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>> Hello good afternoon everyone, to those of you on the east coast and those of you
on the west coast joining us, thank you and good morning to all of you. My name is Dr.
Astril Webb and I am the Director here at the National Center for Health and the Aging.
I want to thank and welcome all of you to today’s topic, which is Making Community
Connections: Chronic Disease Self-Management Education in your Federally Qualified Health
Centers and the discussion today is centered around making this part of your patient centered
medical home transformation. So we are really delighted, we have wonderful line up of speakers
today, and at the end of the presentation we will take any questions that you have and
try our best to make sure that our expert panelists have the opportunity to answer the
questions for you. So today we are delighted to have Ms. Kristie Kulinski, who is the Senior
Program Manager with the Center for Healthy Aging at the National Council on Aging, as
our moderator for today’s webinar discussion. She provides training and technical assistance,
guidance, and program management to state government agencies and community based providers
implementing evidence based health promotion programs including Stanford’s Chronic Disease
Self-Management Program. So Kristie thank you so much for agreeing to moderate today’s
session and I will now turn it over to you
>> Great, thank you Dr. Webb and I would like to introduce our two speakers and then toss
it over to them, so we can get started with our webinar. We have Chris Katzenmeyer, she
is a Gerontologist and the Executive Director of the Consortium for Older Adult Wellness,
dedicated to training professionals and evidence based programs that enhance wellness of older
adults. COAW is also successfully focusing on the bridge that reimburses community programs
when older adults are referred by clinics via the Affordable Care Act. Chris was the
coordinator of the state wide Senior Wellness Initiative and is an adjunct professor at
Metro State College. She received the 2010 Denver Business Journal’s Champion in Health
Care Award for providing innovative and effective new strategies in healthcare. Joining Chris
is Lynnzy McIntosh, Lynnzy is Vice President at the Consortium for Older Adult Wellness.
She trained to be a Chronic Disease Self-Management program leader in 2008 and joined COAW’s
staff later that year. She now supervises implementation of evidence based programs
throughout Colorado, including integration of falls prevention and self-management classes
in the health system, as well as individual practices seeking national recognition of
Patient Centered Medical Homes. She also is the first Chair of the new Colorado state
wide CDSMP, or Chronic Disease Self-Management Program, Collaborative and starting in January
will be working on behalf of the collaborative with the State Unit on Aging and Health Care
Policy and Finance on a voucher program for Medicaid reimbursement of the Chronic Disease
Self-Management Program. So now I would like to turn it over to Chris and Lynnzy.
Hello everyone, friends and colleagues, thank you for asking us to do this webinar. We are
very happy to share this information with everyone, and it was stated that this is Making
Community Connections: Chronic Disease Self-Management Education in Federally Qualifies Health Care
Centers. We hope this presentation will spark and ensure you that CDSMP, or Chronic Disease
Self-Management Program, can be implemented successfully in a Federally Qualified Health
Care Center. One of the learning objectives that we would like to share with you is to
really help to assist you in initiating this program, the Chronic Disease Self-Management
Program within a Federally Qualified Health Care Center, and then have an open discussion
at the end of this presentation to really talk about the connection between chronic
disease self- management and a patient centered medical home. We really hope this fosters
a collaborative interaction between patients, providers, and community based organizations.
And I want to emphasize again that we are very happy to be able to share this information
based upon successful models that have appeared in Colorado. Just very briefly, the Consortium
for Older Adult Wellness is a non-profit organization, we were founded in 2001 and we are really
a consortium of like-minded organizations that are working in health care and with the
Affordable Care Act we were looking at patient centered care. And we are doing this across
Colorado and with some friends in other states as well. Our major focus is just on increasing
the health options for older adults and if you want to know more about it we are at coaw.org.
I want to move on so that we can get to the meat and potatoes of this today. So what I
would like to do now is turn this over to my colleague Lynnzy McIntosh, who really has
done the pioneering for all of this in this work, so Lynnzy.
Well thanks. Pioneering? I like that. Well welcome everybody, we are very happy to be
here, I want to start out with a couple of shout outs, first to our pal Dr. Webb, who
just completed her training to be a leader in Chronic Disease Self-Management out in
Colorado with us. Also hello to Judy Simon and her friends and coworkers form Maryland
as well as our friends here in Colorado, that are AAA and also members of our state wide
collaborative. As well, I want to especially acknowledge the Colorado Community Health
Network which is the organization including Renee Carl who is hopefully on the call with
us, who is our partner in the work we are doing with federally qualified health centers.
And in particular of course our thanks to the National Council on Aging, who have shared
so much with us and have supported us in so many ways. Not just me and COAW, but all of
us in making all of this happen, so we are very happy to be here. We are going to start
with what is self-management? And I know that all of you on the call are in very different
places in what you are doing and how you are doing it. So forgive me if I repeat some things
that you already know, just sort of nod your head and we’ll get through them quickly.
And if it’s information that you don’t know, hopefully it will be enough to get you
started and then please get in touch with us and let us know if there is any way can
support you in furthering your knowledge or if you have answers for our questions we really
want to hear from you, answers are always more exciting than anything. So what is self-management?
When we start working with clinics and health systems in general, one of the big questions
is what is the difference between self-management, medical management, and self-management support.
And so this is the official definition, how I like to talk about it though is a little
different, because I think this definition makes it sound really formal but if you figure
that if I’m a very sick patient I spend about 3% of my time with my health care systems
and providers ,that means 97% of my time I’m spending making my own decisions and choices.
So the medical management piece, you all can handle in the 3% of the time and then you
give me instructions, advise, directions, procedures, tests, medication, act. But that
97% of the time, I need to make choices and changes in decisions on my own. And it’s
that 97% of the time that is addressed with self-management. Self-management support,
if you will, is the part that the practice can be involved with and the clinic can be
involved with that helps me make choices and changes that are in my own best interest or
at least minimize choices that may not be in my best interest. But the self-management
support piece is always the clinic, the staff, the health system can support me as the patient
in my own self-management. So how does that self-management piece work with in the whole
health care transformation, patient centered medical home movement, patient activation,
and most importantly within your organization. And I realize on the call today that we have
people that are here because they are community based organizations, they are AAAs, they are
also from the FQ world, and from the clinical world, so we are going to try and talk about
it from both perspectives as much as we can with in the time we have. Self-management
really is a pivotal piece of everything that is happening in health care transformation,
because the patient really is the center of the activity. The problem is that we haven’t
always shared that with the patient, so we need to start the whole conversation when
we are talking about self-management/self-management support care coordination with have we talked
with the patient about what we can do and what they are going to be responsible for
doing. Self-management in terms of patient centered medical home recognition, PCMH is
all about changing the way health care works and changing the perspective from being one
of a fee for service base, from a view of a gate keeper perspective, to something where
what I’m doing as a patient is really seen as the center of what’s happening and that
everyone is surrounding me and supporting me. So the 2011 NCQA, National Center for
Quality Assurance, guidelines really reinforce the critical role of the patient decisions
and choices of what they are doing and really recognizes that. That includes the need to
document the capabilities the patient has for self-management , also to document self-management
goals, and to give tools and to provide resources and to document that as well. Also to provide
counseling on healthy behaviors, and for those of you especially in the FQ world know that
behavioral medicine/ behavioral changes are really a key factor to the overall health
of the patient and that ultimately involves a lot of arranging things like mental health
intervention, substance abuse treatment, and then to provide that link to community resources,
not just to have a book at the front desk within a FQ that says here are all the different
agencies we know that do everything, but what specific community resources work with the
patients you are seeing in your practice. This is an overview of what the PCMH standards
are, and again most of you who have been doing a lot of this work, and this is the work that
we have been doing with the Colorado Community Health Network, these are all of the six standards
for NCQA, and what you see when you look at all of them, this first one is Access and
Continuity of Care, which involves when do you see a patient, how do you make it easier
for patients to come in, how do you provide culturally and linguistically appropriate
services. Talk about being something that supports the patient, knowing you can get
in to see your physician and why they care what your first language is or your choice
of how to be communicated with, talk about something that will really help establish
a relationship with the patient and make them feel involved from the very first standard
there. There are also things like patient panelment, and if you look down at standard
number 3, that is to plan and manage care and that involves the whole care management,
care plan for a patient which can include a treatment plan but also include the self-management
goal that the patient has. So if you look at a big umbrella, this is the whole care
management of what we are going to do with our patients. There is a piece of it that’s
all the clinical things, my patient is diabetic, my goal for this patient are to lower the
A1C levels, and have them become compliant with their medication. To do that we are going
to have to do a diabetes medical intervention class, to do that we are also going to put
them on medication, and then we have their self-management goal which might include referring
them to a community based class. So you then go into then this standard, PCMH 4, which
is to provide self-care support and community resources. That self-care support is really
what is my patient going to do with the 97% of their time and how can I help them make
those connections, that includes being able to document goals on what I want to accomplish
as a patient and my ability to do that, also the referrals that are being made to things
like a quit line, to a chronic disease self-management class, so we are going to talk more about
that but I get excited because it’s such an integral part of what NCQA is about. And
we really have found in Colorado that putting self-management/ self-management support at
the heart of that, it make it easier for the patient to understand the transformation,
but also it really makes it easier for a FQ staff to understand the importance of the
transformation. So clearly it’s important, we like it, we want more of this. So what
I want to say about this is that when FQs are going through, or any practice, when you
are going through your application for patient centered medical home you document everything,
and if you look at all of these different components, you are measuring, you are tracking,
you are coordinating, you are documenting, you are making graphs, and I can see all of
you are on the call, in my head, are doing this work. But the truth is engaging the patient,
engaging me in the office is the only way to really Impact those clinical outcomes.
You can measure processes all you want to, you can weight me 20 times a day, you can
take my A1C every moment of day and night, but the only thing that will change those
numbers, is if I move differently, if I eat differently, if I actually take my medication
as directed, if I follow you advice, if I make better choices, all of that is on me
to do. And so that’s what makes those A1C’s go down, that’s what makes my ability to
deal with my condition go up. So clearly that is a brilliant idea, having me be an involved
and activated patient, teaching me all about self-management and my role in my health care,
that’s all good. So when we talk to practices we say, so why can’t we do that, why can’t
we do this? And the answer would be, what you see on your screen there, which is time.
You just don’t have time to sit with a patient for hours and hours to talk about the difference
between clinical management, self-management, self-management support, your role, their
role, etc. And as a patient we have gotten in the habit, and I include myself in this,
in thinking that I can go to my provider and they will fix it. And to come to the understanding
that, it is not your to fix, that we can work on it together, but there are no magic pills.
It’s really hard for us to understand within the confines of a regular traditional time
in an office. So how do we do this, what do we do to help make this work? Well what we
suggest is that you don’t try and do it all within what is happening within the clinic,
but do really lean on one of the skills we have available to us, which is the art of
referring to community based resources. Now that includes not only something like a quit
line, or a silver speakers program but to those community based/evidence based programs
that are available all around you and sometimes in some communities are really well kept secrets.
So we want to talk about what’s available and how to connect both from the clinical
side and from the community based organizations side. So what makes self-management work for
you and within a clinical setting, is that this is not something that is going to interfere
with medical management at all, in fact those of you who are familiar with evidence based
programs know that they have very clear definitions of what they do, and what they don’t do.
And why you may be asking, what is an evidence based program, why and evidence based program,
as opposed to something you can write within the practice. The reason for that is an evidenced
based program, much like evidence based guidelines, are the gold standards. They have been researched,
they have been demonstrated, documented, and can be replicated. And that’s what is necessary,
not only for best practices within your practice, but also is the key towards eventually having
these reimbursable, paid for, grant driven however the funding sources look in your area.
But it’s based on evidence based programs, it’s based on are they on the NCOA list,
are the classes on the Centers for Disease Control list. So all of those things are very
important and that’s why evidence based programs are what really drive it. It’s
a model that can be demonstrated and conducted again and again. Fidelity is a big component,
so that the classes we are doing here, in Colorado, are the same classes you are going
to be doing in Maryland or Florida or Texas or California, and that’s very important
across the board. The reason that we talk about the self-management program, especially
the chronic disease self-management program as really the foundation piece, is that it
really uses multiple strategies, multiple interventions, it’s designed to help activate
a patient, it is not necessarily designed for patients who are already triathletes,
because if you’re a triathlete and you come to talk with you clinician you have a very
different conversation than someone that is a couch potato, or has four comorbidities
and is socially isolated. Those are very different conversations and what we are talking about
is those patients that are deactivated, those patients that are the couch potatoes, that
maybe yet don’t have a sense that they have choices and options in their own lives and
in their own care. The chronic disease self-management program really helps promote connecting that
patient with other folks that are in a similar situation, so that no matter what their diagnosis
they realize that there are other people going through similar issues. It also is a way for
the practice to move all of this off of their plates and share the load a little bit with
the community based organizations, who can then help support you patients in making the
changes that you are hoping they will want to make. So to move along here, what exactly
is the Chronic Disease Self-Management Program? Again we use it as a foundation class, because
I like to call it a gate way class, sort of like a gateway drug. But this is a gateway
class, because this is one of those classes that literally you see light bulbs go on over
people’s heads. And I know that sounds like I’m over stating it, but anyone who has
ever been in the chronic disease self-management program class has witnessed this. And it’s
that moment where we realize that the chronic condition that we’ve been living with is
ours, and that because it is ours there are changes that we can make to help us feel better.
We maybe can’t get rid of it, but we can affect it. So the chronic disease self-management
program, out of Stanford University, written by Dr. Kate Lorig, over 20 years of proven
impact, it’s just the goal standard for this kind of work. It is offered in small
venues, we’ve had it in coffee shops, in church basements, in recreation centers, senior
centers, all the way up to classes within federally qualified health clinics, which
we will talk about later. It’s offered around the world, it’s available in 21 languages,
there are programs within the chronic disease self-management education portfolio that are
specific to diabetes, we’ve just been involved in some translational research, evidence basing
a new character survivor curriculum that’s also led at Stanford that’s chronic disease
self-management. There is also a curriculum for pain management, there is one for ***/AIDS,
so there are a number of different things that are all offered on that same premise,
which is that people with ongoing health conditions have very similar problems/concerns, and they
need to deal not only with their condition, with the story of the diagnosis, but the impact
that it makes on your life, the impact it makes on your emotions, and how to manage
those things. The other part of this that I think is really important is that the programs
are lay leader led, as opposed to health care professional led. In fact the research would
show that they are just as effective, if not more effective, when they are led by lay leaders,
which means that they are more cost effective. So the class itself is six weeks long, two
and a half hours a session, and tell me how you’re going to find that much time where
with a deactivated patient within your regular practice schedule, it’s just not going to
happen. So referring to a community based organization, it’s the way to make it work.
Within the class area they are going to be exposed to exercise and nutrition information,
medication management, stress management, falls prevention, also how to talk with your
doctor, communication skills not only with their doctor but with their family, how to
deal with difficult emotions and depression, how to breath, how to just do distraction.
They can help manage not only difficult emotions, but pain management, and the art of action
planning. Action planning is what relates directly back to goal setting, and documenting
of goal setting is a part of what you need for patient centered medical home recognition,
so it all works together. I would tell you that we frequently get asked about how we
are going to get people into a class where they have to sit for two and a half hours,
and the truth of the matter is, it always comes up it’s always a question, and it
isn’t an issue for the people in the class. They make it work, because they are getting
something out of the class. There are many different types of interactions that take
place in the class lectures, there’s brainstorming, there’s a lot of interaction. The two and
a half hours goes very quickly, we have people who, we just finished a class where a lady
brought her own chair, not just her own pillow, but a chair, she literally brought her own
chair, her own food, her own water, that would be a different story. But anyway, the idea
is this will not stop people. So the benefits to the practice, external resource, don’t
have to recreate the wheel, going to reinforce the feedback loop to the practice on what
your patients are really concerned about, you can document it in terms of patient centered
medical home term, definitely shift the interaction with the patient. There are quality measures
that give you data that you can document, not only on the referral but on the patients’
goal, and updates on that, and it just really helps all the way around. In terms of the
community based organization, what it can do is help a community based organization
make those classes more accessible to the folks you want to serve, it gives you a way
to reach people who are socially isolated who are isolated by their medical condition.
So in terms of results, the program that we are doing right now in Colorado Community
Health Network, we’re working with 10 new federally qualified health center sites in
collaboration with them. Their goal is to get their patient centered medical home NCQA
application in and receive at least a level one, but hopefully level three all across
the board. So right now, 6 out of those 10 are active in one way or another, or more
will become activated, that would be practice activation as opposed to patient activation,
but by the winter of 2012. These range from very large, multisite FQ’s to very small
frontier locations where there are one provider on site, and they’re an FQ. 8 of the 10
practices that we have had discussions with, within this cohort, will eventually have classes
in English and Spanish. 5 of the 10 of them are now offering classes on site, and when
I say on site I mean within the federally qualified health center. Either in the conference
room after hours, in the front office after hours, during hours in a classroom, many different
ways but actually on site. 5 of the 10 of those have now trained at least one person
in the CDSMP curriculum, so they can lead classes, not all of them are planning on doing
the classes themselves but by taking the training and understanding the curriculum and how it
works, they are able to explain it to patients, providers, and really train the rest of the
staff. We have a lot of important work that’s done with the front office staff and the back
office staff in terms of involvement in the referrals process and the follow up process.
Referral results, the referral results that we have gotten have been really good, 26%
now of all of the work that we do across the state is a direct result of direct physician
referral or a provider referral. We have noticed that, roughly 50%-52% of people that are referred
by their provider we can reach and go into the next available class that is being offered
to them. Additional members we follow up on outside of that 52%, we follow up on them
as much as we can. We have people that it takes us a while to get to them because what
we see with our work is the same thing you see in the practice in terms of difficulty
getting them on the phone sometimes, difficulty in communicating with them in terms of how
important something is for their health, transportation issues. But of the people we have reached,
we’ve had them say that I can’t do it now, sometimes we don’t reach them, 52%
of them say they will come and they do attend the next session, but we’ve never had a
person who was referred by a physician say no I’m not going to do it, so that’s good
feedback for us. And then what we do is we give that information back to you. I want
to spend a little time on the process and the details for how we make this work. This
is really important for how the community based organization works. Each of these boxes
represents a lot of time and skills and talent, so it’s hard to talk about this in any great
detail, we are going to share with you a little bit later on how we can get more of that information
to you. If you want more information please email us or ask questions at the end of it.
We start out meeting with the practice, and doing some messaging and training. We also
make a point of discussing with the practice, who is going to be involved in self-management
support, what does that mean. Then the clinician introduces the opportunity for the class to
the patient, the patient then signs a referral form or a referral is done. We work with the
clinics so that the referral is handled the same way they would handle a referral for
say physical therapy, so that the patient takes it seriously and the provider takes
it seriously. Then from our end we at COAW and in community based organization, they
would contact that referred patient and they would enroll them in class. Now we spell all
of this out in a care compact that we actually do with the practices, we really encourage
all of the community based organizations we work with to do that same thing so that you
now the expectations and they are clearly spelled out. COAW then communicates weekly
back with the practice to let them know who we have been able to reach, who we haven’t
reached, and what we have learned. Sometimes what we learn is that the patient doesn’t
understand why they have been referred, because they may have oxygen tanks, arthritis, 5 comorbidities
but if they don’t understand that those are chronic conditions and there is something
they can do about them, then we can feed that information back to the practice and you can
have a conversation with the practice or with the patient. The patient that attends the
chronic disease self-management class and is part of the program, we ask them to write
a letter back to the practice at the end of the six weeks talking about what they’ve
learned, what they understand now about managing their condition, and most importantly what
their goal is for the next 3-6 months. This gives you something you can then follow up
with at the practice. And this is what the referral form looks like, it’s very simple,
it has a place for the patient to sign so it’s HIPAA compliant, we ask that these
be faxed in but we also have a centralized referral system so that we do have HIPAA compliant
ways for those to be emailed to us as well. And we can work with EMR’s if need be, so
that things can come directly from the EMR to us. This is that feed-back form, and this
is evolved over time. I want to draw your attention just to this bottom piece, that
talks about my action plan for the next 6 months. So in this case my goal is to stay
healthy for as long as I can, I want to be here to see my grandkids graduate, that’s
your motivating factor right there. The specific action that they are going to do is to walk
with a neighbor, they are documenting 3 times a week, Monday, Wednesday, Saturday, and their
confidence level. Those things are all things that need to be documented within the patient
chart for NCQA. So all of that information is there and is a start and gives you something
really good to talk with the patient about. Now clearly that is a whole lot of stuff that
we have went over in a really fast way, so what we have discovered is that we need more
time to really sit down with folks and go through in detail. So Chris is going to tell
you a little bit about this opportunity, that a good word for it, what we are doing in January
which by the way is ski season in Colorado. I’ll make this very brief because I know
we want to move into question and answers, but we have had a lot of questions about how
this works in detail, how do the details work, is this hard work. So what we are going to
do is we are going to have a workshop in Denver, in January, and here is the information here.
We will give our phone information at the very end here and our email information so
if you would like to come to Colorado in January we will take good care of you and hopefully
give you all of the nuts and bolts that you need to do this in your area. I would just
like to say that our presenters are going to coming not only from the National Council
on Aging, but we will also have folks here from Health Care Policy and Finance Colorado
State Unit on Aging, also our friends at Colorado Community Health Network who is our FQ group,
Colorado Foundation for Medical Care and Health Team Works. And what we really want to do
with this is to take all those questions you have about how you do this in your particular
situation, and with your particular FQ, and with your particular community based organization,
and what does a care compact look like, and to give you samples and have a chance to work
through it. So one other point I guess is that we will have a lot of video from people
in the FQ’s, that are actually doing this work, so we are going to put a lot of video
together so they can come to this particular workshop and share with you how it is actually
working within the FQ. We hope you can come, it’s really not that snowy in January, not
in Denver, but there is going to be good snow on the ski slopes. So I just want to close
by saying thank you, we are going to take a bunch of questions, that’s how you contact
us. And the big thing I want to say is that we have been fortunate enough to do this work
now with federally qualified health centers as well as individual practices of all different
sizes who are working on their patient centered medical home work. And it is not something
that is incredibly difficult to do but there are many moving parts and we have learned
many lessons and we are happy to share how not to do it, as well as how to do it. So
that’s it and I’m going to turn it back over to Kristie I think so we can hopefully
answer questions or you guys can give us answers. Great, thank you so much Chris and Lynnzy
that was such a great presentation and for those of you who have a question and haven’t
typed it in yet I do encourage you to use the chat box on your screen, and we have had
a couple that have come in. And I just want to remind everyone that if they are interested
in learning more about the Chronic Disease Self-Management Program or even in learning
more about the agencies or organizations that are offering the program in their state who
they can connect with, they can find that information on our website which is NCOA (for
National Council on Aging) .org and just search chronic disease self-management program and
you will find the information that you need. So our first question, you spoke about the
role of community based organizations and offering the program but then you also touched
on the federally qualified health centers that you are currently working with that many
of them are offering the program on site, so they are delivering and internal model.
So if a federally qualified health center is interested in offering CDSMP on site within
their organization, do you have any suggestions for the best type of staff, so would it be
nurse, a medical assistant, health educator, etc. to train our facilitators especially
given the intent of the program to be a lay leader facilitated model?
That’s a really good question, I would say what we have seen is that MA’s are wonderful
at this, patient navigators are wonderful at this, we’ve had front office staff who
have always wanted to be more involved in patient care in some tangential way. So this
gives them the opportunity to be a part of the process. I will also say that although
the model is not designed to be a medical model, we’ve had nurses and retired nurses
that are great at collating the program. One of the things that we talk about a lot within
the curriculum is taking off your medical hat and really sticking to it being a lay
leader presentation of the material. In fact it is really important, that with in the classes,
anytime a medical thing comes up we refer people back to the clinic or back to their
provider and that just sort of standard operating procedure. I would say who ever, if you are
working on patient centered medical home recognition, there is usually a QY team and there are people
within that team that are really excited about the whole transformation, and those are the
folks no matter what their title that are really good at this work. We’ve had paramedics,
we’ve had EMT’s, but I also think that MA’s are a great untapped resource. And
just to piggy back, in support of the MA part of what Lynnzy’s saying, is often times
there is a MA turnover, medical assistant turnover, and we have seen MA’s embrace
this program and really their whole work turns around, they really feel very purposeful and
we love seeing that very much. Thank you. Do you find that trained staff
can only lead classes in their place of employment, or how has that worked with the federally
qualified health centers that you’ve partnered with? Are they able to offer workshops in
the community, perhaps in locations that are more accessible for the patients that need
access? All of the above. What we try and do is to
talk with whoever the agency is that’s working with training the leader, so if it’s an
FQ we would talk with them about the fact that clearly this is someone they are training
with the intention of them working with in the FQ. We also will talk with them when they
train as a leader about their availability to help with other classes within the community,
and we’re in a position what we do is stipend those, so they are like a paid volunteer to
do that. So we really work on an individual basis, sometimes we find that within certain
communities the thought is that a class is better not held at health facilities, that
they want the class at the community center, at the health department, at the local bank,
at the coffee shop, rather than within the practice. Frequently though we also find that
they want it within the practice, because they know the patients knows how to get there.
So you can really kind of make a case either way, and that’s why it really varies community
by community, and why community based organizations working with a FQ can really help answer some
of these questions, but when we train a leader we are trying to present it so that they have
knowledge that they may, at least from our prospective, have the opportunity to teach
additional classes on top of their regular work load, If they want.
Thank you, and we have had a couple of questions that have come in specific to cost and or
how the program is funded through the FQHC, either what funding sources or just in general
how/what resources go into supporting the program?
That’s a complex answer and I’m glad it came up because that’s everybody’s question.
The work that we are doing currently to help support federally qualified health care centers
to get the chronic disease self-management program embedded is through a partnership
with the Colorado Community Health Network, which is also through a grant from Kaiser
Permanente. So the work of getting the NCQA status and the self-management component embedded
is through that part. But once you do that, then there is the work of keeping the class
going and keeping the class going not only for the federally qualified health care center,
but also having trained leaders available to teach the class. So that actually is a
different funding stream at this point for us. The training dollars are generally paid
for by the federally qualified health care center or clinic that is becoming a patient
centered medical home. So you have that cost sharing, and then the cost of technical support
to keep that moving is actually though the Consortium for Older Adult Wellness and we
have different kinds of funding streams for that. But the other piece that is just happening
in Colorado that we are very excited about is the Medicaid Voucher, and also we are doing
some voucher work from our grants and the Administration on Aging. So with that combination
we will be able to help the federally qualified health care center receive some reimbursement
to be able to support this program ongoing. The goal is to make it as sustainable and
workable on an ongoing basis, I think what gets expensive for the clinics is to start
and stop and start again. So if we can help them really embed the program, embed the referral
program, and then see the positive outcomes with their patient, that really is what makes
it workable. So if they realize that we can help reduce their work load, rather than add
to their workload that’s really helpful and I would say that the FQ’s where we have
worked have seen that it’s well worth their time, in terms of investment. When we are
working with the grant dollars, either through the AOA and our partnerships with the State
units on Aging or with the Medicaid vouchers and our partnerships with Health Care policy
and Finance, our goal is to really help strengthen the relationship of the community based organizations
and federally qualified health centers so that they can become a really ongoing mutually
beneficial relationship. There are ways to make this work I think within any community,
it’s a little bit different community by community, but there are definitely way to
do it. Absolutely, and just one other caviar, is as Lynnzy said the big picture, in the
big picture you know patients are going to get better and patients will be able to do
a lot more self-management, consequently reducing the health care dollars being spent on that
particular chronic condition, in that particular patient. Just briefly, one of the things starting
in Colorado with the Medicaid Voucher here, and I don’t know if other states are doing
it but it would be lovely to talk with them if they are, is there will be some clinical
outcomes done and measured to see specifically how health care dollars are saved through
this program with folks on Medicaid. So hopefully we will have some more answers on that in
a year or so. Thank you, we have had a couple of questions
that have come up regarding whether or not you are willing to share some of those great
forms that we saw the screen shots of? The patient referral form, the physician follow
up letter, those forms are they publicly available and are you willing to share?
Yes we are willing to share, and will be happy to do that. I would also be happy to share
that process form, I only wish it was as easy to put together as the slides, but yes I will
be happy to do that and if you want to I can send you the forms, or you can give us a call,
or you can also look on our website and send me a email from them. It’s coaw.org and
there is a contact button there and we can send you those materials.
Thank you, and can you just do a quick repeat of the CDSME, the self-management education
component, that need to be documented in the electronic health record as required by NCQA?
And is there a template or a screen shot of that, or perhaps we can even share the slides
from this power point presentation with everyone. Yea happily, I think that slide is a really
good one because it gives you kind of an overview. You know CDSME, or the chronic disease self-management
program, is not the only program that will work for this, we just think it’s the best
because it’s the gold standard. What is necessary for the NCQA is to have community
resources, a list of community resources available and to help connect patients to self-management
education. There is also a piece about connecting patients and giving patients self-management
tools. Now a tool can be something like a food journal, a blood glucose journal, an
action planning form, tips to relieve stress all those kinds of things can qualify as support
materials that are handed to patients. Also those referrals to community based organizations
or to self-management opportunities are a part of it so if for example you want to refer
someone to a self-management class that referral and then printing out that referral, those
two pieces, can be used to help document the work you are doing for Standard 4. The actual,
them attending the class just gets you a much healthier patient, but the actual having the
knowledge, the connection and the referral to the class is what helps you with the NCQA
piece. The other part that it will help with though is having patients that come back and
are able to be more engaged in the process, that allows you to do that goal setting on
an ongoing basis. But one of the things that folks going through their NCQA work will know
is that over 50% of you patients, your chronic condition patients, need to have a goal, a
self-management goal within their care plan. Either in their files or in their EMR and
that is something that is tricky to set with the patient because if you have never been
exposed to what goal setting is, action planning, what’s the difference between saying that
I want to lose weight, which is a goal, to I’m going to walk 3 times a week and take
my diabetes medication. So those are patient goals and action plans and those kind of things
need to be seen with in all of the, or a good percentage of the patient files. That skill
set is one that is hard to teach a patient within an office visit, but is very teachable
and doable within a community based class. So I would say, Standard 4 is very important.
Standard 3 clarifies what the difference is, and how to document a care plan, and a treatment
plan and a self-management goal. So those are the two biggies.
Great, and we still have a couple of questions left and I want to make sure we have time
to answer as many as possible. So is the certificate from the class that shows successful completion,
I know that a number of the workshops, you know the participants who attend 4 out of
6 get a really nice completion certificate, Is that a required document to be included
in the EHR as part of the NCQA process? No, it is not, documenting the referral is
the biggie. What we do as an added on is to document whether, how we are following up
the referral, if they are attending, and then what their attendance is, but the actual certificate
of completion is not required. Thank you, and a question from a community
based perspective, as a community based organization they have an infrastructure already for CDSMP,
they have leaders, they have a coordinating process, and they are looking to engage a
federally qualified health center. What do you think are one or two core messages that
they should include when they are reaching out to the FQHC’s to demonstrate to them
the value and the impact of this program? I would find out first of all, if you know
if they already are a patient centered medical home and if they are or they are not, to know
a little bit more about the language of what a patient centered medical home is. And then
to contact them and say, I understand you are a patient centered medical home and part
of what that means is self-management for your patients and self-management goals for
you records and we can help you with that. And then be willing to understand that they
are going to need to lean on you in terms of how to get their patients into the class.
That you can help teach them those skills in a really short, quick, succinct way.
Thank you, and can you speak a little bit more about your experience in partnering with
the FQHC’s that you have up and running now? Is COAW, is there a coordinator there
at COA who’s responsible for coordinating those workshops, or coordinating workshops
in the community for the FQHC? And are any of the workshops being reimbursed through
the FQHC. They are not currently being reimbursed through
the FQHC, we are looking to have them reimbursed starting in 2013 through the different Medicaid/Medicare
programs coming through. We are also working on reimbursement for the diabetes self-management
program in some of our locations in Colorado, that’s a project that’s in the works.
The diabetes curriculum is the only one right now that’s directly reimbursable through
Medicare, but there is a whole process that has to happen before that’s possible, but
we’re learning the process. What is happening with the FQ’s is, and I don’t remember
the rest of your question, I just lost the first part of the question, Kristie I’m
sorry can you repeat that? No that’s fine. I think it was more about
the role of the community based organization? And the coordinators, that’s right. How
we do it is that we have coordinators on staff here that, and we have one coordinator who
works specifically, our pal Josh Phifer who comes from, he’s worked with several different
federally qualified health centers and safety net clinics and so he can speak that language.
He’s a MA by training and what he understands is what it’s like within a clinic on the
ground working day by day, so he helps with setting up those classes, the referral process
and calling back the referrals. As does the rest of our staff, but it’s really his baby
in terms of working with the classes. Then we all get involved with it, and sometimes
it means a community based class that a AAA is offering, but we say how would you feel
about doing the class instead of at your office or at the rec. center how would you feel about
hosting it at the clinic site. So that’s kind of how we work it, so it’s part of
our ongoing day to day work, but I would say it’s becoming a good portion of what we
do. Thank you, and is there a quick and easy way
that an organization can learn whether or not a federally qualified health center is
either a certified patient centered medical home or going through the process of being
certified. The quickest way I can think of is that I’d
call them, I would call them and I would say, you know are you a patient centered medical
home or look at their website. They have all worked so hard to do this, that it will say
on their website we are proud to be a level 3 patient centered medical home. But the truth
of the matter is, the transformation is whether they are applying under the NCQA guidelines
or the other guidelines. The whole care coordination piece, the Affordable Care Act, all of this
transformation is taking place nationally, so the easiest wins would be to work with
the people who are looking at NCQA or some other patient centered medical home designation.
But every FQ, is involved in this transformation and nationally the FQ’s are really being
looked at as the model of care, and really being able to serve a broad community. So
you are probably safe contacting any FQ and asking about their status.
Thank you, and one final question. For those federally qualified health centers that have
already gotten up and running, what are you noticing so far as participant recruitment
and retention? We know that sometimes filling workshops can be the most challenging thing
and that simultaneously retention can be a challenge as well, so what has your experience
been within that setting, especially with populations that perhaps do have challenges
regarding access to transportation, persistent chronic conditions, etc.
I wish I could give you a really good quick answer on that one, what we are noticing is
that it really varies class by class, it really varies flu season/not flu season, it really
various what the primary diagnosis is of the person in the class. I think anybody who has
done these classes knows chronic pain patients tend to miss more classes, for example than
patients with arthritis or diabetes. So what we see is it really varies a lot and so far
we have not seen any great difference in terms of retention and completers in that population
or if it were in an FQ setting than we do in other settings. And I would say it’s
a couple of points lower but it isn’t enough that it’s a huge difference in terms of
planning. What I would say though, is what we do see are the gratitude and the light
bulb moments of the folks that are the FQ population, those that are vulnerable, or
have not had as much access to services when they get it within a class like this, when
the light bulb goes on it really changes not only how they work with their own system of
support but it changes their families lives, they talk to their friends about it, it impacts
the whole practice as well. So you can’t really measure that in the same way, but it’s
really meaningful work and the classes are really meaningful within those locations to
the people that are participants. Wonderful, Chris and Lynnzy thank you so very
much for this presentation. We got great feedback via the chat, great questions, and I know
Chris and Lynnzy personally. They are very very willing to help answer additional questions,
so for those of you who maybe later on today or tomorrow morning a question pops into your
head, they are great about answering your questions and helping you out. So Chris and
Lynnzy thank you so very much and I would like to turn it back over to Dr. Webb to close
us out. Alright, thank you so much. First of all , Kristie
I have to thank you very much for moderating this session, it has been truly phenomenal.
And again I would like to thank the speaker form COAW, Chris Katzenmeyer and Lynnzy McIntosh,
I think you shared so very very insightful information and I can tell you from first-hand
experience how applicable this is, especially to the FQHC’s that want to continue to provide
a patient centric model of care for their patients. And I think for most of the community
health centers who use community health workers, I think it’s a phenomenal opportunity to
get them trained as well to be possible facilitators and leaders in chronic disease self-management
program. So again thank you so much for the information shared, for those of you who have
any further questions, feel free to reach out to either Lynnzy and Christine at COAW,
at coaw.org, that’s their website and you will be able to contact them directly through
there. Feel free to reach out to us at the National Center and we would be happy to get
the information so that your questions can be answered. So again thank you for joining
us for today’s webinar, thank you to all of our speakers, our facilitator and we hope
that you will all implement chronic disease self-management programs at your FQHC’s.
Thank you everyone for joining us today. �