essentially a data-driven process to identify high needs patients who could benefit from more active outreach to engage them in their healthcare, supported by student teams.
The program began this past spring with two RN to BSN nursing students and two occupational therapy students who were imbedded in the WCHN High Risk Navigation Program at Norwalk Hospital. Together with the Norwalk team and local community agencies, they worked with identified patients to assist them with establishing more stable health care provision. The goal is more consistent medical attention through primary care providers, resulting in regular health maintenance and decreased inappropriate utilization of sites such as emergency departments to address medical crises. The students also learn about social determinants of health, such as food or housing insecurity, that often need to be addressed in order to optimize patients’ health outcomes.
Initial results from the program and feedback from patients, providers and the community have been positive. The aim is to better address patients’ needs through active engagement, improve care quality, and reduce overall healthcare costs, according to Dawn Myles, WHCN’s vice president of Performance Innovation.
“The conceptual model for the program was based on the hotspotting work of Jeffrey Brenner, M.D., in Camden, N.J. Our program is formally called ‘iCAN’ (Interprofessional Community Academic Navigation),” stated Myles. “Students engage with and follow select high-risk patients while experiencing work as part of an interprofessional team and addressing the social determinants of health that exist in our populations.”
A conversation between SHU President John Petillo, WCHN’s President and CEO John Murphy, College of Health Professions Dean Patricia Walker and College of Nursing Dean Mary Alice Donius in 2016 sparked the idea for a SHU/WCHN collaboration. Murphy had read about initiatives that could reduce emergency room patients’ tendency to relapse into a previous condition or mode of behavior. Donius thought there was an opportunity to reduce ER visits by carefully managing cases.
They decided to create a model with an educational foundation and to work with WCHN’s High Risk Navigators and the established Community Care Teams (CCTs). These teams are comprised of representatives from WCHN and community agencies, including social services, law enforcement, corrections, community housing, shelters, soup kitchens, community counseling, and others, and they meet weekly to discuss high risk patients. These patients have a range of behavioral health and medical conditions. Among the members of the CCT, there is a “coming together” via various touchpoints in the community to connect with patients and work as a team to create treatment plans for them.
To get started, Sacred Heart representatives sat in on some CCT meetings to see how patients were followed and how their needs were addressed. Donius then turned to Clinical Assistant Professor of Nursing Tammy Testut who has a strong home care and case management background, and Myles to create a pilot. “Given all the moving parts and logistics, it came to fruition fairly quickly,” said Donius.
Testut was appointed as iCAN’s academic coordinator and started working closely with Myles and Tait Michael, M.D., WCHN’s CCT medical director and a psychiatrist, on the program’s particulars. The students who were involved in the spring pilot interviewed and worked with the homeless in the local community, helping with medical concerns, housing issues, patient assessment and any other needs they could address. One result was a noticeable decrease in ER use among those patients.
The positive outcomes spurred program organizers to expand the teams—with SHU faculty and students from the Social Work Master’s Program—and create a coordinated curriculum that began this semester. Now there are a handful of students—nursing students who are already RNs but are back at school for their bachelor’s degrees, and social work students—working at Norwalk Hospital, and another team plans to start at Danbury Hospital in the spring. “These students are mature and experienced individuals who bring a wide variety of work and life skills to the student navigation team,” said Testut.
In addition, there are plans to have SHU undergraduates assist community care agencies, such as homeless shelters, to offer support and to experience those environments first-hand.
“There are great needs in the community and opportunities for further partnerships. WCHN is a true example of an effective and efficient community partnership,” Testut noted.