IMPACT QIC Action Period Call January 19, 2017 8am

Welcome! Whitney Young HRHCare Yonkers OpenDoor Family Health Network NOCHSI Aspire UB MD NYSDOH

Today’s Agenda Welcome and roll call National Diabetes Prevention Program (NDPP) Program overview and reimbursement status – Sue Millstein, NYSDOH Implementing a referral system – Charles Welge and Tricia Bulatao, Albany County Department of Health Open Q & A Review of Data and PDSAs Other updates and questions  

NDPP Program – Sue Millstein Overview and Reimbursement Status

Local IMPACT: Albany County Get Healthy. Stay healthy. NDPP Referral Development & Implementation

Development of NDPP Referral Process Build Awareness Providers Community Risk-Assessment Screening Build NDPP Capacity Schedule NDPPs Diagnose & Refer Process Mapping Bidirectional Referrals CHW Engagement Stages being worked on concurrently

Build Awareness: Providers Prediabetes Detailing to PCPs Presentation from peer champions Tools for assessing risk Tools and/or procedure for documenting diagnosis Awareness about self-management program Held ~2 months before NDPP scheduled to start – time to ID need, prescribe bloodwork, follow up with dx & referral

Build Awareness: Community Community Awareness Outreach Events Prediabetes Risk Assessment Tool Referral to PCP Packet to give to PCP Referral to NDPP CHW Follow-Up HELD AT PRIORITY POPN GATHERINGS - Tabling: PCPs, wellness events Group Presentations: Prediabetes Packet: CHW contact, Risk Assessment Results, PCP listing CHW record contact information of those at risk for follow up

Build NDPP Capacity 50-60 20 10 Scheduling of NDPP Classes Promotion of Classes Setting an Enrollment Goal Engage PCPs in Recruitment One new class per month Fliers about 6-4 weeks in advance Start high and work with PCPs to meet initial enrollment goal

Increasing Diagnosis & Referral Process Mapping ID who is capturing undiagnosed, when and why ID who is missing diagnosis, when and why ID areas for improving efficiency & consistency Alerts Use of HIT ID what is working and why

YES YES YES NO NO YES NO Screening / Risk Assessment Lab Testing Diagnosis PCP assesses need for testing PCP reviews lab results & time stamps receipt in eCW PCP enters order for lab test in EHR PCP informs pt about need to get tested Pt gets HbA1C lab drawn same day as order written Lab completes analysis (offsite) Results sent to WYHC via eCW YES NO Pt has pre-DM aeb HbA1C = 5.7-6.4% PCP diagnoses pt with pre-DM No further evaluation for pre-DM YES YES NO NO PCP diagnoses pt with chronic disease KEY: PCP – primary care provider Pt – patient eCW – eClinicalWorks (EHR system) Pre-DM – pre-diabetes aeb – as evidenced by NHE – nutrition health education Pt advised to repeat HbA1C in 3 years YES NO

YES YES YES YES NO NO NO YES NO Follow Up Referral PCP diagnoses pt with pre-DM PCP enters code in EHR PCP informs pt of pre-DM diagnosis PCP refers pt to RD Pt accepts RD referral YES YES YES YES NO NO NO PCP diagnoses pt with chronic disease Diagnosis missed 1. 3 calls made, letter sent & pt unable to be reached 1. PCP provided NHE over phone & sets f/up appt & HbA1C recheck YES PCP refers pt to RD NO Pt reassessed & re-engaged at f/up appt. Pt lost to pre-DM care until re-engages with agency Pt lost to pre-DM care until re-engages with agency

YES YES NO NO YES NO YES NO Referral Pt accepts RD referral Pt keeps appt with RD 1. CC makes appt with pt for RD visit 1. Automated reminder call system confirms appt with pt Pt meets with RD for goal setting, NHE, & action plan YES YES NO NO 1. CC or front desk staff reaches out to pt to reschedule with RD. Pt lost to pre-DM care until re-engages with agency YES NO Pt reschedules appt with RD Pt keeps appt with RD YES NO Pt lost to pre-DM care until re-engages with agency

Increasing Diagnosis & Referral Utilization of HIT Prediabetes Register Follow Up Plan Pilot Procedure Identify Leader and Support Staff Challenge identifying meaningful data, reports

Increasing Diagnosis & Referral Utilization of Prediabetes Register Patient informed of diagnosis if not already known NDPP invite letter sent (2-4 weeks before class) Follow up phone call (1 week before class) Explain benefits of NDPP Enroll patient with prediabetes over the phone Instruct patient to enroll online * 96 previously undx, 60 contacted, 21 enrolled, 10 completeres

Bidirectional Referral Summary PCP RD/CDE NDPP CHW

Questions & Comments

Other Questions You’ve Raised Hearing from organizations doing NDPP.  What is the staffing, workforce and experience been like Referrals - how do we improve referrals for NDPP or lifestyle change programs How do you get patients to commit to the program given the length Alternatives - Group models, mobile models, web-based models Sustainability - how do we make this model sustainable

Data Review

Clinical Hypertension Measures

Clinical Prediabetes Measures

Chart Review - Hypertension

Chart Review – Prediabetes

Team Report Out: The Good… The Bad… The Ugly…

Reminders Data Due February 5 Next AP Call February 16 8am – Home Blood Pressure Self Monitoring Does this time work? Should we continue with 3rd Thursday at 8am Details on continuation coming!