1. Group Health’s experience September 24, 2015| Kathryn Ramos Implementing CDSME in an integrated health care system

2. Group Health  Began in 1947 as a non-profit, consumer-governed health system dedicated to making quality health care available and affordable  Mission: To bring together care, coverage, research, and philanthropy to serve members and create healthier communities  600,000 members in Washington and North Idaho  Integrated group practice: 25 medical centers  Contracted provider network: 9,000 physicians

3. Patient-centered care and innovation Core values reflected in initiatives to:  Partner with patients:  Healthier lifestyles  Clinical preventive services  Chronic disease self-management  Activate and engage patients:  MyGroupHealth  Health Profile  Shared decision-making  Provide evidence-based, planned care through:  Coordinated outreach  Opportunistic care  Deliver patient-centered care through medical home

4. Rationale for CDSME at Group Health  Evidence shows improved skills, self-efficacy, outcomes  Patient-centered  Low-cost intervention  Enable clinical staff to focus on complex medical issues instead of self-management skills  Engage members as volunteers, as well as patients as participants

5. Group Health’s Model

6. Guiding principals 1.Strive for population impact 2.Enable equal access to CDSME regardless of where member gets care 3.Offer program in various ways to respond to patients’ unique needs 4.Maintain ongoing commitment to exploring new and innovative approaches 5.Recruit graduates from the CDSME programs to train as Lay Leaders to deliver the workshops

7. In-Person CDSME  Started in 1998 with Chronic Disease Self-Management Program at 4 pilot sites  Now offered in 18 medical centers and online  Total reach since 1999 = 6,000 participants  66 active volunteer leaders  Retention to date in 2015: 78%  Current focus: fidelity, leader recruitment and training, leader and participant retention

8. Diabetes Self-Management Program  Pilot in 2012 funded by Group Health Foundation Partnership for Innovation  Pilot reach:  14 workshops  179 participants completed 1 or more sessions (65% retention)  Reach in 2014:  17 workshops  206 participants completed 1 or more sessions (72% retention)  Goals for 2015  23 workshops  300 participants complete 1 or more sessions (75% retention)

9. DSMP pilot feedback “Today I received my latest blood and kidney test results, and for the first time in my adult life they all were within normal ranges. My A1c was 5.7….”

10. Reach 1999-2014

12. Recruitment Strategies

13. Targeted recruitment mailings  Primary recruitment strategy for in-person workshops for both CDSMP and DSMP  Mailed 6 weeks before workshop  Mailing list criteria:  ICD-9 codes for chronic conditions such as arthritis, heart disease, asthma, COPD, fibromyalgia, and diabetes  visited doctor in past 2 months  patient at clinic where workshop is held  Uptake rate: 10%

14. Provider tools, workflow, and outreach  After Visit Summary from EMR  Point of care prompts in EMR to encourage referrals  Clinic-based champions encourage referrals in team huddles and emails  Built into medical home as a standardized referral  Emails and posters sent to clinic staff and champions 6 weeks before start of workshop  After workshop starts, email patient lists to clinic leaders

15. Embed in member tools and resources  MyGroupHealth for Members  Health Profile  www.ghc.org website www.ghc.org Workshop locations & schedules Register on website Single sign-on to LWCC online  Group Health Resource Line  Member publications

16. Lessons learned

17. Patients as ambassadors  Highlight volunteers’ stories on staff website, external website and in newsletters  Have leaders present to staff and prospective participants at Medical Centers  Open presentations with a patient story

18. Lessons learned Leadership buy-in  Involve leadership. Share targets, performance, improvement processes, and impact with them to keep them engaged  Clarify how CDSME supports strategic goals Connecting with clinical staff  Make referrals easy and systematic  Embed referrals into standard workflow  Use multiple awareness-raising and recruitment strategies  Look for clinic champions – including nurses, medical assistants, social workers, clinic managers

19. Ongoing commitments  Recruit and retain leaders in underserved areas  Grow the leader pool from the workshops  Integrate with clinical care  Raise awareness in the midst of competing priorities  Coordinate with community organizations to expand reach into our contracted network  Create opportunities for “SMS light”

20. The importance of community partners  Partner with other organizations to expand reach and share resources and expertise  Collaborate on leader recruitment, training, sharing  Share and standardize best practices and tools

21. Discussion