Tools for Better Health. Referral Toolkit. Health Care Providers

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1 Tools for Better Health Referral Toolkit Health Care Providers A guide to working with providers to establish a referral system for evidence-based self-management programs.

2 Table of Contents How to Use Referral Toolkit... 3 Referral Forms & Procedures... 4 Referral Diagram... 5 Referral Form... 6 Provider Feedback Form... 7 Outline of Duties... 8 Program Information... 9 Quick Facts More Facts Data Success Stories Frequently Asked Questions Promoting CDSME to Patients Contact Information Health Connections Bureau of Health Promotion Kansas Department of Health and Environment 1000 SW Jackson, Suite 230 Topeka, KS Phone: This publication was supported by the Cooperative Agreement Numbers # 1U58DP and 5U58DP , funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services. Updated

3 How to use the Referral Toolkit This toolkit is designed to help CDSME coordinators and leaders communicate to health care providers how the referral process works, and why providers and patients would benefit from participating in the referral process. This toolkit is not designed to simply be handed to a provider or to be read cover to cover during a presentation. However, providers are welcome to keep a copy so they can use the tools provided while planning and implementing the referral process. The toolkit is designed to present information in various formats to meet the needs of different learning styles. Steps for recruiting providers 1. Read the toolkit and understand the referral process. If you don t understand, talk to your local or state CDSME coordinator. 2. Work with your local or state coordinator to identify opportunities to present the referral process to providers and existing partnerships in your area. Local coordinators will track presentations to avoid duplicate presentations. 3. Develop an action plan for approaching providers in your area. 4. If possible, include your local coordinator (or another partner if you are the local coordinator) in your presentation or meeting plans. 5. Choose the best tools from the toolkit to meet the needs of your presentation. 6. Have the meeting / give the presentation. 7. Follow-up within a week to see who you need to talk to next to implement the referral process. It is very likely that the office manager will be more involved with the referral process than the health care provider. This may require a second meeting with the office staff. 3

4 Referral Forms & Procedures 4

5 Referral Process Diagram 6. Provider Feedback Form sent to referring provider. 7. Provider follows up with patient on goal -setting and action plan. 1.Provider introduces CDSMP opportunity to patient. Patient completes Patient Referral Form. 5. Patient completes Provider Feedback Form describing what s/he learned during workshop. 4. Patient attends CDSME workshop. 2. Patient Referral Form sent to to KDHE or local coordinator. 3. State or local coordinator contacts patient and enrolls them in a workshop. Blue box signifies provider action step 5

6 Fax referrals to: referrals to: Questions: Call PATIENT INFORMATION Tools for Better Health Patient Referral Form Patient Name Best phone number to reach you: Best time of day to contact you: May we leave a message: Yes No Language English Spanish Other (specify) I understand that KDHE will inform my provider about my participation in Tools for Better Health. Patient Signature Date PROVIDER INFORMATION Provider name Clinic Contact Person: Phone: Fax: 6

7 Tools for Better Health Self-Management Programs I was referred by my provider. Provider Feedback Form My Name Today s Date Dear Health Care Provider, I want to let you know that I have been attending the Chronic Disease Self-Management Program class to help me better manage my own health. Today I am in my final class of the 6 weekly sessions and I am sending you my thoughts about my chronic conditions, taking care of myself, my goals and my action step. What I have learned about my health is: I didn t know that my chronic condition was affected by: The things I do now that have helped me the most to manage my chronic conditions are: My Action Plan for the next six months is: Long term goal: Specific action step: How much/often? When? Confidence Level (0-10): We will forward this letter to the provider who recommended this program to you so you may continue your health action planning at your next appointment. 7

8 Outline of Duties Duties of Referring Providers 1. Maintains complete and up-to-date clinical record including demographics. 2. Transfers information as outlined on the KDHE Referral Form 3. Informs patient of need, purpose, expectations and goal of the referral. 4. Provides KDHE with a single referral contact person for the provider s office. 5. Communicates with patients who decline class participation, do not respond to attempts by KDHE to contact them, and who do not attend class after enrolling, and advise KDHE how to proceed. 6. Follows the principles of the Patient Centered Medical Home ( medical-home). Patient-centered: A partnership among practitioners, patients and their families ensures that decisions respect patients wants, needs and preferences, and that patients have the education and support they need to make decisions and participate in their own care. Comprehensive: A team of care providers is wholly accountable for a patient s physical and mental health care needs, including prevention and wellness, acute care and chronic care. Coordinated: Care is organized across all elements of the broader health care system, including specialty care, hospitals, home health care, community services and supports. Accessible: Patients are able to access services with shorter waiting times, "after hours" care, 24/7 electronic or telephone access, and strong communication through health IT innovations. Committed to quality and safety: Clinicians and staff enhance quality improvement to ensure that patients and families make informed decisions about their health. Duties of KDHE or Local Coordinator 1. Provide a single referral contact person for patients and provider. 2. Contact the referred patient within five business days. 3. Provide staff training and support on making referrals to self-management programs. 4. Communicate with provider regarding patients who decline class participation, do not respond to attempts by KDHE to contact them, and who do not attend class after enrolling. 5. Provide written documentation of patient enrollment and course content to provider. 6. Provide data regarding referrals, enrollment, completion rate, patient feedback to providers, and demographic summary to the provider on a regular basis. Print Provider s Name: Provider s Signature: Date: 8

9 Program Information 9

10 Quick CDSME Facts Workshops NEVER give medical advice. A large body of scientific evidence shows compared to non-participants workshop participants showed significant improvements in the following areas: Exercise Cognitive symptom management Communication with physicians Self-reported general health Health distress Fatigue Disability Social activity limitations Reduced days in the hospital and fewer outpatient visits Workshops are 6 weeks long with an informational meeting a week prior to the first workshop. Each session lasts 2.5 hours. Family and caregivers of people with chronic conditions are encouraged to attend workshops. Workshops are typically free, although some organizations may charge a small fee. KDHE can help you train workshop leaders in your organization. There are currently four workshop types available in Kansas: 1. Chronic Disease Self-Management Program (CDSMP) 2. Tomando Control de su Salud (Spanish CDSMP) 3. Diabetes Self-Management Program (DSMP) 4. Programa de Manejo Personal de la Diabetes (Spanish DSMP) Patients are 18 times more likely to attend a self-management workshop if their provider recommends it. (CDC Approach to Provider Outreach) 10

11 More Facts There is strong evidence across studies that CDSMP has a beneficial effect on physical and emotional outcomes, and health-related quality of life. This statement is based on high-quality information, standardized measures and is made with a high degree of confidence. The program consistently results in greater energy/reduced fatigue, more exercise, fewer social role limitations, better psychological well-being, enhanced partnerships with physicians, improved health status, and greater self efficacy. It is generally (although not always) associated with reductions in pain symptoms. 1 Be part of evidence-based workshops offered worldwide The Chronic Disease Self-Management Education (CDSME) series are evidence-based workshops developed in the early 1990s by the Stanford Center for Research in Patient Education. Considered the gold-standard in self-management education, these workshops are now used internationally in 15 countries and more than 39 U.S. states. CDSME has been proven to significantly help people with chronic diseases. In conjunction with your treatment plan, these programs teach participants how to exercise and eat properly, use medications appropriately, problem-solve every day situations, and communicate more effectively with family members and health care providers all positive life skills to enhance well-being. These interventions help participants reduce pain, depression, fatigue and frustration; improve mobility and exercise; increase energy; and boost confidence in their ability to manage their condition. Additional information Stanford School of Medicine Patient Education Visit this site for detailed information about the Stanford self-management programs. Centers for Disease Control and Prevention Learn more about research and evaluations supporting the Stanford programs. 1. Evidence-based Healthy Aging Program. Review of Findings on Chronic Disease Self-Management Program (CDSMP) Outcomes. Stanford University. Available at patienteducation.stanford.edu/research/ Review_Findings_CDSMP_Outcomes1%208%2008.pdf. 11

12 Kansas CDSME Data Collaboration with KFMC Leaders Participants KFMC KDHE KDHE has partnered with the Kansas Foundation for Medical Care, the only other active license-holder for Stanford s programs. This chart shows the number of leaders and participants our partnership had from January 1, 2014 through July 1, Tomando Workshops, DSMP 32 Workshops, 15 CDSMP Workshops, 210 S-DSMP Workshops, 1 Total Number of Workshops to Date by Program KDHE obtained a license to facilitate the Stanford programs in Since then KDHE has facilitated 210 Chronic Disease Self Management workshops, 15 Diabetes Self-Management workshops, 32 Tomando Control de Su Salud workshops, and the first Spanish DSMP workshop began in spring Cumulative Participant Reach Completers Cumulative Participant Reach with Completers As of July 1, 2015, KDHE has facilitated 258 workshops with 2,494 participants. Of those participants, 1,938 attended at least 4 of the 6 sessions

13 Kansas Success Stories Much Needed Improvement It [CDSME] has taught me a lot about my Asthma and how to live a better life. [A leader and I] discussed my weight problem, since starting this course I have started walking. When I began I weighed 224 lbs. As of today I weigh 206 lbs. I m breathing better, eating and sleeping better; just all over I feel a much needed improvement. CDSME Gets an A+ Just wanted to inform you of an interesting class I have been attending. It is on health, nutrition and exercise. It has been very helpful and the instructors have been fun and very interesting. We learned how different emotions can affect our eating, sleeping and pain, and what we could do to help them by proper exercise, eating and dealing with our emotions. I d give this class an A+. Diabetes Back in Control A CDSMP leader at a workshop hosted by the Kansas Statewide Farmworker Health Program described a client who had been diagnosed with diabetes: She had seen a physician and had prescriptions to control her diabetes, but she had not seen the doctor or taken medicine for a few months because of concerns over money. She was working hard to watch what she ate and also tried to walk each day. She felt pretty good and had decided she did not need to see the doctor or continue her medication. However, inspired by a CDSME leader who stressed the importance of regular doctor visits, she decided to make an appointment at a local clinic with the help of her Farmworker Health Case Manager. At that first appointment she was surprised to learn that her blood sugar was near 500! Since her body had become accustomed to that level, she was feeling reasonably good despite this dangerous level. The CDSME course reinforced to this client and others the importance of regular primary care, of taking prescribed medications and monitoring health status very closely. This client, through the help of the Farmworker program, found a way to access more affordable medications to help her with her blood sugar level and her cholesterol. Walking Again Denise Dias, a program leader in Sedgwick County said, We had a gentleman who was in a wheelchair. He told us that he could walk, but had almost given up walking and chose to use a wheelchair almost all of the time. When it came time for making an action plan, he decided the first week to get up out of this wheelchair and walk across his small apartment to the kitchen at least three times. Week one was a partial success. In the weeks following he continued to add a small amount to the distance he would walk each week. By week six, he reported that he could walk across his apartment, down the hallway and outside on the balcony to enjoy the fresh air. He had done that 5 of the 7 days and was completely successful. It is amazing how this program can encourage someone who had self-doubt to make some small changes to improve his quality of life. 13

14 Frequently Asked Questions How do self-management programs work? CDSME workshops are free or low-cost programs that help individuals with chronic conditions learn how to manage and improve their own health, while reducing health care costs. The programs focus on problems that are common to individuals dealing with chronic conditions such as pain management, nutrition, exercise, medication use, depression and communicating with providers. Workshops are facilitated by two trained leaders, one or both of whom have a chronic condition themselves. These trained leaders guide workshop participants through an evidence-based script once a week for six weeks. Through the curriculum, participants focus on building the skills they need to manage their conditions by sharing experiences and providing mutual support. The following Stanford programs are offered in Kansas: Chronic Disease Self-Management Program (CDSMP) Diabetes Self-Management Program (DSMP) Tomando Control de su Salud (culturally adapted Spanish CDSMP) Programa de Manejo Personal de la Diabetes (culturally adapted Spanish DSMP) Who should attend a self-management workshop? People with chronic long term conditions including but not limited to: Alzheimer s or dementia Asthma Arthritis Diabetes Heart Disease Mental Health Conditions Obesity and overweight Parkinson s, Epilepsy Stroke ANY ongoing health concern Friends, relatives and caregivers of someone living with a chronic condition are encouraged to attend as well. Adults of any age can benefit from the skills taught in this workshop. Is reimbursement available if I refer my patients to a workshop? It is possible to receive reimbursement for referring to the Self-Management Programs. The first reimbursement possibility is through care-coordination models such as the Patient Centered Medical Home or Health Home models. Your role in the model will determine your level of reimbursement. More information about PCMHs in Kansas can be found at For information about Health Homes visit KanCare_Health_Homes_Program_Manual_SMI.pdf. The other option for reimbursement is to bill insurance companies directly for education services that the practice provides. The Center for Medicare and Medicaid Services (CMS) is currently set up to reimburse providers of diabetes education. Visit for more information about billing CMS. 14

15 Private Insurance companies are open to negotiating with their contracted providers regarding reimbursement for education for both people with diabetes and those with other chronic diseases. We encourage providers to initiate discussions with their insurance networks. Why should I refer my patient to chronic disease self-management classes? These workshops are evidence-based programs developed by Stanford University. Patients learn strategies to self-manage such as setting small, action-specific steps to reach a goal. Workshop participants are more engaged in their health care and patient feedback gives providers documentation of patient s self-management goals. What will KDHE do when we receive your patient referral? KDHE will contact you to acknowledge receipt of the referral. KDHE will contact your patient within 5 business days to discuss attending a workshop. KDHE will update you on the status of all your referrals including attempts to reach, contacts, workshop registration information and any barriers encountered. KDHE will contact each patient a minimum of three times. Further contacts will be determined after consulting with the provider. What will KDHE say to my patient? KDHE staff will introduce ourselves and say we received the referral from their health care provider to the CDSME workshops. KDHE will assume that if the patient s signature is present on the form, you have briefly introduced the class to your patient and they will be expecting a call from us. If a patient s signature is not present on the referral form, KDHE will assume you have mentioned the referral to the patient and have noted the referral in your charting. KDHE will discuss the times, locations and dates of the closest classes available, and the class content, stressing that the class is not a medical intervention, but a self-management program. KDHE will mention the positive responses received from people just like them who have attended classes. KDHE will inform the patient they have been referred to class because the health care provider thinks the class is important for them and will be beneficial. Does the program replace existing programs or treatments? No. These workshops help participants work with providers to get the care that best meets their needs. Self-management skills enhance regular medical treatment. These skills are especially helpful for people with more than one chronic condition who are likely dealing with several doctors, nurses, and other professionals at the same time. This program never offers medical advice. Participants are encouraged to discuss any specific medical issues or medication questions with their health care provider. What are the benefits of the program? Stanford University s self-management education series is one of the most studied programs in existence. A meta-analysis of several studies conducted by CDC is available at 15

16 Compared to non-participants CDSME workshop participants showed significant improvements in: Exercise Cognitive symptom management Communication with physicians Self-reported general health Health distress Fatigue Disability Social/role activities limitations Reduced days in the hospital and fewer outpatient visits. How are the self-management workshops different from other patient education classes? Disease-specific education classes are designed to assist newly diagnosed participants in learning the information and skills necessary to care for their specific medical condition. These classes are led by nurses, health educators or doctors. Social and psychological adjustment to living with the condition is introduced, but is covered in a limited way. Chronic Disease Self-Management Education programs were designed to fill the gap between receiving doctor s orders and implementing the necessary changes in their daily lives required to follow doctor s orders. The programs develop the skills needed for patients to deal with the selfmanagement of their disease(s) and with the life changes and emotions that are part of living with a chronic illness. The workshops help patients manage common problems such as fatigue, communicating with friends, family and providers, dealing with anger and depression, and designing and maintaining an appropriate exercise program. In addition patients learn decision-making and problem-solving skills that help them manage their diseases as well as manage the rest of their lives. Chronic diseases account for 75% of all the money the U.S. spends on health care. There is a potential savings of $6.6 billion just by reaching 10% of Americans with one or more chronic conditions. (National Council on Aging, 2014) 16

17 Promoting CDSME to Patients 17

18 Letter/ Template Use/adapt this template to conduct efficient follow-up and referral with patients who have been identified as having a chronic condition. Dear <<PATIENT NAME>>, Thank you being a patient of the <<PRACTICE NAME HERE>>. We are writing to tell you about a service to improve your health. Based on our review of you medical chart, we have determined you have a chronic health condition. This means the effects of your condition are long-lasting and should be managed regularly. We have some good news. There are self-management workshops available to help people with chronic conditions. These workshops are coordinated by our partners at the Kansas Department of Health and Environment (KDHE). Self-management workshops are designed to help people gain selfconfidence in their ability to control their symptoms and help people learn how their health conditions affect their daily lives. These workshops complement the care you are receiving through our office. We sent KDHE a referral for you to attend a self-management workshop. Someone from the KDHE network will call you to discuss the workshop, answer any questions you may have and, if you are interested, enroll you in the workshop. Please feel free to call the KDHE Coordinator at We hope you will take advantage of this opportunity, which can give you the tools to live a happier, healthier life. Sincerely, Dr. <<PHYSICIAN NAME>> 18

19 Sample script for phone outreach Hello <<PATIENT NAME>>. I am calling from <<PRACTICE NAME>> to tell you about a Chronic Disease Self-Management Workshop we d like you to consider attending to manage your health condition. This program is designed to help people gain self-confidence in their ability to control their symptoms such as pain, fatigue and depression. We would like to send a referral to our coordinating partner, the Kansas Department of Health and Environment. Would you like to learn more about the workshop? (Wait for answer.) (If patient answers yes) Someone will call you to discuss the workshop, answer any questions you may have and, if you re interested, enroll you in the workshop. (If patient answers no, skip to last bullet.) Please feel free to contact KDHE at Do you have any questions for me? Thank you for your time and be well. Workshop Details for easy reference: Workshops are typically free, although some organizations may charge a small fee. Workshops are once a week for six weeks. There is an informational meeting a week prior to the first workshop session. Not a lecture class, but an interactive workshop that will help you learn to do the things you want to do in relation to your health. Family and caregivers are welcome to attend. 19

20 Are you living with arthritis, asthma, diabetes, high blood pressure, high cholesterol or another chronic condition? Chronic Disease Self-Management Education (CDSME) can help! Learn and share with others Focus on what you want to work on Manage your health & control symptoms For people living with ongoing health conditions, family members & caregivers 1 in 2 Americans has a chronic disease That s 145 million people $$$$ 75% of health care costs in the U.S. are from chronic diseases Physical Limitations Shortness of Breath Difficult Emotions Depression Stop the cycle before it stops you! Fatigue Stress & Anxiety Pain Poor Sleep The workshop put me back in charge of my life and I feel great. I only wish I had done this sooner. - CDSME Participant 50,000, million Americans have arthritis - the most common cause of disability To learn more visit This material was prepared by the Great Plains Quality Innovation Network, the Medicare Quality Improvement Organization for Kansas, Nebraska, North Dakota and South Dakota, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-GPQIN-KS-GEN-37/0115 we do CDSME because it works Data source: Centers for Disease Control and Prevention. Chronic Diseases and Health Promotion. This publication was supported by Cooperative Agreement # 1U58DP from the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC.

21 Kansas Department of Health and Environment 1000 SW Jackson Suite 230 Topeka, KS Feel better. Be in control. Do the things you want to do. Find out more about other Tools for Better Health programs: Diabetes Primary Prevention Stepping On Fall Prevention Enhance Fitness Walk With Ease Take Control of Your Chronic Condition Tools for Better Health

22 Put Life Back Into Your Life. Attend a Chronic Disease or Diabetes Self-Management Workshop. In just a few weeks, I got back to feeling better and back to being the kind of person I like to be. Are you an adult with an ongoing health condition? If you have conditions such as diabetes, arthritis, high blood pressure, heart disease, chronic pain, anxiety, Tools for Better Health can help you take charge of your life. You ll get the support you need, find practical ways to deal with pain and fatigue, discover better nutrition and exercise choices, understand new treatment choices, and learn better ways to talk with your doctor and family about your health. Sign Up Now. Spaces Are Limited. Join a free 2 ½-hour workshop, held each week for six weeks, either Chronic Disease Self-Management (CDSMP) or Diabetes Self-Management (DSMP).* Learn from trained volunteer leaders living with health conditions; at least one leader facilitating a workshop must have a chronic condition. Set your own goals and make a step-by-step plan to improve your health and your life. *Spanish workshops are available. To register or get more information, please call: Now I have more energy than I ve had in years. I m calmer and more confident about my health. The workshops put me back in charge of my life, and I feel great. I only wish I had done this sooner.

23 Learn tools for better health! If you are living with an ongoing health condition (such as arthritis, asthma, diabetes, high blood pressure, or depression) or are a caregiver of someone who does, this is for you! Chronic Disease Self-Management Education (CDSME) workshops are interactive learning opportunities that teach techniques to manage common symptoms. Workshops are low-cost and led by trained leaders who are also living with an ongoing health condition. Workshops include: Decision-making and problem-solving skills Fatigue management Dealing with anger, depression and difficult emotions Communicating effectively with family, friends and health professionals Using medication appropriately Making informed treatment decisions Healthy eating One workshop participant chose to use a wheelchair over walking before attending the workshop. He used his weekly action plan to begin taking more steps and rely less on his wheelchair. By week six, he reported that he could walk across his apartment, down the hallway and outside on the balcony to enjoy the fresh air 5 out of 7 days. Everyone was so happy for him they clapped and cried at the same time! It is amazing how this program can encourage someone who had selfdoubt to decide for himself to make some small changes to improve his quality of life. CDSME Leader The workshops put me back in charge of my life, and I feel great. I only wish I had done this sooner. CDSME Participant Contact Us

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