May 2016 MNRI Work Session Record

Coordinated By:

Medical Neighborhood Referral Infrastructure Project In-Person Work Session May 20, 2016 Record of Learning Meeting Participants  Jane Acri, Central Ohio Area Agency on Aging  Barabara Camfield, YMCA of Central Ohio  Kristin Casper, Charitable Pharmacy of Central Ohio  Dave Ciccone, United Way of Central Ohio  Matthew Dewit, Central Ohio Primary Care  Maurice Elder, LifeCare Alliance  Courtney Elrod, Equitas Health  Elio Harmon, Alliance Healthcare Partners  Dottie Howe, CliniSync  Shanna Huber, Ripple Life Care Planning  Isi Ikharebha, Physicians CareConnection  Megan Gish, Clintonville-Beechwold CRC  Matt Kehlmeier, National Church Residences  John Leite, HCGC  Reggie Lipscomb, Physicians CareConnection  Michelle Missler, HCGC  Sanleda Morgan, United Way of Central Ohio

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Laura Moskow Sigal, Central Ohio Diabetes Association Mary Mutegi, Physicians CareConnection DeAndree Norris, United Way of Central Ohio Shawnetta Padgett, Central Ohio Diabetes Association Noreen Palmer, Helping Hands Health & Wellness Center Francine Pettay, Central Ohio Primary Care Cathy Phillips, LifeCare Alliance Laura Poling, Charitable Pharmacy Victoria Redden, CliniSync David Reierson, United Way of Central Ohio Tonia Robertson, Central Ohio Primary Care Melinda Rowe, LifeCare Alliance Carly Skillington, Mount Carmel Health Partners Barbara Sullivan, Franklin County Office on Aging Jennifer Tiedt, Central Ohio Area Agency on Aging Colleen Wesley, The Breathing Association

Welcome and Framing Thank you to Matt Kehlmeier and National Church Residences for hosting the session and providing us with refreshments. To view the slides used during the session, please click here.

Introduction to the Franklin County Pathways Community HUB (Dave Ciccone, United Way of Central Ohio) The goal of the MNRI project is to implement shared referral infrastructure among healthcare provider organizations and social service agencies to advance accountable care coordination in the medical neighborhood. While shared infrastructure is an important step towards accountable care coordination it is also important to identify and align with other care coordination initiatives taking place in the community. One such effort is the Franklin County Pathways Community HUB being coordinated by the United Way of Central Ohio.

Dave Ciccone shared a briefing on the HUB model and responded to participants questions. If you have additional questions regarding the HUB you can connect with Dave at (david.ciccone@uwcentralohio.org).

Work Session #1: Exploring the lessons learned from implementing/using a shared referral infrastructure In order to help project partners learn from the experience of others using the CliniSync Referral Tool we asked participants to break into small groups and discuss the following questions.  What lessons have you learned from implementing/using the shared referral infrastructure?  Adopting new habits that incorporate CliniSync use by provider staff.  Allow accountability knowing actual person assigned to a referral  Behavior change is a big piece of system use.  Building relationships/trust with organization in the medical neighborhood.  Changing workflow  Developing habits and changing workflow.  Everyone still invested in the tool and sees value in it!  IT limitations for home visits.  Lack of being in the referring partners’ programs?  Line staff feeling as though this is an extra thing. Changes in work flow.  Lower referral volume—are there barriers to use?  Physicians with low referrals—do patients benefit?  Prompt response  Very hard to get staff to change to a new system when old system is very efficient.  What best practices has your organization identified that have made the shared referral infrastructure more effective?  Having one person check every day for referrals.  Having one or two key people to check for referrals and forward along.  Using search words to find whatever care a patient needs.  Variety of resources for easier access. For example access to medical records.  Very initial stages of implementation—still exploring best practices.

Work Session #2: Exploring approaches for continuing to improve the referral network  What activities could HCGC, CliniSync, and/or project partners do to improve the referral network?  Add more agencies to the network.  Build awareness. Educational events/ CEWs/networking events, etc.  Contact/service list cheat sheet  Description of resources available to help with referrals.  Easier way to find providers and services offered.  Events designed to facilitate integration between social services and medical office staff.  Getting more behavioral health providers is great!  HCGC could add value through continued learning sessions and relationship building.  I really like the idea to document referral network/contacts/services via a Google doc.  Need notification once we have a new referral.  Networking events.  Notifications of new referrals.  Perhaps a triage tool to allow for an easy transfer system when organizations don’t have social workers of case coordinators. Possibly use portions of something like HandsOn Central Ohio.  Sample recording of sending process—online training to go back to.  Show all services per organization online.  Streamline communications—notifications when get referrals. People who get referrals typically do not make referrals.

Closing Based on feedback from project participants we will continue to host in-person sessions on a quarterly basis. We will send out a poll in early Q3 to schedule a date for our next session. If you have any partners that would be a good fit for the project please let us know.

Thank you for participating!