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Healthy Ager: an interprofessional, service-learning, town-and-gown partnership.

ABSTRACT Healthy Ager, an interprofessional service-learning clinical experience for health professions students, is a semester-long program of wellness and falls prevention for community-dwelling older adults. It provides a foundation for competency in geriatrics for students in nursing, physical therapy, social work, and communications disorders. Such interprofessional education is recommended by the Institute of Medicine.

Key Words Interprofessional Education--Older Adults--Service-Learning--Education-Community Partnership

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HEALTHY AGER OFFERS A WELLNESS AND FALLSRISK-ASSESSMENT PROGRAM FOR COMMUNITYDWELLING OLDER ADULTS, AS WELL AS A SERVICE-LEARNING CLINICAL EXPERIENCE TO HEALTH PROFESSIONS STUDENTS AT A SOUTHEASTERN UNIVERSITY. The program fulfills the National League for Nursing (NLN) vision for transformed nursing education (2011) and provides a model for interprofessional collaboration between a university and a community organization.

Healthy Ager is a full-semester spring course for accelerated second-degree bachelor of science in nursing (BSN) students, as well as students in the doctor of physical therapy (DPT), social work (SW), and communication disorders (CD) programs. Begun in 2003 to provide clinical experiences in geriatrics for BSN and physical therapy (FF) students, the program evolved to include SW and CD students during the spring 2011 semester and clinical lab science (CLS) students in 2012.

The program's success comes from the intentional, careful coordination of school schedules and older adult recruitment between the community-based Center on Aging-Northeast (town) and the university (gown). In 2003, the university was approached by the community partner with the idea of providing students in the health care professions a clinical experience involving community-dwelling older adults as opposed to the ill, frail elders typically seen in clinical settings. The "town" aspect of the partnership allows faculty to concentrate on delivering care through the students and leaves marketing and recruitment to the community partner.

The Curriculum and Program Structure In the fall of each year, the university and community partners meet to discuss plans for the coming spring when the program takes place. Curriculum and logistics are discussed and changes are implemented for continuous improvement. The community partner begins recruitment in early January, based on the number of students enrolled in the PT and second-degree, accelerated BSN programs.

Coordinated on the university side by a faculty team from PT and nursing, the program enrolls students in their respective discipline's clinical courses and in a common BlackBoard course (Health and Wellness) placed within the PT core curriculum. This common course serves as a place for online orientation, course resources, announcements, group assignments, and online discussion.

During the first two weeks of the 14-week semester, students self-select into teams of PT and BSN students. In 2010, 16 PT students and 14 nursing students cared for 18 older adults; in 2011, 24 PT students and 22 nursing students cared for 27 older adults; and in 2012, 30 PT students and 21 nursing students cared for 33 older adults. Due to the uneven ratio of nurse to PT, some students were paired with more than one partner to serve the needs of the older adult participants. Five to six more participants than students are recruited each year because historically, some drop out and students are left without a patient. In 2012, when fewer individuals dropped out of the program, the students accommodated the increased demand by forming multiple teams.

Each team is comprised of a PT and a nurse paired with a Healthy Ager. Throughout the program, SW, CD, and CLS students interact with the team to provide services. For example, the SW students complete depression and cognition assessments and assist with community referrals; the CD students conduct hearing screens; and the CLS students draw blood. In 2013, dietetics students will be added to the team to complete nutrition assessments and counsel participants.

PREPARING FOR MEETING CLIENTS Members of the nursing-PT student teams complete Personal Wellness Profiles (www.wellsource.org) to assess their own wellness and risk for cancer, diabetes, and heart disease. Nursing students perform a physical assessment on their PT counterpart and the PT students reciprocate. Thus, students have an opportunity to become familiar with the assessments before meeting the older adults. Two SW students assigned to the program enter after the first two weeks, and CD students assist only during hearing assessments. CLS students draw blood for metabolic panels at the beginning and end of the program.

An online component takes place during weeks three through eight. The goal is to build students' geriatrics competencies. Every week for six weeks, PT, BSN, and SW students enter an online folder containing resources on specific aspects of aging. Discussions touch on universal design as an aspect of falls prevention, how changes in hearing and vision affect cognition, spirituality and the older adult, the role of fragility in falls, sexuality and aging, and health professionals' attitudes toward older adults.

An example of questions posted to the discussion board is this one about universal design: "Look at the principles of universal design and the home redesign information from AARP in the Universal Design folder. If you were a 75-year-old living where you live now, what accommodations would need to be made to make your space conform to universal design principles?" By thinking about their own homes, students may consider the principles of universal design, priming them for the upcoming home visit and assessment of an older adult's environment. Students have said that the discussion board is valuable in preparing them for encounters with older adults. Online reading assignments and discussions help students understand older adults' behaviors and limitations over the course of the semester.

CLIENT RECRUITMENT AND ASSESSMENT Several months before the program starts, community-dwelling older adults are recruited by the nurse director of the program at the medical center serving the geriatric population of this southeastern state. Participants must have a medical release from a physician and agree to go to the university for two hours twice a week for 10 weeks. During the first four weeks of the semester, the older adults come to the campus for twice-weekly two-hour appointments with their student teams. Each team helps the older adult complete a Personal Wellness Profile. The team completes a falls-risk assessment and evaluates balance, strength and endurance, nutrition, medication, mood and cognition, and hearing. Participants receive a more thorough audiogram if warranted.

Once assessments are finished (see Table), the team meets with the participant (and caregiver, if appropriate) to review findings, set goals for the 10-week program, and create a wellness plan that's individualized and focused on building strength and fitness. Participants are divided into risk groups for falls based on Dynamic Gait Index and Berg Balance Test scores. Education for those in the low-risk group includes fall-prevention strategies and addresses fragility factors such as osteoporosis, vitamin D supplementation, hydration, and diet. Those in the high-risk group receive the same education as those in the low-risk group, plus a program to improve balance by focusing on deficits as determined by the NeuroCom Balance Manager, which determines the source of balance deficits (vestibular, somato-sensory, visual, or a combination) and therapies to address them. At the end of the program, participants are reassessed to determine changes in overall wellness, balance scores, and falls risk.

FROM THE CLINIC TO THE HOME Midway through the program, PT and nursing student teams make home visits to assess for fall hazards. If there is concern about issues within the realm of social work, the SW student may accompany the team. Students create a map of the environment that includes the width of doorways and walkways, accessibility of bathrooms and kitchen, and hazards in entranceways. Recommendations are shared with the older adults. This experience becomes a relationship builder. The older adults are pleased to have the students visit and invariably serve refreshments.

The benefits of the home assessment were seen when a BSN, PT, and SW team visited the home of a woman who had right-sided hemiparesis resulting from a stroke. The house was on a dirt road, and the front porch was rotting and unsafe; walkways were cluttered with trash. The woman was cared for by her daughter, who lived with an abusive, alcoholic husband. As a result of the team's work with the family, the daughter made the decision to move into town and leave her abusive marriage.

Gradual but often dramatic changes in older adults have been seen toward the program's end. In 2010 and 2011, all of the 45 older adults participating in the program achieved some reduction in fall risk as measured by improvements in the Berg Balance Test, Dynamic Gait Index, and the Personal Wellness Profile.

CELEBRATING ACCOMPLISHMENTS The last day of the program, students and participants bring food for a potluck celebration coordinated by the town and gown faculty at a community location. A faculty member leads a discussion of what group members learned from one another and how the program might be improved.

During one celebration, students acknowledged that their views of aging had been changed by getting to know older people who embrace life regardless of age. Older adults said that associating with high-performing college students renewed their faith in the next generation of health care providers. The Healthy Agers said that they intended to maintain their wellness in the coming months and were introduced to the community senior center.

Healthy Agers and students received photographs of their teams as a reminder of their partnership, exchanged email addresses and phone numbers, and promised to stay in touch. In reflective journals, students wrote about the friendships they had formed with older adults and the respect they had developed for other disciplines. The students learned that "old" can be hip, fun, adventurous, accomplished, and excited about life.

Lessons Learned Faculty have learned several lessons since the program began in 2003. At first, for example, questions in the Personal Wellness Profile were assigned to team members according to discipline. But soon, faculty noticed a move toward interprofessional care as team members asked the questions together. When BSN students accompany a Healthy Ager to the health assessment labs for a physical exam, the PT students watch the exam and help in taking vitals and assessing muscle strength. In turn, BSN students watch PT students complete strength and balance assessments.

Leaps in clinical confidence are noted among some students as they learn to manage their time, hone their clinical skills, and grow comfortable in their role. While some students organize their time easily and approach the assessments methodically, others are immobilized. Faculty gently coach them to take the assessments one at a time and not be intimidated by the wide scope of the assignment. Students learn that preparation makes a difference in the quality of the assessments and the amount of information gathered. Occasionally, faculty help students in the assessments and model expected behaviors, attitudes, and skills. Students report that this experience is valuable in developing their clinical decision-making skills and making them feel like real clinicians.

All students are challenged by the work of an interprofessional team. Nursing students learn to use their limited time wisely by providing short lessons tailored to their Healthy Ager, or by following up on previous weeks' interventions. All team members share the notebook that documents the care for each Healthy Ager. The notebook functions as a communication tool between team members as students work to complete their weekly documentation. Each day, assessments and students' notes are completed and signed off by a faculty member.

Some older adults initially resist visiting a social worker because they believe that social workers deal only with mental health issues. When this stigma is identified, the SW students make themselves available during the exercise sessions for private consultations. Interaction with the SW students gives BSN and PT students first-hand information on the community resources available on a variety of topics, including elder abuse, sexuality, caregiver strain, and advance directives.

The Teaching of Interprofessional Practice In a qualitative analysis of student reflective journals (Atlas.ti; Version 6.2.27), valuing the learning experience of work in an interprofessional team, valuing the need for adequate collaboration and communication among team members, improved health care delivery, and improved wellness for the older adult because of the team emerged as dominant themes. These themes are similar to core competencies for interprofessional practice identified by the Interprofessional Education Collaborative Expert Panel (2011): Values/Ethics for Interprofessional Practice, Roles/ Responsibilities, Interprofessional Communication, and Teams and Teamwork.

To develop problem-solving skills, students are challenged to take ownership of some aspects of organizing and scheduling. For example, despite the parking permits they receive, parking on the college campus can be a problem for participants. Students instruct them to drive under the breezeway attached to the building where the program takes place, and a team member parks the car for them. This valet service is provided at the end of the day as well, allaying participants' fears of falling.

The older-adult wellness clinic allows students and faculty to put into practice the principles of interprofessional care. The World Health Organization (WHO) states that interprofessional education occurs "when students from two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes" (WHO, 2010). The five interprofessional competencies (provide patient-centered care, apply quality improvement, employ evidence-based practice, utilize informatics, and work in interdisciplinary teams) identified by the Institute of Medicine summit on health professions education (IOM, 2003) are incorporated in course expectations and outcomes. Also, the project builds upon the behavioral expectations for interprofessional collaboration identified by the American Association of Colleges of Nursing (2008) and incorporates the IOM (2009) call to prepare nurses to pursue careers in the care of older adults, to access evidence-based interventions, and to provide interdisciplinary care in community settings.

This educational experience provides competency in geriatrics for the licensure and certification of health care professionals, as recommended by the IOM (2008). It also fulfills the NLN's vision that "direct knowledge of older adults in planned, intentional encounters is necessary in order for nurses to promote human flourishing with scientifically grounded nursing judgment" (2011).

In May 2011, the Interprofessional Education Collaborative convened an expert panel to develop competencies for interprofessional practice that would "engage students of different professions in interactive learning" (p. 1). Citing the work of D'Amour and Oandasan (2005), the collaborative suggests that a shift in education and practice is taking place, and that this new discipline is called interprofessionality. Elucidating the characteristics of this discipline is the ongoing work of the Healthy Ager project. Preliminary work includes a qualitative analysis of themes noted in students' reflective writings that have shown the values, codes of conduct, and ways of working that inform the concept of interprofessionality.

Over the past seven years the Healthy Ager project has evolved from working with relatively healthy older adults to recruiting older, multi-ethnic adults with multiple chronic conditions. The increased complexity of the patients requires weekly communication and coordination among student team members. Faculty watch students grow from reluctant participants in a peripheral clinical experience to members of a committed team with an older adult at its center. Many students call it the best clinical experience of their program, saying it makes them feel more confident and competent.

The teaching of interprofessional practice begins with faculty discussing their expectations and concerns with one another. Working out the framework of interprofessional education among faculty takes time, humility, patience, and lots of work. Adding community partners to create a "town and gown" collaboration adds another layer. Communication and transparency among all parties are the keys to success. If, at times, this effort does not seem worthwhile, all doubts disappear when the students greet an older adult with a hug and all go off to learn together.

References

American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved from www.aacn.nche.edu/Education/pdf/ BaccEssentials08.pdf/

D'Amour, D., & Oandasan, I. (2005). Interprofessionality as the field of interprofessional practice and interprofessional education: An emerging concept. Journal of Interprofessional Care, 19(5), 8-20.

Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, DC: National Academies Press.

Institute of Medicine. (2008). Retooling for an aging America: Building the health care workforce. Washington, DC. National Academies Press.

Institute of Medicine. (2009). Forum on the future of nursing: Care in the community. Washington, DC: National Academies Press.

Interprofessional Education Collaborative Expert Panel. (201 I ). Core competencies for interprofessional collaborative practice: Report of an expert panel. Retrieved from www.aacn.nche.edu/Education/pdf/ IPECReport.pdf

National League for Nursing. (2011). Caring for older adults [NLN Vision Series]. Retrieved from www.nln.org/ aboutnln/livingdocuments/pdf/ nlnvision_2:pdf

World Health Organization. (2010). Framework for action on interprofessional education and collaborative practice. Retrieved from http://whqlibdoc.who.int/ hq/2010/WHO_HRH_HPN_10.3_eng. pdf

Rebecca L. Matthews, DNP, RN, IBCLC, is an associate professor in the accelerated and traditional baccalaureate programs at Arkansas State University, Jonesboro. Beverly Parker, MNSc, RN, is director of education, Center on Aging-Northeast and director of the St. Bernards Senior Health Clinic, Jonesboro, Arkansas. Shawn Drake, PhD, PT, is associate professor and chair, Department of Physical Therapy, Arkansas State University, Jonesboro. For more information, contact Dr. Matthews at rmatthews@astate.edu.
Table. Healthy Ager Interprofessional Assessments

Discipline Assessments and Lead

All Personal Wellness Profile
 American Geriatrics Society-British Geriatrics Society
 Clinical Practice Guidelines for Prevention of Falls
 in Older Persons
 (www.americangeriatrics.org/files/documents/health_
 care_pros/Falls.Summary.Guide.pdf)

Nursing Beers Criteria for Potentially Inappropriate
 Medication Use in Older Adults
 (www.americangeriatrics.org/files/documents/beers/
 2012BeersCriteria_IAGS.pdf)
 Physical assessment
 Pittsburgh Sleep Quality Index
 Mini-Nutritional Assessment and 48-hour diet recall
 Screening Questionnaire for Adult Immunization
 Chronic disease self-management goal setting
 Environmental assessment

Physical Cardiac risk stratification
therapy Dynamic Gait Index
 Berg Balance Test
 Six-Minute Walk Test
 Urinary incontinence screening
 Environmental assessment with nursins

Social work Geriatric Depression Scale
 Mini-Cog
 Modified Caregiver Strain Index as needed

Communication Hearing screening
disorders

Dietetics All nutrition assessments and teaching will be with
 dietetic students in 2013.
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Author:Matthews, Rebecca L.; Parker, Beverly; Drake, Shawn
Publication:Nursing Education Perspectives
Date:May 1, 2012
Words:2987
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