MDE 8104: Complex Care in the Community 15-16

Contact:

Davida Leayman
Allentown, PA 18101
Ph: 484-862-3067
Davida_M.Leayman@lvhn.org

The Neighborhood Health Centers of the Lehigh Valley (NHCLV) is a Federally Qualified Community Health Center serving the under-served community of Allentown. Understanding health in a broad context, we seek to partner with our patients and community to build skills for stronger families and a healthier community. In June of 2012, NHCLV along with three other sites around the country entered into a partnership with Dr. Jeff Brenner’s Camden Coalition of Health Care Providers to develop outreach teams and community support based on Dr. Brenner’s innovative work in Camden. Teams work intensively with “Superutilizers” who have multiple hospitalizations and a tangled story of poverty, isolation and co-morbidity. NHCLV has partnered with Congregations United for Neighborhood Action (CUNA), Community Exchange Timebank and Parish Nursing Coalition to meet our superutilizers when and where they need us most – in the hospitals, in medical offices, in their homes and communities – to develop the relationships and understanding they need to break the pattern of high cost, low value interaction with fragmented systems of care.

This elective is designed to introduce senior students to comprehensive, relationship centered care for complex patients in community settings. At the intersection of community health and primary care, students will work with our Outreach Teams as health coaches and story gatherers to partner with patients and learn from the patient's point of view what it takes to live a good life in the face of complex illness. Students will participate in daily team rounds, home visits, accompany patients to specialist and primary care visits, and Students will also have opportunities to work closely with our community engagement including our Timebank service exchange and community organizing. In addition, students will have opportunities to practice in our community health center.

Objectives

Identify social determinants of health across the lifespan that contribute to complex illness
Walk with patients and describe how healthcare systems designed to help sometimes hurt people
Develop empathy and deeper understanding by creating digital stories with patients about their lives and healthcare experiences
Develop skills in health coaching for self management of complex health issues using motivational interviewing techniques
Describe the roles in interdisciplinary team and progression to transformation for patients engaged in program
Compare and contrast NHCLV Superutilizer program with other programs serving similar populations
Describe the health policy implications of learnings from personal experiences including service delivery redesign, payment reform, and outcomes at local, state and federal levels
Reflect on implications for relationship centered care in student's vision of personal practice

Evaluation
Students will work in close contact with the interdisciplinary team and participate in daily huddles. They will meet with the elective director at or before the beginning of the course to set learning goals, and at the midpoint and end of rotation to debrief experiences and offer feedback. Students will provide the course director with weekly reflections. End of rotation assignments include a three minute digital story created collaborative with a patient and a final presentation to the team and leadership group on the topic of their choice. Grading for this elective will be S/U (Satisfactory/Unsatisfactory). Students who complete all assignments and engage respectfully with the team and patients will be assessed as satisfactory by the elective director.

Any interested student must contact Dr Lecher to plan specific goals and activities for the elective.