- PDF Free Download

Size: px

Start display at page:

Download ""

Estella Washington
6 years ago
Views:

2 CDSME & Falls National Resource Centers Annual Meeting Dianne Davis, MPH Karol Matson, RD, CDE May 2016

3 How We Approached Achieving CDSME Sustainability 1. Established value proposition with healthcare payers 2. Won contracts with healthcare payers 3. Built a multi-regional CBO provider network to scale delivery capability

Program Timeline Summer 2014 - Begin planning process for outreach and engagement January 2015 Contract Signed Fall 2014 - Partners at Home Network develop

4 Program Timeline Summer Begin planning process for outreach and engagement January 2015 Contract Signed Fall Partners at Home Network develop statewide CDSME network of contracted providers April 21, Contact Center goes live May Need to integrate additional referral sources into current process

Outreach for Population Health: What s Required Contact Center Partners developed a new engagement strategy to reach out to and engage a significant managed care population 52,000 referrals in

5 Outreach for Population Health: What s Required Contact Center Partners developed a new engagement strategy to reach out to and engage a significant managed care population 52,000 referrals in the first year Significant IT investment required Customer Relationship Management (CRM) platform Interactive Voice Response (IVR) system Auto-dialer Motivational Interviewing Script Development

6 Customer Relationship Management (CRM) Utilized by Partners for leader and host site management We needed to: manage large numbers of referrals, send letters, map host sites and members Easily integrates with other cloud based utilities Stores analytics

7 Interactive Voice Response (IVR) Interactive Voice Response (IVR) purveyor Receive data from plan through Safe File Transfer Protocol (SFTP) site Create campaigns Drop initial letter to members Auto-dial members and provide ability for them to transfer to Contact Center

Motivational Interviewing-Based Script Intrinsic motivations for change Work with Consultant to develop a Motivational Interviewingbased

8 Motivational Interviewing-Based Script Intrinsic motivations for change Work with Consultant to develop a Motivational Interviewingbased script Train agents on script, including role-playing and listening on initial calls and providing feedback Agents are bi-lingual English/Spanish

9 Significant technical knowledge required Controls the speed of the calls coming into the Contact Center Notifies agents of how many contacts are waiting for call Stores call related analytics Auto-Dialer

10 Geomapping Large MCO Population Centers

11 Workshop Host Site

12 Workshop Host Site Micro-Target

Personal goals Barriers to achieving goals After

13 Member Engagement Contact Center Agents use Motivational Interviewing (MI) Readiness for change Personal goals Barriers to achieving goals After acceptance of workshop Readiness level to participate? Assist with barriers

14 Conversion Rate Snapshot: November 2015 Conversion rate of 2.7% Industry average conversion rates are 1-2%

15 CBO Network Partner Referrals CRM Generated Provided to Network Member Plan for Cloud Based Transmission

16 Partners at Home CDSME Network

17 Network Challenges Insurance Coverage HIPAA Compliance Issues Workshop Planning Strategies Staying Connected to Network Members

18 Key members from Healthier Living Coalition knitted into a business network Increasing revenue for smaller CBOs Bringing new workshop participants into CBO sites Usual Work, New Standards Best Practices

19 Why Contract With Us? Proven, effective outreach for population health Costly, complex and time consuming to do it alone Requires specialized expertise Buy it, don t build it!

20 Thank you for listening! Any Questions?

21 Chronic Disease Self Management Education Falls Prevention Depression Counseling Wellness/Risk Assessment and Chronic Care Management Hubs of Activity: Centralized, Coordinated Program Processes Carol Nohelia Montoya, FMD, MPH

22 Agenda FHN: History and Mission History of Hub development Processes, Resources, Tools for Hub Activities

23 FHN: History and Mission : Healthy Aging Regional Collaborative (HARC): local, two counties, South Florida, grant driven. Initiative to maintain learning network, training academy, QI and data management for a network of 18 agencies delivering EBP in the community. 2015: HARC was transformed into FHN, expanded a statewide network of networks driven by ADRCs and supported with functions and experiences from HARC with the goal of achieving sustainability.

24 FHN Mission and Vision Mission: Increasing the delivery of sustainable evidence-based health and wellness programs through the development of laboratories of community innovations that target improving health outcomes and reducing healthcare cost Vision: FHN is a statewide model for effective collaboration among lead organizations serving aging and disability populations; creating sustainable pathways to link clinical and community services in the promotion of health and wellness. Values: Person-Centered Collaborative and Innovative Quality and Outcome driven Cultural sensitive and linguistic appropriate Focused on reducing health disparities

25 Provider Network Each AAA/ADRC has a network that includes: Senior Centers Elder Housing Nutrition Sites Parks Community Centers YMCA Adult Day Care Public Libraries Centers for Independent Living

26 Wellness and Prevention Hub Concept Satellite hub Satellite hub Satellite hub Satellite hub Central Hub ADRC Satellite hub Satellite hub Satellite hub 52 Hubs identified to date clustered around the 11 ADRCs. Next Step: Build infrastructure for sustainability for each hub

27 Definition of a Wellness and Prevention Hub Wellness and Prevention Hub is an established site within a defined geographical area offering evidencebased programs under the joint leadership of the local ADRC and FHN These sites: a) schedule prevention programs b) do outreach c) have a registry of community health workers d) have a network of outreach sites and health care payers

28 Menu of Evidence-Based Programs CDSME: Falls Prevention: CDSMP DSMP PEARLS EW MOB Tai Chi for Arthritis for Falls Prevention Tai Chi for Better Balance Otago

29 Hub Development FHN has centralized process, resources and tools available to ADRC for PSA wide capacity building and hub development ADRC is responsible for selecting hubs and ensuring hubs have sustainable funding streams

30 Processes supporting statewide Hub development Planning, Management and Evaluation Team formed by representatives of the 11 ADRCs and FHN. Statewide menu of evidence-based programs (license and training capacity provided by FHN) Registry of Trained peer leaders/community health educators/community health workers Centralized data management and information system for QI Centralized clinical supervision (via tele-health) Medicare billing provided by FHN Contractual negotiations done by FHN with Managed Care Organizations

31 Resources FHN Staff: Network Manager, QI Manager, and Training Manger HFSF small grant to bridge from grants to sustainability ACL Falls and CDSME statewide capacity building grants Contract with WellMed for Falls Prevention Contract under review with Humana

32 Tools Training tool kits QI and fidelity monitoring tool kit Marketing and community education flyers and brochures GIS mapping for Hub decision-making

33 Lessons Learned New way of doing business: Each agency may be at a different stage of readiness to change Move with each member in a way that facilitates change from where they are to action and maintenance Conceptual and operational change takes time. Moving from a hierarchical relationship to a collaborative partnership. Behavior change in network member is similar to behavior change in people: Does network member wants to do it? [we don t all have to do the same thing at the same time] Are we driven by measurable objectives? [network agreements are driven by concrete objectives that are measurable] Are we sure that work is achievable? [Are we flexible to problem solve and change objectives if necessary?

34 Contact Information Carol Nohelia Montoya FMD, MPH Network Manager Tel

PEER EDUCATOR DEVELOPMENT & LEADERSHIP: Keeping Leaders Engaged and Tools for Recruiting Strong Leaders

PEER EDUCATOR DEVELOPMENT & LEADERSHIP: Keeping Leaders Engaged and Tools for Recruiting Strong Leaders Tuesday, August 20, 2013 2:00-3:30 PM PDT C A L I F O R N I A HEALTHIER LIVING Living Your Best Life