Addressing Structural Inequalities in Healthcare: An Interprofessional Model of Care Coordination

Purpose:There has been significant discourse surrounding the widespread system failures within healthcare during COVID-19. The healthcare system, strained by the pandemic, also exposed inequalities and racial bias exist within the system that often makes it difficult for accessing quality care. Older, frailer, and poorer persons across the United States have been the most impacted by COVID-19. Even prior to COVID-19, in our community, persons living in zip codes in the poorest, most marginalized areas of the county had a 12 year decrease in life expectancy than those living in the wealthier zip codes.

Our FlourishCare team, received funding through the COVID Cares Act, as part of our Geriatric Workforce Enhancement Program (GWEP) grant, to create innovative programming for individuals that were the most impacted by the pandemic. Remote patient monitoring (RPM) is one intervention been shown as an effective way to assist persons in managing their chronic conditions, in particular, those dealing with hypertension, diabetes, and COPD. RPM has been shown to reduce hospitalizations for patients with chronic conditions.

Methods: For RPM, patients from our Optimal Aging Clinic were identified as struggling in managing hypertension, diabetes and/or COPD. We focused on patients that lived in zip codes that were poorer, more marginalized areas of our city, and where access to healthcare services often posed a challenge. For each RPM patient, a technology assessment is conducted with patients prior to their first home visit. If a patient did not have internet access, or a smart device, we provided them with a hotspot and/or tablet. Interprofessional teams of nursing and social work learners were assigned to work with patients enrolled in the program. The kits that our team provides the patient with, is through VitalCare, and contains all of the necessary technology, as well as a virtual app platform, that allows a patient to check their heart rate, blood pressure, oxygen levels, glucose levels, temperature and weight. This information was then disseminated to the team coordinating the patient’s care.

Results: The sample was mostly female (88%), African American (64%) and retired (70%). The mean age was 60 (SD=4), and 40% had less than a high school diploma. All patients were initially assessed using our team’s GWEP holistic assessments, known as the FlourishCare Index (FCI). The FCI was developed as a clinical measure to assess the effectiveness of our integrative health model (FlourishCare Model) to address to the biological, psychological, individual health behaviors, access to health services, environmental and social determinants of health. After 3 months in the program, we saw a significant improvement across all determinants of health, with a particular overall change in access to health services and individual health behaviors.

Conclusions: This study showed the importance of providing patients with access to technology and how the support of an interprofessional team can improve patient outcomes, lead to improvements in individual health behaviors and improve health literacy.