2018 Population Health Focused Pilot
Quality Improvement Activity (PHFPQ)
Vocational Rehabilitation
For questions or technical assistance, please contact:
Brittney Jackson, LMSW, MBA
Patient Services Director
(203) 285-1213

A priority of the Network is to serve as a resource to both dialysis patients and professionals throughout PHFPQ activities. 

DISCUSS: Talk with dialysis team members and patients to identify root causes of barriers in vocational rehabilitation referrals/patient receiving services.

OUTLINE: Develop a Plan-Do-Study-Act (PDSA) cycle to address identified barriers.  
The Network is working with 20 facilities, representing 10% of the Network 1 service area. The Network aims to improve patient education about vocational rehabilitation (VR) and employment networks (EN), regular elicitation of patients' goals, and genuine efforts to achieve them. Moreover, as a result of the QIA patients will better understand the benefits of goal setting, VR and EN services, and how to utilize those services.
If you have any questions about the facility's role and responsibilities for implementing the QIA, please call 203-285-1213.
NOTE: Documentation of vocational rehabilitation status in CROWNWeb is vital, as it will be the source of measuring improvement at the facility-level.

Tools & Resources
Throughout this project, participating facilities will receive tools and resources for patient self-management, goal setting, and VR/EN patient education.  Please carefully review the How to Use This Toolkit document to understand the resources provided and how patients should be guided through the 5-steps of the Your Life. Take Charge! Roadmap & Action Plan.
The Generalist Intervention Model (GIM)
Dr. Karen Kirst-Ashman is a Licensed Clinical Social
Worker who has spent years teaching and writing
about social work practice. She has written six social
work textbooks, including Understanding Generalist
Practice (with Grafton Hull). One of Kirst-Ashman's
and Hull's key foci is the Generalist Intervention
Model (GIM).
The GIM seven-step model for planned change is
directed to individuals, groups, and communities
(Kirst-Ashman & Hull, 2013). This model will help
staff members partner with patients from a
strengths-based perspective to set goals that will be
incorporated into their care plans, monitor their
progress, address barriers, and follow up with the
patients on both clinical and self-management goals.

The seven steps of the GIM include:
1. Engagement (Motivational interviewing and
active listening)
2. Assessment (Articulate a clear statement of the
need, problem, or situation)
3. Planning (Prioritize needs, establish goals, set
action steps)
4. Implementation (Follow plan and revise when
5. Evaluation (Monitor progress)
6. Termination (Evaluate achievement of
objectives/maintain and continue progress)
7. Follow-up (Discuss problems & address barriers)
Project Goals

* Participating facilities shall demonstrate a ten (10) percentage point increase in referrals to EN/VR agencies in by September 30, 2018.


* Participating facilities shall demonstrate a five (5) percentage point improvement in the number of patients receiving EN/VR services by September 30, 2018.

We Want to Hear from YOU!
Please contact the Patient Services Director if you have questions, comments, or specific barriers that you would like to address.  Let us know if you have identified any best practices that you would like to share with the community.