Medical Neighborhood Referral Infrastructure Project
December 16th Work Session
Today’s Agenda • Welcome & Introductions • CliniSync Updates • Sharing Lessons Learned from the Project in 2016 • Exploring Approaches for Implementing Screening
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Medical Neighborhood Referral Infrastructure Project • Alliance Healthcare Partners • Central Ohio Area Agency on Aging • Central Ohio Diabetes Association • Central Ohio Primary Care • Charitable Pharmacy of Central Ohio • Clintonville-Beechwold Community Resource Center • Equitas Health (formerly ARC Ohio) • Helping Hands Health and Wellness Center www.hcgc.org
Project Participants • Kroger Pharmacy • LifeCare Alliance • Lower Lights Christian Health Center • Metropolitan Family Care • Mount Carmel Health Partners • Physicians CareConnection • PrimaryOne Health • Ripple Life Care Planning • Southeast, Inc. • Syntero • The Breathing Association • YMCA of Central Ohio
Medical Neighborhood Referral Infrastructure Project
Committed Participants
•
Caliber Patient Care
•
Franklin County Office on Aging
•
Health & Wellness Pharmacy
•
Lutheran Social Services
•
Mount Carmel Medical Group
•
National Church Residences
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Medical Neighborhood Referral Infrastructure Project
December 16th Work Session
CliniSync Updates Karen Bishop, Ohio Health Information Partnership
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Medical Neighborhood Referral Infrastructure Project
Sharing Lessons Learned
Small Group Work Session
• What has been the value of the project for your organization? • What are the challenges of the project for your organization?
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Medical Neighborhood Referral Infrastructure Project
2016 Referral Activity
Timeline 80
75
70 60
69
51
50
44
40 30
20
22
29
27
20
19
14
10 0 Jan
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Feb
Mar
April
May
June
July
Aug
Sept
Oct
Medical Neighborhood Referral Infrastructure Project
2016 Referral Activity
Organization 250 216 200 167 150
100 77 50
0
61
47 20
0
00
0
12
12
31
12
0
00
0
Sent www.hcgc.org
59
05
00
Received
30
50
03
13
02
00
Medical Neighborhood Referral Infrastructure Project
Sharing Lessons Learned
Small Group Work Session
• What are we learning from the 2016 referral activity data? • What goals can we set for 2017 based on the referral activity data?
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Medical Neighborhood Referral Infrastructure Project
December 16th Work Session
Exploring Approaches for Implementing Screening
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Medical Neighborhood
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 resultsbased practices • Align Shared Infrastructure: Link/make sense of shared infrastructure being utilized in the region www.hcgc.org
Medical Neighborhood
Impact on Chronic Conditions Project
Reduce Variation: Adopt and spread consistent use of results-based practices for Diabetes and/or Depression starting with screening & education.
Education
Care Coordination
Screening
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Coordinated by:
SelfManagement
Medical Neighborhood Impact on Chronic Conditions
PURPOSE: Improve chronic condition management by advancing results-based practices with clinical and social service organizations. •
•
•
Adopt and spread utilization of PHQ-9 to screen for depression in 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
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Pilot Organizations
Central Ohio Primary Care Physicians CompDrug Mental Health America of Franklin County
Ohio Department of Health Syntero
Medical Neighborhood Referral Infrastructure Project
Implementing Screening
What are the opportunities and challenges of screening diabetic patients for depression utilizing the PHQ-9 screening?
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Medical Neighborhood Referral Infrastructure Project
Closing
2017 Work Session Planning
Thank you for all of your hard work this year.
Happy Holidays
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