Date post: | 25-Dec-2015 |
Category: |
Documents |
Upload: | solomon-west |
View: | 219 times |
Download: | 4 times |
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
You can also dial in using your phone.
United States +1 (571) 317-3122
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 | [email protected]