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TRANSCRIPT
Community – Clinical Linkages:A Rural Health Sustainability Story
Presenter: Lisa Packard, MSQI Consultant & CDSME T-Trainer
March 27, 2018
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Qualis Health • A leading national population health
management organization• The Medicare Quality Innovation Network - Quality
Improvement Organization (QIN-QIO) for Idaho and Washington
The QIO Program • One of the largest federal programs dedicated to
improving health quality at the local level
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Washington’s Sustainability Story
Diabetes prevalence in underserved populations
Diabetes Self‐Management Program (DSMP) workshops
Community Participatory Approach
Multi‐sector/cross‐sector and public‐private partnerships
Implementationto Sustainability
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Framework for Discussion
The Data
The Theory
The Practice
“The Ability to be maintained at a certain rate or level”: Sustainability
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The Data
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The Data: Prevalence
15.7 16.018.1
19.0 19.5 19.7 19.9 20.0 20.6 21.3 22.0 22.1 22.7 23.325.3
26.9
0.0
5.0
10.0
15.0
20.0
25.0
30.0
State Rate (20.51%)
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Washington Beneficiaries:15 miles from DSME sites
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Prevalence among Dual Eligibles
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Disparities in Diabetes Care
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The Theory
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Reducing Health Disparities
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The Practice
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Adult Learning – Basis for Self-Management Education
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SMRC’s Diabetes Self-Management Program
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SMRC’s Diabetes Self-Management Program
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Adult Learning Principles
Brainstorming Guidelines• Anyone can share• No commenting during the brainstorm• No questions until after• Clarification waits until after
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Brainstorm
What is another name for a boss?
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The Triple Aim Framework
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Value of CDSME Workshops• For communities
• Patient-centered• Engagement
activities• Peer-group support• Confidence
building
• For clinics• Improved health outcomes• Improved quality
performance outcomes• Patient attraction and
retention
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Value of CDSME Workshops
Estimated cost savings
$714 per person savings emergency room visits and hospital utilization*
- $350 CDSME estimated program costs
$364 per person net savings
Ahn S, Basu R, Smith ML, Jiang L, Lorig K, Whitelaw N, Ory MG: The Impact of Chronic Disease Self-Management Programs: Healthcare Savings through a Community Based Intervention. BMC Public Health, 2013, 13 (1):1141
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Sustainability Innovations & TrendsMedicare and Medicaid billing
Payment reform quality measures• Diabetes: DSMP• Chronic Disease: CDSMP
Insurance carrier billing
State • Regional opportunities
Federal• Significant investment• “Experienced, licensed organizations exist throughout the country—
partner with them!”
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Community-Based Approach
Affordable HousingSenior
Apartments
LibrariesCommunity Colleges
Senior CentersLions ClubChurches
Faith‐Based OrganizationsVolunteer
Organizations
HospitalsFirst Responders
ClinicsDistrict Health DepartmentsPharmacies
Area Agencies on AgingTribal
GovernmentsState
Departments of Health
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Implementation Sustainability
Technical Assistance
for Developing
Program budget
Job descriptions
Project management
planning
Marketing materials
Lay leader training
& In-Service
Networking with greater
CDSME community
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Learning CDSME Communities and Intentional Partnering
Program quality
Program efficiency
Program coordination
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Regional Approaches
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Leader Trainings
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Sample Workshop Flyer
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Workshop Materials
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Qualis Health’s EDC Program
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Current Sustainability WorkRegional
Approaches
Sustainability Conferences
Train-the-Trainers
Nuts & Bolts from Soup to
Nuts
Coopetition
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Thanks and Appreciation
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Q & A
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Contact Information for Co-authors
Lisa Packard, MSQI Consultant
CDSME [email protected]
(206) 288-2565
Jamie Hunter-MitchellHealth Promotion Consultant
CDSME Master [email protected]
206-288-2351
For more information: http://medicare.qualishealth.org/projects/everyone-with-
diabetes-counts
This material was prepared by Qualis Health, the Medicare Quality Innovation Network - Quality Improvement Organization (QIN-QIO) for Idaho and Washington, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. WA-EDC-QH-3399-03-18.