1. University of South Florida, Tampa Family Health Centers, and Senior Connection Center Partnership
Faisel Syed, MD
Sherry Hoback, MBA, BSN, RN
Edward Kucher, MBA
Kathryn Hyer, PhD, MPP; Rita D’Aoust, PHD, ACNP, ANP-BC, CNE, FAANP, FNAP; Lucy Guerra, MD, MPH; Melanie Michael, DNP, MS, FNP-C, CPHQ; Cheryl Wilson, DNP, ARNP, ANP-BC, Adrian N.S. Badana, MPH and Ross Andel, PhD
Charlotte McHenry, MPH; Katie Parkinson, MBA
These are the partners;
Tampa Family a

2. USF GWEP AIMS
Transform the federally qualified primary care practice model through the infusion of geriatric knowledge into clinical practice.
Prepare IM, FP DNP, ARNP, PharmD future leaders through geriatric infused primary care rotations, Byrd Alzheimer’s clinic experience, and homecare visits to homebound elders.
Build dynamic referral system for TF to receive access to appropriate home and community-based long-term care supports and services from Senior Connections and back to TF providers

3. Partnerships
Level 3 Nationally-accredited Patient Centered home. Values integrated care but responsible for primary care.
Aging Resource and Disability Center for
five counties in Tampa bay area. Receives
OAA and State general revenue money.
Establishes priority score for long-term care supports and services. Long waiting lists and waiting time for services

4. Illustrative Examples: “Practice Transformation”

5. Successes
Implementation of NCOA “training for existing and new care management staff, patient navigators at TFHC”
Dedicated person at SCC for referrals, assessment for services and feedback between TFHC and SCC
Implementation of specific geriatric-focused HEDIS and Healthy People 2020 Older Adults metrics into existing performance improvement/feedback processes at TFHC
Implementation of gerontologic education for all providers and staff at TFHC
Keeping in mind that process improvements attained through application of the PDSA typically involve a series of sequential and iterative cycles, the attainment of the goals associated with each of the ideas listed here would probably occur in increments.
Aim 1: Transform the TFHC FQHC primary care practices by infusing gerontologic and geriatric knowledge into clinical practice by providing structured geriatric interprofessional education for providers and all clinical staff
TFHC leaders have infrastructure and processes in place to support continuous performance improvement and are already using the PDSA cycle to advance organizational quality and safety priorities.
Within the context of this project, these systems and processes will be expanded to include a strategic and specific focus on the objectives associated with Aim 1.
Illustrative examples of potential practice improvement projects in this category which align with the overarching goals and aims of our project include….

6. Tensions Practice “transformation” can be insulting
Defer to University for education but prefer short online training.
TF does not want “research” limiting value
QI projects require discussion prior to implementation

7. USF/TF QI vaccination project
Objective 1: Understand that the baseline rate of pneumococcal vaccination, and especially Pneumovax 23 (PPSV23) vaccination, was unacceptably low among geriatric patients at a Federally Qualified Health Center (FQHC) in Tampa, Florida.
Objective 2: Develop interdisciplinary team of learners to address barriers.
TF concerns about “research” with patients and reputation with findings
Goals of excellence for practice may conflict with goals of cost-effective care

8. RCI/PDSA Project Examples
Implementation of systems and processes to provide for seamless referral and coordination of care between TFHC and SCC
Develop system of tracking within TFHC to identify needs and referral (ie. electronic health system flag)
Develop system of tracking within SCC for information and appropriate referral (ie. changes in the number and type of referrals from TFHC over time; level of priority score for waiting lists for services)
Deliver TFHC provider and staff training on resources available at SCC through the Older Americans Act (e.g. respite care, Meals on Wheels) and other services (e.g. adult day care).
KL: Case management team taking responsibility for SCC referrals has been very beneficial from my clinical perspective. One patient with transportation issues who needed close follow up was able secure transportation via transportation services by the time of her next appointment. However, this process is dependent on the provider inquiring about needs. I attempt to consistently ask patients about financial, transportation constraints, etc but identifying needs would be better targeted if we developed a form (at least in Spanish and English) enumerating SCC potential services for patient to fill out to self-identify concerns while waiting for provider. Case management is very good at identifying ahead of time people who could benefit from health and wellness classes, diabetes self management classes, and behavioral health, which we discuss during morning rounds, but they can only identify needs based on information that is documented within the chart. TFHC fletcher has a brief monthly site meeting - this is a potential opportunity to provide all providers and staff at this site, not just at GWEP, with information/handouts regarding SCC services. I would like to emphasize how integral case management services has been to ensuring patient’s receive proper care and follow up.

9. Illustrative Examples: Curricula and Clinical Learning

10. Clinical Immersion Experience: Creating GWEP clinic
NP students
Rotation with USF faculty member, IM Resident, NP students in GWEP clinic at TFHC-40 hours each
RN students
Rotation in GWEP clinic and with TFHC case management
Pharm D students to begin rotation in January 2017
KL: I would benefit from having sample of curriculum/goals for RN students to better know how to target my teaching for them. I often have them rotate between taking vitals/triaging and they often shadow myself and NP/Residents. I feel they are more engaged when I ask them to assist with pt education and assessments. From faculty perspective, it is an learning process in ensuring participation and active learning of all trainees and balancing this with the needed efficiency and timeliness required for clinic. I feel that from my perspective, the NP students are consistently enthusiastic and motivated trainees and consistent patient advocates. Having NP students who have rotated through the TFHC system is also extremely helpful as the EMR, although with many benefits, is often frustrating to myself as a new provider and to Residents who are here for such a limited time.

11. “Learn at Lunch”
Development of series of lunchtime learning activities at TFHC for MD’s, NP’s, NP students, Case Managers, RN students
Topics including TF and SCC delivery
Aging and Sensitivity in Geriatrics
Falls in Elderly
Functional Assessments in the Elderly
Caring for the Older Adult: Geriatric Syndromes
Polypharmacy of the Older Adult
Pain Management in the Elderly
Advance Directives
Caregiver Support
Health Literacy and the Elderly

12. Primary Care of Older Adults
24 Items questionnaire developed for USF faculty and TFHC primary care needs.

13. TFHC Provider Survey Response
Most Requested training
Assess and manage multiple chronic conditions
Help patients manage care among different providers and services
Determine needs in social support/living arrangements and refer for supports and services
Identify at risk drivers and recommend appropriate counseling
Least requested
Take an age-appropriate patient history and perform physical assessment
Prevent and manage osteoporosis
Sexual function
Identify obstacles and opportunities for physical activity

14. Implications for USF Faculty
Differentiating “older adults” from any adults in order to change “status quo” and not create ageism.
Learning about and working with other health curricula
Intentional clinical learning with GWEP team
Appreciation and understanding of the intricacies of caring for older adults- goals of care
Understanding the difference between what we know and our comfort level with teaching to students

15. Implications: Practice TFHC
Acculturation – FQHC vs Academic Health Center
Different missions FHQC – importance of seeing patients, ability of faculty to miss clinic hours.
Language of “practice transformation” seems insulting
Data demands and impact on practice personnel
KL- As a new provider, my biggest challenge is developing my efficiency while providing trainees sufficient time to evaluate patients and formulate treatment plans in FQHC setting. For example, new patients are never actually in 1 hour slot, but always in 30 min slot, which appears to be c/w TFHC template but limits ability to perform a comprehensive geriatric assessment in complex new older patients, many who have not had any recent care and require translation services. We have been addressing this by ensuring close follow up for review of labs and to further address concerns. Walk ins at times are added to a full schedule to ensure patients are seen in timely manner, but this also makes it more difficult to finish on time and ensure TFHC staff due not go over their allotted hours. So far, TFHC has been very responsive & flexible when discussing patient scheduling & I think this will continue to improve as I become more facile within system.

16. TFHC Credentialing of USF faculty Process-evolved over time
Universally required documents
Paperwork and Licensing Materials for FQHC/ State
Provider-specific training- TF system
Learning the Electronic Health Record- Integrity creates Quality metrics for FQHC
Learning the TFHC billing process
KL: For me, I found on-site training for the EHR is very important, especially when locating where to document quality measures. I believe that it is essential prior to starting. I would have benefited from a more formal, scheduled tour/explanation of TFHC’s clinic site specific policies ie where Baker Act forms are located, expectations of MA duties, what immunizations are available, etc.

17. Getting on same page Developed/ Developing
FQHC 101- required for all trainees
Senior Connection 101- required for all trainees
Welcome to GWEP- overview of project and need to develop Primary care workforce to meet needs of older adults
Carry forward to videotape additional material

18. Lessons Learned
Primary care at FQHC is very different from academic primary care settings and practices
Population is young old –takes time to build older cohort for schedule
Cohort is not stable- Older patients may leave when Medicare-eligible may not need many repeat visits
Medicare eligible members chose bronze plans- not accepted at USF Alzheimer’s clinics
KL: Cohort also not stable b/c due to financial, transportation issues, even older patients with complex health issues are reluctant to come back for follow up visits or physicals due to cost and I have noted only often come when medications have run out, or acute issue. Also, patients have to call to schedule their apt if they are not coming back in a month’s time which places the onus of follow up on them.

19. Florida Dual-eligible: Managed Long-term supports and services
Long-term supports and services system is evolving in Florida
TFHC contracts with Medicare/Medicaid SNP providers
Cognitive assessment training challenges:
Referrals for more specialized assessment-to where?
How diagnosis influences management in primary care?
How does SCC work with managed care case managers
KL: currently making dedicated appointments to discuss memory, anticipated safety issues, and more thorough assessment of needs with patients and families for patients who meet diagnosis of dementia and are unable to follow up at the Byrd for interdisciplinary CARES assessment. Once pharmacy joins, they will be a welcome and needed addition, and I would like this population to be on the priority of list of appointments with them.

20. Common lessons repeated
Turnover is constant among all partners
It takes time to develop common language to work together and “getting the right people in the right seats”
Calendars are never aligned well
Humor and transparency increase trust

21. Questions