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Enhancing Outcomes & Education Through Collaboration: The Bridging the Gaps/St. Agnes LIFE CHF Protocol. Claudia Siegel, MA, MPA Lucy Wolf Tuton, PhD Elizabeth Barthmaier, MSN, CRNP Emily Amerman, MSW. The Partnership. Bridging the Gaps.

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Enhancing Outcomes & Education Through Collaboration:

The Bridging the Gaps/St. Agnes LIFE CHF Protocol

Claudia Siegel, MA, MPA

Lucy Wolf Tuton, PhD

Elizabeth Barthmaier, MSN, CRNP

Emily Amerman, MSW

the partnership
The Partnership

Bridging the Gaps

the challenge
Can we collaborate on a project to teach students about interdisciplinary care that also will have a demonstrable benefit for the clients and the site?The Challenge
the outcomes
The Outcomes

1 Based on PA Health Care Cost Containment Council data for 2003-2005.

2 CHF group entry flexible, some variation possible

bridging the gaps program
Multi-disciplinary health professions education program in Philadelphia (also w/ UPitt, LECOM, Delaware)

Pre-clinical, interdisciplinary, health-related community service (1991), Seminar Series (1997), and Clinical Rotation (2001)

Collaboration among all Philly AHCs & other institutions

Community partners serve as host sites

Seventeen years old in 2007

Bridging the Gaps Program
btg model
BTG Model

Didactic & Skill-building components

Continuity of contact

Collaborative Service-Linked Partnerships w/ Community Orgs.

AHC – Community Supervision

Inform the community


st agnes life a pace program
PACE = Program of All-Inclusive Care for the Elderly (BBA 1997, orig. in 70s in CA)

Goal: keep elderly in community, at home

Clients: nursing home certified, typically Medicaid but others can participate

Capitated program: provides all services, basic living, preventive, primary, acute and long-term

Interdisciplinary team (physicians, RNs, NPs, SWs, OT, PT, dietitian, CNAs, etc.)


Adult day care center (3X wk), w/ on-site clinic

St. Agnes LIFE, A PACE Program
pace participants
80 years old on average

Mostly female

7.9 medical conditions, usually of chronic nature

Only 7 percent nationally are in nursing homes

PACE Participants
st agnes life
Opened 1998 under St. Agnes Medical Center (SAMC), Catholic community hospital in south Philadelphia

2001-04 served 378 people

Very frail: average death rate 14% annually

65 FTE staff, relatively low turnover

Now serves 10 zip codes in south and north Philadelphia

Two PACE centers, one co-located with housing

2004: SAMC became St. Agnes Continuing Care Center

2005: 137 participants, dual capitation

St. Agnes LIFE
btg st agnes life common interests
Vulnerable populations

Preventive health practice

Environmental factors impacting health (broad definition of health)

Interdisciplinary care and training

Collaboration focused on client population

BTG-St. Agnes LIFE Common Interests
btg st agnes life mutual benefit
St. Agnes LIFE Benefit

Special projects enrich program

BTG clin. rotation requirement

Encouragement of ID model/training

Fresh ideas & stimulation

Participant enjoyment of students

BTG Benefit

IDT Experience

Community health setting

Geriatrics/geriatric philosophy

Managed care at its best

Creative interventions

Big picture/small picture

BTG/St. Agnes LIFE Mutual Benefit
btg life clinical educational cross fertilization
Medicine, Social Work, Clinical Psychology, Creative Arts/Dance Therapy, Occupational Therapy, PharmacyBTG-LIFE Clinical& EducationalCross-Fertilization



btg st agnes life chf protocol interdisciplinary responsibilities
BTG/St. Agnes LIFE CHF ProtocolInterdisciplinary Responsibilities

Social Work

Assessment, Caregiver contact & support


Assessment, wkly eval monitoring, pharm. coord.

Creative Therapies

Increase well-being, socialization, sense of self


Monitor drug therapy, consult w/ med & nursing


Assessment, decrease anxiety, increase pain tolerance

Nursing-not in original stu IDT

Wkly evals (weights, etc.), monitor, report to CRNP/Med Dir

Occupational Therapy

Evaluate/promote home safety, personal energy conservation


CHF Protocol Generation & Implementation

BTG students intro to PACE and role of IDT

BTG students collaborate in researching CHF and designing potential CHF protocol

BTG students introduce protocol, discuss potential outcomes with LIFE IDT--“BUY IN”

Gradual IDT acceptance and implementation of protocol

Student role became ancillary

btg st agnes life successes
Prevented hospitalizations

Integration of CHF protocol into LIFE SOP

Student evaluations of experience

Improvement of client quality of life

BTG-St. Agnes LIFE Successes

BTG/St. Agnes LIFE Difficulties

• Identifying and selecting participants with CHF for the protocol—flexibility based on site needs

• Managing logistics of completing weights weekly and bi-weekly; space, time, staff changes

• Covering staffing shortages

• Data collection: tools and continuity

• Coordinating disparate student schedules

  • Measuring quality of life
the necessities
Common goals

Demonstrable mutual benefit

Commitment to collaboration, no matter what

Flexibility & patience

Willingness to admit mistakes, to discuss all details, and to problem-solve together

The Necessities
would we do it again
Would We Do It Again?
  • We would and we will:
  • New partnership with New Courtland LIFE, also a PACE program
  • Serves 12 Philly zip codes, co-located with housing
  • Electronic medical record, emphasis on staff continuing education, quality of life and outcomes improvement