Medical Neighborhood Impact on Chronic Conditions (MNICC) September 1, 2016 Record of Learning Medical Neighborhood Impact on Chronic Conditions Participants • Jane Acri, Central Ohio Area Agency on Aging • David Applegate MD, OhioHealth • Belinda Bardall, The Ohio State University Wexner Medical Center • Dave Ciccone, United Way of Central Ohio • Jimmie Davis, Franklin County Public Health • Tonya Fullwider, Mental Health America of Franklin County • Amy Headings, Mid-Ohio Foodbank • Liz Kitchen, Ohio Department of Health • Berrie Mabins, Ohio Department of Aging • Mary Mutegi, Physician CareConnection
Coordinated by:
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Julie Poierer, Lifecare Alliance Caroline Rankin, YMCA David Reierson, Care Coordination Network Brenda Rendelman, Central Ohio Diabetes Association Laura Moskow Sigal, Central Ohio Diabetes Association Jenny Xu, Central Ohio Diabetes Association
Healthcare Collaborative of Greater Columbus • John Leite • Michelle Missler • Krista Stock
Medical Neighborhood Overview Purpose: Advancing accountable care coordination across clinical and social service organizations • Relationships: Strengthening the relationships between clinical and social service organizations • Reduce Variation: Adopt and spread results-based practices • Align Shared Infrastructure: Link/make sense of shared infrastructure being utilized in the region Key Learning: Medical Neighborhood Impact on Chronic Conditions Purpose: Improve chronic condition management by advancing results-based practices with clinical and social service organizations. Objective: Reduce Variation: Adopt and spread consistent use of results-based practices for Diabetes and/or Depression starting with screening & education. Proposed Pilot Project Idea Screen Diabetic Patients for Depression Proposed Objectives • Adopt and spread utilization of PHQ-9 for diabetic patients • Deployment of technical assistance for pilot organizations screening diabetic patients for depression • Shared learning across pilot participants Please click here to view presentation slides.
MNICC Work Sessions Session #1: What are the opportunities and challenges of implementing a pilot project using the proposed objectives in our community? Opportunities: • Decreased stigma surrounding mental health • Improve process of how and when to follow up • Improved care • Increased awareness of community resources • Increased compliance due to everyone being screened • Increased opportunity for treatment • Integrated physical and mental health • Leveraging existing care coordination activities to screen and keep clients connected to services and self-management programming • Opportunity for prevention • PHQ-9 on all patients, not diagnosis related
Challenges: • Building a referral network • Buy in from providers • Clarity of diabetic population • Competition among program providers • Costs associated with screening • Disseminating the information into the community • Follow up for treatment • Language and cultural barriers • Recognition that chronic disease self-management requires sustained engagement with patient • Resources in community • Time challenge for screening process and patient education
Participants came to the collaborative agreement that the following objectives would be utilized to implement a pilot project within our community: MNICC Objectives • Adopt and spread utilization of PHQ-9 for patients who self-identify as diabetic • Strengthen relationships among project participants to raise awareness of resources available in Greater Columbus • Share learning and best practices to improve care coordination among the medical neighborhood participants
Session #2: From your unique perspective, what will it take to move this pilot project forward? • • • • • • • • • • • • • • • • • • • •
Allocate time for process change and to provide patient education regarding screening and depression Building relationships/resources Buy in from providers (all staff involved) Champion at the organization Clear outcomes Determining where diabetics come from, where are we screening? Involving other organizations other than health organizations IT interaction Key players: CareCoordination Network Knowing what behavioral health resources are available Making sure there is a standard of having the referral loop closed Needs to be sustainable and aligned with other work Non-clinical language for referral and discussion about mental health PCP prescription for first line care Refine the process we use for follow up with community resources Strong process Using students in the healthcare field to push this project forward Utilize care coordinators to make referrals Utilize current agencies that have expertise Who will fund this?
Next Steps •
Participants in the room determined the modified objectives were a good place to start. Participants will continue to shape this project within our region.
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Based on participant feedback, HCGC will finalize a project charter and reach out to individual organizations to gauge interest in participating in a pilot.