WELCOME TO THE CLINICAL CENTER GRAND ROUNDS,
A WEEKLY SERIES OF EDUCATIONAL LECTURES FOR PHYSICIANS AND
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CENTER AT THE NATIONAL INSTITUTES OF HEALTH IN
BETHESDA, MD.
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TOMORROW'S CURES.
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GOOD AFTERNOON AND WELCOME TO
TODAY'S CLINICAL CENTER NURSING
GRAND ROUNDS.
I'M DR. COURTNEY ACTING DIRECTOR
OF THE NURSING INSTITUTE OF
RESEARCH.
BEFORE WE BEGENERATED I HAVE A
FEW HOUSEKEEPING ITEMS TO
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AND ALLOWS TO YOU MAKE ANY
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ROUNDS TOPICS.
YOU CAN SUBMIT YOUR COMMENTS
TODAY BY CONTROLLING DOWN AND
CLICKING ON THE SEND LIVE
FEEDBACK BUTTON ON THE WEBSITE.
TIME WILL BE ANSWERED AS TIME
PERMITS AND AT THE CONCLUSION OF
THIS PRESENTATION EMPLOY NOW
SWITCHING OVER TO THE REASON
WE'RE ALL TUNE NOTHING TODAY.
I AM DEEPLY HONORED TO INTRODUCE
DR. ANDRIEA WALLACE, A TRUE
VISIONARY IN THE LEADER AND
INTEGRATING THE CONDITIONS OF
WHERE WE WORK, PLAY AND LIVE
WITH CLINICAL CARE.
DR. WALLACE IS A ASSOCIATE DEAN
OF PROFESSOR AND WERE AT THE
UTAH COLLEGE -- RESEARCH AT THE
UTAH COLLEGE OF NURSING.
DR. WALLACE IS ALLY RESPECTED
RESEARCHER WHOSE CAREER FOCUSED
ON DESIGNING AND IMPLEMENTING
HIGH QUALITY INTERVENTIONS TO
IMPROVE OUTCOMES FOR PATIENT
POPULATIONS ISSUES SHE'S NOT
JUST OBSERVING THE GAPS AND
CARE, BUT SHE'S ALSO ACTIVELY
CREATING TESTING AND SOLUTIONS
THAT CAN BE FEASIBLY INTEGRATED
INTO ROUTINE PRACTICE.
ALL MINDFUL OF THE RESOURCE
CONSTRAINTS.
HER EARLY WORK ON HEALTH ACCESS
AND CHILDREN LAID THE FOUNDATION
FOR A CAREER DEDICATED TO
INNOVATIVE SYSTEM LEVEL CHANGE.
DR. WALLACE'S RESEARCH HAS BEEN
CONTINUE LOWSLY SUPPORTED BY NIH
AND HRQ UNDERSCORING THE
RIGOROUS IMPACT OF HER WORK.
MOST RECENTLY SHE'S FOCUSED ON
IMPROVEMENT OF PATIENT CARE IN
ED SETTINGS BY SCREENING SOCIAL
DETERMINANTS OF HEALTH AND
APPLYING RISK MODELING
TECHNIQUES.
THIS WORK IS INCREDIBLY
IMPORTANT AS NURSING SCIENCE
PLAYS A VITAL ROLE IN BRIDGING
THE GAP BETWEEN RESEARCH AND
PRACTICE, DEVELOPING SOLUTIONS
THAT ARE BOTH EVIDENCE BASED AND
PATIENT-CENTERED.
NURSING SCIENCE IS UNIQUELY
POSITIONED TO IMPROVE PATIENT
OUTCOMES IN A WHOLISTIC PATIENT
SYSTEMS BASED WAY.
THE NATIONAL INTUITY OF NURSING
RESEARCH IS AT THE FOREFRONT OF
SUPPORTING THIS ESSENTIAL WORK,
NINR'S COMMITMENT TO FUNDING
NURSE LAB RESEARCH LIKE
DR. WALLACE'S IS A HEALTHIER
INVESTMENT TO THE FUTURE FOR
ALL.
WE BELIEVE IN THE SYSTEMS AND
MODELS ARE CARE AND DISCOVERIES
AND BREAKTHROUGHS IN DISEASE AND
EMPOWERS PEOPLE AND COMMUNITIES
TO OPTIMIZE THEIR OWN HEALTH.
TODAY DR. WALLACE WILL SHARE HER
EXPERTISE ON INTEGRATING SOCIAL
AND CLINICAL CARE, BUILDING BEST
PRACTICES FOR ADDRESSING HEALTH
RELATED SOCIAL NEEDS AND I KNOW
WE ARE ALL VERY EAGER TO HEAR
HER PERSPECTIVES ON THIS TIMELY
AND CRITICAL TOPIC.
SO PLEASE I DIDN'T EVEN ME IN
EXTENDING A WARM WELCOME TO
DR. ANDREA WALLACE.
>> THANK YOU SO MUCH FOR THE
OPPORTUNITY TO BE HERE.
LET'S GET STARTED.
I TRUST THAT EVERYONE CAN HEAR
THIS OKAY?
>> YES.
>> OKAY.
GREAT.
SO I HAVE NO FINANCIAL OR
RECOLLECT CONFLICTS OF INTEREST
RELATED TO THE CONTENT OF THIS
PRESENTATION TODAY.
SO, YOU KNOW I KNOW YOU ALL AT
THE CLINICAL CENTER AND I WANTED
TO SAY WE'RE PRACTICE DISCIPLINE
IN NURSING AND YOU KNOW YOU
UNDERSTAND THAT EACH OF US HAS A
WHY BEHIND THE RESEARCH WE
PURSUE, AS THE DOCTOR MENTIONED
MY OWN WHY BEGAN EARLY IN MY
NURSING CAREER WORKING WITH
CHILDREN WITH ASTHMA IN DENVER.
I SAW THAT MEDICATIONS AND
APPOINTMENTS WERE NOT ENOUGH,
WHAT REALLY SHAPED OUTCOMES WERE
THE SOCIAL REALITIES FAMILY
FACED WHILE COPING WITH A CHILD
A ASTHMA, SUCH AS SUPPORTING,
SCHOOL, AND OTHERS.
THAT LED ME TO DO A STUDY ON HOW
SOCIAL INFLUENCES SOCIAL
ACSETION TO PATTERNS THROUGH
ILLNESS.
LATER THROUGH AN T32, WE FOCUSED
ON FINDING PATIENTS WHERE ARE
THAT I, ACCOUNTING FOR LITERACY,
SUPPORT SYSTEMS, LONG DISTANCE
PS TO CARE.
AS A SHIFT TO ADULT WITH
CONDITIONS, LIKE DIABETES, PAIN
AND COAGULATION DISORDERS ISSUES
THE PATTERN HELPED, WHAT
MATTERED IS WHAT EXISTED OUTSIDE
OF THE CLINIC AND YET WHAT WE
MOST OFTEN RELY ON IN IS THIS,
WHEN PATIENTS STEP INTO OUR
CLINICAL SETTINGS, A DEMOGRAPHIC
SNAPSHOT IN THE EHR THAT TELLS
US VERY LITTLE ABOUT THE
PATIENT'S LIFE AND WHAT'S KEY TO
MANAGING THEIR CONDITION, SO MY
WHY WHICH HAS EVOLVED INTO A
CORE QUESTION: HOW CAN WE ALIGN
MODELS THAT WORK WITH THEIR
LIVES WHERE THEY LIVE, WORK AND
CARE FOR OTHERS THAT, WOS IN
FAST PACED CLINICAL SETTINGS,
THAT'S BEEN MY PURPOSE AND
PASSION FOR NEARLY 2 DECADES
NOW.
SO WITH THAT, TODAY, WE WILL
EXPLORE OW SOCIAL CARE
INTEGRATION CAN HAPPEN ACROSS
SETTINGS, HOW CLINICIANS AND
PATIENTS ENGAGE WITH IT, HOW WE
APPLY IMPLEMENTATION FRAMEWORKS
AND WHAT KINDS OF DIGITAL AND
TEAM BASED INTERVENTIONS MAKE
THIS ALL POSSIBLE.
SO LET'S FIRST START BY DEFINING
THE LANDSCAPE TO EXPLORE WHY
THESE NEEDS MATTER AND WHAT
MAKES SOCIAL CARE DISTINCT FROM
BROADER PUBLIC HEALTH EFFORTS
AND THROUGHOUT THIS TALK TODAY,
YOU WILL SEE WHAT WE SEE IN OUR
SOCIAL LAND SCAPE HERE AT THE
UNIVERSITY OF UTAH.
NOW THIS SLIDE IS KEY, IT
DISTINGUISHES BETWEEN FACTORS OF
THE POPULATION LEVEL AND MORE
ACTIONABLE INDIVIDUAL LEVEL
NEEDS.
WHAT WE CAN IDENTIFY AND
INTERVENE ON IN HEALTHCARE
SETTINGS.
ONE THING TO RECOGNIZE IS THAT
EVERYONE LISTENING TODAY IS
SUBJECT TO SOCIAL DETERMINANTS
OR DRIVERS OF HEALTH.
THESE ARE SIMPLY SOCIAL FACTORS
ASSOCIATED POSITIVELY OR
NEGATIVELY WITH HEALTH OUTCOMES.
AS WE MOVE TO SHOACIAL RISK,
THESE NEGATIVELY AFFECT HEALTH
BUT AT THIS LEVEL IT'S NOT
NECESSARILY YET ACTIONABLE.
WHEN WE MOVE TO SOCIAL NEEDS WE
BECOME MORE ACTIONABLE,
ASSESSING FOR THE CONCRETE
TANGIBLE MORE AND IMMEDIATE
NEEDS THAT ARE CRITICAL FOR WELL
BEING SUCH AS HOUSING AND FOOD
AND RELATED FACTOR AND 1 THEY
WILL DISCUSS AS PART OF
INPATIENT CARE IS SOCIAL SUPPORT
THAT IS INSTRUMENTAL.
HAVING HELP WITH HEALTH RELATED
TASKS SUCH AS WOUND CARE,
COOKING AND ERRANDS DURING
HOSPITALIZATION ARE PART OF THE
ONGOING MANAGEMENT OF A CHRONIC
DISEASE.
AND I JUST LOST MY SLIDES.
SO I APOLOGIZE FOR THAT.
IRB APOLOGIZE, I WILL HAVE TO
SHARE AGAIN.
IT WAS EVERYONE SEE THIS.
>> NOT YET.
>> THE BEST LAID PLANS, YOU ALL.
I HAVE TO DO THIS FAST.
ALL RIGHT, DO YOU SEE MY SLIDES
NOW?
>> WE DO.
>> SO NOW OF COURSE THESE
PERCENTAGES CHANGE DEPENDING ON
HOW AND WHERE THEY'RE EXAMINED
AND YOU DO A WEB SEARCH, I'M
SORRY, YOU WILL FIND MANY
COLORFUL SECOND QUARTERLES THAT
LOOK LIKE THIS BUT WITH
DIFFERENT PERCENTAGES, BUT THIS
IS TO ILLUSTRATE THAT, JUST AS I
EXPERIENCED AS A CLINICAL NURSE,
RECENT EVIDENCE SHOWS THAT MOST
OF OUR HEALTH AT THE POPULATION
LEVEL IS DETERMINED BY SOCIAL
VERSUS BIOLOGICAL REALITIES AND
THE CRUX OF WHY THIS MATTER
SYSTEM THAT PEOPLE DON'T LIVE IN
CLINICAL SETTINGS, YET MUCH OF
OUR CARE STILL OPERATES AS IF
THEY DO.
AND 1 OF OUR TEAMS CHALLENGES
HAS BEEN TO COMMUNICATE THE
EFFECTS OF THE SOCIAL FACTORS AT
POPULATION LEVEL TO SYSTEMS
FOCUSED ON INDIVIDUAL OUTCOMES,
LOCAL DATA HELPS ILLUSTRATE
THIS, HERE'S A VISUAL OF WHY WE
CARE ABOUT SOCIAL CONTEXT, THIS
IS URBAN SALT LAKE CITY, WHERE I
LIVE AND WHERE THE UNIVERSITY OF
UTAH HEALTH AND MAIN CAMPUS ARE
LOCATED, THERE ARE MANY MAPS
LIKE THIS DEMON TRAITING HEALTH
OUTCOMES
OUTCOME.
BUT THIS IS PERSONAL FOR ME,
THESE ARE NUMBERS FROM THE AREA
WHERE I BUY MY COFFEE IN DOWN
DOWN SALT LAKE.
BUT SCRINNING FOR NEEDS IS
NASCENT.
IN THIS 2022 REPORT COLLEAGUES
AT UCSF REPORT THAD WHILE
PATIENTS ARE GENERAL LYE OPEN TO
HAVING QUESTIONS ASKED OF THEM,
PROVIDERS ARE RESTRAINED IN HOW
THEY ARE ASKED, COLLECTED ARE,
SHARED AND USE THE.
BUT SINCE THE 2022 REPORT WE ARE
SEEING RAPID TOP DOWN MOVEMENT
AS SYSTEMS WIDELY RECOGNIZE THE
SOCIAL FACTORS IN HEALTH.
CMS IS 1 MAJOR DRIVE WHERE WE
HAD REGULATIONS IN PLACE SCREEN
AS PART OF PATIENT ADMISSIONS
BUT WITH THAT COMES COMPLEX
GORCHANCE, INTERROPERABILITY AND
CONSENT, AND UNCOVERED HERE IN
ACADEMIC HEALTH SYSTEMS. THIS
IS BECAUSE WE'RE NOT ONLY
SCREENING FOR NEEDS BUT WE'RE
ALSO TRYING TO CONNECT PATIENTS
TO SERVICES BEYOND THOSE CLINIC
WALLS, OUT IN OUR COMMUNITY
SETTINGS.
SO WHEN WE EMBARKED ON THIS
WORK, WE DECIDED TO BREAK THIS
ISSUE IN 3ICISMEM PIECES
CRITICAL TO DRIVING CRITICAL
INTEGRATION OF SOCIAL
INFORMATION BY CLINICIANS AND
HEALTH SYSTEMS.
WHAT WE SHOW HERE IS THAT FOR
SOCIAL INFORMATION TO ACTUALLY
IMPROVE CLINICAL CARE AND HEALTH
OUTCOMES, WE NEED METHODS FOR
UNDERSTANDING PATIENTS SOCIAL
CONTEXT THAT ARE CONSISTENT AND
EFFECTIVE.
WE NEED THE INFORMATION TO BE
COMMUNICATED TO CLINICAL TEAMS
AND USED TO GUIDE CLINICAL
DECISION MAKING AND IT HAS TO DO
SOMETHING AND NOT BE INFORMATION
FOR INFORMATION'S SAKE.
AND WITH THE UNDERSTANDING THAT
THIS IS ABOUT PATIENT'S SOCIAL
CONTEXT, WE NEED TO INVOLVE
PATIENT'S PERSONAL RESOURCES AND
WHEN APPROPRIATE COMMUNITY BASED
SERVICES TO WHICH THEY HAVE
ACCESS.
SO NOW I WILL SHARE FINDINGS
FROM STUDIES WE'VE LED ACROSS
OUTPATIENT AND IN PATIENT
SETTING STARTING FIRST WITH
OUTPATIENT.
OUR PURPOSE WAS START INDEED
2017 HAS BEEN DEVELOPING A MEANS
OF ETHICALLY AND EFFECTIVELY
IDENTIFYING SHOACIAL NEEDS THAT
CAN BE USE INDEED RETEEN CARE
WHEN THE WORK ISN'T NECESSARILY
SUPPORTED BY RESEARCH STAFF TO
FACILITATE ACCESS TO COMMUNITY
BASED RESOURCES AND THEN TO
INTEGRATE COMMUNITY BASED DATA.
TO DATE WE COMPLETED OVER 70,000
SCREENINGS FUNDED BY HRQQ AND
NINR, AND OUR WORK IS GRANTED IN
A PARTNERSHIP WITH UTAH 2 AND 1,
WHICH IS PART OF A REFERRAL
CENTER OFFERING CONNECTIONS TO
FREE AND LOW COST COMMUNITY
BASED PROGRAMS LIKE FOOD AND
HOUSING TO ALL THOSE WHO DIAL
2-1-1.
AND THROUGH THE YEARS THIS HAS
TAKEN A LOT OF WORK BUT THE
OVERVIEW OF HOW THIS IS DONE IS
QUITE SIMPLE.
PATIENTS EITHER SELF-COMPLETE OR
ADMINISTER THE NOW VALIDATED 10
ITEMS SINCERE SCREENER, IT'S
ADAPTABLE WHICH IS KEY IN
CLINICAL SETTINGS, WE'VE
SCREENED IN PERSON WITH VARIOUS
LEVELS OF STAFF OR PATIENTS CAN
SELF-COMPLETE DURING OR BEFORE A
VISIT USING A PORTAL SUCH AS
ETHICS OR MY CHART, USING A
HIPAA LINK TO THE 211 DATA
SYSTEM, WE REFER THEM TO A
COMMUNITY SERVICE NAVIGATOR WHO
AIMS PARENTS TO TEXT, OR E-MAIL
WITHIN 48 HOURS OF SCREENING AND
WE COMPILE DATA FROM INSIDE AND
OUTSIDE THE HELT NEEDS AND THE
COMMUNITY OUTREACH PROCESS, OUR
PARTNERSHIP WITH THE 211 HAS A
ROBUST ENCOUNTER AND RESOURCE
DATABASE HAS ALLOWED US TO DO
THIS.
AND OF COURSE, THIS IS DISPLAYED
DIFFERENTLY AND TOUCH PADS ON
THE EHR BUT THIS IS A CLEAR
VISUAL OF WHAT IS ADMINISTERED
ON THE LEFT ARE QUESTIONS FROM
THE 10 ITEMS SINCERE SCREENER
WHICH TAKE A MINUTE TO COMPLETE
AND ON THE RIGHT IS INFORMATION
GATHER FRIDAY THOSE WHO WOULD
LIKE TO BE CONTACTED BY 211 FOR
SERVICE CONNECTIONS.
AND THIS SNAPSHOT COMES FROM
WHEN WE FIRST IMPLEMENTED THE
SOCIAL NEED SCREENER AS PART OF
ROUTINE EMERGENCY DEPARTMENT
CARE, WHILE THESE ARE FROM 8000
PATIENTS AND AGAIN NOW WE
CONNECTED KREENINGS OF OVER
70,000 PATIENTS ACROSS SITES,
WHAT IS REMARKABLE ABOUT IT IS
THIS, IS HOW CONSISTENT THESE
HAVE REMAINED OVER TIME, NEARLY
HALF OF THOSE WHO COMPLETE
SCREENING REPORT AT LEAST 1
UNMET NEED IN ED, THE MOST
REPORTEDNY NEEDS ARE FOR
UTILITIES RENT OR MORTGAGE, AND
COLLECT EVALUATION PROCESS LIE
ARE ALMOST PREDICTIVE OF WANTING
OUTREACH.
BUT EITHER WHEN THESE ARE
IDENTIFIED ONLY 44% MADE CONTACT
WITH THE RESOURCE NAVIGATOR AND
FEWER THAN ONE-THIRD ULTIMATELY
CONNECKED WITH THE COMMUNITY
SERVICE SHOWING JUST HOW MUCH
CAN BE LOST BETWEEN SCREENING
AND SUPPORT.
THE RIGHT SIDE OF THE SLIDE MAY
ALSO SHOWS WHY SOME MAY COMPLETE
THE SCREENER.
THIS IS MOSTLY FOR REFUSALS OR
CLINICAL REASONS LIKE TRAUMA OR
COGNITIVE IMPAIRMENT, BUT ON THE
OTHER SIDE ARE STAFF AND WORK
FLOW RELATED BARRIERS AND
IMPORTANTLY WE FOUND PATIENTS
WITH MULTIPLE LEADS WERE FAR
MORE LIKELY TO ACCEPT HEALTH AND
A KREENING TOOL AND BOTH VALID
AND RERIEBL. RE-- RELIABLE.
APPROXIMATE AND BEYOND THE
SCREENING AND CONNECTION RESULTS
WE'VE BEEN ABLE TO BEGIN INSIGHT
INTO THE MULTILEVEL NATURE OF
THESE NEEDS AND THESE LIKE FOOD
AND SECURITY CORRELATE WITH
COMMUNITY RESOURCE AVAILABILITY,
A LACK OF DIGITAL ACCESS IS A
KEY BARRIER IN DELIVERING FOLLOW
UP SUPPORT AND THESE NEEDS ALL
LAYER UPON 1 ANOTHER ESPECIALLY
WITH THE NEED FOR HOUSING, RENT,
MORTGAGE AND ACROSS URBAN AND
FRONTIER GEOGRAPHY.
BUT THIS IS WHY COMMUNITY
SERVICE NAVIGATION LOOKS LIKE,
IN HER INITIAL CALL, A 211
NAVIGATOR SPOKE WITH THE
PATIENT'S DAUGHTER WHO SHARED
THAT SHE NEEDED HELP WITH MEALS
AND TRANSPORTATION TO MEDICAL
APPOINTMENTS ISSUES THE
NAVIGATOR GAVE THE DAUGHTER A
LIST OF RESOURCES AND SCHEDULED
A CALL, AND AT 2 WEEKS, SHE
FOUND OUT THE PATIENT HAD O WAS
83, HAD MS AND HEART CONDITIONS
AND THEIR HUSES IS ON OXYGEN,
THEIR DAUGHTER IS OVERWHELMED
WITH WORK AND SCHOOL AND UNABLE
TO CONNECT WITH RESOURCES, THE
NAVIGATOR CONNECTED THE PATIENT
TO AGING AND ADULT SERVICES AND
HELPED COMPLETE APPLICATIONS FOR
MEALS ON WHEELS AND RISE FOR
WELLNESS, AS A RESULT THE
PATIENT AND HER HUSBAND BEGAN
RECEIVING MUCH NEEDED MEAL
DELIVERIES AND TRANSPORTATION TO
FUTURE MEDICAL APPOINTMENTS THE
FOLLOWING WEEK AND THIS IS
REALLY THESE STORIES ARE WHAT
KEEP US GOING IN THIS WORK.
AND THIS SLIDE SUMMARIZES
COMBINED FINDINGS OF OVER 65 IN
DEPTH PATIENT INTERVIEWS
ADDITIONAL FOCUS GROUPS WITH
FRONT LINE STAFF.
THIS WAS A SUBSTANTIAL QUAL
FIGHTIVE EFFORT CONDUCTED AS
PART OF OUR NINR STAFF.
WE HEAR FROM STAFF, THEY ARE
STRONG TO SUPPORT WITH RESOURCES
ARE AVAILABLE BUT THEY ALSO
DISCOVERED ASKING SENSITIVE
QUESTIONS ESPECIALLY WHEN
ANSWERS ARE UNCOMFORTABLE.
PATIENTS ON THE OTHER HAND
LARGELY VALUED UNIVERSAL AND
SINCERE SCREENING, BUT THEY FACE
SIGNIFICANT BARRIERS IN THIS, A
LACK OF AWARENESS ABOUT WHAT
RESOURCES EXIST, STIGMA BELIEFS
ABOUT WHO REALLY DESERVES HELP
HELP SEEKING AND NAVIGATING
SYSTEMS FOR ELIGIBILITY
REQUIREMENTS.
ONE THEME WAS THE DIGIT DIVIDE.
PATIENTS FREQUENTLY LACKED
INTERNET ACCESS OR STRUGGLED
WITH DIGITAL LITERACY, MANY
STRUGGLES REMAIN AND PATIENTS
STILL NEED SUPPORT.
SO THIS WORK HIGHLIGHTS WHERE
SYSTEMS FALL SHORT AND WHERE WE
NEED TO FOCUS TO TRULY ENABLE
CONNECTION AND FALTHROUGH.
THIS IS PART OF THE REASON WHY
WITH STRONG CROSS SECTOR
PARTNERSHIPS, DIGITAL ACCESS
BARRIERS TO HEALTH AND SOCIAL
CARE IS A FOCUS OF OUR MOST
RECENTLY FUNDED NINR STUDY.
SO TECHNICALLY SPEAKING, THIS
APPROACH OF SCREENING AND
REFERRAL WORKS.
INCLUDED HERE ARE 2 OF OUR
MARXAISEING 211 NAVIGATORS LEX
AND PATTY WHO WORKED WITH US
OVER THE YEARS BUT THE REAL
CHALLENGE IS ENGAGEMENT, MAKING
PEOPLE FEEL SAFE SHARING
INFORMATION AND TRUSTING PEOPLE
LIKE LEX AND PATTY WHEN THEY
REACH OUT TO OFFER HELP.
SO NOW LET'S CHECK OUT THIS.
USING THE SUMMARY, DEVELOPING
SOCIAL SUPPORT QUESTIONS DEVELOP
INDEED OUR PRIOR WORK,
SUGGESTING ERRANDOMIZED TRIALS
MEDICATION AND BILLING, OUR ARK
STUDY AIMED TO SYSTEMATICALLY
AND UNIVERSALLY OOH DENTIFY
SOCIAL NEEDS AND SUPPORT DURING
HOSPITALIZATION, THE GOAL WAS TO
UNDERSTAND WHETHER AND HOW THIS
INFORMATION CAN INFORM AND
IMPROVE HOSPITAL DISCHARGE
PLANNING, WE CONDUCTED A
PRAGMATIC TRIAL INVOLVING OVER
4000 DISCHARGES EXAMINING OW
SCREENING INFLUENCED BOTH
DISCHARGE PLANNING PROCESSES AND
OUTCOMES.
WE USED AN INTENT TO TREAT
APPROACH AND SEGMENT ANALYSIS TO
AFFECT LOOK AT CHANGES IN
PRACTICE OVER TIME.
THIS WAS CONDUCTED IN THE
CONTEXT OF REAL WORLD CLINICAL
CARE, SO RANDOMIZATION AT THE
UNIT LEVEL WASN'T FEASIBLE WE
USE A PRE-AND POST DESIGN WITH
THE WASH OUT PERIOD BETWEEN
PHASES.
OUR HYPOTHESIS WAS THAT
IDENTIFYING AND COMMUNICATING
PATIENT NEEDS AND AVAILABLE
SUPPORT DURING HOSPITALIZATION
WOULD LEAD TO BETTER OUTCOMES BY
STRENGTHENING INFORMATION
BETWEEN CARE TEAMS AND IMPROVING
QUALITY OF DISCHARGE PLANNING.
AND THIS GRAPHIC ILLUSTRATES THE
COMPONENTS OF THE INTERVENTION
ITSELF, AT ADMISSION, UNIT BASE
CASED MANAGERS COMPLETED SOCIAL
NEEDS AND SOCIAL SUPPORT
QUESTIONS AS PART OF THEIR
INITIAL ASSESS AM, THE STUDY
TEAM TRACKED PATIENTS WITH
RESPONSES NOTED IN THE
IDENTIFIED NEEDS AND THE IF,A
CYSTANCE WAS REQUESTED.
FOR PATIENT WITH IDENTIFIED
NEEDS WE SENT ALERTS TO
TEAPPEDDING PHYSICIANS FLAGGING
THE RELEVANT INFORMATION, AND
THEN OTHER TEAM MEMBERS COULD
REVIEW THIS IN A DEDICATED
SUMMARY DISCHARGE TAB, USE THE
SUMMARY TO ADJUST PLANS AND
ASHES JUST AS NEEDED.
WE ALSO GATHERED ADDITIONAL
OUTCOME DATA INCLUDING CAREGIVER
AND NURSE REPORTED READINESS
BOTH OF WHICH ALONG WITH PATIENT
READINESS FOR ASSOCIATE WIDE
READMISSION RISK AND OF COURSE
WE FOLLOWED UP ON HEALTH SERVICE
USE, MOST NOTABLY, 30 DAY
ADMISSION TO THE HOSPITAL, AS
WELL AS E. D.
AND THESE TABLES HAVE HIGHLIGHTS
DISCHARGE PROCESSES WITH A FOCUS
ON OUTCOMES, FIRST WHETHER
FAMILY INTERACTION WAS
DOCUMENTED IN THE DISCHARGE PLAN
AND SECOND, WHETHER THE
DISCHARGE OCCURRED AFTER
2:00 P.M., WHICH CAN DELAY CARE
COORDINATION FOLLOW UP, FOR
DOCUMENTED FAMILY INTERACTION,
AND WE SAW MODEST BUT
SIGNIFICANT EFFECT OVER TIME,
SPECIFICALLY THE TIME AND TIME
AFTER VARIABLE SHOWING OVERALL
INCREASE IN DOCUMENTATION,
INDEPENDENT OF THE
INTERVENTIONAL TIME, BUT IN
CONTRAST, THOSE OCCURS AFTER
2:00 P.M. WERE MORE DIRECTLY
ASSOCIATED WITH THE
INTERVENTION.
AFTER IMPLEMENTATION, PATIENTS
IN THE INTERVENTION GROUP WERE
SIGNIFICANTLY LESS LIKELY TO BE
CHARGED AFTER 2 P.M. THIS WAS
NOT SUSTAINED BY OVER TIME, IT'S
SHOWN BY TIME AFTER RESULT, SO
TO SUM UP, WE SAW DISCHARGE
TIMING AND COMMUNICATION
PROCESSES, ESPECIALLY
IMMEDIATELY FOLLOWING
IMPLEMENTATION, BUT SUSTAINING
THAT CHANGE WILL LIKELY REQUIRE
ONGOING REINFORCEMENT.
THIS IS TOLD TO ASSESS THE
QUALITY OF DISCHARGE SUPPORT PER
PATIENTS AND ASSOCIATED WITH THE
READMISSIONS.
AND UNFORTUNATELY THERE WAS NO
NOTABLE CHANGE IN THE OPERATIONS
AND EMERGENCY DEPARTMENT VISITS.
BUT ARE THOSE THE ONLY QUESTIONS
AND OUTCOMES?
THANKFULLY BECAUSE WE CONDUCTED
A MIXED METHOD STUDY THAT ALSO
TRACKED IMPLEMENTATION OUTCOMES
WE ARE ABLE TO SEE THERE WAS
MUCH MORE TO THE STORY.
IN THIS STUDY, 29% OF PATIENTS,
ALMOST ONE-THIRD OF THOSE
ASSESSED BY CASE MANAGERS WERE
IDENTIFIED AS HAVING LESS THAN
ADEQUATE HOME RESOURCES, WHAT'S
IMPORTANT IS THAT RN ASSESSMENTS
ALIGN WITH READINESS DISCHARGE
REINFORCING THE VALUE OF NURSING
INPUT IN SAFE DISCHARGE
PLANNING, AND THIS HIGHLIGHTS
HOW THE RNs USE THE UNIQUE
SOCIAL INFORMATION WE COLLECTED
AS PART OF THE STUDY, NOT JUST
CLINICAL DADA TO MAKE THESE
DETERMINATIONS AND TOP
PREDICTERS OF INADEQUATE
SUPPORT, IS HIGH CLINICAL RISK
BUT ISN'T THAT SURPRISING, BUT
LIMITED FAMILY OR SOCIAL SUPPORT
AND FINANCIAL AND INSURANCE
BARRIERS.
A SOCIAL SUPPORT STANCE STOOD
OUT AS A KEY FACTOR INFLUENCING
RN JUDGMENT.
AND THIS SLIDE SHOWS WHY RN
SOCIAL ASSESSMENT MATTERED TO
OUTCOMES.
WE FOUND THAT PATIENTS WITHOUT
SOCIAL SUPPORT HAD A GREATER
LIKELIHOOD OF RETURNING TO E. D.
WITHIN 30 DAYS AND IMPORTANTLY
WHEN SOCIAL RISK INFORMATION WAS
AVAILABLE IT DIRECTLY INFLUENCED
DISCHARGE PLANNING.
PATIENTS IDENTIFIED AS HAVING
FEWER RESOURCES OR MORE LIKELY
TO BE DISCHARGED TO HOME HEALTH
OR SKILLED NURSING FACILITIES TO
INSURE THEY ARE LINKED TO
IMPORTANT SERVICES AND IT'S
IMPORTANT TO NOTE THAT THESE
CAME IN FROM FACILITYS, THEY
CAME FROM HOME.
SO THIS IS CLEAR, INDGREATING IN
SOCIAL SCREENING CAN HELP PLAY
AN IMPORTANT ROLE IN PREDICTING
PATIENT DISCHARGE OUTCOMES.
SO NOW LET'S FRAME THE
IMPLEMENTATION DATA TO SEE WHERE
THAT LEADS US NEXT.
FROM THE DATA DISCHARGE THAT I
JUST GAVE, WE HAVE A GOOD DEAL
OF EVIDENCE OF HOW SOCIAL
INFORMATION IS KEY TO THE
CLINICAL DECISION MAKING BUT,
DESPITE THAT, ONLY HALF OF
PATIENTS ACTUALLY RECEIVE
SCREENING AFTER IT WAS
IMPLEMENTED IN THE UNIT AND
ENGAGEMENT DROPPED OVER TIME,
WHY IS THIS?
THE CASE MANAGERS TOLD US THIS,
THEY SEE SOCIAL SCREENING AS
REDUNDANT WITH CURRENT
ASSESSMENTS COMPLETED BY
THEMSELVES AND OTHERS ON THE
TEAM.
THEY SEE IT AS OUTSIDE THEIR
SCOPE OF PRACTICE AND THEY DON'T
THINK SCREEN SUGGEST NECESSARY
FOR EVERY PATIENT.
THEY ARE SIMPLY OVERWHELMED BY
THE IDEA OF KNOWING EVERY
PATIENT IN THIS LEVEL OF DETAIL,
THEY BELIEVE THEY COULD TELL WHO
SHOULD BE ASKED THE QUESTIONS.
THEY WERE ALSO HEAVILY
INFLUENCED BY THE IDEA THAT THE
INFORMATION WOULD GO UNUSED BY
THE TEAM AND THAT THEY DIDN'T
THINK THEY COULD OFFER SOLUTIONS
FOR THE PATIENTS WITH NEEDS,
THEY FELT THEY AND OTHERS
COULDN'T DO ANYTHING WITH THE
INFORMATION AND I WANT TO POINT
OUT THAT THESE CONCERNS ARE NOT
UNIQUE TO THESE NURSE CASE
MANAGERS, THESE ARE VERY SIMILAR
CONCERNED AS THOSE RAISED BY
STAFF IN THE EARLY DAYS OF OUR
SOCIAL NEEDS SCREENING IN THE E.
D.
WHEN ATTENDING PHYSICIANS WERE
ASKED TO REFLECT ON INTEGRATING
SOCIAL SCREENING AND DISCHARGE
PLANNING, THERE WAS A STRONG
SENSE OF SHARED RESPONSIBILITY
AS 1 SURGEON PUT IT, I NEED TO
MAKE SURE THAT THE CARE
CONTINUES AFTER THE HOSPITAL.
THIS SUGGESTS PHYSICIANS SEE
CONTINUITY OF CARE AS PART OF
THEIR ROLE EVEN WHEN IT EXTENDS
BEYOND CLINICAL BOUNDARIES.
PHYSICIANS RELIED ON INFORMAL
COMMUNICATION NORMS TO ADDRESS
SOCIAL NEEDS INITIATING
CONVERSATIONS DIRECTLY WITH
PATIENTS AND CASE MANAGERS
WITHOUT A FORMAL PROCESS, FOR
EXAMPLE, IF I SENSE A PATIENT
HAS A MAJOR POST DISCHARGE NEED,
I CAN THEM DIRECTLY AND LOOP IN
CASE MANAGEMENT INFORMALLY.
THIS KIND OF DISCRETIONARY ON
THE FLY COORDINATION THOUGH,
SHOWS INITIATIVE BUT IT ALSO
POINTS TO VARIABILITY IN HOW
NEEDS ARE ACTUALLY ADDRESSED.
AND FINALLY, THERE'S TENSION
BETWEEN LIMITED CONTROL AND HIGH
ACCOUNTABILITY, 1 PHYSICIAN
SHARED, I COORDINATED WITH
SOCIAL WORKERS AND FAMILIES BUT
I FEEL VASTLY LIMITED IN WHAT I
CAN DO TO SUPPORT FAMILIES
WITHOUT HOUSING OR INSURANCE,
THE CAPTURES FRUSTRATION MANY
CLINICIANS FEEL WHEN STRUCTURAL
OR SYSTEMIC BARRIERS LIMIT THEIR
ABILITY TO ACT EVEN WHEN THE
NEED IS CLEAR.
THESE INSIDES POINT TO
OPPORTUNITIES FROM TEAM PATHWAY
BASED SUPPORT AND POLICY LEVEL
SOLUTIONS THAT,A LIEN
RESPONSIBILITY WITH ACTUAL
CAPACITY.
SO THIS SLIDE TURNS US TO THE
IMPLEMENTATION RESEARCH LODGEEC
BE, TO MAP OUT OUR STUDY DESIGN
AND LEARNING PROCESS, WE BEGAN
BY IDENTIFYING THE DETERMINANTS,
THE CONDITIONS WE KNOW COULD
INFLUENCE IMPLEMENTATION.
THESE INCLUDED STRONG EVIDENT
QUALITY WITH PRIOR TRIALS AND
EHR INTEGRATION ALREADY IN
PLACE.
CHALLENGES IN THE INTERSETTING
LIKE BURN OUT, LOW PERCEIVED
PRIORITY AND EXTERNAL
LEADERSHIP, EXTERNAL DRIVES SUCH
AS POLICIES AND REGULATIONS,
INDIVIDUAL LEVELS LIKE STAFF,
PATIENT ROLES, STIGMA AND MORAL
DISTRESS, BASED ON THOSE WE LAID
OUT OUR IMPLEMENTATION STRATEGIC
PLAN EDGE IS, ADAPTING THE
ORIGINAL PROTOCOL TO ENGAGE WORK
FLOWS, ENGAGING STAFF EARLY AND
BUILDING VISUAL INTEGRATION INTO
THE EHR, HIRING STAFF
SPECIFICALLY TO,A CYST WITH
SCREENING AND EMBEDDING
STRUCTURED FEEDBACK LOOPS.
THESE STRATEGIES WERE MEANT TO
ADDRESS REAL BARRIER BUT HERE'S
THE KEY POINT, WE WEREN'T
ENTIRELY SURE WHICH MECHANISMS
WE WERE ACTIVATING, WOULD
CONFIDENCE IMPROVE, WOULD
COMMUNICATION GET BETTER, WOULD
TEAM TRUST SHIFT, THAT'S WHAT WE
NEED TO OTHER THAN, NOT JUST HOW
THEY IMPROVED BUT WHAT HAPPENED.
AND ON THE OUTCOME SLIDE, WE
TRACKED STANDARD IMPLEMENTATION
MEASURES LIKE MAINTENANCE AND
ALSO PROCESSED COMMUNICATION AND
DISCHARGE QUALITY AND 30 DAY
RETURN VISITS.
SO THIS MODEL GUIDED OUR
APPROACH BUT IT SHOWED US WHERE
MORE APPROACH WAS NEEDED
ESPECIALLY IN CONNECTING
STRATEGY TO IMPACT.
SO WE DUG INTO THIS MORE
RECENTLY TO SEE WHAT WE CAN
REALLY IDENTIFY AS REASON STAFF
ADOPTED THIS AS A PRACTICE.
DESPITE STRONG MOTIVATION AND
BELIEF IN THE VALUE OF
SCREENING, FRONT LINE STAFF FACE
TENSIONS THAT ARE HARD TO
NEFFIGATE ALONE AND THAT LEEDS
US TO A DEEPER TRUTH, INDIVIDUAL
COMMITMENT IS NOT ENOUGH IF THE
SYSTEM AROUND THEM ISN'T SAFE
AND SUPPORTIVE.
THIS FRAMEWORK HIGHLIGHTS
LAYERED EXPERIENCE OF CLINICAL
STAFF ON 1 HAND THEY FEEL A DEEP
MORAL DRIVE TO RESPOND TO
PATIENTS SOCIAL NEEDS, THEY
RECOGNIZE THE CONNECTION BETWEEN
THOSE NEEDS AND HELT OUTCOMES,
BUT THEY ALSO EXPERIENCE
UNCERTAINTY AROUND RURAL
BOUNDARIES, DISCOMFORT
NAVIGATING EMOTIONALLY COMPLEX
CONVERSATIONS AND FRUSTRATION
WHEN THERE'S NOWHERE TO REFER
PATIENTS.
SO ADOPTION DOESN'T DEPEND ON
TRAINING AND KNOWLEDGE, IT
CLARIFIES EXPECTATIONS, PROTECTS
EMOTIONAL LABOR AND INSURES THAT
WORK FLOWS AND TOOLS ALIGN WITH
REALITIES.
WHAT WE'RE SEEING HERE IS THAT
THE DECISION TO SCREEN IS NOT
JUST CAN I DO THIS, BUT ALSO
LIKE WILL THIS BE SUPPORTED WHEN
I DO?
THAT DISTINCTION IS CRITICAL FOR
IMPLEMENTATION SUCCESS.
AND OUR DATA SUGGESTS THAT 1 OF
THE MOST IMPORTANT AND OFFENSE
OVERLOOKED FACTORS IN SUCCESSFUL
SOCIAL NEEDS SCREENING AND
PSYCHOLOGICAL SAFETY, NOT JUST
FOR PATIENTS BUT ALSO FOR STAFF.
SCREENING FOR SOCIAL NEED SYSTEM
A RELATIONAL TASK, IT'S NOT JUST
CHECKING BOXES, THESE QUESTIONS
CAN SERVE AS HARD SHIFT, TRAUMA
AND FEAR OF THE JUDGMENT, FOR
PATIENTS IT MAY FEEL RISK TOW
DISCLOSE BUT FOR STAFF IT CAN
FEEL JUST AS VULNERABLE TO ASK
ESPECIALLY WHEN THEY INSURE HOW
THE INFORMATION WILL BE USED AND
WHETHER THEY CAN TRULY HELP.
FROM SYSTEM SCIENCE, WE KNOW
THAT FAILURES ARE OFTEN SYSTEMIC
AND NOT INDIVIDUAL AND THAT
WORKPLACE CULTURE CAN SUPPRESS
FEEDBACK AND REINFORCE SILENCE.
IF STAFF DON'T FEEL SAFE RAISING
CONCERNS OR DEVIATE FREE
RADICALS GENERATED TASKS LISTS
THESE MOMENTS OFTEN GET SKIPPED.
BUT WHEN PSYCHOLOGICAL SAFETY IS
PRESENT WE SEE DIFFERENT
BEHAVIORS.
IN OUR STUDY, A NURSE DOING
DISCHARGE TO CLARIFY SOCIAL
NEED.
A CASE MANAGER SUGGESTING
IMPROVEMENT AMS TO THE SCREENER
ITSELF TEAMS INCLUDING ROUND
DEBRIEFS NOT JUST IN CLINICAL
METRICS AND WHAT THIS TELLS US
IS THIS, IF WE WANT SOCIAL NEEDS
SCREENING TO WORK AND NOT JUST
BE A CHECK BOX, WE MEDE TO
DESIGN SYSTEMS THAT FOSTER
RELATIONAL TRUST AND
PSYCHOLOGICAL SAFETY, BECAUSE
ULTIMATELY THIS WORK ASKS
EVERYONE, PATIENTS AND STAFF, TO
BE JUST A LITTLE VULNERABLE, AND
THAT ONLY WORKS AT THE
ENVIRONMENT ITSELF IS SAFE.
SO NOW LET'S TURN TO THIS
VERSION THAT BUILDS ON AN
EARLIER MODEL BY SOMETHING WE
HADN'T ACTUALLY ARTICULATED.
THE MECHANISMS WE BELIEVE ARE
PLAGUED AND WHERE WE MIGHT GO
NEXT.
HERE ARE QUALITATIVE AND
IMPLEMENTATION WORK, WE SAW
SUCCESS WASN'T JUST ABOUT THE
SCREENER IS BUILT INTO THE WORK
FLOW OR INTEGRATED INTO THE EHR,
IT CAME DOWN TO HOW HOW CLINICS
SUPPORTED THE TASK AND CARRIED
IT OUT CLEARLY.
THAT'S WHERE WE NEED A POWERFUL
LENS, IT SUGJEFULTS PEOPLE ARE
ABLE TO ENGAGE IN AND SUSTAIN
MEANINGFUL ACTIONS WHEN 3 CORE
NEEDS ARE MET, COMPETENCE, CAN I
DO THIS WELL?
RELATEDNESS DOES THIS MATTER TO
THE PEOPLE I SERVE OR WORK WITH?
AUTONOMY, DO I HAVE CONTROL HOW
THIS FITS IN MY ROLE?
WE SEE THESE REFLECTED IN THE
DATA.
CLINICIANS WERE ASKING, CAN I
RESPOND IF A PATIENT SHARING
SOMETHING SERIOUS?
DOES IT REALLY HELP THE PATIENT
OR IS IT JUST ANOTHER CHECK BOX
IN DO I HAVE A SAY IN HOW THIS
IS IMPLEMENTED?
THESE ARE THE MECHANISMS WE
BELIEVE SHAPE SUCCESS, AND BY
IDENTIFYING THEM, WE NOW HAVE A
PATH FORWARD, WE START DESIGNING
IMPLEMENTATION STRATEGIES THAT
SUPPORT CONFIDENCE, A SENSE OF
RELATIONAL MEETING AND
PROFESSIONAL AUTONOMY, INSTEAD
OF ASSUMING THE WORK FLOW ALONE
ISN'T ENOUGH.
IN OTHER WORDS THIS THEORY SEES
THAT SOCIAL NEEDS SCREENING IS
AS MUCH ABOUT MOTIVATION AND
MEANING AS IT IS ABOUT TOOLS AND
TRAINING.
AND THAT'S THE SHIFT
IMPLEMENTATION SCIENCE HAS
HELPED US MAKE.
FRONT LINE INSIGHTS AREN'T GOING
TO BE ENOUGH, WE NEED STRUCTURED
WAYS TO UNDERSTAND WHAT WORKS,
WHERE IT FAILS AND HOW TO ADAPT
IT TO CONTINUE MOVING US
FORWARD.
THIS BRINGS US TO WHY HYBRID
DESIGNS ARE SO, ESSENTIAL TO
THIS WORK.
AS WE JUST SAW ON THE ILM,
UNDERSTANDING SOMETHING WORKS
ISN'T ENOUGH, WE NEED TO
UNDERSTAND HOW, WHY AND UNDER
WHAT CONDITIONS IT CAN BE
IMPLEMENTED SUSTAINABLY AND
EQUITABLY.
THIS IS WHERE HIGH SCALING
SOLUTIONS MY A HIGH CLINICAL
ROLE.
THEY ALLOW US TO LOOK AT PROESES
ISS SIMULTANEOUSLY WHICH IS
ESSENTIAL WHEN YOU ARE TRYING TO
RELATE TO SOMETHING ESSENTIAL
AND COMPLEX AS SOCIAL SCREENING.
EQUALLY IMPORTANT WASSURE MIXED
USE METHODS, QUANTITATIVE DATA
TOLD US WHAT WAS HAPPENING BUT
QUALITATIVE INSIGHTS TOLD US
WHY, THAT'S HOW WE WERE ABLE TO
UNCOVER COMECHANISMS LIKE
PSYCHOLOGICAL SAFETY AND TEAM
CLARITY.
AND AS WE THINK ABOUT MOVING
THIS FORWARD TOWARDS WIDE SPREAD
ADOPTION IMPACT, IT'S HYBRID
MIXED METHOD SCIENCE THAT GIVES
US THE CLEAREST PATH NOT JUST TO
BUILD EVERYDAYS BUT DESIGN
SYSTEMS WHERE THE EVIDENCE COMES
TO LIFE.
AND THIS SLIDE HELPS ILLUSTRATE
WHERE WE CAN'T AFFORD TO STAY
LOCKED IN THE TRADITIONAL
RESEARCH PIPELINE, WHEN WE
SEPARATE EFFICACY, EFFECTIVENESS
AND IN A RIGID SEQUENTIAL FACES
WHAT HAPPEN SYSTEM WE GENERATE
PROMISING INTERVENTIONS BUT THEY
REMAIN STUCK INITEOLATED PILOTS,
THEY DON'T SCALE AND THEY DON'T
SUSTAIN AND THEY RARELY MAKE IT
TO THE ROUTINE CARE IN A
MEANINGFUL WAY.
YOU CAN SEE HERE ALL PIPELINES
STOPPING SHORT OF REAL WORLD
IMPACT, THIS FRAGMENTATION MEANS
EACH TEAM REINVEBTS THE WHEEL
AND STRONG EVIDENCE MAY NOT
TRANSLATE INTO PRACTICE.
THIS IS ESPECIALLY PROBLEMATIC
FOR SOCIAL NEEDS SCREENING WHERE
CONTEXT SEEMS TO MATTER SO MUCH.
SCREENING IN THE E. D. ISN'T THE
SAME AS SCREENING IN OB OR
PRIMARY CARE OR OVERALL HEALTH
SYSTEM, TO AVOID THESE
DISCONNECTIVE PILOTS WE NEED TO
DESIGN FOR SPREAD AND
SUSTAINABILITY FROM THE START
AND THAT'S WHAT HYBRID SCIENCE
AND IMPLEMENTATION SCIENCE ALLOW
US TO DO.
THEY HELP US ASK NOT JUST WHAT
WORKS BUT WHAT WORKS WHERE, FOR
WHOM AND UNDER WHAT CONDITIONS
AND THAT'S WHAT MOVES US FROM
INNOVATION TO REAL HEALTH SYSTEM
TRANSFORMATION.
TO AVOID THE FRAGMENTATION WE
JUST SAW AND MOVE TOWARDS
SCALABLE SUSTAINABLE SYSTEM
CHANGE REALLY TO UNDERSTANDING
AND ACTING UPON SOCIAL NEEDS, WE
NEED MORE THAN JUST GOOD
EVIDENCE, WE NEED
INFRASTRUCTURE, HERE WE HAVE 5
ESSENTIAL BUILDING BLOCKS THAT
SUPPORT THE TRANSITION FROM
PROMISING SOCIAL NEEDS PILOT TO
REAL WORLD PRACTICE ACROSS
SYSTEMS, BUT FIRST WE NEED TO
ALIEVEN FUNDING, SHARED
INVESTMENTS AND LONG-TERM
INFRANCIS COLLINS STRNTHURE LIKE
DID SHE BOARDS OR WORKFORCE ONLY
HAPPENS WHEN FUNDERS AND
IMPLEMENTERS ARE WORKING FROM
THE SAME BLUEPRINT.
WE ALSO NEED TO STRENGTHEN
LEADERSHIP COMMITMENT.
WITHOUT IT, METRICS AND
PRIORITIES DRIFT AND WITH IT WE
GET CONSISTENT APPLICATION OF
METRICS AND PRIORITIES ACROSS
SITES, WE NEED TO MIC SURE IT
ENSURES METRICS, AND SUPPORTS
INTEROPERABILITY ASK CONSIST EPT
MEASURE: WE NEED SYSTEMS THAT
SUPPORT INTEROPERABILITY AND
MAKE IT EASY TO MEASURE WHAT
MATTERS IN CONSISTENT WAYS AND
FINALLY, STANDARDIZED METRICS,
SO THAT THE DATA FROM 1 SITE
MEANS SOMETHING TO ANOTHER,
WITHOUT THIS WE CAN'T SCALE OR
COMPARE AND THIS IS A GROWING
PRIORITY THAT'S HIGHLIGHTED IN
RECENT WORK.
AND TOGETHER THESE BUILDING
BLOCKS HELP US SHAPE ISOLATED
INNOVATION TO COORDINATED SYSTEM
LEVEL IMPACT.
AND TO TRULY SUPPORT SYSTEM
CHANGE WE NEED TO BUILD EVIDENCE
BASED AROUND WHAT IT TAKES TO
INTEGRATE SOCIAL AND HEGHT CARE.
THIS SLIDE SHOWS KEY FOCUS AREAS
WE'RE STUDYING IN OUR CURRENT
PROGECS EACH OF WHICH CONNECTS
DIRECTLY TO THE CHALLENGES I
DISCUSSED TODAY.
SCREENING AND REFERRAL WE'RE
COMPARING APPROACHES ACROSS
POPULATIONS AND PLATFORMS,
WHETHER THE EHR OR USING
EXTERNAL SYSTEMS LIKE SALES
FORCE TO UNDERSTAND WHAT WORKS
BEST AND WHERE, WE ARE ALSO
INVESTING IN PATIENT ENGAGEMENT,
TESTING STRATEGIES LIKE LAB
COLLABORATIVE GOAL SETTING, SO
PATIENTS AREN'T JUST SCREENED,
THEY'RE SUPPORTED.
AND WE'RE LOOKING BEYOND METRICS
TO PATIENT REPORTED OUTCOMES AND
REAL WORLD SERVICE
CONNECTIONINGS OUT IN THE
COMMUNITY.
WE'RE STUDYING STAFF ENGAGEMENT.
HOW CONFIDENCE AND ROLE
INFLUENCES SUCCESS AND THIS IS
CRITICAL FOR SUSTAINABILITY AND
SCALING.
AND SPREEKING OF SUSTAINABILITY,
WE'RE EXAMINING THESE TESTING
DIGITAL TOOLS THAT CAN EXTEND
NAVIGATION SUPPORT WITHOUT
OVERBURDENING CLINICAL TEAMS
WITH THE MOST RECENT NINR FUNDED
STUDY AND EACH OF THESE REFLECTS
A PART OF THE SYSTEM THAT MUST
BE ONLINE AND WE'RE LEARNING IN
REALTIME THROUGH ONGOING STUDIES
WHAT IT MAKES TO MAKE THE
INTEGRATION EFFECTIVE AND
SUSTAINABLE.
LET'S EPPED BY ZOOMING OUT FROM
WHERE WE BEGAN BY WHAT WE SEE IN
THE EHR.
A TYPICAL SCREENING RESULT MIGHT
LOOK LIKE AICISMEM CHECK BOX OR
FLAGGED RISK, A HOUSING
INSECURITY, AND FOOD, AND WHAT
WE SEE FROM THIS SHEET IS A
SNAPSHOT CAPTURE INDEED DATA AND
TIME.
BEHIND IT IS A REAL PERSON, WITH
A FAMILY, STORY, HOME, LIFE AND
STRUGGLING WITH A CHRONIC
CONDITION.
THESE PHOTOS REMIND US AGAIN,
THIS WORK MATTERS FOR EVERY
PATIENT, WHETHER IT'S THE PARENT
CHOOSING BETWEEN MEDICATION, THE
OLDER ADULT NAVIGATING MOBILITY
ANDITEOLATION OR THE COUPLE
TRYING TO SIMPLY LIVE WELL AND
LIVE WITH DIGNITY, THIS IS WHO
WE DESIGN THANKSGIVING FOR.
WHEN WE TALK ABOUT SOCIAL NEEDS
AND CARE, IT'S NOT JUST ABOUT
BUILDING A BETTER WORK FLOW,
IT'S ABOUT MAKING SURE
HEALTHCARE MEETS PEOPLE WHERE
THEY ARE AND REFLECTS WHAT THEY
ACTUALLY NEED TO LIVE WELL.
SO AS WE BUILD THESE SYSTEMS,
LET'S REMEMBER FROM THE
INDIVIDUAL TO THE SYSTEM, THIS
SCIENCE, THIS NEARING SCIENCE
AND ABOUT EVERY PATIENT WE
SERVE.
AND WHAT WE'VE DONE IN THE PAST
AND WHAT WE'RE DOING NOW IS
GREAT, BUT NOW LET'S TALK ABOUT
YOU HOY WOO WILL CHARGE FORWARD.
OUR TEAM IS CURRENTLY WORKING ON
AN RCT OF AN EHR INTEGRATED
KREENING AND REFERRAL SYSTEM FOR
COMMUNITY BASED ORGANIZATIONS,
SOME OF WHICH I TALK ABOUT
TODAY, BUT WE HAVE SO MUCH MORE
ON THE HORIZON BUT THE REALITY
IS THAT A LOT OF WHAT IS
IMPLEMENTED IN OUR CARE SYSTEMS
IS WITHOUT RIGOROUS STUDY, MANY
SUCH AS THOSE LISTED HERE ARE
EXCITING INNOVATIONS BUT REAL
WORLD EVALUATIONS OF
EFFECTIVENESS, SUSTAINABILITY OR
SCALABILITY, IMPLEMENTATION
OUTPACES OUR UNDERSTANDING OF
WHAT WORKING FOR WHOM AND IN
WHAT CONTEXT AND OFTEN PATIENT'S
VOICE IS ABSENT IN PROWR
OUTCOMES EVALUATION AND MUST BE
INCLUDED.
SO AS WE THINK ABOUT SOCIAL
INTERVENTIONS, WE NEED TO BE
CLEAR, THIS MUST INVOLVE NURSING
SCIENCE.
NURSES ARE UNIQUELY POSITIONS TO
BRIDGE EVERY LAYER OF CARE FROM
THE PATIENT AND FAMILY AT THE
CENTER TO THE BROADER NETWORK OF
COMMUNITY PARTNERS.
WE'RE PART OF THE DIRECT CARE
TEAM.
WE LEAD CARE COORDINATION.
AND WE SERVE AS THE CONNECTATIVE
TISSUE ACROSS DISCIPLINES AND
SETTINGS.
THIS BIG RED ARROW REPRESENTS
THE VERTICAL REACH OF NURSES,
THEY OPERATE ACROSS ALL LEVELS
OFTEN SIMULTANEOUSLY, THAT GIVES
THEM CRITICAL INSIGHT INTO
WHAT'S WORKING AND WHERE SYSTEMS
ARE BREAKING DOWN.
BUT IT ALSO MEANS THAT NURSING
SCIENCE BRINGS THE LENS WE NEED
TO MOVE BEYOND PILOTS AND INTO
SUSTAINABLE SYSTEMS THAT IMPROVE
HEALTHCARE.
WHETHER IT'S UNDERSTANDING
PATIENT CONTEXT, DESIGNING WORK
FLOWS THAT WORK IN REAL WORLD
CARE ENVIRONMENTS OR BUILDING
TRUST WITHIN TEAMSES ARE NURSING
SCIENCE ISN'T JUST HELPFUL HERE,
IT'S ESSENTIAL.
AND THIS IS WHERE NURSE
SCIENTISTS BRING ENORMOUS VALUE,
AND WHERE WE MUST CONTINUE
INVESTING.
WE NEED TO PLACE GREATER
EMPHASIS AND TRAINING ON SKILLS
THAT ARE ALREADY PROVING
ESSENTIAL FOR IMPACT, COMMUNITY
ENGAGEMENT WHICH BUILDS TRUST
AND INSURING INTERVENTIONS ARE
RELEVANT, DEVELOPING FLU
ENSELLING IN MULTILEVEL CROSS
SECTOR DATA ASK ANALYTICS, A
MUST FOR EVALUATING COMPLEX
INTERVENTIONS ACROSS HEALTH AND
SOCIAL SYSTEMS.
STRENGTH EVENING THESE
CAPABILITIES HELPS NURSES TO
EVALUATION REAL WORLD ACCESS AND
SUSTAINABILITY OF COMMUNITY
BASED ORGANIZATIONS.
THIS KIND OF WORK GENERATES
EVIDENCE THAT DRIVES SYSTEM
LEVEL CHANGE IMPROVING OUTCOMES,
REDUCING AVOIDABLE UTILIZATION,
ADDRESSING DISPARITIES AND
BUILDING MODELS THAT ARE
SCALABLE AND SUSTAINABLE.
SO AS WE LOOK AHEAD TRAINING THE
NEXT GENERATION OF NURSE
SCIENTISTS AND CORE AREAS WILL
BE KEY TO ADVANCING HEALTH AND
HEALTHCARE.
SO AS WE CLOSE, I WANT TO
REFLECT ON WHERE WE ARE IN THIS
MOMENT AND WHY THIS WORK MATTERS
MORE THAN EVER.
THIS YEAR MARKS THE 40 RGT
ANNIVERSARY OF THE NATIONAL
INSTITUTE OF NURSING RESEARCH, 4
DECADES OF ADVANCING SCIENCE
THAT NOT ONLY IMPROVES CARE BUT
REDEFINES WHAT CARE WITH BE.
THIS IMAGE, THIS LANDSCAPE
REMINDS US, JOURNEY OF NURSING
SCIENCES HAS ALWAYS BEEN 1 OF
DEPTH, PERSISTENCE AND
TRANSFORMATION, IS ABOUT
NOTICING WHAT OTHERS MISS,
ASKING DIFFERENT QUESTIONS AND
DESIGNING SOLUTIONS THAT REFLECT
THE FULL COMPLEXITY OF PEOPLE'S
LIVES NOT JUST THEIR CONDITIONS
BUT THEIR COMMUNITIES, STRUGGLES
AND STRENGTHS.
IN THIS PRESENTATION, WE'VE
EXPLORED HOW WE CAN INTEGRATE
SOCIAL NEEDS IN THE CARE IN A
WAY THAT'S MEANINGFUL AND SO
THAT IT'S SCALABLE.
WE LOOK AT HOW WE MOVE FROM
FRAGMENTED PILOTS TO SUSTAINED
PRACTICE, AND WE'VE SEEN THAT
DOING BETTER MEANS BUILDING
SYSTEMS THAT SUPPORT THE PEOPLE
DOING THE WORK AND THAT NURSES
ARE UNIQUELY POSITIONED TO LEAD
THIS TRANSFORMATION, THE SCIENCE
WE SHAPE TODAY, THE QUESTIONS WE
ASK, THE METHODS WE REFINE, THE
PARTNERSHIPS WE BUILD WILL
DETERMINE THE NEXT 40 YEARS OF
NURSING SCIENCE, SO LET'S KEEP
GOING, LET'S CONTINUE THIS
JOURNEY, NOT JUST FOR DOING
BETTER SCIENCE BUT TOWARD
CREATING A BETTER HEALTH SYSTEM
FOR EVERYONE WE SERVE.
AND BEFORE CLOSING I WANT TO
TAKE A MOMENT TO ACKNOWLEDGE THE
MANY PEOPLE AND PARTNERS WHO
MAKE THIS POSSIBLE, SO NOT
UNLIKE THIS COLORADO RIVER
RAFTERS THIS JOURNEY IS A HUGE
TEAM.
OUR PROGRESS HAS BEEN SUPPORTED
BY FUNDING FROM AHRQ AND NINR
INCLUDING THE SINCERE NEEDS
STUDY AND HEALTH IT, WE ARE
ESPECIALLY PROUD TO HIGHLIGHT
THIS IN THE NINR'S 40 YEARS OF
SCIENCE TO IMPROVE CARE, THIS
WORK HAS BEEN SHAPED BY A TRULY
INTERDISCIPLINARY TEAM INCLUDING
FACLETY, RESEARCH STAFF AND
STUDENTS AS WELL AS VITAL
COLLABORATIONS AND CARE TEAMS
ACROSS NURSING MEDICINE, THERAPY
AND IT.
TOGETHER, THEY'VE HELPED US NOT
ONLY STUDY THE INTEGRATION OF
SOCIAL ASSESSMENTS AND CARE
DELIVERY, BUT ALSO LIVE OUT THE
COMPLEXITY AND TEAM WORK ALL OF
THIS REQUIRES, I'M INCREDIBLY
GRATEFUL, AND COMMITMENT TO
DOING BETTER FOR PATIENTS.
SO I'M ALWAYS HAPPY TO CONTINUE
THE CONVERSATION WHETHER WORKING
ON SIMILAR CHALLENGES, THINKING
ABOUT IMPLEMENTATION IN YOUR OWN
SETTINGS OR HOW TO INTEGRATE
BETTER CARE AND SCIENCE, THANK
YOU AGAIN FOR YOUR TIME, YOUR
ATTENTION AND YOUR SHARED
COMMITMENT TO IMPROVING CARE AT
NIH, I LOOK FORWARD TO WHAT WE
CAN BUILD TOGETHER.
>> WOW THANK YOU SO MUCH
DR. WALLACE FOR SHARING YOUR
WORK WITH US AND SHOWING
DIRECTLY HOW THE RESEARCH IS
LOOKING AT SOCIAL NEEDS AND
EPITHELIALIGRATION AND
ENHANCEMENT OF SYSTEMS CAN
DIRECTLY IMPACT THE CARE OF
CLINICAL PATIENTS AND YOU
COULDN'T HAVE SAID IT BETTER IN
TERMS OF ALSO SHARING WHERE WE
ARE WITH OUR 40th ANNIVERSARY,
WE'RE INCREDIBLY EXCITED TO
SHARE WITH ALM OF YOU WHERE WE
ARE AND HOW WE MOVE FORWARD AND
WHERE WE'RE MOVING TO NEXT AND I
THANK YOU FOR HIGHLIGHTING THE
WORK YOU'VE DONE AS PART OF THAT
CELEBRATION AS WELL, THERE WILL
BE MORE TO COME.
WE DO HAVE TIME NOW TO TAKE
QUESTIONS AND I WILL LOOK AT THE
VIDEOCAST CHAT TO MAKE SURE
THERE ARE QUESTIONS.
PLEASE MAKE SURE TO BRING THEM
FORWARD BUT I WILL TAKE LIBERTY
AS I WAIT FOR A FEW OF THOSE TO
COME THROUGH TO ASK YOU 1 IN
PARTICULAR TO START WITH AND I
WANTED TO TALK ABOUT THE UTAH
211 PROGRAM, THE SCREENING AND
IF YOU COULD SHARE WITH US
SPECIFIC STRATEGIES YOU FOUND
MOST EFFECTIVE IN INSURING THAT
PATIENT WHO IS ARE REFERRED TO
THIS COMMUNITY BASED RESOURCES
ACTUALLY CONNECT WITH AND ARE
UTILIZING THE SERVICES.
SO COULD YOU TALK ABOUT THAT.
>> THAT'S BEEN A HUGE EMPHASIS
OF OUR CURRENT WORK.
SO THE CURRENT TRIAL WHICH WAS
ENROLLMENT LAST MONTH SO WE'RE
THRILLED TO LOOK AT THOSE DATA.
WE'RE WAITING FOR THE FOLLOW UP
SURVEYS TO GET COMPLETED, THE 6
MONTH FOLLOW UP BUT WE'VE TESTED
STRATEGIES FOR ENGAGING PATIENTS
IN REALLY USING -- APPLYING
HEALTH BEHAVIOR STRATEGIES
AROUND GOAL SETTING AND FOLLOW
UP SUPPORT SO WE'RE TESTING
INCREMENTAL GOAL SETTING, ACTION
PLANNING AND ESSENTIALLY SMART
GOALS WITH THE PATIENTS AS PART
OF OUR PROCESS AND THEN WE'RE
COMPARING WITH THE TENSION,
CONTROL AND STANDARD PRACTICE
WHICH IS OFTEN GIVING PATIENTS,
YOU KNOW 4 OR 5 REFERRALS WHICH
WE APPRECIATE FROM THE SERVICE
NAVIGATORS THAT THEY WANT TO
GIVE PEOPLE AS MUCH INFORMATION
AS POSSIBLE DURING A CONTACT BUT
WE ALSO FIND THAT THAT WAS
REALLY OVERWHELPING THE
PATIENTS, SO WE'RE TESTING
DIFFERENT ENGAGEMENT STRATEGIES.
AND PART OF THE NEW STUDY THAT
WE FOUND THAT AGAIN, DIGITAL
CONNECTIONS WERE REALLY KEY.
IT'S A LIMITATION FOR MANY OF
OUR PATIENTS IN TERNALS OF
HEALTH LITERACY -- IN TERMS OF
HEALTHITYERACY AND ACCESS TO THE
INTERNET PARTICULARLY IN THE
RURAL AND FRONT -- FRONTIER
AREAS AND WE'RE WORKING ON
GETTING PHONES IN PATIENTS HANDS
AND TESTING THE BENEFIT OF THAT.
AND THEN THERE'S A HOST OF OTHER
STRATEGIES, SHARING PICTURE,
STORIES OF PATIENTS, LOOKING AT
TRUST, EXPLAINING TO THE
PATIENTS WHY WE ARE DOING THE
SCREENING BEFORE WE ENGAGE IN
THE QUESTIONS.
>> SO THAT'S ACTUALLY A PERFECT
SEGUE TO A QUESTION THAT CAME TO
MY ATTENTION WHICH IS RELATED TO
THE SINCERE SCREENER AND HOW
IMPORTANT IT IS TO BE ABLE TO
INCLUDE SCREENERS WHEN WE DO
CLINICAL INTERVENTION AND JUST
TO THE POINT WE WERE SAYING
CONSIDERING THE DIGITAL DIVIDE,
DIDN'T COMPLETE THE SCREENER,
VIA SELF-COMPLETION OR VERBALLY
WITH STAFF, WHAT CAN WE DO
BETTER TO REACH THIS INDIVIDUAL
TO INSURE EVERYONE HAS ACCESS TO
THE SOCIAL NEEDS SCREENING.
>> WELL, WE ACTUALLY -- SO, JUST
WITHIN THE PAST YEAR, IT IS
FULLY INTEGRATED INTO OUR EHR,
SO THAT'S BEEN VERY HELPFUL, AND
WE'VE BEEN CONNECTING A LOT OF
TRAINING WITH THE NEW STAFF WITH
THE HEALTH AND GIVING THEM
CAREFUL SUPPORT AROUND
ENGAGING
PATIENTS IN THESE CONDITIONS.
SO OUR SCREENING RATES AND RATES
HAVE GONE DOWN CONSIDERABLY
SINCE THAT ALL HAPPENED.
YOU KNOW THOSE EARLY REPORTS
WERE -- REALLY REFLECTED THE
RELUCTANCE OF THE E. D. STAFF IN
APPROACHING THE PATIENTS AND
THIS IS WHERE REALLY WE
ENCOVERRED SO MUCH WORK ABOUT
VULNERABILITY, AND ABOUT WE HOW
AS CLIN GZS WE PREDETERMINE WHO
SHOULD BE SCREENED AND WHO
SHOULDN'T BE AND SO WE'VE REALLY
WORKED ON THAT WITH THE STAFF
AND CONTINUE TO DO SO.
BUT THIS IS AN AREA THAT REALLY
CLINICIANS STRUGGLE WITH ON A
REGULAR BASIS, YOU KNOW, WHY AM
I ASKING THESE QUESTIONS IF I
DON'T HAVE SERVICES BUT WE'RE
VERY FORTUNATE IN THAT
PARTNERSHIP WITH UTAH 2 AND 1,
WE DO HAVE A METHOD FOR
REFERRING PATIENTS AT LEAST TO
SERVICES, EACH IF THEY DON'T
ULTIMATELY RECEIVE ASSISTANCE,
THEY AT LEAST HAVE SOMEONE TO
CONTACT.
>> THANK YOU FOR THAT.
SO WE'RE GETTING ANOTHER
MESSAGE, SOMEONE IS SAYING THANK
YOU SO MUCH FOR YOUR TALK WITH
AN EXCLAMATION POINT.
I WOULD LO TO HEAR MORE ABOUT
HOW I ENVEGZ SUPPORTING THE
TYPICALLY TIGHT KNIT CBOs, AND
PATHWAY GIVES MANAGING CASE
LOOEDS BEYOND JUST FUNDING AND
FOR THESE ORGANIZATIONS.
>> YES, SO WE'VE BEEN WORKING
WITH IT, WE'RE VERY FORTUNATE
THAT WE HAVE A RELATIVELY TIGHT
KNIT COMMUNITY OF CBOs WHO
HAVE BEEN REALLY ENGAGED IN THIS
WORK AND ARE -- WELL THEY HAVE
LIMITED RESOURCES THEY ARE ALSO
VERY SUPPORTIVE OF INCREASING
THE CONSISTENCY AND OUTREACH
THAT THEY DO RECEIVE.
IN TERMS, WE ACTUALLY DO HAVE A
SYMPOSIUM COMING UP TO EXPLORE
SHARED RETURN ON INVESTMENT WITH
THE CBOs, WE'RE ENGAGING THE
CBOs HERE AT THE UNIVERSITY OF
UTAH WITH HEALTH ECONOMISTS AS
WELL AS OTHER SOCIAL SCIENTISTS
AS WELL AS CLINICIANS TO TALK
ABOUT HOW WE CAN DEVELOP A WAY
WHERE WE SHARE IN THE BENEFIT
BECAUSE SO OFTEN TIMES WE BUILD
THESE SYSTEMS AROUND THE
CLINICAL INFRASTRUCTURE AND WE
REALLY NEED TO BE BUILDING IT
AROUND THE CBOs AND THEIR
CAPABILITY.
SOME OF THE BEST ADVICE I GOT
WHEN I FIRST EMBARKED ON THIS
WORK IT WAS FROM SOMEONE IN OUR
DIGITAL INNOVATIONS LAB WHO SAID
THE BUILDER THE INFRASTRUCTURE
AROUND 211, NOT TO EXPECT THEM
TO ADAPT TO OURS AND IT HAS BEEN
KEY IN OUR SUCCESS.
SO I GUESS THAT MIGHT BE A ROUND
ABOUT WAY OF ANSWERING SOME OF
THAT, I HOPE, BUT I'M ALWAYS
HAPPY TO ENGAGE, HAVE YOU MY
E-MAIL.
SO THANK YOU.
>> THANK YOU, I WILL SWITCH US
OVER FOR A BIT THAT WE HAVE SOME
OF OUR CLINICAL NURSES CHIME
NOTHING AND I WANT TO GO TO THE
IN-PATIENT STUDY WHERE WE TALK
ABOUT BARRIERS ENCOUNTERED WHERE
THE SOCIAL NEEDS SCREENING
PROTOCOL.
HOW DO YOU ADDRESS THAT?
>> SO WE HAVE RIGHT NOW, WE'VE
SHIFTED GEARS A BIT TO FOCUS ON
FAMILY CAREGIVERS IN OUR CURRENT
ARC WORK BUT OUR NEXT PHASE IS
TO GO BACK TO THOSE CLINICAL
NURSES AND TRY TO FIGURE OUT HOW
TO ENGAGE BECAUSE ACTUALLY AS
PART OF THE CMS REGULATIONS, OUR
NURSES ARE NOW ASKING SOCIAL
NEEDS QUESTIONS AS PART OF THEIR
WORK FLOWS, SO, WE HAVE STARTED
ENGAGING WITH THEM, AND REALLY
IT IS ABOUT UNDERSTANDING JUST,
I THINK THE SELF-DETERMINATION
THEORY, WE HAVE FOUND IT'S BEEN
REALLY HELPFUL TO COMMUNICATE
THIS, REALLY TRY TO FIGURE OUT
WHAT FEEDS THEIR SOUL, HOW THEY
-- HOW THEY CAN HAVE TOOLS TO
REFER PATIENTS, INCREASE THEIR
COMFORT AROUND THESE
CONVERSATIONS AND ALSO MAKING
THEM SEE THAT IT'S SOCIAL
FACTORS IMPACT WORK FLOWS
WHETHER OR NOT THEIR DOCUMENTED
OR EHR OR NOT.
YOU KNOW WHEN YOU'RE TRYING TO
DISCHARGE A PATIENT AND YOU
SUDDENLY REALIZE THEY DON'T HAVE
SOCIAL SUPPORT, A RIDE HOME,
WHERE YOU REALIZE A PLAN OF CARE
IS NOT GOING TO WORK BECAUSE
SOMEONE LIVES BY THEMSELVES AND
THERE'S NO WAY THEY'RE GOING TO
BE SENT HOME WITH A WOUND BAG OR
WHATEVER THE CASE MAY BE, THOSE
ARE JUST SOME OF THE EXAMPLES
THAT WE'VE SEEN.
SO IT'S MAKING IT RELEVANT, IT'S
REALLY TRYING TO GIVE THEM
COMMUNICATION TOOLS AND THEN WE
HOPE BY ALSO EXPANDING OUR
REFERRAL INFRASTRUCTURE TO THE
IN-PATIENT SIDE WHICH WE'RE
WORKING ON NOW THAT IT WILL ALSO
GIVE THEM A TOOL SO THEY CAN
FEEL BETTER ABOUT ASKING THE
QUESTIONS, WITHOUT FEELING LIKE
THEY NEED TO ADDRESS IT BECAUSE
REALLY IT'S OUR COMMUNITY
PARTNERS WHO ARE THE EX PERS IN
THIS TO BE HONEST, SO WE NEED TO
JUST FIGURE OUT A WAY TO MAKE
SURE THAT COMMUNICATION IS MADE.
SO HOPEFULLY THAT WORRY ANSWERS
YOUR QUESTION.
IT'S A TOUGH QUESTION.
>> IT'S A TOUGH QUESTION RIGHT,
IN ORDER TO BE ABLE TO DISCUSS.
I THINK THIS 1 WILL PIGGYBACK
PRETTY WELL TO THE 1 WE JUST
DISCUSSED.
SO YOUR RESEARCH FOUND THAT 29%
OF PATIENTS ASSESSED BY RNs
HAD LESS THAN ADEQUATE
RESOURCES, SO GETTING MORE IN
THE DISCHARGE OF A PATIENT, WHAT
HAVE YOU FOUND THAT HAS WORKED
IN TERMS OF INTERVENTION TO
IMELEMENT AND IMPROVE THE
PATIENT'S HOME RESOURCES?
>> SO WE FOUND THAT THE NURSES
AGAIN, WERE IF THEY KNEW ABOUT
THE INFORMATION THIS, IS ABOUT
MAKING IT SYSTEMATIC AND
UNIVERSAL.
WE KEPT USING THAT TERM OVER AND
OVER AGAIN DURING THE STUDY, IT
IS ABOUT HOME HEALTH, IT WAS
ABOUT, YOU KNOW SKILLED NURSING,
BUT WE ACTUALLY DO HAVE A TOOL
THAT WE ARE BEGINNING TO TEST
IN-PATIENT SIDE WHERE THE
PATIENT IS ACTUALLY AN APP, IT'S
TO HAVE THE PATIENT COMMUNICATE
OR THINK THROUGH THEIR PARTIT
PATTERY PLANNING, GET THEM
THINKING ABOUT THE RESOURCES
THEY HAVE AT HOME AND ALSO
ENGAGE WITH 211'S RESOURCES TO
SEE IF THEY CAN FIND RESOURCES
WITHIN THE COMMUNITY SO THE PLAN
CAN BE SHARE WIDE FAMILIES.
SO THAT'S AN INTERVENTION WHERE
WE NEED TO ENGAGE PATIENTS MORE
PURPOSELY AND MORE PARTICIPATORY
PLANNING AND WE'VE HEARD THAT
FOR CAREGIVERS AND PATIENTS
AFTER DISCHARGE, WHY DIDN'T I
KNOW THAT I NEEDED TO DO THIS?
YOU KNOW, I WOULD HAVE DONE
THINGS DIFFERENTLY, I WOULD HAVE
SET UP CARE WITH MY NEIGHBOR,
YOU KNOW WHATEVER THE CASE MAY
BE.
SO CONTINUE TO WORK ON THE
QUALITY OF THAT DISCHARGE
EDUCATION AND REALLY TRY TO GET
PEOPLE TO PLAN AHEAD.
BUT WE ARE WORKING ON TOOLS TO
HOPEFULLY HELP WITH THAT AS WELL
AS TO HELP MEASURE CAREGIVER
ENGAGEMENT AS WELL, SO FAMILY
CAREGIVERS.
>> AND IN RECOGNITION OF TIME I
WILL TURN IT OVER TO YOU AND CAN
IF THERE WERE ANY ADDITIONAL
THINGS TO SHARE WITH THE
AUDIENCE BEFORE WE CLOSE?
>> I DON'T THINK SO.
IT'S BEEN SUCH A PRIVILEGE TO DO
THIS WORK, BOTH FOR THE PATIENTS
AND OUR COMMUNITY SERVICE
PROVIDERS, THE CBOs THAT WERE
PROVIDED IN 1 OF THE OTHER
QUESTIONS, WE ARE SO THANKFUL TO
HAVE THIS REALLY TIGHT KNIT
COMMUNITY HERE AFFILERATED WHY
THE UNIVERSITY OF UTAH, WE ARE
REALLY TRYING TO EXPAND OUT INTO
THIS BEING A REGIONAL EFFORT.
WE COVERED MOST LAND MASS OUT OF
ANY ACADEMIC HEALTH CENTER IN
THE COUNTRY, AND SO WE'RE REALLY
TRYING TO FIGURE OUT HOW TO DO
MORE OUTREACH AND SERVICE
CONNECTIONS FOR THOSE WHO MAY BE
IN RURAL AND FRONTIER SETTINGS.
SO IT'S JUST BEEN SUCH A
PRIVILEGE TO DO THIS WORK.
WE'RE CONTINUING OUR WORK ON
BOTH THE IN-PATIENT AND
OUTPATIENT SIDE AND HOPEFULLY AN
OPPORTUNITY TO CONTINUE
LEARNING.
SO THANK YOU SO MUCH FOR
LISTENING TODAY AND AGAIN, I AM
-- I WAS HAPPY TO COLLABORATE
AND ADDRESS WHATEVER QUESTIONS
OR NEEDS THAT MAY ARISE.
SO HAPPY TO CORRESPOND WITH
ANYONE.
>> WELL, DR. WALLACE, THANK YOU
AGAIN SO MUCH FOR TAKING THE
TIME TODAY TO SHARE YOUR WORK
WITH US AND TO ACTUALLY TRULY
BRINGING A PICTURE TO THE EASE
AND CHALLENGES OF DOING RESEARCH
THAT HAS DIRECT APPLICABILITY TO
HEALTHCARE AND SHOWING WHERE
NURSING LED SCIENCE REALLY DOES
HAVE THE ABILITY TO IMPACT OUR
HEALTH FOR EVERYONE.
I WILL BE REMISS IF I DON'T
POINT TO WHAT'S ON THE SCREEN
RIGHT NOW.
PLEASE REMEMBER IF YOU ARE HERE
TO COLLECT CME CREDITS, THAT THE
CODE IS 57904.
AND WITH THAT WE WILL CLOSE FOR
THE AFTERNOON.
AND THANK YOU AGAIN, SO MUCH FOR
YOUR TIME AND JOINING US.
>> THANK YOU.