Bi-Directional Referrals: Considerations for Health Care Providers



good afternoon everyone and thank you for joining today's webinar on bi-directional referrals to the national diabetes prevention program I would like to introduce monta doc our director of program delivery and impact at the evidence-based health interventions division of the YMCA of the USA to introduce today's speakers hi everybody thank you Matt for that introduction I just wanted to thank everybody for joining us today for the final webinar in our three-part webinar series as a reminder for those who maybe work on the first two webinars this series stems from work we've been doing as part of a cooperative agreement with the Centers for Disease Control division of diabetes prevention the series is designed to provide national diabetes prevention program providers and healthcare providers with an overview of how electronic health records and supporting tools and systems are currently being used in the field for type 2 diabetes prevention this webinar will also provide an overview of current challenges facing the electronic health record or EHR landscape and potential new and emerging EHR related technology that can be used to overcome in those challenges today's webinar will be facilitated by our colleagues from the American Medical Association AMA has worked closely with y USA in evaluating the healthcare system side of the bi-directional referral process their webinar targets health care systems and healthcare providers and the purpose of their webinar today is to describe methods of referring patients with pre-diabetes to lifestyle change programs that are part of the National diabetes prevention program the webinar will cover systemic approaches to screening and identification of eligible patients referral mechanisms and approaches to closing the referral loop highlighting key challenges and emerging best practices today's speakers are Linda Murakami and Kate Kate Curley Linda Murakami is a registered nurse with a clinical background in medicine and oncology Linda has extensive experience implementing quality improvement programs and healthcare settings she serves as senior program manager at the American Medical Association overseeing the practice facilitation component of AMAs crimes disease programs Kate Curley is a practicing family medicine physician serving as director of chronic disease prevention at the AMA she provides clinical leadership for AMAs chronic disease programs and has several years experience guiding healthcare systems in developing and implementing diabetes prevention strategies I'll now turn it over to Linda to begin today's webinar thank you so thanks for allowing us to join you guys today we're just going to review our objectives describe the key components of pre-diabetes identification and bi-directional referral processes to lifestyle change programs that are part of the National DPP diabetes prevention program review different approaches or examples of utilizing technology solutions to facilitate the identification and referral processes discuss the key barriers that health systems may encounter and key considerations when implementing technological solutions to facilitate bi-directional referrals to LCP and outline recommendations and emerging best practices for the healthcare organizations with different levels of a chai tea health information technology sophistication so the AMA partnered with the Y in an effort to find ways to perform bi-directional electronic referrals so that healthcare providers could easily refer qualifying patients to the lifestyle change programs at local YMCA s small teams that the AMA along with stakeholders at the Y in the CDC met with health care providers and in person and on the phone to investigate how current process systems that are in place are working and when they're initiating these referrals to these programs discussion also included methods for communication page communicating patient updates from the ymcas back to the healthcare provider teams these teams provided an understanding of what works the barriers they encountered when establishing attack electronic firls and how they're communicating we're going to now discuss the pre diabetes identification and LCP bi-directional referral process but first we want to kind of talk about why we're here today and why we need to develop these processes for referring patients to programs to prevent diabetes in the first place for preventing type 2 diabetes there's 84 million American adults that have pre-diabetes and pre-diabetes is defined as people who have elevated blood sugar but it's not high enough to be diagnosed as diabetes typically these patients have an a1c of five point seven to six point four or a fasting blood glucose between 100 and 125 or an oral glucose tolerance test result of 140 to one want 199 those who have it are an increased risk of developing type 2 diabetes unless they adapt lifestyle changes that reduce weight and increase physical activity while we talk about the millions who have pre-diabetes 9 out of 10 are unaware that they have it cardiovascular and renal risks show a high prevalence in people with pre-diabetes once diagnosed with diabetes a hundred percent of these patients are more likely to develop hypertension the economic burden is estimated to be 237 billion dollars in direct costs in 2017 working to get patients to the clinic and have regular check-ups and bloodwork are vital and identifying patients in this population there are three standard ways to test for pre-diabetes draw blood for an a1c fasting glucose or perform the glucose tolerance test you can see listed on the slide what defines pre-diabetes for each type of the tests the risk factors for risk factors for pre-diabetes mirror those of diabetes these patients are overweight or obese have increasing age and a family history of type 2 diabetes fall into the population of racial or ethnic minorities and live sedentary lifestyles studies show that for patients who have pre-diabetes they're aware of it and participate in lifestyle changes through structured programs reduce their risk of develop type 2 diabetes' active participation in lifestyle change which means dietary changes and increasing physical activity was found to be more effective than taking a MU Coast lowering medication such as metformin and while metformin has not been approved by the FDA for a youth in preventing or delaying the onset of diabetes recent guidelines by the American Diabetes Association recommend considering the use of metformin in patients with pre-diabetes especially in those who are under 60 years old have a BMI of greater than 35 kilograms per meter squared or have a history of gestational diabetes here are the guidelines from the United States Preventive Services Task Force also known as USPSTF providing a gravy recommendation for screening every three years screening is based on age and body mass index or BMI using the methods as we mentioned previously of an a1c fasting glucose or glucose tolerance test again those with the abnormal results identifying pre-diabetes should be referred to programs for diet and lifestyle changes such as the lifestyle change programs that are part of the National DPP now we'll start to talk about how you can operationalize this guideline into practice first we'll discuss the process the screen and identify patients with pre-diabetes then we will cover processes for managing these patients with referrals to LCPs and closing the referral loop so step one we're gonna start with here but we're gonna run through this four-step algorithm for identifying patients first you need to determine who will be screened we need we will exclude anyone under age eighteen people who have already been identified as having diabetes and women who are pregnant this could be found in the electronic health record or the EHR or through lab values or on the patient's problem list as a current diagnosis once you've identified the patient population that would be eligible for screening labs drawn for the last 12 months and determine if any previous screening for diabetes or for a glucose glucose screening test is present if there's not you'll move to step three and if there is you'll move to step four when you get to step three you'll find a category that applies to your patient under a the general population you'll check to see if the lab criteria we've previously mentioned under the USPSTF guideline you'll also have the option for your patient under ABA criteria or their risk test at do I have pre-diabetes org if no lab test was done in the last three years you'll want to order one of the three lab options we've been describing hemoglobin a1c a fasting glucose or a glucose tolerance test if your patients previously been diagnosed with pre-diabetes they'll fall into category B and we'll also need one of the three recommended lab tests lastly your patient will fall into category C if they had a history of gestational diabetes also referred to as gdm if one of the three lab tests should be performed I'm sorry one of the three lab tests should be performed if one has not been done in the last three years overall if the patient falls into the general population or has gestational diabetes category lab should be checked every three years and if they have a history of pre-diabetes you'll need to do annual testing here again are the labs and their correlating categories for the category for the results you'll need to interpret your results then manage it based on recommendations moving forward we'll cover management of these patients later in the presentation we also want to be sure to stress that once you die debt that you've diagnosed your patient with pre-diabetes be sure to document the icd-10 code onto the patient's problem list there are two overall approach this year it's helpful to have your workflow to identify the patient know that the care management approaches help leverage identifying patients by running corresponding reports through the EHR you can do this individually for patients you are going to see or identify patients as a group by running a query to identify all qualifying patients in your panel you can also combine these approaches as this may be helpful for clinical settings that do team Huddle's prior to patient visits identifying patients that will or may need labs done as a means to diagnose or rule out pre-diabetes if you're using a team-based care approach know that you don't need to rely solely on your providers or physicians to manage this process running the reports reviewing lab results or performing patient outreach can be delineated to many other members of the healthcare team those interested in more information on team-based care pre-visit planning and pre-visit lab testing can go two steps forward org this website has modules that can help you build these processes into your workflow and here's information to help you build a query for identifying patients through your EHR we've included the icd-10 cones 10 codes and the length codes for lab work in this table as we hope it helps make it easier for you to perform be sure to use both the inclusion and exclusion criteria listed in the table for accurate reporting thanks Linda Kate and now that windows covered the identification process to determine which of your patients might be eligible to participate in a lifestyle change program that is part of the National diabetes prevention program I'm gonna switch gears and spend a lot more time talking about how we can make referrals from the healthcare provider to the lifestyle change program as well as how we can close that referral loop by receiving feedback information from that lifestyle change program provider so before I jump into talking about the actual referral process and how to create a referral pathway let me just quickly cover the big information that should be included in a referral order for an LC P so obviously with any referral you're going to need to include patient information including the patient name and basic demographics like a date of birth it's also very helpful for the lifestyle change program provider if you can include up-to-date contact information and a preferred method of reaching that patient because the lifestyle change program is going to want to reach out to that patient after they receive the referral from the healthcare provider of course as with any referral you also want to include the physician name and the physician contact information so the lifestyle change program provider can reach out to the physician with any questions and so that they know where to send their feedback reports once they do receive that referral information lastly it's extremely helpful if the healthcare provider can include clinical information in that referral that establishes how the patient is eligible for participating in the lifestyle change program so most often that would include a lab test result so again that hemoglobin a1c or fasting plasma glucose or if you're doing it the oral glucose-tolerance test so what was the result as well as the date of the test Linda also briefly mentioned the do I have pre-diabetes org risk test or risk screener we didn't go into great detail about this but patients can be eligible to participate in a lifestyle change program if they have an elevated score on that risk screener most health care providers are identifying their patients by conducting a lab test and that's definitely what we recommend because we do know if a person has an elevated score on the risk test they are at risk for having pre-diabetes or undiagnosed diabetes and you want to confirm that with a laboratory test however some healthcare providers are using the do I have pre-diabetes or risk test as a way of engaging patients and their health and understanding their risk some healthcare providers have actually sent the risk test to patients via the patient portal and so if you do have a patient population that you've identified having an elevated risk score you can refer those individuals as well and again including that information about the risk test result result on that referral is very helpful so the lifestyle change program provider can verify how the patient is eligible eligible to participate in the program so now let's talk about the actual process for making a referral from the healthcare provider to the lifestyle change program and I find it helpful to break this down into two major stuff the first being the order entry are the actual referral form generation or referral order generation and the second major step is actually transmitting that referral from the healthcare provider to the lifestyle change program and you can see here that there are multiple different ways to approach each of these steps so when it comes to generating that referral order really the preferred way is to create an electronic order or an electronic form within the EHR so within the electronic health record and that order or form could include some auto-generated field so you can develop a form where that lab test result is automatically pulled into that referral order saves the providers a little bit of time or you could have fields that are manual entry that require the healthcare team to actually information actually enter information into that referral order most referral orders or referral forms are going to be a combination of these types of information but ideally it's captured within the electronic health record so that there is a long term record that the referral was actually made and the service was requested and ideally that order form contains as much structured information as possible so that it's searchable and discoverable later an alternative if it is to time or labor-intensive to create an electronic order an electronic form would be to simply use a paper referral form that's what we always used to do and sometimes that's a helpful approach just to get things rolling at your organization but again I would note that that electronic order really the ideal for making these types of referrals and then there's the referral transmission piece and that can be done completely electronically which is really the goal of this project and we'll talk about how that was difficult to achieve in a moment alternatively the referral order can be auto faxed from the EHR to the lifestyle change program provider or it can be printed or that paper form can be manually faxed so now I want to walk through sort of how you can combine these different order entry and transmission approaches to actually create referral pathways so first let's talk about that electronic referral by which I mean a completely electronic process and to end electronic process so this I would say is the most difficult to achieve but probably the easiest for the healthcare team to actually utilize once it's been built and developed so in order to have a completely electronic referral process this requires some type of electronic interface between the healthcare provider is EHR and the lifestyle change programs EHR or electronic data management system so I should note here that this was possible in this project because the YMCA is utilizing an EHR to manage their lifestyle change programs this may not be true with all lifestyle change program providers although increasingly many of them are using electronic systems that allow them to receive referral orders but an electronic interface of some sort needs to be established between the healthcare provider and the lifestyle change program in the case of this project we were only actually able to we only observed a complete electronic referral process with one health care provider lifestyle change program pair and in this case they use the direct messaging functionality that was part of their EHR to accomplish this so you need to have that electronic interface available and then you also need to be able to create that electronic order that elect a referral form which also has to include with it specifications for how that referral information will get transmitted from the healthcare provider EHR to the lifestyle change programs referral management system or electronic ease or EHR and then as I said this is a somewhat intensive process to actually build or develop this pathway but then once it is established it's relatively easy for the healthcare providers to then complete those referral orders and then automatically transmit the referral order over to the lifestyle change program provider so that's the first example of a pathway that can be created the more common pathway that was used in this project was for the lifestyle or for the health care provider to create that electronic order or that electronic referral form and then to transmit it to the lifestyle change program provider using an auto fax something that we use a lot in healthcare these days and so again in order to accomplish this you need to have the ability to create that electronic order you can use a combination of auto-generated fields or manual entry fields but again with another electronic order you want to make it as structured as possible and then you still need to include some specifications for how to send that order to the lifestyle change program provider so the order will need to include there the specs will need to be documented for how what is the destination of that auto fax that's going to take place a little bit easier it would seem for health care providers to actually create this referral pathway and it's still relatively easy actually quite easy for the healthcare team to use this referral pathway again they just go in they enter the relevant information into that referral order and then when they sign the order it gets auto faxed over to the lifestyle change program provider and then the last referral pathway that we explored was really a manual fax process and there were two ways that this can take place so one would still be to make that or create that electronic order that electronic referral order which done gets completed by the healthcare team and then it gets printed and so then that piece of paper actually gets manually faxed over to the lifestyle change program and as I noted before the other way to approach a manual fax process is to simply create a paper form from the beginning complete that paper form and then fax that paper form over to the lifestyle change program provider probably the least desirable approach because you don't have that documented referral captured within the EHR unless you were to scan that paper into the EHR but in some ways it's the easiest to get started because it requires the the fewest IT resources to get that type of pathway up and running so that reviews our three sort of major referral pathways that we observed with this project when it comes to actually implementing a workflow on the clinical side is one that are already outlined on the identification stuff the referral step can also involve two potential major types of workloads one being the point-of-care workflow this is what the care team is doing when the patient actually comes in for an office visit and is in front of the care team as when to outlined it does not need to be the physician or the provider who does everything in order to generate and send that referral medical assistants and other team members can be very helpful to tee up that referral in the system perhaps during the rooming process the healthcare provider can then later sign that order and allow that order to get transmitted we've also seen some organizations develop some clinical decision support so for example alerts that pop up when the patient is in the office notifying the team that this patient is eligible for a lifestyle change program referral and then pushing the team towards an order set or an order that can be completed so providing that reminder to the team that the patient is eligible to receive that referral and then the care management approach is sort of any type of approach that the care team might take to identify patients and for patients when they're not directly in front of them for an actual patient appointment or a patient encounter and so the care team whether it's secured manager or another member of the team can run reports to find those patients who are eligible for a referral to the lifestyle change program and then a member of the team can conduct outreach to the patients to notify them that a referral has been made and that a lifestyle change program will be reaching out to them soon to get them enrolled in a program if they're interested you can do that outreach through the patient portal through phone calls or through mail I'll note that we have sample scripts and letters on the prevent diabetes stat website I'll have that link up at the end of the talk so if you're looking for some example outreach materials we do have those on the AMA CDC prevent diabetes stat website quiz note about the messaging though if you're taking the care management approach to refer patients to refer troops to patients and you're going to send them some sort of outreach message to notify them that they're eligible for the program sometimes this is the first time that they're learning of their pre-diabetes diagnosis their physician may not have informed them of this diagnosis before do you have to be careful as you're developing that messaging to the patient you want to make sure that you have a clear explanation about what the diagnosis means and you also give the patient information about how they can contact their healthcare provider if they have questions or if they want to discuss this diagnosis more before they consider enrolling in a program you just want to make sure that the lifestyle change program provider is not the one left explaining the patient's pre-diabetes diagnosis to them or taken by surprise because the patient has not actually learned before so just a note of caution you want to be careful in the messaging but it can be done well and we've worked with a number of organizations who have performed outreach to patients in this way so now that I've talked pretty extensively through the process of making the referrals from the healthcare provider to the lifestyle change program I want to talk for a few moments about closing that for a loop in actually receiving information back from the lifestyle change program provider about enrollment and about patient progress so we recommend that when a healthcare provider organization is setting up the process to make referral that you have some pretty detailed conversations with the lifestyle change program provider about what types of information they can share back with you and when they can send report so first of all you want to make sure you're you're requesting from the lifestyle change program provider information about whether or not the patient actually enrolled in the program so if you send a referral you want to know that that lifestyle change program actually outreach to that patient were they successful in their outreach did they never reach the patient or did they reach the patient and then the patient declined to enroll or did they actually get that patient enrolled so you want to request reports that outline what the result of that enrollment attempt was and then for patients who do participate in the lifestyle change program you want to request in some feedback about patient progress at regular intervals it's really up to health care provider and the lifestyle change program to work together to determine what those appropriate intervals are common ones that we have seen used are for the lifestyle change program to send feedback about eight weeks after enrollment or nine weeks after enrollments and then about sixteen weeks after enrollment those are sort of key key time points in the program and then in terms of what types of data are sent in that feedback what the providers that the healthcare providers really want to see boils down to some information about the patient's attendance so are they showing up pretty regularly are they missing sessions and then what is their progress towards achieving their weight loss goals are they beginning to achieve the 5% weight loss that is really the goal of the lifestyle change program we're showing here a sample progress report that can be used I think the most important things are sort of those dashboard statistics about the weight change and the attendance we also put in an example table that can show weekly progress some healthcare like to see that they can just kind of skim that table to get a sense for to what degree the patient is actually participating but that level of detailed information is not always needed by all healthcare providers so the take-home message is really for the healthcare practice in the lifestyle change program to talk early and work out what types of information can be sent back and at what intervals that information should be sent and now we talk through all the processes for both identifying patients who can participate in the lifestyle change program for making that referral and for closing that feedback loop we want to share with you what the experience was of the healthcare providers who participated in this project with the local YMCAs and we'll boil it down to some of the key barriers and challenges that they encountered as well as some key considerations and then after we talk through some of the challenges we'll talk through some of the emerging best practices that we saw in this project so this is kind of a quick snapshot list of the major challenges or issues that were encountered during this project many healthcare provider organizations talked about competing priorities and these resource needs that were required to launch the project we saw that EHR sophistication really varied from healthcare provider organization to organization interoperability kept coming up as a major challenge and successfully implementing a completely electronic process and data security and data handling issues also came up in discussions as well and then there was a lot of discussion about the importance of doing healthcare provider awareness and engagement and training and so these are all some issues we'll talk through just in a little bit more detail now so computing priority it's what we're healthcare providers talking about when they when they spoke of this issue first of all I would say that every healthcare provider practice or organization that we spoke with and I'll for a little more context I'll mention that this included small practices all the way up to large healthcare systems everyone that we spoke to talked about the importance moving from volume to value based care the challenges associated with moving from volume to value based care they were all sort of feverishly working on implementing new processes and building new infrastructure to be able to do this successfully and I would say that they all recognize that diabetes prevention should fit into value-based care but they were so focused on some of these higher-level changes that needed to take place at their organizations that for some of them it was really difficult to focus on this specific condition or the specific project the healthcare provider is all noted that when they were interacting with an individual patient sometimes they just had more pressing clinical conditions to deal with like hypertension or a like significant pain significant knee pain perhaps is an example and they were always more likely to address the patient's concerns during a visit rather than their own agenda so as those of you who are physicians like myself you'll know that patients often come in with a long list of issues that they'd like to take care of and we're always going to prioritize the patient's concerns over diabetes prevention if we're forced to make choices about how to use our time even though we recognize the diet need prevention is important to address the healthcare providers also spoke about how there were there were no available quality measures so no way to really measure their performance in this area and no incentives associated with working on diabetes prevention so this was a common theme that came up as well and I want to share that the AMA is in the process of developing some quality measures related to diabetes prevention that we anticipate launching hopefully early next year so those will be able to serve as a basis for healthcare providers to be able to measure their performance related to diabetes prevention and hopefully start to serve as a sort of backbone for incentives to be built but in the context of this project there really were it was no measurement or incentive available to the providers and so that made it difficult to prioritize this topic so we learned a lot about resource needs which is a key consideration for all of these organizations that launching you referrals certainly took up a certain amount of staff time and it involved a number of different types of staff members so of course someone needed to be identified to provide administrative support and for many of these projects pretty significant IT support team members needed to participate in identifying patients generating the referrals other team members needed to provide patient education and participate in that information sharing with the lifestyle change program so there are definitely staff resources that needed to be devoted to making this project successful they also needed to devote resources towards training of the healthcare team including finding facilitators creating materials to be able to do this and then there were budget considerations as well certain startup costs particularly in the cases where some of the healthcare organizations were actually considering using technology outside of their EHR to facilitate making the referrals and we'll talk more about that in a couple minutes so EHR sophistication as I said the healthcare providers that we worked with really sort of varied in their EHR sophistication in terms of how complicated some of the builds were that they needed to do for this as well as their ability to take on customization off efforts and be able to actually execute those efforts quickly as we all know most EHR vendors offer some sort of functionality that can be used to make referrals to lifestyle change programs but it pretty much always requires some degree of customization and that customization can be relatively time-consuming and resource consuming and in certain cases because of competing priorities the healthcare providers just couldn't devote the resources towards that type of custom build that they wanted to do so that was a common challenge that we we in cow or they could devote the resources that they were going to be on a wait list and it was going to take significant time to actually get that customization done a note about when elf health care providers considered using technology outside of their EHR third-party app so we've learned from health care providers that they strongly prefer to contain as many processes as possible within their EHR it's easier within their workflows nobody wants to remember a separate password to sign on to some other portal to do something when they're in the middle of taking care of a patient many health care providers simply won't do that they strongly prefer to keep things within their EHR however if it does allow them to address a significant gap in care or it truly offers you know a benefit or a value to to the practice or to the patient's they may consider actually using a solution that is external to their EHR but we heard from the healthcare providers that they were really only willing to consider this if they could use that external solution for other types of high priority health conditions so people did not want to invest in a solution that was just going to be used for pre-diabetes they wanted to consider solutions that they could use for hypertension for diabetes management management for other high-priority conditions for their organization interoperability common common buzzword that we all like to complain about these days because it is a significant challenge and we definitely saw this a lot in this project it's one of the major reasons that most of the healthcare provider and lifestyle change program partners were not able to establish a completely electronic transmission process between the EHR system right as I said in one case direct messaging was able to be utilized between one health care provider and one lifestyle change program pair but for the most part when the organization's explore this possibility it turned out to be more complicated than they thought it was going to be going to take significant resources to actually establish it and because of these significant sort of time and human resources needed they ultimately decided just to not fight it off and they were able to relatively easily do that auto fax and so many of them pursued that path because it was sort of the path of least resistance because of these interoperability challenges data security and handling was an interesting topic because it was viewed differently from healthcare providers a health care provider so some health care providers did have concerns related to privacy and data security when it came to transmitting information from their organization to a lifestyle change program provider these concerns to be overcome with a business associate agreement but different organizations seem to interpret HIPAA differently and have different standards or different requirements to view themselves as being compliant with HIPAA so some organizations required or wanted a consent from the patient to be able to send the information others felt that that consent was actually already captured when the when the patient consented to receive care from them and so they did not need an additional consent to send that referral so again different organizations handled things differently we also saw that healthcare providers wanted to treat the information that they were receiving from the lifestyle change program differently the some healthcare provider said I would love structured fields in my EHR where I can just receive that weight from the lifestyle change program and there it is in my EHR I can see that as a new patient weight whereas other said no I would not want to feels like that it needs to be tagged as information that came from outside of our system and so it would have to fit in a different place within our EHR and we don't we don't know how to create that or we don't have the time and resources to create that so we definitely saw some variability and how health care providers wanted to treat the information that they were receiving back from the lifestyle change program provider okay so now that I spoke about lots of challenges and made it sound like it's extremely difficult to get bi-directional referrals up and running I want to share that actually the organization's were pretty successful in getting this rolling it maybe didn't follow the path that they thought it was originally going to take but they were able to get up and running with making referrals from their organization to the local YMCA local YMCA and I think we were able to identify some emerging best practices along the way that we want to share now so first of all you want to approach this type of initiative like you would approach any other new effort and really put some solid project management approaches in place around this initiative to start out by identifying that project team and we'll talk in a moment about who should be included on that project team you need to work through what is the lifestyle change program offering going to be for your organization is it internal is it external with a community-based organization or a combination of these possibilities you need to have an explicit plan for how you're going to train the healthcare team on the processes that you develop you need to be able to devote resources and people towards identifying patients you need to have a patient engagement process clearly defined and implemented of course you'll actually generate that referral and you'll establish a process for getting five directional feedback back from the LCP so those are the key Keys our project plan steps that you'll need to work through who should be on your team obviously with any good team you're going to have a project lead who's going to be responsible for keeping track of all the things related to the projects and the implementation a physician champion is really really important we saw in this project and that AMA we've seen in a lot of our other work and I will fully fully acknowledge that it does not need to be a physician it can be another clinician but what's important it needs to be somebody who's passionate about the topic it needs to be somebody who can navigate upwards in the organization to gain buy-in from the leadership and gain that commitment from leadership and then this person also has to be able to navigate horizontally to get other members of the team excited and engaged you want to use your champion frequently to support the training of the care team and then you also want to use them to give clinical input into any type of decision that is clinically related so use your champion to weigh in on the identification process the referral process and workflows there you also want to have a population health coordinator or manager and/or that practice manager a practice leader these individuals are going to provide a lot of input into the referral workflows the different roles and responsibilities of the different care team members at different parts of the of the process and you really need their engagement throughout the project we spoke a lot about IT needs so of course you're going to need that health IT staff person involved in the project and that's to develop the the orders that are needed to be placed as well as some other functionalities in the EHR that can be used like registries like clinical decision support or alerts to remind care team members about what they should be doing when they see a patient and then don't forget marketing and communication staff can be extremely helpful in identifying or developing that patient outreach strategy and helping to develop the materials that can support your patient awareness and outreach effort so additional best practices that we saw and mr. lace back to the fact that healthcare providers are dealing with so many other competing priorities that's the extent that you can tie this effort into existing organizational priorities so a common approach that we saw was that most healthcare providers were very focused on their type 2 diabetes management many of them realized that prevention is really the first step in type 2 diabetes man and they had developed lots of infrastructure or lots of processes for managing type-2 diabetes better that they could actually leverage to prevent type 2 diabetes so tie this effort into other organizational priorities and use some of the infrastructure and processes that have already been developed for those other priorities when it comes to identifying patients work with sort of all the pieces of health IT that you have available to you so I've mentioned a couple times you can pull reports you can develop registries you can use clinical decision support to flag patients who are eligible for that referral or who need to have a screening lab test done so kind of pull out all your stops if you can to come at this from a number of different directions use the cure management approach if your staffing allows it so pull those reports do outreach to groups of patients not just individual patients as they come into the office but make sure you have a solid point of care workflow together as well and as we're getting started you don't need to go kind of pull hog you don't need to pull out all the bells and whistles for your first set of referrals get it rolling using the processes that are most familiar to your organization and not terribly resource intensive just to get the ball rolling and to start to get some experience but then the thinking about how you can build out the process add the bells and whistles that will help improve the process as you move along for that referral process like I said earlier the most common process that we saw used was to create that electronic referral order and then to auto fax it to the local lifestyle change program provider we did see a nice workaround one organization was struggling to actually create that that electronic order within the EHR and so instead they developed a smart phrase that could pull in the key pieces of referral information into a text document and I think it's very helpful to have a smart phrase like that that can can surely be used to populate the patient instructions section of an after visit summary and then what you can do is that patient then has the referral information in their visit summary so they know what is happening but you can also just print an extra copy of that and use that that text that was developed to just fax directly over to the lifestyle change program so that was a nice workaround for a healthcare organization that was struggling to create that structure and electronic referral order we also saw that several of the more savvy health care providers started reaching out to other departments in their organization other specialties to see if they were using other referral management solutions that they were not aware of in their own department for example on that one organization the ophthalmology department was starting to explore a new referral management solution that they were finding helpful and so this organization started exploring whether or not they could use this for referrals to lifestyle change programs so get out of your own department and see if anybody else that your organization is potentially using a solution that's be helpful here engaging stakeholders early I think this is true with any new initiative but definitely important in this project and recognize that some of the stakeholders are outside of the healthcare provider organization when you're dealing with a community-based lifestyle change program and the sooner you connect with that program and talk with them about what they are able to do you're going to develop that referral process faster they may have some creative ideas for you that you are not actually thinking about it your own organization and you want to make sure what that you understand what their requirements are in terms of the type of information that they need to receive and what types of information they can share back with you identify that coach or that champion I spoke about that at length already so I won't go into much detail here but again you you want to be able to use that champion for another a number of different activities it's very important to have that champion on your team here team education and training that was something that was very important you can't just build the referral pathway and then hope people will use it you really need to devote some time towards formal training when you want to cover information like why do we care about this what is the evidence behind the program what are the guidelines that support referring to this program and then you want to talk about what they actually need to do what each team members role is in the process and make sure that they actually see the order in the EHR that they actually know how to use it and I would suggest baking your training into kind of standing meetings that you already have at your organization whether it's a monthly practice meeting a quarterly Department meeting it's typically easiest to reach your care team members if you leverage a meeting time that's already in place data security as I said a lot of healthcare provider organizations I kind of had different interpretations about what the requirements were here but certainly executing a business associates agreement between the healthcare provider and the lifestyle change program can really help to make sure that you are staying compliant with privacy issues and then probably the most important takeaway or the most important best practice that we can recommend is to take a phased approach the leverage technology where where it's doable where it's relatively easy to do in the beginning but if you need to just to get referrals rolling start with a low-tech process you know build your relationship with that lifestyle change program provider or start to demonstrate outcomes start to get a feel for what your patients are experiencing and then get more sophisticated using technology to support that process this can help you avoid investing in developing a referral pathway that ultimately doesn't make a lot of sense for your health care providers your patients and the lifestyle change program so if needed start low-tech and then build from there we heard from many healthcare systems that they're really trying to you know solve these problems related to interoperability they're trying to figure out how they can better share information with other health care providers that are outside of their organization and several of them view this project as sort of a good case study or a good use case for testing out new approaches so I think that's another approach that you can take at your organization to prioritize this project use referrals to the lifestyle change programs as that test case to develop new processes for sharing information with other healthcare providers and so that really wraps up our presentation portion of our webinar today before we move into a Q&A session I just want to highlight that we have several resources available to help you in this efforts for healthcare providers the prevent diabetes stat toolkit which is found at prevent abuse dot-org has a number of materials that can support you in determining how to develop your identification referral processes at your organization lots more information about the National diabetes prevention program at the CDC's website as well as the YMCA's diabetes prevention program has the wise websites plus some really great engaging consumer awareness materials that you can actually use as patient engagement materials at the do I have pre-diabetes org website and we don't have it listed here but Linda did mention earlier the steps forward modules which is steps forward org right right Linda and that has some really great sort of practice facilitation or practice management modules pre-visit planning created that lab to based care some really helpful modules they're seeing me available both that stepped forward and on the prevent IV stat toolkit so I will stop there and we'll look to some of the questions ok first question I'm seeing is if they're more success from referrals through the point-of-care process or the cure management process that's really a great question and I'll tell you a little bit depends on the organization so in our experience the point-of-care process results in the higher conversion rate what I mean by conversion rate is the percentage of people who receive a referral who actually then enroll in the program so there seems to be something about having that conversation with a physician and kind of receiving that referral sort of at that moment that you're ready to receive it that results in a higher enrollment rate but it's more difficult to reach significant numbers of people if you're waiting for them to come into the office the care management approach can be very successful it's a great way to reach a larger number of people but expect that you'll get a bit of a lower conversion rate there so you'll do more outreach that will result in a smaller relative percentage of referrals but you could potentially achieve a higher number overall so do more patients enroll if referred by physicians and that's definitely a related question so I'm not sure that I have the we have the fair amount of experience I haven't exactly tested this hypothesis more patients seem to enroll if they believe the recommendation is coming from their physician so it's very helpful for a physician to have a conversation with the patient but also messaging her outreach that comes from the healthcare provider that comes from the clinic that is sort of done in the physicians name on the physicians behalf dr. so-and-so is recommending that you attend this program that appears to be pretty successful as well so I think really the key piece is that the patient needs to understand that this recommendation is coming from the physician even if it wasn't the physician who had the conversation with the patient do patients need to consent to provide their info to the lct so this is a question that is best answered by sort of your risk management and kind of compliance individual at your own organization we have seen it go both ways so I guess the conservative answer would be that the patient should consent but many organizations interpret this as saying that when the patient consents to receive care they're also consenting for their information to be shared with other providers who will participate in their care and so they don't need to consent explicitly for this but again I definitely do not want to give any any legal advice on this webinar so talk to your your own compliance officer to determine the the process that's appropriate for your organization next question is what interval do you recommend for progress reports so I think that so and the question was weekly seems too often we agree I wouldn't ask your lifestyle change program provider to be sending weekly reports I would we've generally seen around eight weeks after enrollments around 16 weeks after enrollment are good time points for sending reports the program lasts for a year but the sessions become less frequent in the second half of the program and so at about six months nine months can be other appropriate intervals to send progress reports it's really up to you if you want to see sort of weekly level data and their progress report but the actual sending of the report probably only needs to happen about it week eight week eight and week 16 all right another question was where can they find a sample patient progress report and I actually do not know if we have that available on our event IV stat toolkit I don't think that we do I will look into whether or not we can share that with attendees on this call it's certainly something that the AMA has if you reach out the contact information on the stat website is certainly something we can share with you or happy to share with anybody and any other questions that are coming in we're just quickly reviewing our question list there's a question are we allowed to use materials from these other sites versus the YMCA exchange you can use really any of the publicly available materials and I think it's a conversation to have between the healthcare provider and the lifestyle change program in terms of what types of forms are actually used between the organization oh good point here so a listener made the comments lifestyle change programs often find that people enroll when their doctor recommends the DPP but find the dropout rate higher than those who had other motivators for enrolling so please don't confuse enrollment with success or completion yep that's a great point program success doesn't stop at enrollment we do know that enrollment and completion rates really both drive success in the program in my experience I have not seen that patients who enroll because of their physician recommendation actually drop out at a higher rate but it's possible you have access to some other data but I think it's a very good point and many of the lifestyle change program providers do do some assessment of readiness but to be very honest with you in terms of understanding what drives success in the program and really what keeps a participant engaged in the program over the long term I think we have we being ma CDC the YMCA others involved in this work have some work still to do there to be able to advise you further on what really drives long-term participation in the program alright and I think that is wrapping up some of the questions that we've received if we've missed any we'll attempt to get some responses to you I think that wraps up the AMA portion of today's webinar

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