January 18, 2017 9:00am -12:00pm CHACT & Videoconference CT-PTN Quality Forum January 18, 2017 9:00am -12:00pm CHACT & Videoconference

Practice as a Community Partner Secondary Driver 1.4

“Practice facilitates referrals to appropriate community resources, including community organizations and agencies as well as direct care providers.” Primary Care Milestone 11; Specialty Milestone 8; Secondary Driver 1.4.4

Objectives Demonstrate the connection of access to community resources and improvement in patient clinical outcomes Identify the opportunities and need for a community based resources referral inventory/directory Identify opportunities for tracking of community based resource referrals.

Average Score on Milestone 11 1 2 3 Practice does not regularly refer patients to available community resources. Practice is compiling an inventory of resources and establishing communication with them to link patients with appropriate community resources. Practice is referring patients to appropriate community resources but does not have a consistent approach for following up on referrals made. Practice has completed its resources inventory and consistently links patients with appropriate community resources and follows up on referrals made.

How Community-Based Organizations Can Support Value-Driven Health Care Greg L Wolverton, FHIMSS TCPI National Faculty Co-Chair

As our health care system transforms more quickly than ever from paying for volume to paying for value, providers have strong incentives to ensure that their patients’ care plans are reinforced and supported outside the clinical setting in people’s homes and communities.

For individuals to achieve better health, providers must be able to connect their patients to social supports and human services while focusing on prevention and wellness in ways that emphasize behavior change. By partnering with community-based organizations (CBOs), such as Area Agencies on Aging (AAAs), providers can help individuals manage their chronic diseases and meet their often overlooked social needs. CBOs can improve patient outcomes by activating patients, avoiding both short- and long-term nursing facility stays, and preventing unnecessary hospital admissions.

How Do We Do It? Develop strategic partnerships Hospitals Other Primary Care Clinics Other Non-Profits (AARP, ACS, Foundations) Long Term Care Always be on the lookout for more Constantly move the needle Improve flow (Direct Messaging, Technology Interfaces) Unified Case Management Work in the best interests of everyone (Don’t forget about your interests)

More Information Resources http://forces4quality.org/af4q/download- document/6414/Resource-primer- qualityequality_partnerprovidercommunity.pdf https://www.ahrq.gov/professionals/prevention-chronic- care/improve/community/index.html http://healthaffairs.org/blog/2015/07/10/how-community- based-organizations-can-support-value-driven-health-care/ http://www.ihi.org/communities/blogs/_layouts/ihi/communit y/blog/itemview.aspx?List=7d1126ec-8f63-4a3b-9926- c44ea3036813&ID=175

CMS Focus on Reporting Announced at Quality Conference in December 2016 Eight proposed common measures NQF, Composite measures and unique TCPi measures List of the measures: NQF 0018: Controlling High Blood Pressure in Patients with Hypertension NQF 0052: Use of Imaging Studies for Low Back Pain NQF 418: Preventative Care & Screening; Screening for Clinical Depression & Follow-up Plan PQRS 402: Tobacco Use and Help with Quitting Among Adolescents NQF 2597: Substance Use Screening and Intervention Composite NQF 2152: Preventative Care and Screening ; Unhealthy Alcohol Use Screening & Brief Counseling (SBIRT) NQF 0028: Preventative Care & Screening; Tobacco Use: Screening and Cessation Intervention TCPi 01: Comprehensive Health and Life Plan TCPi 02: Referral of At-Risk Patients to Community Based Prevention & Support TCPi 03: Medication Management

TCPi 02: Referral of At-Risk Patients to Community Based Prevention & Support Description: This measure is to refer at risk patients of all ages to community resources to provide support and assist the patient with health promotion and prevention. The at-risk patient population for this measure includes: BMI range>26 Pre-diabetes Metabolic syndrome Behavioral/mental health Substance use disorder Numerator: Number of at-risk patients of all ages, referred to local community resources Denominator: Number of at-risk patients of all ages. Measurement rationale: Key aspects of transformation involves both prevention of disease as well as partnerships with the community. CMS emphasizes the importance of community engagement for the achievement of transformation This measure closely aligns with the uses of community resources support transformation. In addition, risk stratification is critical aspect of TCPi Change Package Driver 1.3, Population management, which requires clinicians engage in risk stratification to tailor interventions based upon patient’s risk of poor health outcomes.

What Does Research Show? Community based programs support the efforts we are already making Community based programs can substantially reduce disease incidence and associated morbidity and mortality. For example, in the United states there are over 90 million people with pre-diabetes and 26 million with diabetes. The community- based Diabetes prevention Program (DPP) achieved a 58% reduction in the incidence of diabetes in a pre-diabetic population in the short term and 34% reduction in incidents after 10 years

PCMH+ Community Partnerships Per DSS presentation December 13/14, 2016 “DSS expectation is for care coordination tot assist members to obtain needed social services and resource supports, providers will partner with community organizations to address social, economic and environmental issues that can adversely impact health.” Meaningful impact on social determinants of health Promotes physical and BH integrated care Facilitate rapid access to care and resources

Alana Kroeber Director of information Services 2-1-1 Alana Kroeber Director of information Services

Available 24hours a day, 7 days a week Database of approximately 4,100 health and human service providers offering aprox. 40,000 services Provides information and referrals to health and social service3 programs in your community and around CT Provide crisis intervention Point of access for Children's Emergency Mobile Psychiatric Service Program (EMPS) Point of access for coordinated assessment of housing

Questions to Run on What are the options for building an inventory of resources? What are the options for tracking referrals to community resources? How can we implement a tracking mechanism?