Population Health Tools for Patients with Diabetes: Referrals and Improvement of Self-Management

June 9 2015

11:00 AM - 12:00 PM

Webinar Information

Tue, June 9, 2015 11:00 AM - 12:00 PM Pacific Daylight Time

https://global.gotomeeting.com/join/968989349

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Access Code: 968-989-349

Agenda

Patient Engagement

Population Health Tools

Care Coordination

Referral Strategies and Tools

PCMH

Diabetes Resources

Discussion: Peer Sharing and Learning Your Ideas & What you need

Patient Engagement

Proven Tools to Gauge Engagement: Technology and Processes Engagement is a dynamic process intertwined with many elements of human nature such as empathy, concern, confidence, and care. Tools that assess readiness to engage, establish goals in engagement, and point to the most valuable next steps in care are useful for understanding the readiness of each patient to engage in their care.

Population Health Tools

Recipe box

Community Based Organizations

Relationships

Data dashboards

QI/QA

I2i

E.H.R.

HIE

Population Health Tools and ACA Success

Applications may include:

Computerized physician order entry

Admission, discharge and transfer

Billing

Practice Management

Enrollment

Care management

Health information exchange technology is required to integrate EHRs, claims, laboratory and pharmacy

Key applications for population management include:

Analytics for performance measurement, patient identification and stratification.

Workflow applications that include the ability to create and manage care plans, track events and scheduling.

Patient engagement tools. In the future, these efforts likely will include more than a portal, including other channels such as texting to engage patients.

Diabetes Care Coordination Toolkit

Provides quality improvement approaches that a practice can use to ensure care coordination for people with diabetes

Includes: continuous quality improvement

approaches flow sheets referral letters patient information resources and references

Source: http://www.fmqai.com/library/attachment-library/AssuranceofDiabetesCareCoordinationToolkit.pdf

An Effective Referral System

Ensures a close relationship between all levels of the health system

Helps to ensure people receive the best possible care closest to home

Making cost-effective use of hospitals and primary health care services

Support to community health centers and outreach services

Enhance access to better quality care

A Good Referral System Should: Ensure clients receive optimal care at the

appropriate level and not unnecessarily costly

Hospital facilities are used optimally and cost-effectively

Clients who most need specialist services can accessing them in a timely way

Primary health services are well utilized and their reputation is enhanced

AAFP: Simple Tools to Increase Patient Satisfaction with Referrals

1. Improve internal office communication

2. Engage the patient in scheduling

3. Facilitate the appointment

4. Track referral results

5. Analyze data for improvement opportunities

6. Gather patient feedback

Source: http://www.aafp.org/fpm/2011/1100/p9.html#

Improve Referrals and Transitions

Six elements associated with effective care coordination suggest that successful referrals and transitions should be:

Timely: Patients receive needed transitions and consultative services without unnecessary delays.

Safe: Referrals and transitions are planned and managed to prevent harm to patients from medical or administrative errors.

Effective: Referrals and transitions are based on scientific knowledge, and executed well to maximize their benefit.

Patient-centered: Referrals and transitions are responsive to patient and family needs and preferences.

Efficient: Referrals and transitions are limited to those that are likely to benefit patients, and avoid unnecessary duplication of services.

Equitable: The availability and quality of referrals and transitions does not vary by the personal characteristics of patients.

Source: www.improvingchroniccare.org/index.php?p=Care_Coordination&s=326

Using Referral Partners as Engagement Partners

Referral partners are an important facet of maintaining patient engagement.

be aware of the services the health center provides, the hours of operation, and any areas of specialty.

focus on their needs and ways your health center can partner with them.

Ask about their current patient satisfaction and metrics - create opportunities to jointly educate patients.

“Crucial Conversations” as a resource for more effectively working with reluctant partners.

Referrals between CHCs and Community Based Organizations in Massachusetts

Example of bi-directional referral

Nasuti HealthCare

Dr. Nasuti sees Jane Smith andrecommends health programs.

Jane gives consent for referral to Tobacco QuitLine

and local YMCA.

Tobacco Quitline &YMCA

Jane is contacted by Quitline and starts counseling program to quit smoking.

Jane is also contacted by YMCA for the Wellness Program.

Clinical Setting Transmission from EMR Community Resource

e-Referrals from Provider to (1) Quitline & (2) YMCA

Healthcare Org. Data; Provider Data;Patient Data; Referral Type data.

Nasuti HealthCare

Automatic updates of smoking and exercise program added to EMR.At next appointment, health careprovider is able to see the updateof Jane’s progress in Jane’s own

electronic health record.

Inbound Transaction

Progress report from communityresources to provider

Jane SmithSmoking status at 6 months

post referral, Wellness Program Sessions attended and improvements.

Clinical Setting Transmission to EMR Community Resource

Tobacco Quitline &YMCA

Quitline calls back 6-months postreferral for update. YMCA provides

updates on wellness program progress.

Outbound Transaction

15

A Flexible Health Information ExchangeFor “Clinic to Community” e-Referrals

Tobacco Cessation

Diabetes Screening

CDSMP

Visiting NurseAssociations

Tai Chi, Matter of Balance

Other Community Resources

EPIC

eClinical Works

AllScripts

NextGen

GE Centricity

Etc. Etc. Etc.

e-Referral System

Universal Translator (UT)*

- Secure transmission- HIPAA compliant- Standardizes data

- Path to full integrationCommunity

Referral Feedback Data

Referral Data Items

Referral Data Items

Community Referral

Feedback Data

Electronic Referral

Gateway (eRG)

Clinical Setting

EHRs

Community Setting

Interventions

The Electronic Referral Gateway

Monthly eReferral by CBO Status Report - June 2013

Council on Aging

Type Date Submitted Patient Name Patient ID Sent

To/From Status Priority

CDSMP 5/12/2013 John Jones 23432 Council Sent MediumCDSMP 5/24/2013 Bob Johnson 33221 Council Delivered Medium

YMCA

Type Date Submitted Patient Name Patient ID Sent

To/From Status Priority

Weight Loss 5/2/2013 Sally Smith 12345 YMCA

Boston Staged Low

Weight Loss 5/25/2013 Will Anders 56789 YMCA

Boston Opened Low

Sample Reports

NCQA PCMH 2014 Self Management

2D The Practice Team (MPE)

F5: training and assignment members of the care team to coordinate care for individual patients.

F6: Training and assigning members of the care team to support patients in self-management and behavior change.

F7: Training and assignment members of the care team to manage the patient population

3D Use Data for Population Management (MPE)

Proactively identifies populations of patients and reminds them of needed care based on patient information, clinical data, health assessments and evidence-based guidelines including:

F3: At least three different chronic or acute care services.

3E Implement Evidence-Based Decision Support

Implements clinical decision support following evidence –based guidelines for:

F2: A chronic medical condition.

NCQA PCMH 2014 Care Management & Planning

4A: Identify Patients for Care Management

The practice establishes a systematic process and criteria for identifying patients who may benefit from care management. Process includes:

F3: Poorly controlled or complex conditions.

F5: Referrals by outside organizations (e.g., insurers, health system, ACO), practice staff or patient/family/caregiver.

4B: Care Planning and Self-Care Support

Care team and patient collaborate to develop and update an individual care plan that includes:

F1: Incorporates patient preferences and functional/lifestyle goals.

F2: Identifies treatment goals.

F3: Assesses and addresses potential barriers to meeting goals.

F4: Includes a self-management plan.

F5: Is provided in writing to the patient.

NCQA PCMH 2014 Support Self-Care

4E: Support Self-Care and Shared Decision Making

The practice has, and demonstrates use of, materials to support patients in self-management and shared decision making. The practice:

F1: Uses an EHR to identify patient-specific education resources and provide them to more then 10% of patients.

F2: Provides educational materials and resources to patients.

F3: Provides self-management tools to record self-care results.

F4: Adopts shared decision making aids.

F5: Offers or refers patients to structured health education programs, such as group classes and peer support.

F6: Maintains a current resource list on five topics or key community service areas of importance to the patient population including services offered outside the practice and its affiliates.

F7: Assesses usefulness of identified community resources.

NCQA PCMH 2014 Referrals

5B: Referral Tracking and Follow-Up (MPE)

F8: Tracks referrals until the consultant or specialist’s report is available, flagging and following up on overdue reports.

5C: Coordinate Care Transitions

F6: Obtains proper consent for release of information and has a process for secure exchange of information and for coordination of care with community partners.

HRSA BPHC FQHC 19 Requirements

2. Required and Additional Services: Health center provides all required primary, preventive, enabling

health services and additional health services as appropriate and necessary, either directly or

through established written arrangements and referrals. (Section 330(a) of the PHS Act)

DM Self-Management and Referrals are also impacted by the community health needs assessment, scope of service, data collection/reporting and QI.

Diabetes Self Management & Referral Resources

Referral Rx tare pad. * Refer a friend letter.Pow-Toon marketing cartoons.* Recruiting tips.Nvhealthyliving.org

Stanford University DSMP

AADE & CDE in NV

Build relationships with AADEs and CDEs:

American Association of Diabetes Educators (73 in NV as of 6.9.15)

https://nf01.diabeteseducator.org/eweb/DynamicPage.aspx?Site=AADE&WebKey=cf6c53f0-27cf-474a-b1d1-dbad85535aac&FromSearchControl=Yes

National Certification Board of Diabetes Educators (NCBDE) (15 in NV as of 6.9.15)

http://www.ncbde.org/find-a-cde/

Insurance DM Programs

Ask insurance providers what they offer

Encourage them to offer more for DM patients

Care coordination

Community Based Organizations for DM

The Nevada Lions Diabetes Awareness and Action:

Helping to prevent diabetes and helping diabetics live a healthier and happier life is a mission of Lions Clubs International.

Each local club can engage its members in diabetes education programs

Lions Hunt for Diabetic Peripheral Neuropathy (DPN)

Free Foot Screening Program Lions Hunt for Prediabetes. Take the

Diabetes Risk Test and please tell your friends about it. http://ndep.nih.gov/am-i-at-risk/diabetes-risk-test.aspx.  Members are also being informed about the YMCA Diabetes Prevention Program through the cooperation of Barbara Carter.

PCMH Referral Linkage

Programs & Services NVHealthyLiving Diabetes Management Resources

DM Tools

The Future: Reimbursement for DSME

Additional Resources

American College of Physicians (ACP) provides a 2010 position paper to address the gaps that exist in care coordination when a physician refers a patient to a specialist: The Patient-Centered Medical Home Neighbor: The Interface of the Patient-Centered Medical Home with Specialty/Subspecialty Practices .

AHRQ Publication No. 11-0064. Rockville, MD: Agency for Healthcare

The Endocrine Society’s Managing the Transition of Care for Patients with Type 1 Diabetes This resource provides a number of materials to help with transition of care specific to type 1 diabetes.

Research and Quality. 2011: Coordinating care in the medical neighborhood: critical components and available mechanisms.

NDEP resource to help teens with diabetes make a smooth transition from pediatric to adult health care.

Group Discussion

What can you add to the resources and ideas shared today as used in your health center?

What will you use?

What will you share with others?

What is one thing you learned that you will act upon?

Feedback for Today’s Webinar

What worked well and should be repeated?

What didn’t work well and should be adjusted in the future?

What are your Action Steps from today?

Keeping Connected

Dawn Gentsch, MPH, MCHES, PCMH CCE

Nevada Primary Care Association

PCMH and Program Consultant

515.360.1731 M | dgentsch@nvpca.org