Across the nation, individuals with complex medical and social needs, often the result of social determinants of health (SDOH), use emergency rooms and hospitals frequently. These patients comprise 5 percent of the population but account for 50 percent of national healthcare expenditures.
Despite high utilization, they’re falling through the cracks of a fragmented healthcare system. Indeed, medically and socially complex patients are receiving ineffective care, in part, because the U.S. health system has historically separated behavioral, social, physical and occupational health and because our workforce isn’t equipped to address the SDOH that drive outcomes. As a result, there’s a crisis in caring for them.
Jefferson has long been at the forefront in developing a new complex care educational model to train the next generation of providers to deliver integrated, person-centered care for patients with complex needs. The Jefferson Center for Interprofessional Practice and Education (JCIPE) was recently awarded a three-year grant from the Josiah Macy Jr. Foundation on “Learning to Practice Collaboratively for the Benefit of Patients with Complex Needs.”
This grant supports a new Complex Care Curriculum (3Cs) that enables students to identify the unmet health and social needs of complex patients and learn best practices from effective clinical care models to work to address them while transforming our healthcare system. The educational goals of the 3Cs are to train health professions students to think more broadly about the lives of patients with complex health and social needs; recognize the impact of SDOH on health outcomes; learn to work as collaborative team members; and positively impact health outcomes of patients with complex health and social needs.
This new 3Cs curriculum builds upon JCIPE’s current menu of interprofessional educational experiences, particularly the Health Mentors and Student Hotspotting programs. Health Mentors is a required longitudinal interprofessional education curriculum for all first- and second-year students from 10 disciplines. Interprofessional teams of students are partnered with a community member volunteer (health mentor) who has a chronic condition or impairment.
The program allows students to observe how a person’s social and physical environment interacts with health and well-being; understand and value person-centered car; meet health professional students from professions other than their own; and value and respect the varied and changing roles and contributions of the members of the interprofessional team.
Jefferson has been a leader in Student Hotspotting since the program’s inception in 2014
Student Hotspotting is a voluntary, six-month interprofessional education curriculum for advanced students from different disciplines, where teams of interprofessional students work directly with patients with complex health and social needs using a person-centered approach. Students learn about barriers to care faced by individuals; the importance of coordinated care and a person-centered approach; the value of interprofessional collaboration and community partnership; and the significance of patient experiences and stories.
Partnering with the National Center for Complex Health and Social Needs, Jefferson has been a leader in Student Hotspotting since the program’s inception in 2014 and was recognized as one of four national Student Hotspotting hubs in 2017.
“The 3Cs curriculum will allow students to better understand how fragmented and overwhelming the healthcare system can be to navigate and appreciate how socioeconomic factors impact health and well-being and lead to disparities in health outcomes,” says Dr. Brooke Salzman, co-director of the Jefferson Center for Interprofessional Practice and Education and project principal investigator.
The 3Cs curriculum will allow students to better understand how fragmented and overwhelming the healthcare system can be to navigate.
–Dr. Brooke Salzman
There’s a strong emphasis on SDOH and how that impacts one’s wellness and health, says Dr. Tracey Earland, project co-principal investigator and occupational therapy associate professor.
“By collaborating with these individuals and walking in their shoes, students begin to understand their narrative,” Dr. Earland says. “For instance, the patient isn’t taking their medication not because they’re obstinate or ‘noncompliant,’ but because they’re having challenges affording, accessing, organizing, understanding and/or tolerating their medications. They may not have the money or someone to take them to the pharmacy. We really want this experience to shape the way our students think about the root cause of health and social challenges.”
By collaborating with these individuals and walking in their shoes, students begin to understand their narrative.
–Dr. Tracey Earland
Under the guidance of interprofessional faculty and clinical advisers, students will develop their teamwork skills; increase their knowledge of, comfort working with and empathy toward medically and socially complex patients; advocate on behalf of their patients; and collaborate with community partners. The grant also will allow Jefferson to collect and analyze program data, assess the impact of 3Cs and, eventually, disseminate the model nationally.
“The hope and ultimate outcome is that students across the country are prepared and invested in providing high-touch, personalized, authentic care to patients with complex health and social needs,” Dr. Earland says, “and they are motivated to continue this work within their careers, helping to mitigate the crisis in care for patients with complex health and social needs.”
