1. IMPACT QIC Action Period Call
January 19, 2017
8am

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

3. 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

4. NDPP Program – Sue Millstein
Overview and Reimbursement Status

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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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 = %
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

12. 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

13. 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

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

15. 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

16. Bidirectional Referral Summary
PCP
RD/CDE
NDPP
CHW

17. Questions & Comments

18. 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

19. Data Review

20. Clinical Hypertension Measures

21. Clinical Prediabetes Measures

22. Chart Review - Hypertension

23. Chart Review – Prediabetes

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

27. 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!