Making Community Connections: Chronic Disease Self-Management Education in FQHCs

1. Making Community Connections: Chronic Disease Self-Management Education in FQHCs Christine Katzenmeyer Executive Director Consortium for Older Adult Wellness Lakewood, Colorado Lynnzy McIntosh, Vice President/Implementation Director Consortium for Older Adult Wellness Lakewood, Colorado

2. Learning Objectives To assist you in initiating, or further developing, a chronic disease self-management program within a Federally Qualified Health Center. To discuss the connection between chronic disease self-management education and patient centered medical home recognition. To improve the quality of health care by fostering a collaborative interaction between patients, providers, and community-based organizations. To discuss COAW’s statewide initiative with FQHCs and patient-centered medical homes and success stories.

3. Who Are We? COAW: A 501(c)(3) non-profit organization founded in 2001 by Colorado Gerontologist, Christine Katzenmeyer. A statewide consortium with 90+ partnering organizations/agencies across Colorado. Expertise focusing on healthy aging of the older adult; provision of evidence-based training to health professionals and lay leaders on Falls Prevention and Self-Management. Expertise in practice transformation and the art and science of Self-Management Support. Evidence-based offerings include: 1) Healthier Living Colorado™ (CDSMP), 2) N’Balance™, 3) Tai Chi for Falls Prevention, 4) Matter of Balance ™, and 5)Stepping On ™.

4. What is Self-Management? How does Self-Management work within Healthcare Transformation, Patient Centered Medical Home (PCMH), Patient Activation, any YOUR organization? The tasks that individuals must undertake to live well with one or more chronic conditions. These tasks include having the confidence to deal with medical management, role management and emotional management of their conditions. Institute of Medicine 2004

5. Self-Management and PCMH Recognition 2011 Version Reinforces the critical role of patient Self-Management and practice Self-Management Support DocumentSelf-Management capabilities Document Self-Management goals; provide tools and resources Counsel on healthy behaviors Assess/provide/arrange for mental health/substance abuse treatment Provide community resources

6. Engaging the patient is the ONLYway to successfully impact clinical outcomes… as opposed to process measures.

7. CDSMP as a Key Component of NCQA PCMH Standards

9. What makes a self-management program work for you…and your patient? Designed to enhance medical treatment. Evidence-based: a tested model-intervention that has demonstrated, replicable results. Use multiple strategies and interventions. Empower (activate) patients to increase control. Promote collaboration among providers, organizations, individuals, families, caregivers and community. Resources need to have a fidelity component to ensure that programs are being delivered to achieve the proven outcomes.

10. Why CDSME? Over 20 years of proven impact ‘Gold standard’ of evidence-based programming Offered locally and worldwide Available in 21 languages Premise – people with ongoing health conditions Have similar concerns and problems Deal not only with their condition, but its impact on their lives and emotions Lay Leaders teach the workshop as effectively as health professionals

11. CDSMP 6 Week Class Series Exercise and nutrition Medication usage Stress management Talking with your doctor Dealing with emotions and depression Action Planning!

12. CDSMP Benefits to the Practice External resource No need to re-create the wheel Reinforces communication “feedback loop” Documents self-management in PCMH terms Documents the shift in patient interaction Quality measures Delivery of data to practice Patient activation and patient engagement Increase in patient confidence levels

13. Results- Federally Qualified Health Centers 10 new FQ sites in collaboration with the CCHN. 6 FQs now active, 4 in winter of 2012. Range from large multi-site, to small one-site clinics. 8 of the 10 practices will have classes in English and Spanish. 5 of 10 now offering classes on site with provider referrals. 5 of 10 now have at least one CDSMP trained staff member. Clinical and front office involvement in referrals. Transportation is an issue.

14. Referral Results 26 % of all COAW attendees in CDSMP are referred by physicians Recent project started with 10 new internal medicine clinics in Denver’s Front Range Practices ranged from single provider, to single location to a large multi-site FQ practice Practices requested classes in Spanish All classes are on their sites Roughly 52% of referrals attended first available CDSMP class. Additional % enrolled in the next class Referrals continuing, no one has said “no” Transportation is a major issue, 40% of practices Communication within the practice is an issue.

15. The Process and the Details

16. Feedback Form Referral Form

17. Feedback Form

19. Thank You! Christine Katzenmeyer, Executive Director Chris@COAW.org Lynnzy McIntosh, Vice President/Implementation Director Lynnzy@COAW.org 303-984-1845, 888-900-2629 www.COAW.org info@COAW.org