Coordinated By:
Medical Neighborhood Learning Group Work Session January 6, 2015 Record of Learning Meeting Participants Leigh Anne Hehr, American Cancer Society Roy Bobbitt, Central Ohio Diabetes Association Denise Bugara-Dlugo, Ripple Life Care Planning Jimmie Davis, Franklin County Public Health Felipe DeJesus II, Southeast, Inc. Courtney Elrod, AIDS Resource Center Ohio Linda Gillespie, Central Ohio Area Agency on Aging Elio Harmon, Alliance Healthcare Partners Shanna Huber, Ripple Life Care Planning Matt Kehlmeier, National Church Residences Liz Kitchen, Ohio Department of Health
Rose Kramer, Franklin County Public Health David Maywhoor, UHCAN Ohio Sarah Miller, Community Refugee & Immigration Services Laura Poling, Charitable Pharmacy of Central Ohio Caroline Rankin, YMCA of Central Ohio Marci Ryan, Godman Guild Sandy Stephenson, Southeast, Inc. Steve Thompson, Helping Hands Health & Wellness Center Carrie Wirick, Netcare Matt Yannie, United Way of Central Ohio
Next phase of work on the Medical Neighborhood in 2016
Work Session #1 Discussion Question: What results-based practices are being used in the Greater Columbus Medical Neighborhood to impact diabetes and/or depression? Participant Reflections Best Practices o Addressing and treating multiple needs whenever possible, because they are often co-occurring. o Care-coordination is important to managing conditions both in the individual and system capacity. o Diabetes education class o Lifestyle management—diet, travel, crisis, # of doctors o Medication management. o Onsite mental health counseling—for substance abuse and mental abuse (interrelated) o Patient, community, provider education. o Reduce complications/hospitalizations leads to harm reduction. o Regularity in screenings, education, supplies, diabetes clinic, care management, resources. Results-Based Programs and Resources o A1c annual logging o BAM: ADAMH assessment. o Central Ohio Diabetes Association classes for diabetics
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Clinical guidelines EBP: wellness management FQHCs screen for diabetes and depression Healthy U: diabetes program. Kroger pharmacy: not sure about specifics of the program. LifeCare Alliance foot clinic Ohio Department of Health program for caregivers: long-term care issues. OhioHealth ENGAGE Program: “mental health first aid” PPOD: CDC screening toolkit for diabetes YMCA Diabetes Prevention Program
Work Session #2 Discussion Question: What are the strongest opportunities for alignment to reduce the variation of results-based practices being used? Participant Reflections Awareness i.e. PPOD, making it easy for providers to share successes. Awareness of resources Capitalizing on momentum related to quality improvement measurement Compiling resources Community knowledge--what is everyone doing? Difficult to align on best practices when funding sources do not necessarily incentivize you to do so. Education! There were a number of great points, tools, etc. that were mentioned. Even within the group there were things mentioned, or not known. Bring all the tools/ideas together with the largest providers/stakeholders in the community to develop the “best” course of action. Focus more on prevention Look at the bright spots or what practices are being used and have seen success. Duplicate those for more physicians to use, or community based agencies. Sharing of information consistently. Cooperation! Trusted neutral entity with convening power to make changes actionable (importance of/emphasis on collaboration) Unified assessment of options/messaging to lead to practice improvement.
Closing Participants were asked to provide their feedback on the perceived value of the learning session. They were also asked to write down a key reflection from the session, and suggest topics for future discussion. Results are included below. Meeting Scheduled All sessions hosted at the Nationwide & Ohio Farm Bureau 4H Center from 8:30 – 10:00am March 2, May 4, July 6, September 7 www.hcgc.org/medical-neighborhood-learning-group/
Learning Session Value Survey Very High High Medium Low No
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What are the key reflections you are taking away from today’s session?
Are the number of best practices helpful or not? Care management and patient engagement are key. Dental needs greater focus—oral and nutritional health. Healthy U program. I appreciate HCGC’s willingness to speak openly about how “messy” this work is going to be. So many groups that I’ve been in are frustratingly unrealistic about their goals and end up burning out. I really like the focus on “results-based”, not necessarily evidence-based Importance/possibility for impact in outcomes-based payment (to push this work forward) Increased understanding of the variety of services available. Lots of information sharing that I will use to share with my co-workers. Lots of resources available need to coordinate More communication between groups of different interests needed. Need for coordination/collaboration Need to develop new ways of messaging these programs in order to more effectively reach and engage patients. Need to educate organizations and patients about available programs. Results-based practice being used in communities. Seems like a good start for beginning this conversation. Seems like there is an opportunity for additional MH/SA providers—today seemed diabetes/general health care provider heavy. Seems that everybody is on board to make this happen. Self-management is hard to do if you’re poor. Sharing revealed new resources. Such a great session—lots of opportunity to standardize across these chronic conditions. There are a lot of variables to consider when planning a strategy There are many barriers—including struggles for patients and companies. There are many providers doing great work and future coordination will improve community health. There are many results-based best practices being used in Central Ohio. There are so many programs/practices that exist, but no easy way of connection people yet. There is a huge need for a tool that is used more commonly by providers. There is a lot being done at various organizations and there is much that can be shared to benefit the community. There is a lot of work to be done. It would be very helpful if hospital systems, or large physician groups were part of the group. Value of motivational interviewing.
What healthcare transformation topic(s) should we consider discussing at future learning sessions?
Collaboration across systems/bringing groups together to be solutions oriented. Community Health Worker role in disease management/depression. Continued discussion surrounding coordination. Continuum of patient care and establishing a gold standard for referrals. Data collection and analysis. Data that can be distributed at each location describing efforts. Elderly-care—different thinking of elderly in regards to healthcare. Further examination of care coordination best practices/options Homelessness—addiction—healthcare barriers How disparities in health care providers has an impact on quality of care. I look forward to expanded healthcare topics beyond diabetes and depression. Learning from other larger cities if they’ve done anything similar with care coordination. National standards for diabetes and depression. How can we reflect that in individual practices. Reflections/lessons learned from partners who are using the CliniSync tool. We are also seeing a lot of patients that are hypertensive. Is that another area that we could focus? Would be good to learn about these sorts of efforts in other parts of the countryspecific to diabetes and depression.