Bi-Directional Referrals: Considerations for National DPP Providers



good afternoon everyone and thank you for joining today's webinar on bi-directional communication with Healthcare Partners key considerations for national diabetes prevention program providers I will now turn it over to Robin solare senior behavioral scientists with CDC's division of diabetes translation to introduce today's speakers thank you for joining us today thank you so we are in the second of a three-part webinar series this series stems from work we've been doing with the y USA the American Medical Association and CDC's chronic disease center for offices oh sorry informatics and information resource management and an internal team of scientists local health analyst and contractors this series is designed to provide you with an overview of how electronic health records or EHRs and supporting tools currently being used in the field for type 2 diabetes prevention our first webinar was an introduction for lifestyle change program providers using electronic health records for national diabetes prevention program referral and feedback the purpose of today's webinar is to explore learning from project funded by CDC looking at bi-directional communication between National Diabetes of engine program lifestyle change programs and health care providers this webinar will explore what may influence successful implementation of bi-directional communication and provide aromas for organizations wishing to move forward down a path of effective bi-directional communication with healthcare partners to better meet the needs of the national diabetes prevention let's go change program participants master guard gasps sorry guys hi Randall and Hayley and Suzie monstas here are members of the evidence-based health intervention division at the wise national resource office YMCA of the Y USA masa is the director of policy delivery and impact Randall ins is a technical advisor for evidence-based health interventions and Susie is manager program delivery today and along with other colleagues on the health care integration team masa Randall in and Suzi support local YMCA delivering Y us a Evans based health interventions such as the YMCA's diabetes prevention program along with other programs that help individuals prevent or delay the onset of chronic disease as well as programs develop hope develop to help those living with chronic conditions live their healthiest lives I'll now turn it over to Randall and Hayley to begin today's treatment hello and again thank you for joining us for the second part of our three part series around bi-directional communication as we move through this presentation we plan to discuss a brief overview making the case bi-directional referrals and their benefits a brief summary of the e referral project understanding the key drivers for bi-directional report referrals our implementation recommendations and of course we will have time for your questions we wanted to take a moment and level that with some key terms that you will hear throughout today's presentation the purposes of this webinar a referral is an order or prompt from a health care provider or HCP for a patient to participate in the National CPP lifestyle change program the National diabetes prevention lifestyle change program or national GP plcp is any approved community-based healthcare based or otherwise version of the national VPP LCP an electronic medical record or EMR is the digital version of the paper charts in the HTTP office the electronic health record or EHR is often used interchangeably with EMR and have all of the same functions as an EMR but includes a broader view the patient's health and the ability to share information with other clinicians involved in the patient's care and lastly enter operative bility is the ability of different health information technology seamlessly communicate and exchange data a bi-directional referral considers both the information the referral going from the health care provider or system with the lifestyle change program as well as information or feedback going back to the healthcare system or referring health care provider as you can see from the graphic the information the communication should and can be fluid from being partners now let's take some time to discuss the benefits of bi-directional referrals and the current landscape around the use of collaborative relationships between healthcare and lifestyle change programs can truly impact the health of the community but this is unlikely without establishing effective lines of communication bi-directional research ensure information is using between partners increases the number of touch points a patient has allows positive reinforcement from the healthcare provider keeps the lifestyle change program front of mind with the healthcare provider and improve continuity of care all of these things are beneficial for health care providers and lifestyle change programs alike to improve patient experience and a direct referral is typically sent via fax mail or email allowing for proactive follow-up from the lifestyle change program whereas an indirect control happens when the physician hands the patients are resolved with the onus on the patient to reach out a direct electronic referral occurs by using the healthcare provider EHR system – the lifestyle change program again allowing for proactive follow-up by the lifestyle changes program whereas the indirect a referral is sent to the EHR from the EHR to the patient placing the follow-up as the patient responsibilities with the growing desire for an implementation of electronic health records within the healthcare system the demand for electronic referrals or every girls have also increased optimally the use of eerie growl helps streamline communication between the referring health care provider and the receiving clinic or partner at its most functional use it also helps to provide simple compliant methods for communication and ensures that a referral is received in a timely manner often times the more traditional method of paper-based referrals being handed to the patient with the goal of the patient taking the next step to follow up adds to the potential and beeps to today and care where in some cases no care at all bi-directional electronic pathways can remove the middleman and ensure the connection will be made and acted upon as you may know healthcare is shifting from the old model where health care providers get paid for the amount of services they provide to a value-based model where value is defined as both improvement in quality and cost under the new model providers are incentivized to use evidence-based medicine engage patients upgrade health IT and use data analytics to get paid for their services when patients receive more coordinated appropriate and effective care providers are rewarded as providers work to demonstrate value by including their patients health they have to keep track of the referrals they make and the outcomes of those referrals which requires bi-directional communication with partners they refer to you this allows quality access and efficiency to work together and overall improve outcomes eh rs can help demonstrate the help in can help demonstrate value and healthcare by improving methods of referral tracking allowing for increases and data driven approaches ensuring efficiency and functionality and they also allow for timely and seamless care transition by helping to avoid gaps in care simply put the implementation of bi-directional referral pathways is instrumental and care coordination and along with other system of enhancement guidelines and registries has the potential to reduce complications and even the incidence of chronic disease is used in conjunction with evidence-based health strategies that are proven to support behavior change and reduce risk when a closed loop communication is established and program providers share patient feedback with their refering health care partners it enhances the ability of those partners to integrate this knowledge into clinical care and ultimately reinforce behavior change with their patients in the end working towards a reduction in complication and even the incidence of disease will now shift and discuss a brief overview of our project with funding from the CDC's division of diabetes translation YMCA of the USA selected for local providers of the YMCA's diabetes prevention program and worked with the American Medical Association and CDC to build and implement bi-directional Erie neural communication pathways with existing health care partners using an EHR as we begun working through this project it became clear through conversations with a local wise and their healthcare partners the numerous challenges to implementing bi-directional Erie rule and that's we should dress focus of the original project goals of increasing clinics community linkages bi-directional referral and developing best practices to gaining a better understanding of the drivers and things to consider when thinking about implementing bi-directional Erie world and based on our wealth of learning we received localized and their health partners during this project the wives and their health care partners tested two main research methods remote call that's orbiting where an analogue fax line forwards an electronic paper fax into an EHR and direct messaging a fully electronic communication from EHR the EHR additionally they tested sending feedback for the health care providers by sending clinical letters electronically via the EHR here's a list of the project wives and their health care partners please note that while it appears that many of the healthcare partners use epic it is important to remember that there are many different instances of ethics and the versions used in this project we're not the same we would also like to take this time to thank our wives and health care partners for all of their hard work on this project each by experienced an increase over baseline from referring health care providers additionally we recognize the project period is longer than the baseline which would have also impacted the number of referrals but one note of interest is that while referrals increase you know was not necessarily due to seamless integration of bi-directional Erie pearls as didn't necessarily happen but there were many important drivers at play which we will discuss in this next section I will now turn it over since Uzi Montes year manager program delivery to discuss subscribers and greater details thanks Brandon hi everyone is Susie so I'm gonna move us along into the key drivers section so as we've been discussing throughout the project it became really clear that there wasn't a single blueprint or a single best practice or way to really facilitate successful electronic bi-directional communication pathways so what we decided to do instead was really try to categorize into these four main areas so people environment process and technology what are the different considerations that might either facilitate or even limit implementation of bi-directional referrals and feedback and often or you know what we used to come up with these different drivers with a lot you know based on the feedback from the local lives that were a part of the project as well as information that we gained from their health care providers as a part of key informant interviews and site visits so a lot of this is what was gathered throughout the project so one of the main areas that is really foundational is relationships so it's absolutely critical that there is a strong relationship established and that is positive between the lifestyle change program and the healthcare provider or the organization and this can take time it really isn't something that happens overnight it takes a lot of convening their meetings where both stakeholder groups are coming together and they're really understanding and demonstrating to one another what are all the inputs what's going to be needed to make this work and how can we continuously evaluate how we're going to work together and how can we come together with a common goal and plan so that we are all on the same plate all the same page and can execute all of this and in the most feasible way possible so again this is something that really takes time it doesn't happen overnight the most important thing kind of happening at the outset is that trust that's being built between the different partners or stakeholders and you know especially as we're we're thinking about ourselves or this audience as the lifestyle change program provider really important that you're able to build that trust with those health care providers initially so that they feel comfortable they might not be used to repeat re they might not be used to referring to organizations that are community based or organizations outside of their health care system so really important that you're demonstrating the value that you bring to the table and it is a tremendous value so don't have her undersell yourself but really important that they have a good understanding of that and then they'll feel more comfortable referring their patients another thing that we we've noted with this area of relationships is that it's really important to try and use a team-based approach so that it's not just one person from your organization working with one person from that practice or that hospital or whatever that setting might be because we found that if there is staff turnover then it's almost like you're starting from scratch with that relationship and you don't want all that hard work to go to waste so really important that there's a team-based approach and that you know that there is this more I guess robust relationship that's being established across multiple stakeholders so that if there is a change or you know someone goes on leave or something happens like that all the work that you put into this is not lost so again in an ideal state both stakeholder groups have a shared understanding of each groups inputs and expectations there's a clear sense of shared desired outcomes and it's possible a formal partnership some sort of Memorandum of Understanding or a more formal agreement being in place that clearly outlines these things is always helpful it's always helpful to have something to refer back to you something in writing we know that it's not always easy to get to that place but that can be really helpful if along that continuum the relationship evolved to that place so along the same lines of relationships is this area of health care provider champions this came up I would say across all the sites that were part of this project and as a theme I would say we continue to hear especially with our work with with local wise working with healthcare partners and the importance of champions is that this is someone that's really passionate about this this is someone that's driven someone that really is invested in this work and really does value the lifestyle change program and your organization so by having that champion in place they can then help spread the word they can motivate others within their practice or system they can encourage buy-in and contribution sometimes you know healthcare providers only want to hear from their peers or other health care providers you know so there might be folks that aren't as as open or aren't as familiar was working with a community-based organization and so it's really important that we can identify as early as possible who is someone that can really champion these efforts and really kind of drive you know what might need to happen even incrementally so whether it's providing input on workflows helping to integrate clinical clinical guidelines into the patient identification and decision support processes you know they might be able to answer questions from their peers as things start to get implemented they might be able to provide feedback on the process that you're working on together so really important to think about who this could be and in that you ideal state it doesn't really have to necessarily be a physician or the chief medical officer or you know someone with a specific title we've seen champions kind of run the gamut so it's really what's important is that they're engaged and they want to you know commit some time and effort to this and they they do have a voice within their organization they do have the ability to leverage so this could be a physician a nurse or a nurse practitioner or physician assistant registered dietitian even office managers so kind of the front-of-the-house staff that really know everyone and know everything about how their organization functions those folks can also be really influential as well and as we mentioned important although you know it might just be one person initially think about a team-based model so that again if that provider champion moves on something changes all the work that you've put into this relationship and the partnership doesn't go away so think about how the the health care providers champion network can even be expanded I'm now I'm going to shift over to the bucket of environment so just a few drivers in this section and one that I think really complex is the reimbursement climate so folks might be aware that you have the pre-diabetes as a condition or a diagnosis is really still a newer term it's still a newer still or new a newer concept for healthcare providers and oftentimes you know even if healthcare providers are familiar with pre-diabetes and are you know aware of the importance of screening and diagnosing they might not be aware of of you all they might not be aware of the the National diabetes prevention program lifestyle change program and the ability to even refer their patients in to such a program so because of that and because of the absence of consistent mechanisms for appropriate coverage or payment it can be really difficult or can be a variable that healthcare providers are having to either focus on or or be distracted by so for example you know if the healthcare provider does become aware of the lifestyle change program that is in their community that they can refer their patients to if they don't know if there's coverage for that program or coverage doesn't exist or they don't know that there might be other opportunities to help subsidize those cost they might just not refer at all they might be just not comfortable with that lack of understanding of the the cost of the program or their reimbursement situation so that I think can can pose a lot of challenge but on the flip side there are some things that are really positive in this base things like you know Medicare coverage going into effect this could absolutely increase awareness and can bring coverage to a large percentage percentage of the population though we know the the number of Medicare suppliers are still quite small but still it can help raise awareness of this important program and the fact that you know coverage more coverage of at least coming into play another thing that we we already talked about Randleman was covering this whole shift from fee-for-service the paper performance and and basically moving from volume base to value-based care so as health care systems focus on this health care providers are increasingly becoming aware of the importance of demonstrating improved quality and efficiency and ultimately lowering cost and needing to demonstrate that entire contracts so as health care providers are kind of feeling that pressure or their system or organization is feeling that pressure they might be more likely to really think about how they can bring down a bring down those costs by referring their patients to OSL change program and also ultimately improving the health of their patients so in a no where are sorry in an idea of state health care providers are aware of options they're aware of benefits of the program and then if there is coverage and I know it's varies across the country and each individual region is different but if they're aware of what coverage exists and if coverage doesn't exist you know what are the resources that are out there to help subsidize costs that is something that can really help facilitate bi-directional communication so as a lifestyle change program provider it's important to kind of know what are all these different burial variables within the reimbursement base [Applause] so another environmental consideration I think everyone probably is aware of this stuff there are a lot of competing priorities within the healthcare system so I think just like you know the organizations that we all work for healthcare providers also have a number of hats to wear a number of competing priorities competing priorities that on a daily basis can feel like a lot to really manage so especially as we've been talking about moving from volume base to value based that just in itself might limit the ability of health care providers to really focus in on something as specific as diabetes prevention when they have hundreds of other things to worry about when their patient comes in you know primarily they're focused on what is the patient here to see me for today what are what are their you know maybe chief complaints and then okay maybe can we go through this checklist of water what other things might they be at risk for what other things do I need to screen them for it's really a lot to cover in a very small amount of time that they have with that patient so in addition to that health care providers are often in different stages or even developing processes and infrastructure to improve their patient care so you know they might actually be going through a process with their organization where they're focused on one specific clinical quality measure so for example they might be focused on reducing avoidable hospital readmissions because this is often something that's incentivized for healthcare providers you know if they are a part of an accountable care organization for example they might be focused specifically on that one metric so if they're focused on that how are they going to have the ability to incorporate something like pre-diabetes into their workflow that that just might be one potential challenge because there are no clinical quality measures related to the National DPP LCC at this time it just might get pushed lower on the list in terms of competing priorities so really important to think about as a strategic way to kind of you know make sure this doesn't get lost and how can process our workflow that you would work with with your healthcare partner be something that could be duplicated for other efforts other conditions other screenings other you know components of the workflow within the practice so that it's not only specific to diabetes prevention but it could be you know replicated to individuals with diabetes or hypertension screening or any of the other things that healthcare providers are going to have to focus on at some point so that takes me to our section around process so one one area that I'm guessing folks on the call are familiar with pre-diabetes awareness or rather lack of pre-diabetes awareness so this is something that you know continuous video challenge I think we've seen the awareness has increased slightly over time but it's still quite low in terms of individuals you know knowing that they are at risk for type 2 diabetes and I think folks have probably heard the statistic that you know of the 84 million adults in the United States with pre-diabetes only 10% are aware of their condition so really important that you know our healthcare provider partners are kind of activated around that and and understand that it's essential essential for them to kind of reinforce what you know are the factors that might put someone at risk and reinforce that you know if someone does have pre-diabetes they might not fully know the benefits that they could receive by participating in a diabetes prevention program so really important that that health care provider kind of acts on that and reinforces that this is something that's available and you know type-2 diabetes can be prevented or delay so really helping to kind of tap into that and tap into what might motivate an individual to participate in such a program so in an ideal state health care providers are you know they have the front of mind and anytime they interact with someone that might be at risk they are either screening or you know and or referring their patients to a national vgpu I saw change programs so that they can they can see who work on behavior change and lifestyle change to hopefully reduce their delay reduce the risk or delay the onset of type 2 diabetes there's 15 gears a little bit still in the process area but you know we have been you know one of the focus areas was initially this in this whole concept of bi-directional electronic communication so the electronic processes themselves have quite a few different variables within them as it really took key drivers so we wanted to spend a little bit of time talking about this in itself so you know it is feasible to have a fully electronic referral process within a given organization or within an electronic health care record but the challenges that we tend to see are when two different organizations or two different systems are trying to communicate with one another electronically so it's one thing for you know two physicians within the same healthcare system or the same practice to kind of implement workflows so that they can communicate seamlessly with one another but where the challenge arises is when we you know introduce the healthcare provider needing to communicate outside of their group or outside of their system so even if they're communicating with a partner that uses the exact same electronic medical record system there there are many challenges that arise there are different instances of those systems there are there are firewalls there are HIPPA considerations there's just a lot that it goes into this bucket of interoperability challenges so when we're thinking about this it's really important to just consider that that this space is really complex and when we're talking about electronic processes we're talking about both outbound referrals so the information that goes from the healthcare provider to the lifestyle change program as well as inbound feedback so what is the information that that healthcare provider is gonna want to receive so you know progress information for example once someone enrolls in a lifestyle change program we do we have heard and we do tend to see that a lot of healthcare providers are more increasingly becoming responsible for closing and referral so if they do make a referral electronically they're needing to somehow document within their system what happened to that referral so that it you know makes it instrumental for the lifestyle change program to be able to communicate back what happened with that referral otherwise you know that that person is essentially lost the follow-up and so if the healthcare provider can know that you know I referred my patient but they they didn't follow through or they didn't enroll then there's an opportunity for them to continue following up with that patient and hopefully allowing that person to eventually enroll in the program so as I mentioned that those inbound updates are really important so that is something that needs to be factored in here and you know one thing that can be a significant variable is also just the different regulations HIPPA regulations IT compatibility risk management requirements so oftentimes what we see when we're talking about electronic bidirectional communication there's a whole side that needs to be factored in that might require individuals from within you know within both organizations to really work together on what all the different processes might be and what the consideration so in an ideal state IT have been written hizmet requirements are addressed and as early as possible and the development and testing because that that could potentially put up a roadblock if it becomes apparently or on that those things weren't considered also in an ideal see outbound referrals contains sufficient information so both for the lifestyle change program you know they need to be able to receive all the information that they would need to know about a potential participant in the program so that they can ultimately enroll that person in the program and in contact that person and then as well as the information that inbound feedback information needs to be really should be determined with the partner at the beginning so that they're receiving information that's helpful for them we've heard of examples where you know just information was sent back that wasn't used by them or wasn't helpful to the partner and so really important and again to kind of reinforce and and support and build the case for continued referrals from your healthcare partners is that you're providing them the information that they want and that they can use and every healthcare provider might be different you know one provider might want information only about whether or not someone enrolled another provider might want outcomes they might want to know when someone completed and what their average weight loss was at the end of the program so really important that you're working with your partners and figuring out the you know the data content the data format and the timing and the frequency about communication and ideally the healthcare provider is able to integrate any inbound feedback that they would receive received from you into their patients charts so that they can continuously follow up and reinforce all of the the hard work that their patient might be doing as a part of the program another area that's important around process that we heard repeatedly is the importance of training and continuing vacation I think we hear a lot from program providers that you know we went and visited you know our partner or healthcare partner and we told them about the program and they were fully on board and they started to refer and then six months later there was a huge drop off when it we didn't we stopped receiving referrals we don't know what happened well as we were talking about there are a lot of competing priorities for health care providers and and Elsi people life so really important that this is kept front of mind and there are opportunities for continuing education and training both about the availability so making sure it's known that that you are a provider and this is your your capacity where you provide the program and that you're out there and and ready and willing to accept referrals also you know regular training to healthcare organizations staff on what the program is who qualifies for the program what takes fast after someone is referred those other things that can be easily forgotten or kind of pushed off to the side if it's not revisited also important for you know staff at your own organization just you know what are the best practices for how to manage a referral how to communicate and closing that feedback loop and so in an ideal state this is something that isn't just a one-and-done it's something that's revisited as much as it can be and we've even seen examples where LCPs were able to obtain continuing medical education or CME credits for healthcare providers to learn about the lifestyle change program so that you know there there was something kind of a carrot there for providers to continuously gain access to this information and and that did seem to lend itself to an increase in the number of referrals so of course we you know we couldn't you know have this section and less we talked about the importance of evaluation this sometimes gets forgotten it's something an afterthought but evaluation is really important and and thinking about it right from the beginning not waiting okay two years into this relationship you know what should be evaluate and how so if organizations are you know the goal is to increase the the number of referrals into the program organizations working together should really think early on how are we going to assess our success how are we going to measure if what we're doing is working how are we going to make sure that if we have challenges along the way that that we're not just going with the flow and we're going to stop and we're going to address and make change and figure out areas to target for improvement so there are different ways that this could be you know done you know different reports or feedback from staff that are directly connected to the process but ideally evaluation plans are developed right from the beginning and there's you know an ability for continuous improvement improvement from all stakeholders and it's you know we know it's not going to be simple and so it's important to kind of address this whole it's not going to be perfect from the start there's there's going to be trial and error there's going to be goals that we've said and we might not always achieve those goals and ultimately you know how can we minimize frustration and work together for a long-term sustainability so you know one way that that organizations might do this is you know implementing continuous PDSA cycles or quality improvement rapid cycles so that you know it is something that's always front of mind and it is always something that both teams you know both sides of the partnership are always thinking about and assessing so again electronic healthcare I'm sorry electronic health record systems themselves so I was you know speaking to this a little bit earlier on just the both the the positives around electronic health all the potential opportunities that they offer and capabilities to capture data and communicate across systems and within systems but also just the challenges that exist in the marketplace there are multiple systems which you know can allow for universal processes for bi-directional communication about how they're actually operationalize can really be challenging so this whole issue around or faster around technology is is an important one to consider and within each organization both for the healthcare provider as well as the lifestyle change program the knowledge and comfort of using these systems is gonna vary from individual to individual so you know in some cases and I think we've seen where you know a healthcare provider champion for example was really savvy with how their EHR system worked and all the different options that they could either activate or streamline or put into a workflow to help facilitate bi-directional communication in other examples there might be someone very engaged and supportive of this work and wants to make referrals and does make referrals but they have no idea how to manipulate their EHR system and so in that case you know others within that organization might need to be engaged and it might take time to figure out you know how do we use this system that we have to really optimize bi-directional communication and what we also learned throughout this project that I think was significant was just that you know many organizations it seems are having to use additional kind of add-on add-on platforms or external management systems so something that's not their kind of foundational or you know they're drawing a blank on the words the out-of-the-box EGR system doesn't necessarily accomplish everything they need it to so organizations increasingly are having to look at other kind of add-on technologies or platforms to help facilitate things like patient identification patient referrals and just referral management itself since it seems like the EHR system has a lot of jobs or tasks that it must do and sometimes the whole you know referral management pieces is kind of an afterthought and then additionally we know that many if not most to West Athena programs are not using an EHR and that's okay I mean that that is something you know that the the why begin kind of using and and it you know it's not easy and it's not expected that everyone would be using an EHR so what is that kind of pose when you know working with a healthcare provider that is using an EHR system so in an ideal state you know there there will be advancements for interoperability to allow for more automated or fully electronic transfer of information between care team members and that would include the lifestyle change program so you know again I think we kind of see that health care organizations might be able to really move the needle for communication within their own organization but the challenge really seems to come when healthcare providers are trying to communicate with other healthcare provider systems so maybe a specialist or someone you know in a different state or a different system or lifestyle change programs or other community-based organizations that are not within their own network so we know there's a lot of work kind of being done at the national level or you know throughout the country to really help move the needle here but it's going to take some time the concept of interoperability is a large and complex one we have seen you know some functionality that seems to work maybe a little bit more seamless and and that would be something like direct messaging which you know Randall and had mentioned was one of the things that the localizer were a part of this project tested out and so that was a more seamless electronic method for information to go to for information to come from the healthcare provider and so you know kind of minimizing the burden of having to fax or use paper that is you know something that ideally would function and defeasible and then and then as I mentioned there are these add-on modules or different external systems or platforms that could help facilitate and I think we're exploring and seeing more examples of this so I knew listed on here just a couple that we've seen used so paredo is one is the kind of a referral management software that healthcare providers can gain access to or link to their EHR system and Bertha maybe folks on the line have heard of that one and it's another you could google it but it's another kind of platform or cloud-based system that basically allows individuals to kind of look up what options might exist within their community for referral and then redcap is is another just another is the data system again cloud-based but a way to track and manage data and all of these options you know just might be more accessible than an EHR system lower cost and maybe even more user-friendly to help facilitate that data transfer between EHRs or from EHRs to you know another program management system or solution that's used by the LC team so I know that was that was a lot I know the drivers are kind of a heavy section and there's a lot in detail in there hopefully helpful to kind of just provide more context of what we learned over the course of the project and I'm going to transition it over to Montague after it's going to talk about some recommendations for LTP you thank you Susie yeah so I think we share these drivers in part just to help folks understand some of what we learned as you know through our experiences with the project that we did in collaboration with CDC and AMA and also just to help for folks on the line we're thinking about this work think about what might be some of the areas that they will want to proactively address or a plan for this next section is really again very broadly thinking through if you are a provider of the diabetes prevention program you're a lifestyle change program provider and you're thinking about tackling this work if you're already continuing this work and want to move it forward we want us to share some very high level recommendations again based on our learnings about ways where to start and where to go next once you've started not necessarily again suggesting that this is the single approach to doing this but more just to give some ideas about how you might how you might begin and we could spend hours and weeks and months talking about this I think all of you who are on the line and have connected to this world probably would agree so these are very broad in high level but you know we're happy to also dig in offline much spoke to share a little bit more about our learnings and I just wanted to quickly say since we've gotten a couple of questions in the chat about this the the webinar is being recorded in that and that in addition to the slides will be made available once all of the recordings are converted and hosted and so folks who who you know your colleagues who weren't able to be on this call will have access to that and if you want to access the information again you'll have access as well so we'll make sure that information gets sent out once those once that recording is is finalized so as I talked through the recommendations for for LCPs just showing this graphic this is the buckets that we've grouped our recommendation recommendations into and you'll see it's sort of cyclical and circular not necessarily that you have to start in one place because of course you could already be doing this work and we wanted to acknowledge that people are in different places when we talk about the spectrum of this work so so just know that that's that's kind of it's grouped this way it doesn't necessarily mean that you start in one place and only move linearly for it might be revisiting and as Suzy said it might be that you're doing some rapid cycle improvements to kind of figure out how to continually improve improve your processes or your relationships or your ability to receive referrals and share feedback but we are going to talk about it in the context of internal capacity assessment relationship building and cultivation understanding of landscape and opportunity project planning and scope and implementation and evaluation over the next few slides so in terms of assessing internal capacity we talked about that we really wanted to we were really talking about helping organizations think through how they figure out where they want where they are where they want to be so taking some time to identify your current approach for engaging with the healthcare community for referrals for the program if you are doing this currently and if so how far along are you if not where would you like to be in one or two or five years or even if you are where would you like to go and starting to have a plan thinking through based on where you are and where you want to be what that might mean for for your next steps we suggest thinking through the drivers that we listed on previous slides to determine whether they apply to your current context and if so how they might apply again this was really based on our learnings for for this particular project we do think in some cases they are probably universal and as we've connected to two other LCPs or other organizations that have been approaching this work we are sharing similar themes but again every situation is unique every community uniqso so we offer those as suggestions for places to tackle your work or your energy but of course there could be other things that you that are uh playing their communities in terms of additional assessment around your internal capacity sticking through your financial resources your current relationships with the healthcare community who are you currently talking to who who might you already be receiving referrals from if you have those current relationships current staffing you know this does take a lot of energy so what kind of staffing can you allocate toward building those relationships as susie mentioned and working through processes for for referral thinking through your technology your functions and limitations whether you have leadership support and training needs it's really just you know echoing all those drivers and figuring out how all those drivers really apply to you on these flags we've included a couple of examples of assessment tools just if you maybe haven't done this type of work before you haven't done that kind of organizational assessment this could one of these tools for these links could give you a place to start helping guide some questions that you might ask internally or other ways that you might evaluate your your current capacity for we're sticking through bi-directional communication with with health care providers so once you've done that assessment likely you're going to find multiple areas that might you might where you might want to move the needle and I think chances are that it's probably going to be more feasible to just pick a few areas to focus on initially but that over time that you might be addressing different areas of your organizational analysis so setting project goal of creating a target timeline developing a staffing plan again really thinking through how to be intentional about this work because it is something that does at least as we've observed it require a choir a lot of thoughtfulness and a lot of attention and time and and resources in some cases and I think thinking through as part of your capacity assessment of thinking you know the value that you provide as an LCP you know that we want to make sure that we're being very clear about the value that we can provide to our the health care partners and systems in our community and and really crafting that into a pitch for lack of a better word because it's really important that that in order to for those partnerships to be cultivated and grown that we really are meeting each other's needs so thinking through thinking through that in advance and being thoughtful about about how you might have those conversations and incorporate your pitch into those conversations and data always helps so looking at where you can access local data on your program community data as well as national statistics that can be that can be worked into your pitch in terms of relationship building and cultivation this Suzy talked a little bit earlier in the driver section about the importance of relationships I mean that sense it's really key and crucial that you're sneaking through how you might address this piece so you know you'll want to identify who you're going to work with and you know a lot of a lot of you on the call already have relationships with the health care community so thinking through where you have existing relationships that can be leveraged where you might want to form new relationships you know you might want to think about some kind of market analysis so who are the big maybe healthcare systems in your community we might have the larger penetration or if there are community hospitals or FQHCs like if that's if it makes sense to target your energy there that you're you have in a sense of of that healthcare community landscape to help identify where you might want to focus your energy it's not necessarily you know it might not be that you wanted you might have multiple healthcare partnerships but you don't actually want to start with each so really thinking through where it makes sense who is your intended audience and based on that a large healthcare system might be a large hospital system might have different needs than an FQHC that can help help you refine your approach for how you might engage those individuals or find the individual it within the systems to speak with them and then share your plan and hopefully girl relationship once you identify who those people are or those organizations are learning about their needs so being really open and asking questions about what their pain points are what they might be trying to address within their within their context what their goals are so you can understand better we go as we go back to that pitch idea understand better how your organization can define its value within the context of their goals again we're trying to meet means and we have a lot to offer the healthcare community so thinking through how we can make that clear to them and then defining your opportunity so you think conversations to inform your strategy and build relationships and we really think based on our learning that it's key to craft these relationships and partnerships in a way that's mutually beneficial but it's not so much that we are we're saying yes to everything we have to make sure we can do things that are feasible for us and that are meeting our needs as well but thinking through how we how we create a partnership that is a true partnership where there's everyone is sharing accountability and we're all working toward aligned and shared goals and visions so understanding the landscape and opportunity in addition to understanding in the healthcare landscape so knowing what's happening within the healthcare system within your communities is important but really also trying to figure out Suzy talked earlier about EHR she talked about electronic processes and understanding what if you are developing trying to develop bi-directional communication especially one that is going to be electronic what options are available to you what could you potentially implement so thinking through like you know reviewing literature trends in the field to understand a little bit more about how bi-directional and referrals have previously been implemented successfully to help prepare for potential challenges and limitations or even to help help you think through what might be an approach that would make sense for you to tackle maybe talking to LCP in your community about how they've partnered with healthcare organizations for referrals if there's something you know if you have strong collaboration efforts in your community and and their stuff that could be built upon and duplicated or replicated rather than completely reinventing the wheel that might be a good place or might there might be a good way to target your approach talking to maybe other organizations like state health departments and I would listed NACD NACD G here the National Association of chronic disease directors who they you know might be focusing efforts on on ways to address some of these interoperability challenges that we've been talking about finding bridges to connect non clinical program providers with us up with their healthcare partners to address population health and you know NACD has been doing a lot of work around this with a project and the tool helped econnect so there might be existing avenues to think through or to maybe connect to that can help help figure out how to make some of this a little bit more seamless if it's not it's not specifically EHR to EHR it might be EHR to some bridge systems and back to another EHR we're not necessarily even originating from an EHR if you are an LC P that has not adapted the use of an electronic health record and then also talk to your healthcare partners to see you know are they already working with other providers of services that are maybe not clinical in nature not necessarily other LCPs although it could be inclusive of that but do they do they have other practice extenders or are there other community-based referrals that they might be providing and how have they been handling the referrals and the feedback loops with that again suzy talked a lot about the competing priorities within a healthcare system and i think where we can leverage existing workflows and just apply them to to this service it we're all better off word i think it helps a lot with continuity and sustainability so if you have existing healthcare partners or as you're approaching these conversations what might they already be doing and is it something that could just be replicated if you are working in an EHR you have some kind of data system you know doing some homework under to understand the functionalities within what might be different approaches and you know as we were doing this project we spent a lot of time working with within our electronic health record within a team enough to kind of figure out which functions are available within the system that we could test and hopefully refine for the purposes of communication with the healthcare partners and there might be some different functionalities that are available in the systems that are using that could help with this so thinking through what might be some solutions or might be some channels for communication and and they'll need to be familiar with your own data system in order to do that but you'll want to make sure that you can answer questions when you're having those discussions with with the healthcare partners on about what options there are to share information on patients if your healthcare partners are working in EHRs if you can do your best develop a working knowledge of those systems it doesn't mean that you have to adopt the use of the systems or doesn't mean that you have to become experts certainly in those systems and again a lot of those systems are very complex and there may be different instances so even within that that's really going to be a one-size-fits-all approach but but just being familiar even with the language that is common in electronic health records Suzie talked about the use of add-on modules or other that aren't necessarily EHR platforms be familiar with those as options that can help with you know not only data management the potentially referral management so Pareto and Bursa redcap those are the ones she talked about there's also referral MC fibroblasts and these are typically or at least these example specifically are HIPAA compliant web-based applications in some sense that I really have been used for referral management and to address patient leakage the idea of that like a referral is made and then never have there's never any follow-up er action on that so those might be systems or platforms that your health care partners are already using or familiar with and it could be a solution to think through how to how to handle electronics or make things as electronic as possible so that there's some information continuity and standardization but because they're already existence and already addressing things like risk management and HIPAA compliance might be might be a solution that would be worthwhile to pursue if you're if you are operating with that and what trying to health records consider working with the health information service provider to explore options for you referral so health information service provider organizations that they manage security and transport for health information exchange among healthcare entities using specific standards for communication so we talked a little bit about one of the methods that we used in this project was direct messaging and health information service providers can can handle direct messaging they can support direct messaging for communications in terms of project planning and scope Susie mentioned this and you bet and all of you on the cover who have been working in this space probably also know this that each of your healthcare partners or different healthcare entities that you might be working with they're very unique and they might all require different approaches so even if you are able to develop an approach for how we will receive referrals and how we will share feedback with our healthcare partners it might not apply from one partner to the next so being nimble being flexible and being prepared to potentially if you are working with multiple partners at once to adjust how your bi-directional communication pathways might look just something to keep in mind because again they not only might they be on different systems but they might have different means or Susie mentioned they might have different requirements for what type of information to include in the in the feedback or the progress updates that you're that you're ideally providing on their patients want to work collaboratively to ensure mutual understanding on time line communication channel staff roles and plans for ongoing evaluation again just kind of echoing some of what we talked about from a relationship building and management perspective and do you think through workflow development and we recommend where you can to build off existing workflows just ideally to help make sure that the process for identifying workflow maybe isn't too lengthy but also if they're interesting work flows that have been shown to be successful for that for your healthcare partner are there ways that you can just leverage that and just will be less taxing both for the clinical staff as those your staff if that's possible but thinking through as you develop these work clothes what are going to be your processes for how referrals will be handled once receives we found that those healthcare partners do you want to have a sense of what's going to what happens when you get this referral what can our patients expect and what can we what can we expect being clear about what information you need as part of the referral identifying working with your healthcare partner from the beginning to determine what information is needed as part of the feedback loop and again being really clear about that upfront so that we can make sure we're not not only that we're not providing information that isn't necessarily useful to our healthcare partners but that we're also not promising to provide information that is very difficult for us to pull together or maybe that we don't even have the ability to capture so thinking through that piece just so that we are we're not over promising and we're making sure that this referral relationships and communication relationship meets everyone's needs how and when data can be shared and as Susan mentioned how successful we will be measured in some ways in some cases we found that as these partnerships solidify and as as you work to identify what your goals are and what your scope is and what your benchmarks are that there there might be some benefit to developing formal agreements with your healthcare partners whether it's a Memorandum of Understanding or contractual relationship to singing through how that might help with increase and share accountability and that if you have anything if you have to prepare anything related to HIPAA compliance making sure that you're being thoughtful about that upfront because we want to make sure that you know we're we're protecting participant privacy and that we're making sure the information that we capture and transmit is is kept secure even when it's outside of the electronic health records some overall high level suggestions or recommendations around implementation and evaluation so what we've seen is that it's helpful to really get hit the ground running as much as possible to to try to begin implementation and when I say implementation I mean actually starting the process of receiving referrals and/or testing those processes as soon as possible so that you and your partners can focus on joint in a media problem stopping found that there has been some benefit to that as opposed to a very lengthy planning process that you know lengthy lengthy planning process before implementation starts because then you run the risk of you know unintended delays if there is staff turnover or because there are competing priorities often both for you and your health care partner that that could inadvertently push things back so it's also helpful at least again from the experience that we've seen with local YMCAs specifically that this idea around joint problem-solving that also help to increase shared accountability and that sort of similar investment for both partners so kind of hit the ground running and think about how you can iterate and assess as you go we've found has been helpful for getting this work off the ground or getting this work off the ground successfully you might want to consider starting initially with paper-based referrals if you if you aren't already doing this work you know there may be some value and some of the communication pieces like how can I make sure that I'm acted acting on this referral and how do I make sure that I'm communicating back my health care partner I'm referral status in the way that meets their needs and in a way that I can piece of excusably capture speaking through whether it makes sense to start there and then work on moving that to an electronic process might be worth trying that in some cases that you might find that paper-based communication that that meets your needs and that's where you want to stay and that's fine it goes back to your assessment and your your the time you spend identifying where you want to go with this work so as Randall and Sharon when we were talking about the project itself the original our original goal was let's come up with or let's learn and then share what you know what is the process for making a bi-directional electronic referral or communication pathway putting that into place for for lifestyle change programs and as we learned very quickly it just it wasn't going to get to that point it's more about how do we help other organizations think through how they might approach this work and it could be that that's a way to be successful in your community is to focus on paper so we just offer that as a as a suggestion to consider if that's the place that you want to start and maybe that's a place that you know you want to spend most of your time did you mention this already but being prepared to test different approaches over time iterating as you go working through problem solving as you go using the goals that you set for assessment and evaluation to determine where you might make adjustments that's going to be helpful you might end up in different places with each of your health care partners things are going to go at different paces depending on the staffing involved depending on the needs of each community or each partner but just being prepared to to modify your approach over time because you may not be able to start up the gate with something that is going to end up being the most successful approach and then communicating regularly to share a feedback you know there might not be if we take a program like you know the National DPP as an example depending on when you how many programs that are how many people you are serving on an annual basis or depending on the time points when you might be providing feedback to your health care partner you know there might not be super frequent points of contact with your health care partner so being really thoughtful about how you build in communication over time throughout the course of your implementation so that you can continue to address issues Suzy talked about an example where referrals are coming in they're coming in and then after six months it just they sort of dried up if you have those regular communication channels you might be able to anticipate that a little bit a little bit better to be able to be proactive and how to address this and as much as you can use data when possible to assess your your work so that you can make informed decisions around how you might recalibrate so in summary just a quick summary slide and then I'm going to we'll take some will answer some questions that have come in the chat box but remember this is a marathon not a sprint we know that this work is very can be very cumbersome in some places and time-consuming and it can take time and we've we've seen in the community we've seen where local wise specifically have started to build relationships with health care partners that have been one two three years in the making before it got to a place where to be really more intentional around this type of referral and feedback loop and and again that's where that internal assessment and ongoing assessment probably it's going to be really helpful with students to be prepared for that that's not to say it's always going to take a long time but that said it can it may not be it means we might not be getting the referrals or the volume of referrals that we would ideally like very quickly it's not always a single or straight path you want if you want to stay the course we talked a little bit about embracing trial and error there there may be roadblocks and they can challenging but the results can be well worth the effort and to be prepared going in with eyes open and expecting that you might fit some challenges and working collaboratively with your healthcare partners on how you address those will be helpful and and remember that you're not alone so there is a lot of work in this field a lot of energy that's that's being focused on this area so you know CDC as I mentioned before NACD is doing a lot of work around this ama and so a lot of energy trying to figure out what are ways to to support the growth of bi-directional communication whether it's electronic or not so reaching out to other human network can be helpful to to know that there might be existing processes or existing learnings that that you can leverage so it doesn't feel like we are all independently starting from scratch that we're working together to develop more solutions so I'm going to pause now and I know we've gotten some questions that have come in the chat so we will we have about 15 minutes we'll take the questions that we can so first question that has come in let me expand that so we've met with our local providers a number of times and they seem and I'm assuming this means health care providers so we've met with our local healthcare providers and the first times and seem interested in referring but then we never get anything from them what would you recommend oh yeah this is Suzy I can take that one yeah I mean you're definitely not alone we've definitely heard examples of this and we know this can be frustrating especially as we've been talking about you know a lot of kind of investment of time goes into meeting with providers and and if there's a lot of excitement I think at that initial meeting or even subsequent meetings when talking about all the opportunities that could come of this but I would say I mean I again I don't think there's a like Silver Bullet for this but I do do you think it's important to kind of revisit some of what we were covering in the drivers section so you know for example we were talking about the competing priorities that healthcare providers and systems face so you know it could be that whoever you met with absolutely wants to make those referrals but it's just falling off of their radar or something else have kind of been given a priority and it wasn't necessarily up to that individual or group of individuals to make that other thing a priority so important to I would say you know be persistent be consistent go back to those individuals that you met with go back to that organization you know think about if you didn't already is there a single champion or a couple of champions we can identify that way you have a person or a number of people that you can hold accountable for whatever you discuss when you do me in terms of how you want to operationalize referrals we talked about the importance of coming up with shared goals and commitment so if that wasn't something you did initially that would be something to consider and if you can document it even better you know thinking about evaluation and thinking about you know as we've been talking just continuously assessing what's working and maybe what's not and then kind of focusing on those things that aren't working you know let's try something different you know maybe it worked with a different partner but it's not working with this new partner so let's revisit so definitely understand this was a challenge it doesn't mean that you fail that we would just say recommend kind of going back and looking at what you have done what maybe you could still try and and not losing faith just you know being persistent and keep trying okay here's another question in terms of the feedback loop what information do health care providers typically want to receive and how frequently this is rambling yeah I can take this so you know as Suzy mentioned in part of the thigh resection it's definitely provider-specific and and it's important that you have that conversation with with the provider what are they looking for around the detail of that feedback and the timeliness of that feedback we also mentioned that it you know closing that feedback feedback loop is very important for the providers with that value-based care and so you know you want to you want to definitely make sure that you're following up with them around whether or not the people that they may refer did in fact enroll and then if they did enroll you know maybe it's it's sharing information about their attendance their percent weight loss in the program and any other pertinent information that that may may be the provider wants to see specifically around those refer patients a few questions about again about the slides and the links the community assessment links we'll make sure we can we can taste those links into the question box for the for those who asked for them but will also make sure that those things get highlighted as the slides get shared and they're recording get shares as well and and just FYI add those those links for the organizational assessment those are just some examples there and there's tons of them out there I mean you could really just do a Google search you know assessing organizational capacity you'll probably find a host of them so we're not suggesting we're not saying that those are the only ones you should use or even that those are the best ones you should use we just wanted to make sure we offer some examples if it's maybe something that that type of work is new to you so so we'll just make sure that those are those are made available to others to folks on the webinar I just wanted to thank everybody for attending today and I know Rand alone also said this but thank you to the local YMCAs and their health care partners who participated in this project over the last couple years we just learned tremendously from that experience so I wanted to get another shout out to all of their hard work and I know some of them are are on the call today so so thanks for that thank you thank you so much to the why USA team those who put together this webinar but also those of you who have participated in this project over the last two years it has been a great learning experience and I really think it's going to help move things forward with regards to improving enrollment and referrals international diabetes prevention program just want to remind people that if you're interested in learning about the bi-directional referral program from the perspective of the American Medical Association we will have a third webinar this webinar will take place on September 24th from 1:30 to 3 p.m. it should be included in the same invite that you reserve we see sorry for this webinar ama will summarize key learnings on how to implement a bi-directional referral process in a healthcare system they have interviewed healthcare providers and healthcare systems as part of our broader project till they'll be talking about that and you know if you have additional questions or you want to pull in so me helping your provider healthcare system partners to attend that whether I think that would be really helpful so that's it thank you all for your time we really appreciate you attending and again thank you to the wife or for participer putting together the slides and participating in this project and thank you to Deloitte for helping hostess webinar

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