1. Whipping Up the Secret Sauce: How a 10-Hospital Health System and Community Partners are Improving Health Outcomes
Sharon Williams, Moderator
Dawnavan Davis, MedStar Health
Leigh Ann Eagle, Living Well Center of Excellence
Sue Lachenmayr, Living Well Center of Excellence
Craig Behm, Chesapeake Regional Information System for Patients (CRISP)

2. Secret Sauce Agenda Overview/Introductions
Panel presentations- Who we are/What we do
Panel Interview/Q&A
Exercise-35 minutes - participants
What did you learn from this presentation that can inform/impact your integrated care strategies/practices?
Wrap up-5 minutes

3. MedStar Health
MedStar’s Mission: To serve our patients, those who care for them, and our communities.
The largest healthcare provider in Maryland and the Washington, D.C. region, serving more than half a million patients annually.
340M in community benefit in FY17
Using our system’s CHNA to address
health disparities and promote health
equity by addressing:
Chronic disease prevention & management
Access to care/services
Social determinants of health

4. MedStar’s Community Health Approach
Leverage evidence-based chronic disease programs as part of hospitals’ population health management strategy
Provide community health programs as intervention option for providers as part of care delivery on post-acute side
Empower individuals with chronic conditions to manage their health through programs such as Living Well with the goal to support:
improved patient and community health outcomes, appropriate healthcare utilization and long-term cost reduction
Use primary and secondary data to inform program planning, implementation, and evaluation

5. Living Well Program- Program Placement Partner Outreach and Disease Focus
Patient and secondary data were used to identify community-hotspots for each hospital
Hotspots include zip codes surrounding hospitals with high rates of chronic disease prevalence/incidence, charity care cases, and ED utilization
Program Placement: new Living Well workshops sites were placed in community hotspots
Partner Organization Identification/Outreach: Organizations in hotspots were identified and engaged to serve as partners with MSH
Host site
Trainee
Both
Patient chronic disease diagnosis data by focus zip codes were used to determine what disease topic workshop (general chronic disease, diabetes, hypertension, cancer) would be implemented a specific community sites

6. Disease Prevalence/Charity Care/ED High Utilizer Populations

7. MedStar Living Well Rollout
Phased approach
Phase 1- 6 hospitals (Spring/Summer 2017); Phase 2- 4 hospitals (February-April 2018)
Conducted 7 lay-leader trainings
94 lay leaders and MSH staff trained
14 new community program sites
SDOH screener added to intake process
Program added to Cerner EHR for provider referral directly into program
~18% of program enrollment coming from EHR referrals

8. Targeted Outcomes Program-specific
Behavioral- dietary, physical activity, self-management
Clinical- BP, weight/BMI, % fat
Participant/lay-leader demographics
Participant healthcare utilization, readmissions and costs
Process variables
Lay leader and participant recruitment and retention
Number of + social screens/linkage to services

9. Results 200+ enrolled from April- December 2017
67% participants reporting increase self-management
69% participants reporting program satisfaction
60% participants reporting weight loss
64% participants reporting decrease in BP
52% participants reporting decrease in % body fat
94 lay leaders trained, with 63% retention rate
Readmission/cost analysis currently underway (CRISP/claims data)

10. SDOH Comparative Results
In LW Program: About 30% screened for social needs; Of those screened approx. 31% screen positive for 1 or more SDOH. Across system, 60% of those screened identified at least 1 social unmet need.

11. Living Well: Out of 58 screened for SDOH, 34% (n=20) identified food insecurity; 21% (12) housing instability; 17% (10) transportation issues.
System: Out of 568 positive screenings, 19% (110) reported food, 18% (104) reported housing, and 4% (25) reported transportation, 1.9 % (11) reported financial assistance and 1.4% (8) reported job assistance.
Linkages to services varies by program but ranges from 53-89%

12. Maryland Living Well Center of Excellence Who We Are/What We Do
Non-Profit Area Agency on Aging covering 4 rural counties on Maryland’s lower eastern shore
Success in implementing CDSME at the local level resulted in ‘hand-off’ of statewide license and database from Maryland Department of Aging
2015 ACL CDSME grantee as the Living Well Center of Excellence
Partnership with Maryland’s AAAs
Opportunities to contract with hospitals

13. Farm to Table Fresh Ideas, New Utensils
Walk With Ease
CHRONIC DISEASE
SELF-MANAGEMENT
EDUCATION PROGRAMS:
Cancer Thriving and Surviving
Chronic Disease
Chronic Pain
Diabetes
Home Toolkit
Spanish Chronic Disease Tomando
Spanish Diabetes Programa De Manejo
The Living Well Center of Excellence was a designation given to MAC, Inc. by the Maryland Department of Aging when the Stanford license and database ownership was transferred to us.
Currently, the evidence-based programs included are: Stanford Chronic Disease, Chronic Pain, Cancer Thriving and Surviving, Diabetes, Spanish Diabetes, and the Chronic Disease Self-Management Home toolkit.  Also included are Living Healthy with Hypertension, DPP, Enhance Fitness, PEARLS – depression screening program, and Matter of Balance, Stepping On, and Otago for falls prevention. 
The Living Well Program is an evidence based self-management program designed to educate people with chronic conditions. Designed to improve their quality of life, reduces health complications, and their need for emergency care.

14. Secret Sauce Ingredients
Statewide License for Stanford University Chronic Disease Self-Management Education (CDSME), Stepping On Falls Prevention and PEARLS Depression programs
Training, technical assistance, collaborative quality assurance for evidence-based programs
Centralized referral, certified workforce, community-based locations, quality assurance measures, HIPAA compliant
Statewide calendar, quarterly reporting includes: participant completion, pre-/post- clinical measures, patient activation and satisfaction, and long-term goals

15. The Heat that Brings All the Flavors Together
CRISP/Hospital/LWCE 6 month pre/post hospital and emergency department utilization after completion of evidence-based program (EBPs) to establish ROI
Partnering with CRISP to track Social Determinants of Health and referrals to EBPs and community-based services

16. About CRISP
Regional Health Information Exchange (HIE) serving Maryland and the District of Columbia, and collaborating with Delaware, Northern Virginia, Pennsylvania, and West Virginia
Vision: To advance health and wellness by deploying health information technology solutions adopted through cooperation and collaboration
Data source or attribute #
Live hospitals 91
Live clinical data feeds
261 (lab, rad, ADT, CCD)
Live ENS practices
+1,000
Long-term and post-acute care facilities
160
Standalone labs and radiology centers 16
Unique patients in index
+16 million
Patient searches
+400,000/mo
Encounter alerts sent
+2,500,000/mo

17. Core Services
POINT OF CARE: Clinical Query Portal & In-context Information
Search for your patients’ prior hospital records (e.g., labs, radiology reports, etc.)
Monitor the prescribing and dispensing of PDMP drugs
Determine other members of your patient’s care team
Be alerted to important conditions or treatment information
CARE COORDINATION: Encounter Notification Service (ENS)
Be notified when your patient is hospitalized in any regional hospital
Receive special notification about ED visits that are potential readmissions
Know when your MCO member is in the ED
POPULATION HEALTH: CRISP Reporting Services (CRS)
Use Case Mix data and Medicare claims data to:
Identify patients who could benefit from services
Measure performance of initiatives for QI and program reporting
Coordinate with peers on behalf of patients who see multiple providers
PUBLIC HEALTH SUPPORT: Partnerships with Maryland MDH, District of Columbia DHCF, and West Virginia through the WVHIN
PROGRAM ADMINISTRATION: Technical and administrative support for Care Redesign Programs

18. Encounter Notification Service

19. InContext Program Information