Coordinated By:
Medical Neighborhood Learning Group Work Session May 4, 2016 Record of Learning Meeting Participants Kristin Casper, Charitable Pharmacy of Central Ohio Courtney Elrod, AIDS Resource Center Ohio Meredith Finley, Alzheimer’s Association Leslie Fritz, Syntero Elio Harmon, Alliance Healthcare Partners Dottie Howe, CliniSync Shanna Huber, Ripple Life Care Planning Jaclyn Kirsch, Community Refugee & Immigration Services Reggie Lipscomb, Physician Care Connection David Maywhoor, UHCAN Ohio
Alex Meyer, CompDrug Alyssa Nance, Lower Lights Christian Health Center DeAndree Norris, United Way of Central Ohio Tiffany Pannell, COTA Laura Poling, Charitable Pharmacy Caroline Rankin, YMCA of Central Ohio Katie Stone, Columbus Public Health King Stumpp, Netcare Access Laura Wengerd, Home Care Assistance Matt Yannie, United Way of Central Ohio
Update of Medical Neighborhood Referral Infrastructure Project An update on the Medical Neighborhood Referral Infrastructure project was provided to the group. The network is currently undergoing an expansion and new organizations are committing to the project every week. Please click here to learn more about the project, including who is participating. If your organization would like to explore joining the Medical Neighborhood Referral Infrastructure Project, please contact John Leite (john@hcgc.org). Shape the Medical Neighborhood Impact on Chronic Conditions Project
Where is a good place to start to reduce variation in the Medical Neighborhood around diabetes and/or depression management? Collaboration of care for diabetes and/or depression (Care Coordination) Ex: Alignment of referral for continuity of care within the MN once a patient is diagnosed with diabetes and/or depression Education around diabetes and/or depression Ex: Alignment of literature provided to patient upon diagnosis of diabetes and/or depression Screening for Depression and/or Diabetes Ex: Alignment of the screening tool utilized by members of the MN to diagnose depression, i.e. PHQ2, PHQ-9, etc. Self-Management programs for diabetes and/or depression Ex: Alignment of diabetes and/or depression self-management programs in the MN
Participants indicated the area they felt was a good place to start to reduce variation.
Condition Diabetes Depression
Care Coordination 11 8
Education
Screening
5 8
2 3
SelfManagement 1 -
Key reflections from work session A simpler, more targeted message may help educate both patient and provider Align community agencies by focus/mission to impact collaboration Behavioral health organizations screen first for depression and then diabetes, vs. PCP screening diabetics for depression Develop a common language Diabetes prevention also needs to be considered in this work, consistent prevention education messages should go along with management messages Education can also include prevention Education could include individual consumers as well as community Identify existing literature to find shared approaches Increase referrals to organizations that specialize in coordination of care Looked at it with the lens that self-management is the goal and how do we work to get to the goal May not know how to help after screening, need a resource list Medication access for both conditions is important Often rely on PCP to screen but some patients are not connected to a PCMH Screening needs to standardized, how do primary care physicians screen? Started with self-management but then realized it’s the end goal, need standardization of other things to lead to better self-management. Funnel analogy, screening is at the top of the funnel and self-management is at the bottom. Standardization of everything above (care coordination, education & screening) selfmanagement will lead to positive self-management Uniformity needs strengthened from diagnosis to next visit Utilization of the referral tool to help better understand what services the organization offers for each of the conditions Utilizing collaboration of care means families and physicians are linked to community organizations which strengthen and aid in education and appropriate use of resources Wide variation exists in treatment plan and educational information Closing Participants will continue to be engaged in the process of shaping the work of impacting chronic conditions in the Medical Neighborhood. Results of the value survey administered at the conclusion of the session are listed below. Meeting Scheduled All sessions hosted at the Nationwide & Ohio Farm Bureau 4H Center from 8:30 – 10:00am July 6, September 7 www.hcgc.org/medical-neighborhood-learning-group/
Learning Session Value Survey Very High High Medium Low No
xxxx (4) xxxxxxxx(8) xx (2)
What are the key reflections you are taking away from today’s session?
Continued opportunities of shared information and understanding how all of the community initiates are connected. Found the meeting informative, excited to participate in the development of these programs Funnel concept was valuable Good overview of MNRI Project, unfortunate not many questions/feedback was shared Great to hear other organizations’ perspectives and the work they do. Helpful to hear how/why others prioritized collaboration, education, screening, & selfmanagement. Common goal with many paths to get there. Helpful to think in terms of the four areas to tackle. Discussion is integral as our starting point was certainly not our ending point. I appreciated the project overview & updates Interesting learning of how we can collaborate more affectively in the community Process moves so fast, there needs to be time built in to process the data Small group discussion and activity was very informative and useful Today’s session improved my overall learning view of the prospective regarding diabetes Visual of the funnel helped improve my understanding of how the MN can standardize the process of managing chronic conditions