Community-Based Collaboration Models: Promoting Clinic to ...
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Community-Based Collaboration Models: Promoting Clinic to Community Linkages Linda Netterville, RD, LD (Moderator/Speaker), National Resource Center on Nutrition and Aging Jeromie Ballreich, PhD candidate, Johns Hopkins University Tricia Jefferson, RD, LDN, YMCA of Delaware
Transcript of Community-Based Collaboration Models: Promoting Clinic to ...
Community-BasedCollaborationModels:PromotingClinicto
CommunityLinkagesLindaNetterville,RD,LD(Moderator/Speaker),NationalResourceCenteronNutritionandAgingJeromieBallreich,PhDcandidate,JohnsHopkinsUniversityTriciaJefferson,RD,LDN,YMCAofDelaware
Community-BasedCollaborationModels:PromotingClinictoCommunityLinkages
PCPCC2015ANNUALFALLCONFERENCE
NOVEMBER12,2015
Panelists:•LindaNetterville,RD,LD,MealsonWheelsAmerica
•JeromieBallreich,PhDStudent,HealthEconomics,JohnsHopkinsUniversity
•TriciaJefferson,RD,LDN,Director,HealthyLivingandStrategicPartnerships,YMCAofDelaware
•UcheomaAkobundu,PhD,RD,MealsonWheelsAmerica
CommunityServicesfromaPatient’sPerspective
JeromieBallreichNovember12,2015
Aboutme…
• Sufferedaspinalcordinjury(C4/C5)andneardrowningMarch13,2005.• Spentnearly6monthshospitalized• DischargedAugust2005• Myaccidentwasacute,butmyquadriplegiaischronic
Beingapersonwithachroniccondition• Quadriplegiaaffectsmultipleorgansystems• Requirecarefrommultipleproviders• RequireassistanceforADLsandIADLs• 3-4hourseverymorning(ADLs)• 1-3hoursinevening(ADLs)• 4hoursIADLsdaily
• Economistperspective:• $2millioninhealthcareexpendituresincemyaccident
Whyisstayinginthecommunityimportant?
• Iwanttocontribute…• FeelthatIaddsomethingmeaningfultosociety• Beemployed
• Iwanttobeindependent…• Bein-chargeofmycare• Bein-chargeofmylife(where,when,andwhat)
• Iwanttobepartofthecommunity…• Personalrelationships• Socialrelationships
• ALTERNATIVEisinstitutionalliving
Myearlyexperiences(1/2)
• DischargedtomyhomeinCentralPennsylvania• Concernsaboutrurallocation• Concernsaboutaccessibility• Mymotherwasprimarycaregiver
• SocialworkeratMageeHospitalestablished• ContactwithVocationalRehabilitation• ContactwithPennsylvania’sPublicWelfare
• Personalconnectionwithlocaldoctors• Neededmedicalstabilitybeforepursuinglifegoals
Myearlyexperiences(2/2)
• Transportation• Used“CART”-localsharedrideprograminPennsylvania• OfficeofVocationalRehabassistedwithVehiclemodifications
• Homehealthcare• HomenursingagencyweeklyacutecareincludingPT• IndependenceWaiver-Medicaidwaivertoliveathome
• Allocates“X”numberofhours• Mostlyconsumer-employed
• SystemNavigation• NonprofitsincludingCentersforIndependentLiving(CILs)andAHEDD• Independencewaiverservicecoordinator
Myrecentexperiences(1/2)
• In2009,IlefthomeandattendedLafayetteCollegeformysenioryear• 3hoursaway• CoordinationbetweenCollege,OVR,andMedicaidServicecoordinator• FIRSTTIMElivingbymyself(on-campusapartment)
• LafayetteCollegeHealthServices• Alwaysopen• Tookcareofmychronicneeds
• SetbacksatLafayetteCollege• Didnothave24hourcare• Wheelchairtechnicalissues• Agencycare
Myrecentexperiences(2/2)
• EnrolledinMastersandlaterPhDatJohnsHopkinsUniversity• LiveindependentlyinanapartmentinBaltimorewithmygirlfriendandcat• RelyonJohnsHopkinsandGeisingerhealthsystemsformedicalsupport• Homehealthcare(caregiving)providedbyIndependenceWaiver
Caregiving(1/2)
• Integraltomyneeds• ADLs(activitiesofdailyliving)• IADLs(instrumentalactivitiesofdailyliving)• Day-to-daymedicalcare
• Typically,caregiversare• Limitededucation• Mayormaynotbecertified• Minimallycompensated• Largelaborpoolbutverytransitory
Caregiving(2/2)
• Coordinatingcareisajob• Scheduling,hiring,firing,training• Micromanagement• Reluctantboss
• Caregivingnightmares• LPN• Providedroom,board,andhourstowork• First4monthswentfine!• Awfulsituationturnedworse…
• Refusedtoleave• Fewwarningsigns• Vulnerable,anxious,disruptive
Barrierstocommunityliving(1/2)
• Medicaidisprimarypayerforhomehealthcare• Statebystatebasis• Complexsystem• Means-tested• Waitlists
• Accessibilityisnotuniversal• Fewroll-inshowerapartmentsavailableinBaltimore• Doorsandflooringoptionslimited
• Findingtherightcaregiversiscritical!
Barrierstocommunityliving(2/2)
• Homehealthcareisnotfullyintegratedwithtraditionalmedicalcare• Caregivers,healthaidesarerarelyincorporatedintoadoctorsvisit• Day-to-dayjudgementcallsonmedicalcareareonmewithlittlesupport• Traditionalmedicalcareisveryacutefocused• Barrierstoaccesstraditionalmedicalcare
• Appointmentavailability?• Waittimes?• Appointmenttimes?
• Goodhealthisnecessarytopursuelifegoals!
Opportunities
• De-centralizeservices• Integratetechnology• HealthIT• Technologyfornon-healthservices
• Considerbroaderhomehealthcaresolutions• Otherpayersresponsibility• 529(b)plans?• Workforcedevelopment
Success
• Myconditionisomnipresent• Livingindependentlyallowsmetopursuemylifegoals• Myconditionrequires:• Moretime• Moreplanning• Moreresources• Confrontingoccasionalsetback
• HEALTHisthefoundationofallaspectsofmylife(i.e.Maslow’shierarchy)
THANKYOU!
HealthcareBeyondtheClinicSetting:Community-BasedServicesLINDANETTERVILLE,RD,LD
Community-BasedServices
ThereisNoPlaceLikeHome!
TheAgingandDisabilityNetwork:PartnersintheHealthcareSpace
AdministrationforCommunityLiving(ACL)
StateAgingandDisabilityAgencies
Community-BasedAgingandDisabilityOrganizations
TheAgingandDisabilityNetwork:PartnersinHealthcareSpace
HowcanCBOsimpactdeliverysystemreform?
Managingchronicconditions
Activatingbeneficiaries
Diversion/Avoidinglong-termresidential
stays
Preventinghospital
(re)admissions
• Evidence-basedcaretransitions• Carecoordination• Information,referral&assistance/systemnavigation• Medicaltransportation• Evidence-basedmedicationmanagement• Evidence-basedfallpreventionprograms/homeriskassessments• NutritionServices• Caregiversupport• Environmentalmodifications
• Chronicdiseaseself-management• Diabetesself-management• Nutritionprograms(counseling&mealprovision)• EducationaboutMedicarepreventivebenefits
• Evidence-basedcaretransitions• Person-centeredplanning• Chronicdiseaseself-management• Information,referral&assistance/systemnavigation• Benefitsoutreachandenrollment• Employmentrelatedsupports• Community/beneficiary/caregiverengagement
• Transitionsfromnursingfacilitytohome/community• Person-centeredplanning• Assessment/pre-admissionreview• Information,referral&assistance/systemnavigation• Environmentalmodifications• Caregiversupport• LTSSinnovations
TargetedPatientPopulationManagementwithIncreasingDisease/Disability
End of Life
Complex Chronic Illnesses w/ major
impairment
Chronic Condition(s) with Mild Functional &/or Cognitive
Impairment
Chronic Condition with Mild Symptoms
Well – No Chronic Conditions or Diagnosis without Symptoms
Hot Spotters!
EvidenceBasedSelf-Management,HomeAssessmentandHomeMeds
HomePalliativeCare
PostAcuteandLongTermSupportsandServices
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MoreonthevalueofCBOs“Fortheseindividuals[withbothchronicconditionsandfunctionallimitations
requiringlong-termservicesandsupports]toachievebetterhealth,providersmustbeabletoconnecttheirpatientstosocialsupportsandhumanserviceswhilefocusingonpreventionandwellnessinwaysthatemphasizebehaviorchange.Bypartneringwithcommunity-basedorganizations(CBOs),suchasAreaAgenciesonAging(AAAs),providerscanhelpindividualsmanagetheirchronicdiseasesandmeettheiroften
overlookedsocialneeds.”Dr.AnandParekh&Dr.RobSchreiber
“HowCommunity-BasedOrganizationsCanSupportValue-DrivenHealthCare”HealthAffairs,July10,2015
http://healthaffairs.org/blog/2015/07/10/how-community-based-organizations-can-support-value-driven-health-care/
BuildingtheBridge
HealthcareCommunity-BasedServices
Wehavetogetitright!
Questions:
DiscussionQuestion:Whodoyoualreadypartnerandhow?Whatcommunitypartnersorcommunityresourcesdoyouhaveinyourareathatcanbeusedtoimprovepatientcare?
YMCA’s Diabetes Prevention Program
TRICIA JEFFERSON, RD, LDN DIRECTOR OF HEALTHY LIVING AND STRATEGIC PARTNERSHIPS YMCA OF DELAWARE
BenefitsofClinictoCommunityPartnershipsCollaborative Missions Growth in Operations ◦ Approx. 15% growth in practice operations
Lower Healthcare Costs Engaging patients across continuum of care ◦ Primary, Secondary and Tertiary
Better health outcomes Increased healthcare reimbursement Greater Integration and Population Health Aligns with Healthcare objectives: ◦ Accountable Care Act ◦ ACO’s ◦ PCMH ◦ Community needs assessment
| YMCA’S DIABETES PREVENTION PROGRAM | ©YMCA OF THE USA
YMCA’S DIABETES PREVENTION PROGRAMTHE PROGRAM IS: •Led by a trained Lifestyle Coach
•A one-year program: 16 weekly sessions, then 8 monthly sessions
•Open to all community members; YMCA membership is not required
•A Centers for Disease Control and Prevention (CDC)-approved curriculum
PROGRAM QUALIFICATIONS: •At least 18 years old,
•Overweight (BMI ≥25), and
•Prediabetes confirmed via one of 3 blood tests or previous diagnosis of gestational diabetes
•If no blood test, 9+ score on risk assessment
PROGRAM GOALS: •Reduce body weight by 7%
•Increase physical activity to 150 minutes per week
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Nancy R. from Wilmington, DE - lost nearly 10% of her starting body weight! I feel healthier–-terrific even-–and friends tell me I look great. I’ve changed the way I cook for myself and my daughter, and now [she] is checking the packaging on foods, taking smaller portions for dessert and making wiser food decisions. I’m now doing something that is positive for both of us, and I want to tell everyone about it.
DPP Locations StatewideYMCAsites Medical
BuildingSeniorCenters Community
Centers/OtherLibraries/Churches/Stores
BrandywineYMCA SilversideMedical WilmingtonSeniorCenter
BrandywineTownCenter
CalvaryAssemblyofGod
DowntownYMCA GlasgowMedical MiddletownSeniorCenter
ClaymontCommunity WoodlawnLibrary
WesternYMCA PikeCreekSportsMedicineBldg.
NewarkSeniorCenter
HockessinActivityCenter
LewesLibrary
BearYMCA UDStarCampus ModernMaturityCenter
GarfieldParkActivityCenter
ShopRite
DoverYMCA HenriettaJohnsonMedicalCenter
MilfordSeniorCenter DelawareStateUniversity
TerryApartments
SussexYMCA GreenhillFamilyMedicine
LewesSeniorCenter LutherTowers(Wilmington)
IngelsideRetirementApts
YMCAAssociationOffice
MiddletownFamilyCareAssociates
ClaymoreSeniorCenter
BloodBankofDelmarva
HeritageatDover
| DIABETES PREVENTION PROGRAM OVERVIEW | ©2015 35
LocalDataParticipantsattendingatleastonesession(through2014)inDelaware
~1,500
Averageweightlossatendofweeklysessions
4.9%
Averageweightlossatendofyearlongprogram
5.8%
Average#ofweeklysessionsattended 14.1/16
Retentionfromsession1tosession4 92.9%
Retentionfromsession4tosession9 89.6%
Percentofparticipantswithavalidbloodtest
91%
PercentofLowIncomeparticipants 7%
YMCAReach ByTheNumbers
0
10
20
30
40
DPPLocauons
YMCAsitesOther
ParMcipantReferralSources(n=383)InsuranceCompany1%
Other5%YMCAStaff
5%Screening/TesungEvent
6%
Family/Friend12%
Media/Markeung20%
HealthcareProvider51%
HealthcareProviderMedia/MarkeungFamily/FriendScreening/TesungEventYMCAStaffOtherInsuranceCompany
ReferralMechanisms
RetrospectiveLetters 20%EnrollmentRate• 1.Pulldataof
patientswhohaveIFG/IGT(thatdonothaveDM)
• 2.Sendlettersoutwithpracticeletterhead,inviting/referringtotheDPP
• 3.Interested
FlagPatientsintheEHR• 1.Configureaauto-
runmonthlyreportofhighriskpatients
• 2.CreateanalertnotificationinEHRforpatientswithprediabetes
• 3.AlertwilladvisephysicianandotherhealthcareproviderstodiscussandrefertoYMCA’sDPP
PointofCareReferrals78%EnrollmentRate• 1.Patientscome
intotheofficeforannualorf/uvisits.
• 2.Discusslabswithpatient(elevatedBSorA1c)
• 3.SendelectronicreferralorefaxtoYMCA’sDPP
• 4.YMCAwillcallpatientwithin
POCEnrollment
EnrolledNotEnrolled
RetrospectiveLetters384ParMcipantEnrolledasParMcipants
QualityPhysicans
DoverFamilyPhysicians
StoneyBaxerFamilyMedicine
SouthernMedicalAssociates
Mid-AtlanucFamilyMedicine
0 150 300 450 600
2052LexersGenerated
Healthcare/YMCAPartnershipOpportunitiesinDelaware
SharedFacilities-throughexpansionorCapitalprojects
FitnessCentermanagement
CollaborativeLeaseagreementswithancillaryandMedicalServices
Co-Branding/Marketing
IntegratedClinic-to-CommunityreferralsintheEHR
MembershipReimbursementthroughhealthsystem
DirectPayorPartnershipsforevidenced-basedprograms
Underwriting/Supportingevidenced-basedprograms
TriciaJefferson,RD,LDNDirectorofHealthyLivingandStrategicPartnerships
CONTACT:
MealsonWheels:MorethanMealstoSupportHealthandIndependenceUCHEOMAAKOBUNDU,PHD,RD
WHAT ARE MEALS ON WHEELS PROGRAMS?
• Part of the established Home and Community Based System
• Non-profit or government organizations
• Variety of funding including the federal Older Americans Act
• Trusted entity with long history of success
• Delivering both home-delivered and senior center meals and nutrition services
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REFERRAL SOURCES FOR MEALS ON WHEELS PROGRAMS
Referrals for Meals
0%
25%
50%
75%
100%
Hospital, Health Care Facility, or
Discharge Planner
Self Family and Friends
93%
64%64%59%
86%
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*NationalEvaluationofNutritionPrograms-2015
CLIENT PROFILE
– 64% Women
– 37% At or below poverty
– 51% Live alone
– 27% Minority
– 37% Live in rural communities
– 67% Over age 75
HEALTH CONDITIONS
– 51% Take 6+ medications
– 63% 6+ Health Conditions
– 38% Stayed Overnight in the Hospital Last Year
– 57% 3+ IADLs
– 49% 3+ADLs
WHO GET THE MEALS?
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SERVICE OPTIONS ARE DETERMINED BY THE LOCAL PROGRAM
• Types of Meal Delivered
• Hot
• Cold
• Frozen
• Shelf-stable
• Special Diets: Renal, Pureed, Low Sodium
• Ethnically or Culturally Appropriate: Kosher, etc
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OTHER NUTRITION AND NON-NUTRITION SERVICES• Nutrition services provided by Meals on Wheels Programs
– Nutrition education (77 percent)
– Nutrition screening and assessment (52 percent)
– Nutrition counseling (28 percent)
• Non-nutrition services provided by Meals on Wheels Programs
– Safety checks and socialization (the More than a Meal Service)
– Transportation to and from meal sites (76 percent)
– Health promotion and disease prevention activities (63 percent)
– Social activities at congregate meal sites (62 percent)
– Case management (53 percent)
– Assistance with chores or housekeeping (34 percent)
– Grocery assistance (28 percent)
*National Evaluation of Nutrition Programs-2015
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More Than a Meal: Results from a Pilot Randomized Control Trial of a Home-Delivered Meals Program
Conductedby:Fundedby:Commissionedby:
In-person Interviews of all 626 study participants
Participants randomly assigned to daily-delivered meals (n=214), frozen, once-weekly delivered meals (n=202), or to remain on the waiting list (n=210)
Meal delivery began and continued 15 weeks
Conducted follow-up interview over telephone (n=459; 154 in control group, 174 in daily-delivery group, and 131 in frozen, once-weekly
delivery group)
Baseline and outcomes analyses
Study Design
Improvement in Isolation
0%
10%
20%
30%
40%
ImprovementinIsolauon LivingAlone
29%
22%
36%
25%
14%17%
Control DailyDelivered WeeklyDelievered
Improvements in Loneliness
0%
12%
23%
35%
46%
ImprovementsinLoneliness LivingAlone
45%
31%
46%
37%
28%28%
Control Daily Weekly
0%
13%
25%
38%
50%
ImprovementsinLoneliness LivingAlone
26%
18%
42%
32%
18%21%
Control Daily Weekly
Lower Rate of Hospitalizations
• Hospitalized during study period– 14% of individuals who received meals – 20% of individuals in the control group
Falls Among Population of Fallers
0%
20%
40%
60%
80%
Didnotimprove Improved
59%
41%
79%
21%
46%54%
Control DailyDelivered WeeklyDelivered
Feel Safer in the Home
0%
25%
50%
75%
100%
DailyDelivered WeeklyDelivered
70%
80%
Reasons for Feeling Safer
0%
13%
25%
38%
50%
Delivery Meals OutofKitchen StayHome Other
6%
29%33%
31%
24%
6%
11%15%
25%
49%
DailyDelivered WeeklyDelivered
Improvementinfeelingsofanxiety,self-ratedhealth,isolationandloneliness
Decrease in hospitalizations and falls
Improvementinfeelingsofanxiety,self-ratedhealth,isolationandloneliness
Decrease in falls and worry about staying in the home
Daily Home-delivered Living Alone Clients
Improvementsinfeelingsofisolationandloneliness
Decreaseworryaboutbeingabletoremaininthehome
Feelsafer,helpedthemtoeathealthier,moresocialcontacts
Loneliness
Summary• MealsonWheels:APartnerintheHealthcareSpace– Challengefaced• QuantifyingtheimpactofMealsonWheelsservices
– Steps/processcreated• Establishmentofoutcomesresearchprogram
– Keyplayersinvolved• Healthinsurancecompanies,academicresearchers,localMealsonWheelsprograms
– Outcomesachieved• Datasupportiveofpractice-based/anecdotalindicatorsofimpact
– Successfactors/pre-requisites• Goalalignment,willingnesstopartner,&innovativeapproaches
Questions:
DiscussionQuestion:Whatistheprocessusedtocoordinatepatientserviceswithcommunitypartners?Whatarethechallengeswhenreferringpatients?Whatstaffcanstreamlineareferralprocess?
WrapUp:
Community-BasedCollaborationModels:PromotingClinicto
CommunityLinkagesLindaNetterville,RD,LD(Moderator/Speaker),NationalResourceCenteronNutritionandAgingJeromieBallreich,PhDcandidate,JohnsHopkinsUniversityTriciaJefferson,RD,LDN,YMCAofDelaware
