April 8, 2016 Regional Learning Session Collaborative Learning on Healthcare Quality Improvement Initiatives What was the value of today’s learning session? Very High Value: 45% High Value: 42% Medium Value: 12% Low Value: 1% No Value: 0% All slides used during the learning session can be viewed by clicking here. Learning Session Presentations: Keynote: Chronic Condition Management in the Medical Neighborhood Break Out Sessions o Accountable Health Communities (AHC) Model: A national initiative to enhance clinical-community linkages to improve health outcomes o Franklin County Pathways Community HUB: An emerging regional infrastructure that aligns payments with results-based health and social services. o State Innovation Model (SIM) Updates: Aligning payment innovation in Ohio Featured Keynote Presenters
Brenda Rendelman, RD, CDE, Director of Diabetes Education, Central Ohio Diabetes Association Staci Swenson, MA, MSW, LISW-S, Integrated Care Manager, PrimaryOne Health
Summary of Keynote Presentations Partners of the Healthcare Collaborative of Greater Columbus have expressed an interest in developing a collaborative project to impact chronic conditions in the Greater Columbus medical neighborhood. The focus of this work will be to align the interventions and programs being used in the community around results-based practices. The purpose of this work will be to send a unified message to patients on the best practices they can utilize to impact their chronic condition, but also to ensure that what is being used in the community is backed by results. The project will start by focusing on diabetes and/or depression. In order to help shape the project Brenda and Staci presented on the emerging trends and best practices related to managing diabetes and/or depression. Slides used during both presentations can be viewed by clicking here. Learning session participants were asked to reflect on the information shared by the presenters and share where they felt would be a good place to start around aligning this work in our community. What work would your organization be interested in pursuing around diabetes and/or depression management?
Increase the availability and coordination of Diabetes and/or Depression education resources o Assist with collaboration-publications of resources statewide o Becoming a CDE o Contact information for resources available for patient care resource managers for patient referred o Developing a tool kit for PCP, including PA's and NP's o Developing a tool kit for the PCP-Essential that students are educated and aware to identify via screening and implementation in patient care. o Education on updated ADA guidelines o Education, available sources for referrals and motivation for self-help methods via resources, technology, etc. o Empowerment/Education regarding lifestyle changes for diabetes o Further education on Diabetes and Depression management o Goal to develop CDE program
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Incorporate in-house nutrition education (enhancing current program) Learning when and how to introduce available services of healthcare to consumers Mental health/BH Resources for our residents and colleagues More education in group PCP clinics No cost Diabetes education at Healthy Living Center, education on site in community-Dr. offices and churches. Utilize community health workers for community engagement o Noncompliance when patient receives resources. Motivational interviewing techniques as they relate to DM o Offering an educational group course to our clients led by an RN or RD. Would be nice to have a predeveloped program or training tool to use. o Pamphlets for patients that will be referred for both services for the facilities o Policy research support o Provide CODA materials for seniors o Work to spread education and best practices around positive screenings. Other options than antidepressant prescription, education pamphlet, list of counseling options, and calling of insurance to find out about benefits o Would like to expand the reach of our Healthy U classes Interest in integration of mental health and primary care o Additional support helping practices either integrate a BH Provider or provide training for PCP team members to better meet BH needs at the practice o Hearing about others experiences incorporating BH in PCP o Integration of physical healthcare in behavioral health setting. Better understanding of the whole person o Programs in PCP office to help with the teaching and follow up for patients managing their diabetes and/or depression o Sharing learning of BH in PCP setting o Work more collaboratively with PCP to provide education, support and monitoring of chronic conditions o Would love to provide PCP services at MH center or collaborate with major health system to provide services Interest in aligning mental health services o Access to cogitative behavioral therapy o Critical component of work is to fill gaps in mental healthcare. Connection to provider organizations helps identify needs. o Find solutions to access to BH providers. Or peer to peer support for managing BH issues and for resources for patients. Community wide telehealth solution o Gaining Clarity on whether 2 question screening is effective on all population types. Poverty and racism produce similar feelings as depression. Does medication help someone in the context of poverty? o Improved depression screening methods. In process of PHQ-2, advance universal screening o Incorporation and consistent utilization of validated depression screeners across a variety of specialties where depression is a common comorbid with other chronic conditions o More resources for income challenged patients with depression and other MH issues. Exchange patients are almost impossible to get services for in a timely manner-3 month waits o Other ways to screen outside physician office o Postpartum depression in subsidized housing residents, primarily young, single mothers o Support groups for immigrants/ethnic groups led in native language and culturally shaped o Ways to encourage patients to pursue counseling. New mom support groups. Education for providers to encourage lifestyle issue change instead of focusing on medical intervention Interest in pursuing the development of a comprehensive diabetes center o Be a partner in Diabetes center. Would like to be a provider on your resource guide o Interested in working with Collaborative to help make Brenda's vision to life Sharing of results-based practices that have positive impact o Benchmarks or best practices that result in positive outcomes o Best practices for linking diabetes and depression together internally among different levels of expertisecare coordination
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Best practices for patient/member engagement How to motivate the diabetic patient who is not interested in taking care of themselves Video training for patients post appointment. Transportation needs to be addressed Would like to see how others are managing depression referrals as well as best practices for population management - data aspects Strengthen collaborative partnerships focused on impacting diabetes and/or and depression in the community o Can help convene clients who are active in optometry and diabetes o Continue existing work o Continue to work on these projects o Continued interest in how agency programs can collaborate with provider organizations, particularly technology-based programs o Continued involvement in MNRI o Explore how Franklin County Pathways Community HUB can serve as resource/infrastructure to help manage chronic conditions o Graduate students in healthcare administration to work on project work for HCGC o Incorporate additional education & support o Incorporate depression recognition in the family support program o Increase utilization of Community Health Workers in chronic disease management o Interested in more learning opportunities on how to link care for DM and Depression o Interested in supporting any teams working on supporting PCMH, Providers, Case Managers, Care Coordinators, patient support, quality and/or pharmacy. o Partnering with health plans & PCMH to offer Diabetes Healthy U program and offer and address behavioral health for older adults o Resources/connections to community partners for cooking/exercising/lifestyle modification resources o Seeking interest in connecting with provider organizations who would like to do something in the diabetes/depression state around population health in addition to current programs underway tied to HEDIS o Seeking to work with the community & HCGC to develop a unified Diabetes treatment program to ensure that clients receive the same information no matter where they enter healthcare continuum o Very interested in collaboration with both conditions. Creating a better network with community referral and continuity of care o We are seeking to rollout a BH program. Have a goal to build relationships with BH providers in Medical Neighborhood o Working to develop electronic referral from PCP to community resource for diabetes o Would like to be involved. Can reach every RN/LPN in Ohio and can include education which can impact our population o Would love to connect to work being done around Diabetes through HCGC
Break-Out Sessions
Accountable Health Communities (AHC) Model: A national initiative to enhance clinical-community linkages to improve health outcomes Naomi Makni, MHA, Manager, Center for Innovation in Pediatric Practice, Nationwide Children’s Hospital Michelle Missler, LSW, Healthcare Improvement Consultant, Healthcare Collaborative of Greater Columbus Franklin County Pathways Community HUB: An emerging regional infrastructure that aligns payments with results-based health and social services. David Ciccone, AVP Community Impact & Sr. Health Impact Director, United Way of Central Ohio Isi Ikharebha, MPH, Executive Director, Physicians CareConnection State Innovation Model (SIM) Updates: Aligning payment innovation in Ohio Greg Moody, Director, Governor’s Office of Health Transformation
Please save the dates for our scheduled 2016 Regional Learning Sessions All Regional Learning Sessions are held at the Nationwide and Ohio Farm Bureau 4H Center from 8:30 – 11:30 AM August 19th December 9th www.hcgc.org/registration Thank you to all of the participants that were able to attend. We appreciate your time and perspectives. First Name Kelly Angela David Amanda Stuart Nancie Donald Douglas Lori Jeff Larry Joyce Ernest Ladonya Tara Traci Erica Aprile Susan Barbara Antonia
Last Name Aardema Abenaim Applegate, MD Bain Beatty Bechtel Bennett Bennett Bergman Biehl Blosser, MD Bourgault Boyd Brady Britton Brown Brown Burt-Harp Butler Camfield Carroll
Kristin Jennifer Yvonne David Susan Jamie Megan Eric Cindy Krisanna Madeleine Todd Sarah Pat Connie
Casper Castore Christian Ciccone Conner Corder Daugherty Davies Deep Deppen Devitt Dieffenderfer Durfee Ecklar Emerson
Organization The Health Collaborative Nationwide Children's Hospital Ohio Health Physician Group The Ohio State University Health Plan The Ohio State University College of Pharmacy Columbus Public Health The Ohio State University College of Pharmacy The Ohio State University Wexner Medical Center Health Services Advisory Group Healthcare Collaborative of Greater Columbus Central Ohio Primary Care Physicians Helping Hands Health and Wellness Center Ohio Pharmacists Association Mount Carmel Health System The Center for Community Solutions Ohio Department of Aging OhioHealth Group Mt Carmel Health The Ohio State University Wexner Medical Center YMCA of Central Ohio Franklin County Office on Aging The Ohio State University College of Pharmacy/The Charitable Pharmacy of Central Ohio Mount Carmel Health Partners Mount Carmel Health Partners United Way of Central Ohio Preferred Benefits Services Department of Administrative Services Mental Health America of Franklin County Transformative Consulting, LLC Anthem OhioHealth Medical Mutual United Way of Central Ohio Ohio Public Employees Retirement System The Ohio State University Concord Counseling Services
Melissa Sandra Heather Jonelle Heather Sara Julie Stacey Tonya Jeanette Christine Erinn Sara Michelle Veronica Amy Jennifer Beth Katie Laura Shawna Nancy Wayne Shanna Leroy Isi Cindy Erin John Kyle Liz Chip Stephanie Beth Raymonia Kevin John Theresa Robert Kathleen Kate Naomi Tani Sara Toni Margaret
Evans Ferguson Flanagan Flowers Foley Frantz Frazier Friedman Fulwider Gains Garcia Garrison George Groux Hawkins Headings Hetrick Hickerson Higgins Hill Hite Hood Howlett Huber Hushak Ikharebha Irvin Jech Kackloudis Kerley Kitchen Knoop Koscher Kowalczyk Lacy Lanning Leite Leite Lonardo Maedeka Mahler Makni Mann May McDaniel McDonald
Aetna UnitedHealthcare Community and State Aetna Pfizer Ohio Department of Health Nationwide Children's Hospital State Teacher Retirement System of Ohio UnitedHealthcare Community Plan Mental Health America of Franklin County The Ohio State University Wexner Medical Center InHealth Mutual Ohio Association of Foodbanks United Healthcare Columbus Public Health Medical Mutual Mid-Ohio Foodbank Family Medicine Physician OhioHealth Group Nationwide Children's Hospital The Center for Balanced Living OSU Extension, Family & Consumer Sciences Community Properties of Ohio Comprehensive Healthcare Advisors Ripple Life Care Planning BREAD Physicians CareConnection Boehringer Ingelheim The Ohio Academy of Family Physicians Health Action Council Helping Hands Health and Wellness Center Ohio Department of Health CBIZ Prevent Blindness Ohio Association of Area Agencies on Aging Ohio Association of Free Clinics The Ohio State University Healthcare Collaborative of Greater Columbus Physician's Free Clinic ADAMH Board of Franklin County The Ohio State University Ohio Association of Family Physicians Nationwide Children's Hospital The Dispatch Printing Company OhioHealth OhioHealth Physician Group Johnson & Johnson
Pat Julie Srinivas Lynn Nicole Judith Michelle Greg Sally Sanleda Stefanie Gregory De Andree Ahmed Shane Georgia Kevin Steven Jinal Anthony Malcolm Jennifer Celeste Barbara Leslie Brenda Rhiannon Mark Kathy Teresa Melinda Cheri Grace Greg Ann Crystal John Jim Jean Steven Stella Theresa Shawn Michelle Andy Ann
McKnight McMahon Merugu Miller Miller Minaudo Missler Moody Morgan Morgan Morrow Myers Norris Olayanju Olson Oriold Orr Parsons Patel Penn Porter Powell Prince Pryor Reich Rendleman Richman Ridenour Ritchey Roe Rowe Ryland Sabatino Sawchyn, MD Schiele Schlicher Schmeling Schmidt Scholz Schultz Shaw Shipley Smith Smith Smith Spicer
Ohio Academy of Nutrition and Dietetics Susan G. Komen Columbus United Healthcare Community Plan Ohio Dominican University Primary One Health org Central Ohio Primary Care Physicians Healthcare Collaborative of Greater Columbus Governor's Office of Health Transformation Ohio Nurses Association United Way of Central Ohio The Ohio State University Health Plan Medical Mutual United Way of Central Ohio Ohio Dominican University Humana Ohio Health Physicians Group Pfizer Findley Davies, Inc. Nationwide Children's Hospital Columbus Area Integrated Health Services, Inc. Healthcare Collaborative of Greater Columbus UnitedHealthcare Community Plan Doctors West Family Practice Ohio Department of Health Mt Carmel Health Central Ohio Diabetes Association Ohio Department of Health The Ridenour Group Syntero OhioHealth LifeCare Alliance The Center for Balanced Living OhioHealth Group OhioHealth Lower Lights Christian Health Center Medical Mutual The Medical Group of Ohio OhioHealth Healthcare Workforce Transformation Johnson & Johnson Planned Parenthood Greater Ohio The OSU Health Plan AbbVie The Ohio State University Wexner Medical Center Sanofi Ohio Academy of Family Physicians
Adam Tanya Lois Krista Michelle Marian King Barbara Becky Staci Linda Jonathan Arlene Noelle Bruce Andrew William Lisa Amy Randy Gregory Beth Emily Michelle Jenny Shannon Matthew Irina Rob
Spidel Stamp Stauffer Stock Stoughton Stuckey Stumpp Sullivan Sustersic Swenson Szczyt Thomas Vance Waddle Wall, MD Wapner Washington, MD Watkins Watson Wexler, MD Whisman, MD Whitted Williams Williams Wilson Yang Yannie Yaroshenko Zidek
State of Ohio: Department of Administrative Services Sanofi OhioHealth Healthcare Collaborative of Greater Columbus Anthem BCBS Columbus Public Health Netcare Access Franklin County Office on Aging Health Policy Institute of Ohio PrimaryOne Health Mount Carmel Health Partners ADAMH Board of Franklin County Primary One Health org Grant Family Practice Southwest Aetna The Ohio State University College of Public Health Heart of Ohio Family Health The Ohio State University Village Family Medicine The Ohio State University Wexner Medical Center MGO/OhioHealth Group PrimaryOne Health Pfizer Village Family Medicine The Ohio State University College of Pharmacy Columbus Public Health United Way of Central Ohio The Ohio State University Health Plan Pfizer