7/12/2016. A Delivery System Reform Incentive Payment Project in a Multi-site Community-based Primary Care Setting. What is D.S.R.I.P?

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1 A Delivery System Reform Incentive Payment Project in a Multi-site Community-based Primary Care Setting Patricia J Pugh RN, MS, CDE Program Director Chronic Disease Management Baylor Scott & White Health Dallas, Texas What is D.S.R.I.P? Unprecedented opportunity Disclosure to Participants Notice of Requirements For Successful Completion Please refer to learning goals and objectives Learners must attend the full activity and complete the evaluation in order to claim continuing education credit/hours Conflict of Interest (COI) and Financial Relationship Disclosures: No COI/Financial Relationship to disclose Non-Endorsement of Products: Accredited status does not imply endorsement by AADE, ANCC, ACPE or CDR of any commercial products displayed in conjunction with this educational activity Off-Label Use: Participants will be notified by speakers to any product used for a purpose other than for which it was approved by the Food and Drug Administration. Aligns with CMS Triple Aim 1

2 DSRIP activities are divided into four categories, which are interrelated and complementary Program Innovation Begins with a Community Needs Assessment Community Resources ( Food Bank, YMCA) Program team members embedded in clinics Access to EHR Baylor Scott & White Health Population Health Primary Care Homes Patient Engagement Data Analytics Baylor Community Care Chronic Disease Management Model (adapted from The Chronic Care Model, MacColl Institute) COMMUNITY Resources Self-Management Support Patient & Family- Informed, Empowered & Prepared HEALTH CARE ORGANIZATION Delivery System Decision Clinical Information Design Support System Productive Interactions Patient & Family Centered Focused - Coordinated Care Evidence Based Timely, Efficient, Equitable & Safe Prepared, Proactive Practice Team Co-locating the program in the clinic Space for new team members Matrix reporting Program referrals 2

3 Staff Training Disease state experts (heart failure, diabetes, asthma, COPD) Video taping presentations EHR training Marketing Our Message Behavior change involves more than just increased access to health care Matching the desired behavior to the needs, preferences, and desires of our patients Connect core values (e.g. freedom, independence) to benefits from behavior change AADE7 Self-Care Behaviors Behaviors that apply to all chronic diseases Care Coordination and Transition of Care Patient Engagement Tools Motivational Interviewing Stages of Change Shared Decision Making Comprehensive Care Management RN Care Managers in the clinic Care Coordination face to face visits/telephonic Triage Transition of Care (hospital to home to clinic) Reference: American Academy of Ambulatory Care Nursing Position Statement (2011): The role of the Registered Nurse in ambulatory care 3

4 Care Management: Cost Impact Example Recruitment and Employee Attributes Unique positions and responsibilities Behavioral Interview Questions (n = 4427 patients) Peer Interview Emerging workforce at Baylor Scott & White Health Community Health Workers White Paper population health management through the strategic use of CHW s Scope of Practice and Code of Conduct Career ladder Heart for mission work Community Health Workers in the clinic Robust CHW certification training program Adherence to program protocols AADE Competencies for CHW s (paraprofessionals) AADE Practice Synopsis CHW s in diabetes management and prevention Reference: How to get along and have respect for what everyone brings to the table 4

5 The right person - How do we connect with the clinic team and let them know what we need? doing the right thingat the right time Provider Buy-in and Engagement Expectations Building relationships and trust Rounding Provider executive meetings Outcomes Enrollment Program Adherence BMI Screening A1c Reduction How can we support the providers? - RN Care Manager role - CHW role Enrollment Enrolled over 4,000 patients 5

6 Program Adherence Over 30% of patients enrolled in the program had at least 3 education encounters and achieved at least 3 behavior change goals Summary An opportunity for diabetes educators to expand our reach and share our expertise Diabetes Educators know how to connect people to services This is tough work team members need support Sustainability BMI Screening Over 70% of clinic patients were screened and provided with healthy eating and being active education for abnormal BMI A1c Reduction Reduced the % of patients with A1c s >9 to 26.4% compared to baseline of 27.8% THANK YOU Patricia.Pugh@BSWHealth.org 6

7 References Barnidge, E.K., Brownson,C.A., Baker, E.A., Shetty G. Tools for building a clinic community partnerships to support chronic disease control and prevention. The Diabetes Educator. 2010; Vol 32(2), Crespo, R., Hatfield, V., Hudson, J., Justice, M. Partnership with community health workers.: Extends the reach of diabetes educators. AADE In Practice. March A publication of the American Association of Diabetes Educators. Dickinson, J.K, Lipman, R.D., O Brian, C. Diabetes education as a career choice. The Diabetes Educator.2015; Vol 41(6), Martin, A.L., Lipman, R.D. The future of diabetes education: Expanded opportunities and roles for diabetes educators. The Diabetes Educator. 2013; Vol 39(4), McCulloch, Amber. Community health workers in action. AADE In Practice. July A publication of the American Association of Diabetes Educators. Resnick, E.A., Siegel, M. (2013). Marketing Public Health: Strategies to promote social change,(3 rd ed), Burlington, MA. Jones & Bartlett Trehearne, B., Fishman, P., Lin, E.H.B. Role of the nurse in chronic illness management: Making the medical home more effective. Nursing Economics. 2014; Vol 32(4),