Sustainability Best Practices. Darcy Reid, RN, BSN CNN, CMSRN, CDE Program Director

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2 Sustainability Best Practices Darcy Reid, RN, BSN CNN, CMSRN, CDE Program Director

3 Objective Identify innovative strategies for planning sustainability of Office of Rural Health Policy (ORHP)-funded initiatives.

4 What: Program Description North Country Diabetes Project

5 Who: Program Description Champlain Valley Physicians Hospital Medical Center (CVPHMC) Clinton County Department of Health (CCDOH) Joint Council of Economic Opportunity of Clinton and Franklin Counties (JCEO)

6 When: Program Description Grant Years: May 1, 2006 April 30, 2009

7 Where: Program Description Targets Tri-county area in rural Upstate New York Clinton County Essex County Franklin County

8 Why: Program Description Diagnosed population greater than 5,700 Over the age of 45 Under-diagnosed and under reported Region medically underserved Shortage of primary care providers Socioeconomic disadvantaged

9 Program Description Education levels low Affects health behaviors and outcomes Reflected in levels of obesity, smoking, high blood pressure, lack of regular exercise Significant rates of diabetes and complications of diabetes Higher than state average of hospital admissions

10 Program Description Problems of diabetes inadequately addressed Little or no access to outpatient diabetes selfmanagement education (DSME) Suffered consequences of untreated diabetes Unnecessary limb amputations End stage renal disease (ESRD) Increased incidence of cardiovascular disease Increased mortality

11 Program Description No American Diabetes Association (ADA) Recognized program locally Closest was one hour away Decision to address problem based on Medical personnel involved with partnership agencies Discussions with patients in their practice Own personal experiences and frustrations Disturbing data related to this disease in the tricounty area

12 Our Vision To build ongoing community collaboration among core health care providers To increase access to diabetes care To develop physician referral network To establish an ADA Recognized DSME program and expand Medical Nutrition Therapy (MNT) To sustain services post-grant!!

13 Goals Improve health outcomes for individuals age 45 and over with diabetes or at risk for diabetes that complete the ADA DSME or MNT. Increase quality of life for individuals aged 45 and over who have diabetes or are at risk for diabetes and complete ADA DSME or MNT.

14 Community Health Approach Risk awareness Education Need for risk assessment Need for periodic screenings Diagnosis Treatment Self-management education

15 Community Health Approach Stimulate increased referrals for essential medical interventions required by best practice guidelines Eye examinations Foot examinations Testing of blood glucose levels Reduction in incidence of complications Hospitalizations Amputations

16 Community Health Approach Registered Dietitian from CCDOH 51 Home Health Care Registered Nurses (RN) 3 JCEO Case Managers 12 Community Outreach Workers (JCEO) 12 different community sites 26 JCEO volunteers to provide transportation to appointments for homebound seniors

17 Community Health Approach Public Service Announcements Tele-health capability in local libraries Internet access to reliable diabetes education resources; Postings for local services Publication of project s services Office of Aging The Senior Citizen s Council The United Way

18 Outcomes ADA Recognized program DSME MNT CGMS Gestational Insulin starts Insulin pump starts

19 Ability to Sustain Assure plans are solid going into initiative Literature searches for best-practices Involvement of those who will be impacted by the service Gaining the organizations support Make services seamless Plan from the beginning that the partnership will remain after the grant

20 Ability to Sustain Ensure collaboration Maintenance of physician referral network Outreach CCDOH during grant; continued after grant (program director/office coordinator) CCDOH continues support through large events JCEO continue with education (case coordinators and community); rides for those who meet criteria Maintain Partnerships!

21 Outreach Ability to Sustain Main focus on risk assessment, prevention, and referral Broad audience Group opportunities Cost neutral services

22 Ability to Sustain Promotion of program Combined efforts of partners Recognition HANYS; US Senator Charles Schumer; NYS DOH and SUNY Albany School of Public Health; CDC national conference on diabetes; high participant satisfaction; generation of positive health outcomes (reduction in A1c)

23 Ability to Sustain Continue to promote awareness 2 levels: provider and public Improve access to services Show outcomes/quality service A1c, foot checks, eye exams, weight loss, BP control, SMBG, improved QOL

24 Ability to Sustain Medical advisory committee Physicians Nurses Dietitians VP s People with diabetes Collaboration Meeting

25 Ability to Sustain Always be on the look out for other income post-grant/additional revenue sources Other grant opportunities Foundation support Consultation fees Retail merchandise

26 Ability to Sustain Analyze billing and patterns to determine best patient mix for sustainability Developing benchmarks and targets for staff productivity Right staffing mix Reimbursement Medicare, Medicaid, Private Insurers, Charity Cares Negotiate with payors for better rates

27 Ability to Sustain Analyze participant retention patterns Analyze physician referral patterns Patient satisfaction survey Future endeavors plan ahead EMR/Grant Bariatric Population NYS Health Foundation List Serves

28 Ability to Sustain PI Plan to increase physician referrals and increase participant retention (Handout) Physician satisfaction survey Medical Centers weekly newsletter Planned visits to OB/GYN offices round table discussion, visits extended to other specialists 15 office visits to deliver 2008 Self-Learning Module based on ADA s Diabetes Standards of Care Presentations to medical staff Monthly faxes Every 2 years update at EXPLORE Consortium Local radio Television Vignette

29 Ability to Sustain Marketing plan (Handout) Newsprint Radio Library System Pharmacies Faith Community Displays (mall kiosk, annual health fairs, etc.) Senior Outreach Presentations Website Worksite Education Build other alliances Pocket cards/guides Encourage and support patient self-referral Brochures Tickler system f/u for patients Signage Posters in key locations

30 Common Sense Thoughts Hard Work Team work listen to all members (monthly meetings) Never let initiative off radar Don t get too comfortable with status quo In every circle think how your program can be involved/impacted/etc. Watch Trends Be creative, try something different

31 Lessons Learned Adequate numbers of core educators who meet qualifications Line up resources and contacts for troubleshooting reimbursement issues Involve reimbursement experts early on Succession planning Secure adequate resources prior to starting the program Classroom space Ability to grow program Adequate office staff time/system for addressing phone calls/voic Registration process seamless/easy

Welcome to the Emory Diabetes Education Training Academy!

Welcome to the Emory Diabetes Education Training Academy! Session Title: DSME Program Overview: What a Coordinator Should Know About Reimbursement, Coding, Billing and Referrals Speakers: Amie Hardin,