Participant Visits
Individuals, students, and faculty develop a collaborative plan customized to each individual's health conditions, social needs and resources. The goal is to develop longitudinal relationships with community residents.
A Typical Day
A typical day in the Mobile Health and Wellness Program site begins with a 30-minute meeting involving all students and faculty attending for the day. The meeting may include brief updates and clarification of assignments and a short education session on core geriatric content (on which a geriatric knowledge assessment is based). Topics are mapped to the multidisciplinary competencies needed in working with older adults.
Students are divided into groups of three or four (representing different disciplines) to support wellness visits with between two and four student teams operating simultaneously; other students may be involved with home visits and student-led group learning sessions.
Student teams involved with wellness visits interact with the participant to discuss the purpose of the visit and to provide appropriate wellness-based services, care coordination, and referrals as needed. Students rotate activities throughout the day, allowing all students an opportunity to complete the various activities associated with the wellness visits. Faculty guide the students and ensure the needs of the participants are appropriately met.
After each wellness visit, the faculty member debriefs the students, applying evidence-based practice concepts and interprofessional concepts to goal planning and issues discussed during the wellness visit and the morning learning session.
Services
Following the intake assessments, participants can use any or all services offered by the program (as often as once per week when the program is onsite). Participants access the services through on-site wellness visits, home visits, and education sessions. Wellness visits (typically 30-45 minutes per visit) or unscheduled/walk-ins for unplanned or urgent needs can be scheduled.
MHWP team members make home visits (to apartments within the building) for participants who have recently been discharged from a hospital, nursing home, or emergency department and those with a decline in their health status. Students lead group education sessions on a variety of topics, such as nutrition and medication management.
Wellness and health preventive services include chronic disease monitoring (blood pressure, blood glucose, and weight checks), health education, behavioral health assessment and support, and medication self-management education. The program educates participants on chronic conditions to assist with transitions between care settings if needed.
Care Coordination
Care coordination services include communicating changes in clinical status to primary care providers or connecting residents to an appropriate provider (for those without an identified provider). The MHWP team offers to make the call on behalf of the participant, or the option for the participant to make the call themselves. If the participant wishes to contact the provider, they are provided with the health data obtained from the MHWP visit, such as blood pressure measurements or blood glucose readings from the case notes.
The program also links participants to other community service agencies to address social determinants of health. The MHWP team makes these connections on behalf of the participant, or information regarding the community service agency is given to the participant if they prefer to make the contact. For example, areas of greatest need for the MHWP community include transportation and food insecurity.
Intake Assessments
The intake assessments used in MHWP are centered around the 4Ms of an age-friendly system: Mobility, Medications, Mentation and What Matters. The intake assessments used in MHWP include:
- Balance and strength assessments:
- Katz Activities of Daily Living
- Frail Questionnaire
- Vulnerable Elders Survey
- Medication adherence
- Opioid risk
- USDA Food Insecurity
- Social Determinants of Health Screen
- Housing Instability Screen
- Loneliness and Isolation Screening
Participant Notes
After each visit to MHWP, notes are updated in a secure, HIPAA-compliant database. The database is customized to the needs and visits of MHWP. An example of information stored in the database could include:
- date of visit
- location of visit
- visit type
- participant age
- participant’s reason for visit
- participant-reported health conditions
- changes since the last visit (e.g., emergency contact, insurance, pharmacy, primary care provider, allergies, new health condition, changes in mobility, visits to
- primary care provider or emergency room)
- list of assessments and screenings performed at the visit
- time spent during the visit
- education provided during the visit
- name of supervising faculty
Visit Example
Mr. Bishop, a 67-year-old man, approached the MHWP team located in the community room of his apartment building. He requested to join the program because of a “health scare” after fainting in the lobby on the previous day. The incident prompted the building manager to call an ambulance. Paramedics determined that his blood sugar was very low and provided onsite treatment. Although the paramedics encouraged him to be transported to the hospital for follow-up care, he elected not to go.
After obtaining consent, the nursing student conducting the initial history learned that Mr. Bishop had diabetes, hypertension, and heart failure. Because he was unable to remember what medications he was prescribed, Mr. Bishop went up to his apartment. He brought all of his medications with him so his medication profile could be established. During the medication review, it was discovered that one of his insulin pens was empty; he was aware of the need for a refill but could not get a ride to the pharmacy.
He explained that he usually took 40 units from the blue pen and 10 units from the green pen but assumed it was okay to substitute insulin from the green pen when the blue pen ran out. Upon further questioning by the pharmacy student, it was discovered that he could not read and interpret the medication instructions. Also, it was determined that he had been substituting a long-acting insulin with a short-acting insulin, which may have caused a hypoglycemic reaction on the previous day. With Mr. Bishop’s permission, the faculty member contacted the primary care provider (PCP), relayed the events, and informed them about low health literacy concerns. The PCP was unaware that health literacy was an issue.
The pharmacy student called to get a prescription refill, and the social worker student arranged transportation to the pharmacy to pick up the prescription. The MHWP team also developed a self-management plan with Mr. Bishop, including medication self-management and general diabetes education. Further, they recommended regular wellness visits for follow-up. In a debriefing session, the faculty member discussed challenges and barriers to accessing care, diabetic guidelines for older adults, health literacy, and best practices for communication with another provider.