Program Foundations
Established in 2012, the Mobile Health and Wellness Program (MHWP) delivers weekly wellness visits to medically vulnerable and underserved communities at nine sites across the central Virginia region.
The program brings person-centered care in three areas:
- assessment and access to care
- health promotion and prevention services
- addressing social risk factors to reduce inequities
MHWP participants receive access to key services to help them independently manage their healthcare needs, including assistance with care coordination, transitions from the emergency room to an inpatient hospital stay, and health education and coaching.
The aim is to proactively manage health and wellness needs. The program is led by the VCU School of Nursing and faculty partnerships with the VCU schools of Pharmacy, Medicine, Social Work, and the Occupational Therapy, Physical Therapy, Kinesiology, Health Sciences, and Psychology departments.
Program Features
The Mobile Health and Wellness Program provides support for populations across the lifespan. In our sites that offer support for older adults, the model was created with a dual purpose: pairing geriatrics (the medical care and treatment of older individuals) with gerontology (the physical, mental, and social aspects of aging). While the geriatrics-centered program is concerned with minimizing disease and risk factors in aging bodies, it uses a gerontological framework, accounting for an individual's experiences, not just their clinical indications. In other words, shifting the provider's perspective from patient-centered to person-centered.
This holistic approach, taking the personality and environment of participants as well as their social needs into account, allows students who participate as MHWP providers to gain valuable experience integrating clinical education into practice. Through encountering topics such as ageism and elderhood in the curriculum, students are taught to view program participants as still-growing and changing people with an interest in forming new goals rather than as patients in one single moment in time.
The interdisciplinary model of the Mobile Health and Wellness Program offers a robust, interprofessional educational experience for students by incorporating the four core competencies for interprofessional collaborative practice:
- values/ethics
- roles and responsibilities
- interprofessional communication
- teams/teamwork
Many interprofessional learning experiences are classroom-based using case studies as the primary basis for learning. MHWP provides a unique opportunity for students to participate in hands-on learning in an interprofessional environment and gain direct experiences in the core interprofessional competencies.
Watch our video 'Interprofessional Collaborative Practice' to learn more about hands-on learning in an interprofessional environment.
The Mobile Health and Wellness Program is deliberately constructed as an Age-Friendly Health System. The designation means that MHWP’s approach is centered on a set of four evidence-based elements of high-quality care, known as the “4Ms:”
- What Matters
- Know and align care with each older adult's specific health outcome goals and care preferences including, but not limited to, end-of-life care, and across settings of care.
- Medication
- If medication is necessary, use Age-Friendly medication that does not interfere with What Matters to the older adult, Mobility, or Mentation across settings of care.
- Mentation
- Prevent, identify, treat, and manage dementia, depression, and delirium across settings of care.
- Mobility
- Ensure that older adults move safely every day in order to maintain function and do What Matters
The 4Ms create the framework for assessments and education in the MHWP program. Using these four elements as a guide, MHWP seeks to address the issue of health equity within the community.
Participant Example
The following case exemplifies the MHWP process.
MHWP participant Mr. AV reported falls on two occasions over a 20-month period. In addition, AV frequently indicated fear of falling, occasional dizziness and feeling unsteady and weak.
Using the Mobility workflow, a more complete assessment was initiated with medication review, home assessment and evaluation of mobility using the Timed Up and Go (TUG), all indicating positive factors for fall risk.
Education was provided over time about hypoglycemia symptoms and the timing of eating and insulin to reduce hypoglycemia as a risk for falls. After a home visit, the MHWP also offered education to address insulin administration and storage, diabetes self-monitoring and use of a shower chair and rollator to reduce fall risk.
In this case, no intervention plan for referrals was documented, demonstrating a need to continue to work towards improved follow-up from week to week. Student teams working with AV also explored how he was using his rollator in the community, including making the half-mile walk to a grocery store, taking rest breaks as needed.
A year into the COVID pandemic lockdown, AV reported difficulty getting in/out of bed. Through the relationship built over time with AV, MHWP uncovered a number of issues interfering with his ability to achieve his health and wellness goals, including a deep mistrust of the health care system, low health literacy, lack of self-efficacy in managing medications and self-monitoring of diabetes and hypertension, and episodes of feeling depressed or helpless in facing health challenges.
Through education, MHWP helped AV learn how to more effectively communicate with his health care providers, established frequent check-ins and encouragement to build AV's skills in self-monitoring. As a result, AV is has improved self-management of these aspects of his care, exhibited better control of his chronic health conditions and maintained independent living.