1. RN SYSTEM WIDE EDUCATION PRESENTED BY S. FERGUSON, T. DILLON, L. LOCK, J. HASBUN, S. SHAH & R. GAINES Shepherd’s Hope

2. Shobha Shah and Ruth Gaines

3. Goals of Community Project Ensure that a system to educate volunteer staff is in place at Shepherd’s Hope clinics that reinforces the aim of the organization which is to provide: 1. Basic acute nonemergency care. 2. Appropriate timely referral to a permanent medical home.

4. Objectives of Community Project Volunteer will have a referral procedure available that is sustainable and consistently transferable. Volunteer trainer(s) from a pilot location will train volunteers at other Shepherd’s Hope locations in the use of referral process.

5. Review of Literature Studies have shown that a lack of healthcare access causes increased mortality and morbidity. There is a need to use community resources to fullest capacity to mitigate this mortality and morbidity. Inadequacies in existing community referral processes need to be explored. Knowledge regarding availability of community referral resources are lacking.

6. Shepherd’s Hope Survey Considerable gap in nurse’s knowledge regarding role of other community resources. Lack of knowledge and information regarding process. Lack of clear referral criteria.

7. Survey Cont’d Formalized patient pathway to PCAN is likely to: 1. Improve clinical management. 2. Minimize frequent hospitalization. 3. Reduce mortality and morbidity. 4. Increase recommended referrals.

8. Barriers of community referral Inability of healthcare system to meet consumers’ demand Diminished access to care due to low socioeconomic status Lack of insurance Lack of adequate transportation Cultural and language barriers Lack of information Lack of awareness among primary care providers regarding the role and availability of community resources

9. Barriers Continued Less access to preventative health services (Not having primary care available to primary care results in more specialty referrals) Disabling physical mobility limits visitation to resources. Some include:  Chronic health conditions  Diabetes  Musculoskeletal  Cardiac and respiratory diseases

10. Possible Interventions Development of new patient referral process. System to support volunteers in implementing referral process. Potential clinic monitoring system to ensure patients receive appropriate follow up after referral to PCAN.

11. Possible Interventions Possible telephone or follow up appointments with PCAN referrals Providing accurate information of referral location (PCAN clinic) such as name, address and phone number. Providing information to patients on documentation requirement for referral services (PCAN clinic).

12. Lora Lock and Tessa Dillon

13. What is Shepherd’s Hope Free Clinics for the uninsured. Part of PCAN Network. Provides services found in primary practice setting. Not designed to be permanent medical home.

14. What you do Provide access to care. Via case management at Shepherd’s Hope, provide referrals to specialists. Provide medication treatment. Provide competent care. But today we are talking about how you assist in finding a medical home in Orange County.

15. Who we serve The 14% uninsured Seminole County residents. The 19% uninsured Orange County Residents. Individuals, families, and children of multi- ethnic and multi-cultural origin. (Garvan, Duncan & Porter, 2005)

16. Who we serve Any person needing care. Uninsured. Family income at or below 200% of poverty level.

17. What else is offered Medications at no cost (when available). Low or no cost labs at local participating facilities. Low or no cost selected diagnostic tests and stress tests.

18. PCAN Clinics 11 Locations In Orange County 1 location in Seminole County

19. Sherri Ferguson

20. Logistics for PCAN Referral Process 1. Health Center manager to designate trained volunteers to handout referral to PCAN slip (Remaining will be piloted at Tazkiah location) 2. Volunteers to use the “New Patient Referral Process Flowchart” to complete the PCAN Referral Process 3. Return chart to front desk and have volunteer:  Insert copy of Referral Slip into patient’s chart  Verify that Referral Log filled out for that patient

23. Patient's Name Patient Phone Number Date of Visit Center Referred to Call # 1 / Date Appt Made Call # 2 / Date Appt Made If Appt Made Document Time and Date Reason For Not Making Appt After Second Call Sample patient A 407-555- 55553/16/2011 Eatonville Family CenterNo 4/5/2001 @ 130pm

24. Logistics for Referral Continued 4. Once referral is verified, stamp PCAN at the left upper hand front of chart cover. 5. Document outcome of each call Next Clinic Session 1. Health center volunteer to call patients listed on log from previous week 2. Documented outcome of each call in front inner cover of chart and referral log After two calls, if appointment not made, patient is discharged from Shepherd’s Hope Health Center and advised of the same 3. Document discharge in chart

25. Plan Implementation PCAN Referral Procees – Initial Training Location: Tazkiah Shepherd’s Hope Health Center PCAN Referral Process – Initial Training for: Tazkiah Shepherd’s Hope Volunteers Classes Provided by: University of Central Florida Graduate Nursing Students

26. Plan Evaluation Evaluation of “New Patient PCAN Referral Process” will include ascertaining: 1. % of patients referred to PCAN Medical Homes who follow through with referral 2. Compatibility between PCAN Referral Process with health center resources i.e., available man-power, ability to complete follow-up phone calls during clinic sessions, cost-effectiveness 3. Barriers that prevent patients from establishing PCAN Medical Home

27. Long-Term Goals Implement Tazkiah Shepherd’s Hope clinic pilot for at least three months Tweak PCAN Referral Process at the Tazkiah clinic to facilitate compatibility with it’s resources Depending on pilot outcomes, train all new volunteers in the PCAN Referral Process Consistently refer all patients to PCAN Medical Homes Using volunteer trainers, train new volunteers at other Shepherd’s Hope Health centers in the PCAN Referral Process

28. Janina Hasbun Questions?

29. References Garvan, C., Duncan, R.P. and Porter, C. (2005, August). The Florida health insurance study 2004: County estimates of people without health insurance. Retrieved from, http://www.statecoverage.org/files/County%20Estimates%20of%20People%20Without%20He alth%20Insurance%20from%20the%202004%20Florida%20Health%20Insurance%20Study.p df