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CDSME & Falls National Resource Centers Annual Meeting

Dianne Davis, MPH

Karol Matson, RD, CDE

May 2016

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

Fall 2014 -Partners at Home Network – develop state-wide CDSME network of contracted providers

January 2015 –Contract Signed

April 21, 2015 -Contact Center goes live

May 2016 - 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 the first year

• Significant IT investment required– Customer Relationship

Management (CRM) platform– Interactive Voice Response (IVR)

system– Auto-dialer– Motivational Interviewing Script

Development

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

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 Interviewing-based script

• Train agents on script, including role-playing and listening on initial calls and providing feedback

• Agents are bi-lingual English/Spanish

Auto-Dialer

• 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

Geomapping Large MCO Population Centers

Workshop Host Site

Workshop Host Site Micro-Target

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

Conversion Rate Snapshot:November 2015

Conversion rate of 2.7%

Industry average conversion rates are 1-2%

CBO Network Partner Referrals

• CRM Generated

• Provided to Network Member

• Plan for Cloud Based Transmission

Partners at Home CDSME Network

Network Challenges

• Insurance Coverage

• HIPAA Compliance Issues

• “Workshop Planning” Strategies

• Staying Connected to Network Members

Best Practices

• 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

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!

Thank you for listening!

Any Questions?

Chronic Disease Self Management

Education

Wellness/Risk Assessment and

Chronic Care Management

Falls Prevention

Depression Counseling

Hubs of Activity: Centralized, Coordinated Program Processes

Carol Nohelia Montoya, FMD, MPH

Agenda

• FHN: History and Mission

• History of Hub development

• Processes, Resources, Tools for Hub Activities

FHN: History and Mission

• 2008 – 2014: 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.

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

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

Wellness and Prevention Hub Concept

Central Hub

ADRC

Satellite hub

Satellite hub

Satellite hub

Satellite hub

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

Definition of a Wellness and Prevention Hub

• Wellness and Prevention ‘Hub’ is an established site within a defined geographical area offering evidence-based 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

Menu of Evidence-Based Programs

• CDSME:

– CDSMP

– DSMP

– PEARLS

– EW

• Falls Prevention:

– MOB

– Tai Chi for Arthritis for Falls Prevention

– Tai Chi for Better Balance

– Otago

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

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

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

Tools

• Training tool kits

• QI and fidelity monitoring tool kit

• Marketing and community education flyers and brochures

• GIS mapping for Hub decision-making

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?

Contact Information

Carol Nohelia Montoya FMD, MPH

Network Manager

Tel. 305-952-4266

Email: cnmontoya@flhealthnetworks.org