(Slide 1: Matt Zornik) Good afternoon everyone, and thank you for joining today’s webinar on

Bi-directional Communication with Health care Partners, Key Considerations for National

Diabetes Prevention Program Providers. I will now turn it over to Robin Soler, Senior Behavioral

Scientist with CDC’s Division of Diabetes Translation, to introduce today’s speakers.

(Slide 1: Robin Soler) Thank you for joining us today, thank you for this. We are in the second

of a three-part webinar series. This series stems from work we’ve been doing with the YUSA,

the American Medical Association, and CDC’s Chronic Disease Center, Office - sorry,

Informatics and Information Resource Management and an internal team of scientists, public

health analysts and contractors. This series is designed to provide you with an overview of how

electronic health records or EHR’s, and supporting tools are 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 learnings from a project funded by CDC,

looking at bi-directional communication between National Diabetes Prevention Program lifestyle

change programs and health care providers. This webinar will explore what may influence

successful implementation of bi-directional communication and provide a roadmap for

organizations wishing to move forward, down a path of effective bi-directional communication

with health care partners to better meet the needs of the National Diabetes Prevention Lifestyle

Change Program participants.

(Slide 2: Robin Soler)Mamta Gakhar, Randolyn Haley and Suzi Montasir are members of the

Evidence-Based Health Intervention Division at the Y’s National Resource Office, YMCA, of

the Y-USA. Mamta is the Director of Policies, Delivery and Impact; Randolyn is a Technical

Advisor for Evidence-Based Health Interventions; and Suzi is a Manager of Program Delivery.

They, and along with other colleagues on the Healthcare Integration Teams, Mamta, Randolyn

and Suzi support local YMCA’s delivering YUSA evidence 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 developed to help those living

with chronic conditions, live their healthiest lives.

I’ll now turn it over to Randolyn Haley to begin today’s presentation.

(Slide 3: Randolyn Haley) 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 for bi-directional referrals and their benefits; a

brief summary of the E-referral Project; understanding the key drivers for bi-directional referrals;

our implementation recommendations; and, of course, we will have time for your questions and

the answers.

(Slide 4: Randolyn Haley) We wanted to take a moment and level-set with some key terms

that you will hear throughout today’s presentation.

(Slide 5: Randolyn Haley) For 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 DPP Lifestyle Change

Program. The National Diabetes Prevention Lifestyle Change Program, or National DPP LCP, is

any approved community-based, health care based, or otherwise, version of the National DPP

LCP. An Electronic Medical Record, or EMR, is the digital version of the paper charts in the

HCP’s office. The Electronic Health Record, or EHR, is often used interchangeably with EMR

and has all of the same functions as an EMR but includes a broader view of the patient’s health

and the ability to share information with other clinicians involved in the patient’s care. And

lastly, interoperability is the ability of different health information technology systems to

seamlessly communicate and exchange data.

(Slide 6: Randolyn Haley)A Bidirectional Referral considers both the information, the referral,

going from the health care provider or system to the lifestyle change program, as well as,

information or feedback going back to the health care system or referring health care provider.

As you can see from the graphic, the information - the communication should and can be fluid

from both partners.

(Slide 7: Randolyn Haley) Now, let’s take some time to discuss the benefits of Bidirectional

Referrals and the current landscape around the use of referrals.

(Slide 8: Randolyn Haley) Collaborative relationships formed between health care and that

Lifestyle Change Programs can truly impact the health of the community but this is unlikely

without establishing effective lines of communication. Bi-directional referrals ensure information

is moving between partners; increases the number of touch-points a patient has; allows positive

reinforcement from the health care provider; keeps the Lifestyle Change Program front of mind

with the health care provider; and improves continuity of care. All of these things are beneficial

for health care providers and Lifestyle Change Programs alike but, ultimately, work to improve

patient experience and impact health outcomes.

(Slide 9: Randolyn Haley) The two most common referral methods included paper-based

referrals and electronic referrals. A direct paper-based referral is typically sent via fax, mail or

email allowing for proactive follow up from the Lifestyle Change Program, whereas, an indirect

paper referral happens when the physician hands the patient a referral with the onus on the

patient to reach out. A direct electronic referral occurs by using the healthcare provider’s EHR

system to securely send the referral to the Lifestyle Change Program. Again, allowing for

proactive follow-up by the Lifestyle Change Program, whereas, the indirect e-referral is sent to

the EHR from the EHR to the patient placing the follow-up as the patient’s responsibility.

(Slide 10: Randolyn Haley) With the growing desire for an implementation of electronic health

records within the health care system, the demand for electronic referrals, or e-referrals, have

also increased. Optimally, the use of e-referrals helps streamline communication between the

referring health care provider and the receiving clinic or partner. At its most functional use, it

also helps provide HIPAA compliant methods for communication and ensures that a referral is

received in a timely manner. Oftentimes, the more traditional method of paper-based referrals

being handed to a patient with the goal of the patient taking the next step to follow up, adds to

the potential for multiple drop-off points and leads to delay and care, or 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.

(Slide 11: Randolyn Haley) As you may know, health care is shifting from the old fee-for-

service 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 costs. 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.

(Slide 12: Randolyn Haley) As providers work to demonstrate value by improving 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. This allows

for quality, access and efficiency to work together and overall improve outcomes.

(Slide 13: Randolyn Haley) EHR’s can help demonstrate value in health care by improving

methods of referral tracking, allowing for increases in data driven approaches, ensuring

efficiency and functionality and they also allow for timely and seamless care transitions by

helping to avoid gaps in care.

(Slide 14: Randolyn Haley)Simply put, the implementation of bi-directional referral pathways

is instrumental in care coordination and along with other system enhancements, such as clinical

guidelines and registries, has the potential to reduce complications and even the incidence of

chronic disease if 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 referring 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 chronic disease.

(Slide 15: Randolyn Haley) We’ll 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 four

local providers of the YMCA’s Diabetes Prevention Program and worked with the American

Medical Association and CDC, to build and implement bi-directional e-referral communication

pathways with existing health care partners using an EHR.

As we begun working through this project, it became clear through conversations with the local

Y’s and their health care partners, the numerous challenges to implementing bi-directional e-

referrals. And thus, we shifted our focus of the original project goals of increasing clinic

community linkages for bi-directional referrals and developing best practices to gaining a better

understanding of the drivers and things to consider when thinking about implementing bi-

directional e-referrals. And based on our wealth of learning we received both from the local Y’s

and their health partners.

(Slide 16: Randolyn Haley) During this project, the Y’s and their health care partners tested two

main e-referral methods: remote call fax forwarding where an analog fax line forwards an

electronic or paper fax into an EHR; and direct messaging, a fully electronic communication

from EHR to EHR. Additionally, they tested sending feedback to the health care providers by

sending clinical letters electronically via the EHR.

(Slide 17: Randolyn Haley) Here’s a list of the project Y’s and their health care partners.

Please note that while it appears that many of the health care partners used Epic, it is important

to remember that there are many different instances of Epic and the versions used in this project

were not the same. We would also like to take this time to thank our Y’s and health care partners

for all of their hard work on this project.

(Slide 18: Randolyn Haley) Each Y experienced an increase over baseline from referring health

care providers. Additionally, we recognize the project period is longer than the baseline, which

could have also impacted the number of referrals. But one note of interest is that while referrals

increased, we know it was not necessarily due to seamless integration of bi-directional e-

referrals, as this 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 to Suzi Montasir, Manager of

Program Delivery, to discuss these drivers in greater detail.

(Slide 19: Suzi Montasir) Thanks, Randolyn. Hi everyone, it’s Suzi, so I’m gonna move us

along into the Key Drivers section.

(Slide 20: Suzi Montasir) 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 use to

come up with these different drivers was, alot, you know, based on the feedback from the local

Y’s that were a part of the project, as well as, the information that we gained from their health

care providers as a part of key informant interviews and site visits. So a lot of this what was

gathered throughout the project.

(Slide 21: Suzi Montasir) 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 it’s positive

between the Lifestyle Change Program and the health care provider or the organization. And this

can take time; it really isn’t something that happens overnight. It takes a lot convening. There

are 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 page and can execute all of this 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 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

referring to organizations that are community based or organizations outside 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 ever 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’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 group’s inputs and expectations. There’s a clear sense of shared

desired outcomes and if 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, 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 evolves to that place.

(Slide 22: Suzi Montasir) 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 is a theme, I would say, we continue to hear especially with our work with local Y’s

working with health care 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, health care providers only want to hear from their peers, their other health care providers

you know, so there might be folks that aren’t as open or aren’t as familiar with 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 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 an 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 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 dietician, 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 Health care

Provider Champion Network can even be expanded.

(Slide 23: Suzi Montasir) 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 prediabetes as a condition or a diagnosis is really still a

newer term. It’s still a newer, still a newer concept for health care providers. And oftentimes,

you know, even if health care providers are familiar with prediabetes and are, you know, aware

of the importance of screening and diagnosing they might not be aware of the National Diabetes

Prevention Program Lifestyle Change Program and the ability to even refer their patients into

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 health care

providers are having to either focus on or be distracted by. So for example, you know, if the

health care provider does become aware of the Lifestyle Change Program but 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 costs, they might just not refer at all. They might be, you know, just not

comfortable with that lack of understanding of the cost of the program or their reimbursement

situation.

So that I think, can pose a lot of challenge but on the flipside, there are some things that are

really positive in this space. Things like you know Medicare coverage going into effect. This

could absolutely increase the awareness and can bring coverage to a large percentage of the

population though, we know the number of Medicare suppliers is still quite small. But still it can

help raise awareness of this important program and the fact that you know coverage, more

coverage is at least coming into play. Another thing that we already talked about, Randolyn was

covering this whole shift from fee-for-service to pay-for-performance and basically, moving

from volume-based 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 costs

and needing to demonstrate that in payer 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 those costs by referring their patients to a

Lifestyle Change Program and ultimately improving the health of their patients.

So, in an ideal 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 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 variables within the

reimbursement space.

(Slide 24: Suzi Montasir) So another environmental consideration, I think everyone probably

is aware of this but there are a lot of competing priorities within the health care system. So I

think just like, you know, the organizations that we all work for, health care providers also have

a number of hats to wear, a number of 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-based 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 their, you know maybe, chief complaints? And then, okay

maybe, can we go through this checklist of 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 for 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 just might be one potential challenge. Because there are no clinical quality

measures related to the National DPP LCP 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; this how can a process or 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 health care providers are going to have

to focus on at some point. So that takes me to our section around process. So one area that, I’m

guessing, folks on the call are familiar with is pre-diabetes awareness, or rather lack of pre-

diabetes awareness. So this is something that you know continues to be a 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 health

care provider partners are kind of activated around that and understand that it’s 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 delayed. 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 this 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 DPP Lifestyle Change Program so that

they can, they can, you know, work on behavior change and lifestyle change to, hopefully reduce

or delay the onset of Type 2 diabetes.

(Slide 25: Suzi Montasir) So shifting 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 whole concept of bi-directional

electronic communication. So the electronic processes themselves have quite a few different

variables within them as it relates to 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 health care 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 health care 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 are many challenges that arise. There are different

instances of those systems, there are firewalls, there are HIPAA considerations, there’s just a lot

that, kind of it goes into this bucket of interoperability challenges.

So when we’re thinking about this, it’s really important to just consider 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 health care provider to the lifestyle change

program, as well as, the inbound feedback. So what is the information that the health care

provider is going to 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 health care providers are more increasingly becoming responsible for closing a referral

loop. 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 person is essentially lost to follow-up. And so if the health care

provider can know that, you know, I referred my patient but 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, 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:

HIPAA regulations, IT compatibility, risk management requirements. So, oftentimes what we

see when we’re talking about electronic bidirectional communication, there’s this 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 are

the considerations.

(Slide 26: Suzi Montasir) So in an ideal state, IT, HIPAA and risk management requirements

are addressed and as early as possible in the development and testing because that could

potentially put up a roadblock if it becomes apparently later on that those things weren’t

considered. Also in an ideal state, 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 a program and contact that person. And then, as well as, the information the

inbound feedback information needs to be, really should be determined with the partner at the

beginning so that they are 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 support and

build the case for continued referrals from your health care partners, is that you’re providing

them the information that they want and that they can use.

And every health care 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 of that communication. And ideally, the health care provider is able to integrate any

inbound feedback that they would receive from you into their patients chart so that they can

continuously follow up and reinforce all of the hard work that their patient might be doing as a

part of the program.

(Slide 27: Suzi Montasir) Another area that’s important around process that we heard

repeatedly is the importance of training and continuing education. I think we hear a lot from

program providers that, you know, we went and visited, you know, our partner or health care

partner and we told them about the program and they were fully onboard and they started to refer

and then six months later there was a huge drop off. 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 LCP’s alike. 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 you are a provider and this is your capacity where you provide the

program and that you’re out there and ready and willing to accept referrals.

Also, you know, regular training to health care organization staff on what the program is? Who

qualifies for the program? What to expect after someone is referred? Those are 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 in 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 health care providers to learn about the Lifestyle Change Program

so that, you know, there was something, kind of, a carrot there for providers to continuously gain

access to this information and that did seem to lend itself to an increase in the number of

referrals.

(Slide 28: Suzi Montasir) So, of course, you know, we couldn’t, you know, have this section

unless we talked about the importance of evaluation. This sometimes gets forgotten, it’s

sometimes an afterthought. But evaluation is really important and thinking about it right from the

beginning, not waiting, okay, two years into this relationship, you know what should be

evaluated and how. So if organizations are, you know, if the goal is to increase 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 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 the 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 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 going to be trial and error. There’s

going to be goals that we set 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 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 is always something that both teams, you know, both sides of the

partnership are always thinking about and assessing.

(Slide 29: Suzi Montasir) So, again, electronic health care, 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

positive around electronic health record systems, 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 but how they’re actually operationalized can really be challenging. So this whole

issue around or factor around technology is an important one to consider. And within each

organization, both for the health care 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, I think we’ve seen where you know a Health Care 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-ons, add-on

platforms or external management systems so it’s something that’s not their kind of foundational

or you know they’re - drawing a blank on the words – the out-of-the-box EHR 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 Lifestyle Change Programs are not using

an EHR and that’s okay. I mean, that is something, you know, that the Y began, kind of using

and it, you know, it’s not easy and it’s not expected that everyone would be using an HER. So

what does that, kind of, pose when, you know, working with a health care provider that is using

an EHR system.

(Slide 30: Suzi Montasir) So, in an ideal state, you know, 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

health care providers are trying to communicate with other health care 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 that would be something

like direct messaging which, you know, Randolyn had mentioned was one of the things that the

local Y’s 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 health care provider and so, you know, kind of, minimizing the burden of having

to fax or use paper, that is, you know, something ideally would function and be feasible. 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, you

listed on here, just a couple that we’ve seen used, so par8o is one. It’s a, kind of, referral

management software that health care providers can gain access to or link to their EHR system.

Aunt 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 another, just another, it’s a 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 EHR’s

or from EHR’s to, you know, another program management system or solution that’s used by the

LCP.

(Slide 31: Suzi Montasir) So I know that was, that was a lot. I know the drivers are kind of, a

heavy section and there’s a lot of detail in there but, 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 Mamta Gakur, who’s going to talk about some recommendations for LCPs.

(Slide 32: Mamta Gakur) Thank you, Suzi. 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 who are thinking about this work, think about what might be some of the areas that they will

want to proactively address or 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 wanted 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 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 with folks 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 webinar is being

recorded and that, in addition to the slides, will be made available once all of the recordings are

converted and hosted. And so folks 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 that recording is finalized.

(Slide 33: Mamta Gakur) So as I talk through the recommendations for LCP’s, just showing

this graphic, this is kind of, the buckets that we’ve grouped our implementation

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 just know that that’s, kind of, it’s grouped this way, it doesn’t necessarily mean that you start

in one place and only move when you linearly forward, might be revisiting. And as Suzi said, it

might be that you’re doing some rapid cycle improvements to, kind of, figure out how to

continually 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.

(Slide 34: Mamta Gakur) So in terms of assessing internal capacity, we talk 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 health care 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 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 this particular project. We do

think in some cases they are probably universal and as we’ve connected to other LCPs or other

organizations that have been approaching this work, we are hearing similar themes. But again,

every situation is unique, every community is unique, so we offer those as suggestions for places

to tackle your work or your energy. But of course, there could be other things that that are at

play in your communities.

In terms of additional assessment around your internal capacity thinking through your financial

resources, your current relationships with the health care community. Who are you currently

talking to? 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 (Suzi) mentioned and working through

processes for a 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 slides we’ve

included a couple 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

or these links could give you a place to start helping guides some questions that you might ask

internally or other ways that you might evaluate your current capacity for thinking through bi-

directional communication with health care providers.

(Slide 35: Mamta Gakur) So once you’ve done that assessment, likely you’re going to find

multiple areas that 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 goals, 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 lot of thoughtfulness and a lot of attention and time and resources in some

cases. And I think, thinking through as part of your capacity assessment is thinking through the,

you know, the value that you’ve provided 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 the health care partners and

systems in our community. And really crafting that into a pitch, for lack of a better word,

because it’s really important 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 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.

(Slide 36: Mamta Gakur) In terms of relationship building and cultivation, Suzi talked a little

bit earlier in the driver section about the importance of relationships. I mean that’s just, it’s

really key and crucial that you’re thinking through how you might address this piece. So you’ll

want to identify who you’re going to work with. And you know, 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, health

care systems in your community? You might have the larger penetration. Or if they’re a

community hospitals, or FQHC’s, like if it makes sense to target your energy there, that you have

a sense of that health care 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 health care 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 health care system might be a large hospital system might have different needs than an

FQHC. That can help you refine your approach for how you might engage those individuals or

find the individuals within the systems to speak with and then share your plan and, hopefully

grow a 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 context? What their goals are? So you can understand better, 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 needs and we have a lot to offer

the health care community so thinking through how we can make that clear to them. And then

defining your opportunities; so using 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. That 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 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.

(Slide 37: Mamta Gakur) So understanding the landscape and opportunity in addition to

understanding the health care landscape. So knowing what’s happening within the health care

system within your communities is important but really also trying to figure out, Suzi 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 referrals have previously been implemented successfully to help

prepare for potential challenges and limitations or even to help, help you think through might be

an approach that would make sense for you to tackle. Maybe talking to other LCP’s in your

community about how they’ve partnered with health care organizations for referrals. If there’s

something, you know, if you have strong collaboration efforts in your community and there’s

stuff that could be built upon and duplicated or replicated rather than completely reinventing the

wheel. That might be a good place or it might be a good way to target your approach.

Talking to, maybe, other organizations, like, state health departments and we listed NACDD

here, the National Association of Chronic Disease Directors who they, you know, might be

focusing efforts on ways to address some of these interoperability challenges that we’ve been

talking about, finding bridges to connect non-clinical program providers with their health care

partners to address population health. And, you know, NACDD has been doing a lot of work

around this with a project and the tool called E-connect. So there might be existing avenues to

think through or to maybe connect to that can help figure out how to make some of this a little bit

more seamless. If it’s not specifically EHR to EHR, it might be EHR to some bridge systems

and back to another EHR. Or not necessarily even originating from an EHR if you are an LCP

that has not adopted the use of an Electronic Health Record.

And then also talk to your health care partners to see, you know, 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 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, Suzi talked a lot about the competing priorities

within a health care system and I think where we can leverage existing workflows and just apply

them to this service, we’re all better off for it. I think it helps a lot with continuity and

sustainability so, if you have existing health care partners or you’re approaching these

conversations, well what might they already be doing and is it something that could just be

replicated?

(Slide 38: Mamta Gakur) If you are working in an EHR, you have some kind of data system,

you know, doing some homework trying 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 within our electronic health record within Athenanet and that’s 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 health care partners. And there might be some different

functionalities that are available in the systems that you’re using that could help with that. So

thinking through what might be some solutions or might be some channels for communication

and you’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 the health

care partners on, about what options there are to share information on patients. If your health

care partners are working in EHRs, if you can do your best to develop a working knowledge of

those systems, it doesn’t mean that you have to adopt the use of those systems or it 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, it’s not necessarily

going to be a one-size fits all approach. But just being familiar even with the language that is

common in electronic health records.

Suzi talked about 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 but

potentially referral management. So, Par8o, Aunt Bertha, REDCap, those are the ones she talked

about. There’s also ReferralMD, Fibroblast and these are typically or at least, these examples,

specifically are HIPAA compliant web-based applications, in some sense that are really have

been used for all management and to address patient leakage. The idea of that, like, a referral is

made and then it never has - there’s never any follow up or 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 though how to handle electronic or make things as electronic as

possible so that there’s some information continuity and standardization. But because they’re

already in existence and already addressing things like risk management and HIPAA compliance

might be a solution that would be worthwhile to pursue. If you are operating without an

electronic health record consider working with a health information service provider to explore

options for your ereferral, so health information service provider organizations that they manage

security and transport for health information exchange among health care 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 handle direct

messaging, they can support direct messaging for communications.

(Slide 39: Mamta Gakur) In terms of project planning and scope, Suzi mentioned this and all

of you on the call who have been working in this space probably also know this, but each of your

health care partners or different health care entities that you might be working with, they’re

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 health care

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

needs. Or Suzi mentioned, they might have different requirements for what type of information

to include in the feedback or the progress updates that you’re ideally providing on their patients.

You want to work collaboratively to ensure mutual understanding on a timeline, communication

channel, staff roles and plans for undergoing evaluation. Again, just, kind of echoing some of

what we talked about from a relationship building and management perspective.

If you think through workflow development, again, we recommend where you can to build up

existing workflows just, ideally, to help make sure that the process for identifying workflow

maybe isn’t too lengthy. But also if there are existing workflows that have been shown to be

successful for that, for your health care partner, are there ways that you can just leverage that and

just will be less taxing both for the clinical staff, as well as, your staff if that’s possible. But

thinking through as you develop these workflows, what are going to be your processes for how

referrals will be handled once received. We found that those health care partners do want to

have a sense of what happens when you get this referral? What can our patients expect and what

can we expect? Being clear about what information you need as part of the referral; identifying

working with your health care 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 health care partners, but that we’re also not promising to provide information that is

very difficult for us 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 overpromising and we’re making

sure that this referral relationship and communication relationship meets everyone’s needs. How

and when data can be shared, and as Suzi mentioned, how successful it will be measured? In

some cases, we found that as these partnerships solidify and as you work to identify what your

goals are and what your scope is and what your benchmarks are, that there might be some benefit

to developing formal agreements with your health care partners whether it’s a Memorandum of

Understanding or contractual relationship, just thinking through how that might help with

increase and shared accountability. And then if you have anything, if you have to be 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 protecting participant privacy and

that we’re making sure the information that we capture and transmit is kept secure even when it’s

outside of the electronic health records.

(Slide 40: Mamta Gakur) Some overall, high-level suggestions or recommendations around

implementation and evaluation. So what we’ve seen is that it’s helpful to really hit the ground

running, as much as possible 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 and immediate problem-solving. Found

that there has been benefit to that as opposed to a very lengthy planning process that, you know,

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 partners, that that could inadvertently push things back. So it’s

also helpful, at least, again from the experience that we’ve seen with local YMCA’s, 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 it 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 aren’t already

doing this work. You know, there may be some value in refining just some of the

communication pieces, like how can I make sure that I’m acting on this referral? And how do I

make sure that I’m communicating back to my health care partner on referral status in the way

that meets their needs and in a way that I can feasibly 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 time you spend identifying where you want to go with this work. So Randolyn shared,

when we were talking about the project itself 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 lifestyle change programs. And as

we learned very quickly, it’s 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 suggestion to consider if that’s a place that you want to start and maybe

that’s a place that even you want to spend most of your time. Suzi mentioned 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 modify your approach over time because you may not be able to start

out the gate with something that is going to end up being the most successful approach. And then

communicating regularly to share feedback. You know, there might not be, if we take a program

like the you know the National DPP as an example, depending on when you, have any 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 partners. So being really thoughtful about

how you build in communication over time, and throughout the course of your implementation

so that you can continue to address issues. Suzi talked about an example where referrals were

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 better to be able to be

proactive in how to address those. And as much as you can, use data when possible to assess

your work so that you can make informed decisions around how you might recalibrate.

(Slide 41: Mamta Gakur) So, in summary, just a quick summary slide and then I’m going to,

we’ll take some, we’ll answer some questions that have come in the chat box.

(Slide 42: Mamta Gakur) 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 seen in the community, we’ve seen where local Y’s, 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 loops. And again, that’s where that internal assessment and ongoing assessment

probably it’s going to be really helpful to be prepared for that. That’s not to say it’s always going

to take a long time but that 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 to stay the course. We talked a little bit about embracing trial and error.

There may be roadblocks and they can feel challenging but the results can be well worth the

effort. And to be prepared, going in with eyes open and expecting that you might hit some

challenges and working collaboratively with your health care partners and how you address those

will be helpful.

And remember that you’re not alone. So there is a lot of work in this field, a lot of energy that’s

being focused on this area. So you know CDC, as I mentioned before, NACDD is doing a lot of

work around this, AMA, and so a lot of energy trying to figure out what are ways to support the

growth of bi-directional communication, whether it’s electronic or not. So reaching out to others

in your network can be helpful to know that there might be existing processes or existing

learnings 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.

(Slide 43: Mamta Gakur) So, I’m going to pause now 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 health care providers a number of times and they seemed interested

in referring but then we never get anything from them. What would you recommend?”

(Slide 43: Suzi Montasir): Oh yeah, this is Suzi, 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 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, again, I don’t think there’s a like a Silver Bullet for this, but I do

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 health care 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 fallen off of their radar or something else has, 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 meet in terms of how you want to operationalize referrals. We talked about the

importance of coming up with shared goals and commitments, 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 I

definitely understand this was a challenge, it doesn’t mean that you failed. We would just, I’d

say recommend kind of going back and looking at what you have done, what maybe you could

still try and not losing faith, just, you know, being persistent and keep trying.

(Slide 43: Mamta Gakur) Thank you, Suzi. Okay, here’s another question. “In terms of the

feedback loop, what information do health care providers typically want to receive and how

frequently?”

(Slide 43: Randolyn Haley) This is Randolyn. Yeah, I can take this. So, you know, as Suzi

mentioned and part of the driver section, it’s definitely provider specific and it’s important that

you have that conversation 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 loop is very important for the providers with that value-based care. And so, you know,

you want to definitely make sure that you’re following up with them around whether or not the

people that they refer did, in fact, enroll. And then if they did enroll, you know, maybe it’s

sharing information about their attendance, their percent weight loss in the program and any

other pertinent information that maybe the provider wants to see specifically around those

referred patients.

(Slide 43: Mamta Gakur) Cool, thank you Randolyn. Let's see. A few questions about,

again, about the slides and the links, the community assessment links, we'll make sure we can

paste those links into the question box for those who asked for them but we'll also make sure that

those links get highlighted as the slides get shared and the recording gets shared as well. And just

FYI, those links for the organizational assessment, those are just some examples. 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 offered some examples that this may be something

that that type of work is new to you. So we’ll just make sure that those are made available to

others, to folks on the webinar. I just wanted to thank everybody for attending today and I know

Randolyn also said this, but thank you to the local YMCA’s 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 on the call today so thanks for that.

(Slide 43: Robin Soler) Thank you, thank you so much to the Y-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 we really think it’s going to help move things

forward with regards to improving enrollment and referrals into the National 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.

(Slide 43: Robin Soler) This webinar will take place on September 24th from 1:30 to 3:00 pm,

it should be included in the same invite that you received, sorry, for this webinar. AMA will

summarize key learnings on how to implement a bi-directional referral process in the health care

system. They have interviewed health care providers and health care systems as part of our

broader project so they’ll be talking about that. And you know, if you have additional questions

or you want to pull in some of your health care provider, health care system partners to attend

that webinar, 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 Y for putting together the slides and

participating in this project. And thank you to Deloitte for helping post this webinar.