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Whipping Up the Secret Sauce: Improving Health Outcomes in a 10-Hospital Health System and Community

Learn how a 10-hospital health system and community partners are using evidence-based programs and data to address chronic diseases, promote health equity, and improve health outcomes.

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Whipping Up the Secret Sauce: Improving Health Outcomes in a 10-Hospital Health System and Community

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  1. Whipping Up the Secret Sauce:How a 10-Hospital Health System and Community Partners are Improving Health Outcomes Sharon Williams, Moderator Dawnavan Davis, MedStar Health Leigh Ann Eagle, Living Well Center of Excellence Sue Lachenmayr, Living Well Center of Excellence Craig Behm, Chesapeake Regional Information System for Patients (CRISP)

  2. Secret Sauce Agenda • Overview/Introductions • Panel presentations- Who we are/What we do • Panel Interview/Q&A • Exercise-35 minutes - participants • What did you learn from this presentation that can inform/impact your integrated care strategies/practices? • Wrap up-5 minutes

  3. MedStar Health • MedStar’s Mission: To serve our patients, those who care for them, and our communities. • The largest healthcare provider in Maryland and the Washington, D.C. region, serving more than half a million patients annually. • 340M in community benefit in FY17 • Using our system’s CHNA to address health disparities and promote health equity by addressing: • Chronic disease prevention & management • Access to care/services • Social determinants of health

  4. MedStar’s Community Health Approach • Leverage evidence-based chronic disease programs as part of hospitals’ population health management strategy • Provide community health programs as intervention option for providers as part of care delivery on post-acute side • Empower individuals with chronic conditions to manage their health through programs such as Living Well with the goal to support: • improved patient and community health outcomes, appropriate healthcare utilization and long-term cost reduction • Use primary and secondary data to inform program planning, implementation, and evaluation

  5. Living Well Program- Program Placement Partner Outreach and Disease Focus • Patient and secondary data were used to identify community-hotspots for each hospital • Hotspots include zip codes surrounding hospitals with high rates of chronic disease prevalence/incidence, charity care cases, and ED utilization • Program Placement: new Living Well workshops sites were placed in community hotspots • Partner Organization Identification/Outreach: Organizations in hotspots were identified and engaged to serve as partners with MSH • Host site • Trainee • Both • Patient chronic disease diagnosis data by focus zip codes were used to determine what disease topic workshop (general chronic disease, diabetes, hypertension, cancer) would be implemented a specific community sites

  6. Disease Prevalence/Charity Care/ED High Utilizer Populations

  7. MedStar Living Well Rollout • Phased approach • Phase 1- 6 hospitals (Spring/Summer 2017); Phase 2- 4 hospitals (February-April 2018) • Conducted 7 lay-leader trainings • 94 lay leaders and MSH staff trained • 14 new community program sites • SDOH screener added to intake process • Program added to Cerner EHR for provider referral directly into program • ~18% of program enrollment coming from EHR referrals

  8. Targeted Outcomes • Program-specific • Behavioral- dietary, physical activity, self-management • Clinical- BP, weight/BMI, % fat • Participant/lay-leader demographics • Participant healthcare utilization, readmissions and costs • Process variables • Lay leader and participant recruitment and retention • Number of + social screens/linkage to services

  9. Results • 200+ enrolled from April- December 2017 • 67% participants reporting increase self-management • 69% participants reporting program satisfaction • 60% participants reporting weight loss • 64% participants reporting decrease in BP • 52% participants reporting decrease in % body fat • 94 lay leaders trained, with 63% retention rate • Readmission/cost analysis currently underway (CRISP/claims data)

  10. SDOH Comparative Results

  11. Maryland Living Well Center of Excellence Who We Are/What We Do Non-Profit Area Agency on Aging covering 4 rural counties on Maryland’s lower eastern shore • Success in implementing CDSME at the local level resulted in ‘hand-off’ of statewide license and database from Maryland Department of Aging • 2015 ACL CDSME grantee as the Living Well Center of Excellence • Partnership with Maryland’s AAAs • Opportunities to contract with hospitals

  12. Farm to Table Fresh Ideas, New Utensils Walk With Ease CHRONIC DISEASE SELF-MANAGEMENT EDUCATION PROGRAMS: Cancer Thriving and Surviving Chronic Disease Chronic Pain Diabetes Home Toolkit Spanish Chronic Disease Tomando Spanish Diabetes Programa De Manejo

  13. Secret Sauce Ingredients • Statewide License for Stanford University Chronic Disease Self-Management Education (CDSME), Stepping On Falls Prevention and PEARLS Depression programs • Training, technical assistance, collaborative quality assurance for evidence-based programs • Centralized referral, certified workforce, community-based locations, quality assurance measures, HIPAA compliant • Statewide calendar, quarterly reporting includes: participant completion, pre-/post- clinical measures, patient activation and satisfaction, and long-term goals

  14. The Heat that Brings All the Flavors Together • CRISP/Hospital/LWCE 6 month pre/post hospital and emergency department utilization after completion of evidence-based program (EBPs) to establish ROI • Partnering with CRISP to track Social Determinants of Health and referrals to EBPs and community-based services

  15. About CRISP • Regional Health Information Exchange (HIE) serving Maryland and the District of Columbia, and collaborating with Delaware, Northern Virginia, Pennsylvania, and West Virginia • Vision: To advance health and wellness by deploying health information technology solutions adopted through cooperation and collaboration

  16. Core Services • POINT OF CARE: Clinical Query Portal & In-context Information • Search for your patients’ prior hospital records (e.g., labs, radiology reports, etc.) • Monitor the prescribing and dispensing of PDMP drugs • Determine other members of your patient’s care team • Be alerted to important conditions or treatment information • CARE COORDINATION: Encounter Notification Service (ENS) • Be notified when your patient is hospitalized in any regional hospital • Receive special notification about ED visits that are potential readmissions • Know when your MCO member is in the ED • POPULATION HEALTH: CRISP Reporting Services (CRS) • Use Case Mix data and Medicare claims data to: • Identify patients who could benefit from services • Measure performance of initiatives for QI and program reporting • Coordinate with peers on behalf of patients who see multiple providers • PUBLIC HEALTH SUPPORT: Partnerships with Maryland MDH, District of Columbia DHCF, and West Virginia through the WVHIN • PROGRAM ADMINISTRATION: Technical and administrative support for Care Redesign Programs

  17. Encounter Notification Service

  18. InContext Program Information

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