Interprofessional medical and behavioral health clinic in an urban setting:The role of social work

We describe an interprofessional care model that has been implemented in a health and wellness clinic in Newark, New Jersey to address primary care and preventive care needs of an urban, medically underserved, and vulnerable population with a focus on both care and teaching interprofessional care.  The nurse-managed health center uses an interprofessional collaborative practice model that draws upon the expertise of advanced practice nursing, social work, pharmacy, and violence prevention specialists to address physical and/or mental health issues. This collaborative care model with team-based care reflects one method for addressing care coordination and communication issues that have resulted in fragmented care that has become the focus of the Affordable Care Act. In this model, professional team members are also faculty members of a university, whereby they are able to provide supervision for field placements/internships on site and teach classroom-based courses on interdisciplinary care. Students have an opportunity to observe and model professionals’ interaction while learning and impacting lives of clients they serve. Started in late January 2013, to date, the clinic has seen 317 patients (30%male/70%female)with an average age of 41 years and a majority being (56%) being Hispanic. Patients have been diagnosed with hypertension (27%), depression (23%), substance use (28%) and asthma (15%); 10% experience violence. Twenty-three percent of patients see a social worker, 24% a psychiatric nurse practitioner and 19% a pharmacist for intervention. This presentation will describe the model and how the team works together, including students, to collaboratively intervene on medical/chronic disease and behavioral health issues.