Making the Most Out of Your Referrals

1. Making the Most Out of Your Referrals Adam Sharma Director of Marketing and Information Services Health Outreach Partners Richard Silverberg, MSSW, LICSW Managing Director, CCNTR Executive Director, Health First Family Care Center

2. Health Outreach Partners (HOP) • HOP PRIORITY AREAS • Health Outreach and Enabling Services • Program Planning and Development • Needs Assessment and Evaluation Data • Health Education and Promotion • Community Collaboration and Coalition Building • Cultural Competency

3. Caring Community Network of theTwin Rivers High Priority Areas Mutual support and collaboration Cross agency whole community needs assessment Care teams with standing agenda Electronic means to share and report System of care single point/any point access Collaboration and tracking pieces Cross agency sliding fee discount determination Joint development of community health improvement plan

4. Presentation Agenda • Introductions • About Care Coordination • Empowering Patients • Assessing and Prioritizing Patient Needs • Community Collaboration • Tracking and Evaluation • Q & A

5. Integrating Enabling Services to Support a Patient-Centered Medical Home The Whole Person The Team Coordination and Integration of Care Administration Clinical Providers Outreach and Enabling Services The Person’s Community Behavioral Health

6. National Committee for Quality Assurance - Patient-Centered Medical Home Access and communication Patient tracking and registry functions Care management Patient self-management support Electronic prescribing Testing and tracking Referral tracking Performance reporting and improvement Advanced electronic communications

7. Empowering Patients From Werner, D. (1990) Where there is no Doctor, Palo Alto, CA: The Hesperian Foundation.

8. Empowering Patients • Case management can be used to capacitate patients and teach them to navigate a complex system • Case management can help address barriers to health care • Understanding the health and social service system • Understanding what resources are available and how they vary between communities • Understanding how and when to access resources and services

9. Empowering Patients • Establishing your role • Patients will know what to expect from you • Patients will know what you expect from them • Your job is to assist the patient in meeting their goals • Under promise and over deliver • Act as a mentor or teacher • Explain what you’re doing, why you’re doing it, how they can do it next time • Build skills by allowing them to do as much as possible (i.e. making their own calls with your assistance, filling out their own paperwork with your help, etc.)

10. Empowering Patients • Meet patients where they are • Patients have the right to refuse referrals • Patients should seek your assistance and have a vested interest in your work together • Factors that affect empowerment • Patient motivation • Patients with additional barriers or who need extra assistance • Patients with multiple complex problems

11. Assessing and Prioritizing Patient Needs Listen and Learn Prioritize concerns Find out what issues are concerns for the patient Find out what the patient prioritizes These may be different than the priorities you identify Identify resources What resources does your patient have? Personal attributes, support systems, material resources Match needs with resources Help the patient use what is already available when possible If none are available, then seek community resources

12. Assessing and Prioritizing Patient Needs • Essential Skills in Needs Assessment • Listening is a key element of effective communication • Clearly understanding the patient needs helps you serve the patient better • Effective communication is the cornerstone of your work together • The patient clearly understanding you helps the patient help him/herself.

13. Managing Referrals • Readiness for referral • Does the patient see the need for the referral? Are they invested in the process? • Troubleshooting • Help patient plan follow through • Transportation, childcare, payment, needed paperwork • Decrease no-shows • Reminders • Ask patient for their preferred way (call, text, postcard, etc.) • Referral documentation • Educate and prepare the patient • What should they expect? • Who should they talk to when they get there?

14. Tracking and Evaluating • Follow up with referral source • Internal referrals • External referrals • Authorization for Release of Information • Follow up with patient • Speak directly to the patient • Did they go to the appointment? • If not, what prevented them from going? Is the appointment rescheduled or need to be rescheduled? • If so, how was the experience? Are there plans for next steps?

15. Tracking and Evaluation • Documentation • Encounter forms • Percentage of appointments kept • Patient care plan • A formalized plan put together by the case manager with the client delineating a specific set of goals and action steps to reach goals • Updates and changes to plan • Patient charts • Notes that can be included in hard copy chart or in electronic medical record • Appointment calendar • A way for you to keep track of what is coming up and when to do follow ups • Patient satisfaction • Questions performed orally or in written format to track referral utilization and satisfaction with services

17. C CNTR Caring Community Network of the Twin Rivers Working Together for Healthier Communities 841 Central Street, Franklin, NH 03235 Telephone (603) 934-0177 Fax (603) 934-2805 website www.ccntr.org Serving a Regional Population of over 35,000 The mission of the network is to serve the people of 14 small rural municipalities in the region by working to address the problems that exist and develop plans to reduce the impact of these problems in our communities. -Geographic region is one of the poorest regions in the state. -Residents of this region have traditionally been victimized by a number of social problems related to poverty. -Higher than state average chronic illness incidence.

18. Organizational Chart of the Caring Community Network of the Twin Rivers Twin Rivers Community Founded 1996 14 Community Member Seats CCNTR Board of Directors 14 Member Agencies 11/09 Managing Director Standing Committees Nominating Executive Trip Development Health Officers Subcommittees (program oversight) Task Teams Care Coordination Teams Regional Emergency All Hazards Health Planning and Response Basic Needs Community Involvement Public & Community Health Systems Improvement Adolescent Risk Behavior Prevention Team Care, Coordination Outreach, and Access Health Education & Disease Prevention Environmental Health Newfound Primary Care Teams Franklin Elder & Adult Team Franklin Children’s Team Access Managers Group Healthy Homes

19. Caring Community Network of the Twin Rivers Health Home Model Primary Care Network Medical Specialty Services Visiting Nurse Associations Municipal Services Primary Care Teams Faith-Based Groups Community Action Programs Inter agency adult and children’s care coordination teams Individual & Family LRGHealthcare Family Practices School Administrative Units Elder Service Providers Health First Family Care Center (FQHC) Acute Hospital Child Care Centers Mental Health Providers Police, Fire EMT Dentists

20. Service Design through Blended Funding Sources Delivery System Design Funding Source Results

21. CCNTR RHO Partners Healthy Eating Active Living Health First Family Care Medication Assistance Health Link Clinical Care Teams Management Nutritionist, Behavioral Health, Social Patient Disease Registry, EMR Key Measures Planned Visits Clinical: Lower A1c Average (DM), Lower BP Average (CVD) Healthcare: Reduced ER Utilization

22. Building an Information-Rich Environment

23. Assessing Community Organizations • Shared training across agencies • Board level commitment to: • Joint needs assessment • Prevention planning • Resource development • Shared vision for how the community can be better in the future

24. Results of Partnering • Sustainable network • Number of uninsured patients in region receiving preventative services, primary care and specialist treatment • 1995: <100 uninsured patients • 2010: >4,000 uninsured patients As a Result of: • Health First Family Care Center (FQHC) • Increase in Primary Care Physicians • Two Office Locations • HealthLink, Healthcare Financial Counseling • Information and referral system that provides financial counseling, shared sliding fee scale and access to medical, dental, wellness, and prescription services.

25. Results of Partnering, continued • Comprehensive network of agencies that provides the ten essential public health services for the region. • Bring new resources to the region. • $5 million in the past 5 years. • Developed seamless electronic referral system between agencies.

26. C CNTR Caring Community Network of the Twin Rivers Working Together for Healthier Communities 841 Central Street, Franklin, NH 03235 Telephone (603) 934-0177 Fax (603) 934-2805 website www.ccntr.org Partners State National Bi-State Primary Care Association U.S. Department of Health and Human Services-HRSA Community Health Access Network Robert Wood Johnson Foundation University of New Hampshire National Association of County & City Health Officials -Policy Institute -Cooperative Extension Department of Health and Human Services - Division of Public Health Services - Childhood Lead Poisoning Prevention Community Health Institute Southern NH AHEC Endowment for Health Foundation for Healthy Communities NH Charitable Foundation New Hampshire Public Health Association Bureau of Drug and Alcohol prevention

27. Caring Community Network of the Twin Rivers • Measures of success • Improved patient outcomes • Decreased ER use • Decreased incidence of preventable illness in the community

28. Putting it All Together • Case Study Activity • Questions

29. For more information contact us… Adam Sharma Health Outreach Partners adam@outreach-partners.org (510) 268-0091 www.outreach-partners.org Richard D. Silverberg, MSSW LICSW Health First Family Care Center (603) 934-0177 rsilverberg@ccntr.org www.ccntr.org