Participating clinical teams are asked to select a significant but manageable population health project in the program. Teams will apply the learnings from the in-person sessions, along with the materials and coaching from the online environment, to their population health project. At the final session, teams become the teachers and teachback to the cohort, providing lessons learned and insights from their project.
“I wish we knew about this a month or two ago because it’s been life changing for the family members” -Stephen Rennyson, M.D. CMG Stroobants Cardiovascular Center speaking on his team’s capstone project.
“We got a lot out of Evolve; we really did. It was nice to have all those minds together —physicians from different practices and different fields looking at and facing the same challenges” and finding ways to overcome them, said LPN Kathy Jones, one of the six Forest Family Physicians staffers who attended the Evolve training.
In this article, evolve participant Dr. Thomas W. Eppes Jr. highlights the experience of his team through their experience in evolve.
On average, evolve project teams are typically comprised of 3 people. The teams typically include an MD and/or NP, as well as one or more RN, NP, PA, or nurse manager. Examples of past capstone projects include:
- Combining the resources of the heart failure group and hospice for patients with advanced heart failure who met eligibility criteria for hospice services
- Coordinating care of non-sickle red cell disorder patients
- Educating ED patients through video discharge instructions
- Engaging a mobile health vehicle team to advise regarding integration of ophthalmic screening in primary care for the purpose of preventing blindness
- Ensuring safe transitions of high-risk pneumonia patients from inpatient to post-acute care to home
- Improving coordination and access to care through same day appointments for patients requiring high complexity appointments
- Improving identification of palliative care needs and access to palliative care services for hospitalized patients
- Improving the rate of Medicare wellness visits in a family medicine residency training program
- Increasing efficiency and decrease the number of failed transfers of patients, which result from conflict surrounding identifying an accepting provider
- Providing affirming LGBTQ healthcare