Albuquerque Wellness Referral System Peer to Peer SessionBUILD Health Challenge

February 29, 2016

Moderator: Lisa Curtis, BUILD Health ChallengeAlbuquerque BUILD Team Presenters:

- Jim Bullard, Vice President Management Services, Adelante Development Center - Leigh Caswell, Director of Community Health, Presbyterian Healthcare Services- Erin Engelbrecht, Senior Development Manager, Adelante Development Center- Meta Hirschl, Application Developer, Adelante Development Center- Michelle Melendez, Development Director, First Choice Community Healthcare- Valerie Quintana, Community and Clinical Linkages Coordinator, Communities Leading

Healthy Change, Bernalillo County Community Health Council

For direct inquiries regarding the Wellness Referral System, please contact Erin Engelbrecht at enengelbrecht@goadelante.org.

List of Questions:

From start to finish—how long did it take to get the WRS developed and launched?................................................................................................................................... 2

What were some challenges you had to overcome in developing or launching the WRS?..................................................................................................................................... 3

Can you describe the process of working in partnership on this System? All sectors come in with separate goals. How do you ensure that all partners have aligned goals?........................................................................................................................... 3

What role did the community play in the development of the WRS?.....................4

What are your top lessons learned from the development process? Key takeaways that have emerged?........................................................................................... 5

What challenges, if any, were presented around data sharing? How did you overcome those challenges?................................................................................................ 5

How did you get the word out about the WRS?..............................................................5

Can you provide key insights on the WRS implementation process? What, if any, challenges did you encounter?..................................................................................6

Overview of the Wellness Referral System

The Wellness Referral Center (WRC) developed by Adelante Development Center in partnership with Presbyterian Healthcare Services, Bernalillo County Health Council’s Healthy Here initiative

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and First Choice Community Healthcare. The Wellness Referral Center is a based on the Community-Clinic linkages model which creates sustainable, effective linkages between the clinical and community settings to improve patients' access to preventive and chronic care services by developing partnerships between organizations that share a common goal of improving the health of people and the communities in which they live.

Currently, the WRC is linking Presbyterian Healthcare and First Choice Community Healthcare clinics, providers, and patients located low- income neighborhoods in the Southeast Heights and South Valley neighborhoods in Albuquerque, New Mexico to community based activities within their neighborhoods. The goal is for patients to gain support to effectively manage their chronic disease and to promote health and wellbeing. How it works: The providers send referral information about the participant including contact information, demographic insurance data, and specific resource activities to the WRC. The WRC agent contacts the participants and discusses the best options considering location, time and accessibility. The agent registers the participants for the referred resources and discusses with the participant the preferred method of contact for reminders before activities (phone, email, text messaging). Upon completion of the activity the WRC agent contacts the participant for feedback about the experience. Participation information is sent back to the referring provider The WRC offers a basic rewards program that incentivizes healthy behaviors and keeps participants engaged through events, email, texts, and an app.

The community action plan (Healthy Here) initiative, in partnership with the WRC, will increase capacity over time to include more neighborhood clinics, community members/patients to healthy and supportive community-based activities.

From start to finish—how long did it take to get the WRS developed and launched?

In 2013, Presbyterian Healthcare Services completed its IRS-required Community Health Needs Assessment and through that, identified a need to increase access to evidence-based chronic-disease self-management programs, increase access to healthy foods, and encourage people to be more physically active. They found that even though they were investing in community programs, clinics were not referring to them, and no real community infrastructure existed to support the referral process, and clinics were too busy to take this on. In early 2014, they had the opportunity to apply for a CDC Reach grant, and won. That grant supported the building of the referral center. BUILD allowed them to bring in additional resources and expand on the WRC concept.

Implementation steps: They held an all-day planning event on August 26, 2015 with all different partners (~25

people). During this brainstorming session they put together an operations team to develop all the connections and referral system.

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To get the community programs and resources on board they met with each organization to understand their existing sign up program (didn’t want to overstep or takeover). After they understood the current sign-up process, they would discuss how the WRC could assist them, then come to an agreement on how the partnership would operate.

They began conversations with referring agency/clinics to recruit providers to participate in testing the referral system.

In the manner of IHI’s PDSA model of quality improvement, they decided to start small by having one doctor participate to test out the system, and only focusing on one chronic disease (diabetes) in the beginning.

Develop a referral form for the clinic to capture necessary info. Form went through many iterations as they identified information that needed to be captured not only for provider purposes, but also for the WRC and for evaluation purposes.

The system went live in January 2016 when they took the first referral.

Adelante was involved throughout the planning process, but got more involved with the BUILD Health award. Adelante was responsible for developing the Referral Tracking System (RTS) and the wellness rewards program utilizing Salesforce as the platform, and operate the Chronic Disease Management Referral System (CDMRS) & Mobile Market. They set up a system to track who went to the mobile market.

They are still in operational mode, tweaking and working the process.

What were some challenges you had to overcome in developing or launching the WRS?

It was not clear until they started the process that they need a form for people who declined participation. That information wasn’t communicated originally and they quickly realized they still needed to capture that information.

Chronic-disease self-management (CDSM) classes were being cancelled and not communicated to the WRC in real-time. They are figuring out how to make a smaller bridge in communication so they could know real-time what was happening. It is important to make sure classes that are advertised happen, even if there aren’t enough people.. Resolution: exploring whether they can at least agree to hold the first class, and then leave it up to the instructor to cancel if necessary (thus making it a programmatic issue and not a referral center issue). They are canceling classes based on the Stanford university number requirements, but need to figure out how to make it work for the WRC system.

Adoption issue – every clinic has in-house CDSM classes so referrals were already occurring to those in-house resources. You can’t ask a clinic to have a separate form for in-house and for WRC. They did not anticipate that issue.

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Can you describe the process of working in partnership on this System? All sectors come in with separate goals. How do you ensure that all partners have aligned goals?

Having community action plan (Healthy Here) through the CDC REACH grant helped. They partnered with a longstanding community health council in the county. They regularly report through that network to make sure they’re aligning with the action plan and are accountable to stakeholders. There are lots projects related to WRC and it has been key to make sure they’re all aligned and accountable to a broader set of stakeholders. This also helps them feel like they were part of a larger effort.

Energy and Champions! Once Dr. Barnes started making referrals it became real. That kicked it off and they were excited about making it happen. The amount of energy behind this helped. Dr. Barnes was a champion for the WRC. He was a key adopter at that organization – having that champion was key.

Alignment with PCMH Model. This whole process aligned with the First Choice Community Health Center PCMH model, filling a need providers and health coaches had to connect patients with resources in the community. They had some internal education offerings, but needed more and the WRC system really dovetails with First Choice’s internal need to meet its PCMH requirements. It was an easy sell because it helps them achieve PCMH goals of connecting patients with healthy resources.

Clinic Involvement from the Beginning. If they hadn’t had the clinics on board during the development of the software platform and referral form it wouldn’t have worked. Michelle brought the Patient Care Facilitators to the table to share their ideas for what the WRC tool might look like and asked the providers – will this be helpful? They took a stab at drafting the initial first draft of a referral form, and the First Choice Staff was helpful by editing and revising it. This way they had some ownership over the process, but didn’t have the burden of developing a form from scratch.

What role did the community play in the development of the WRS?Valerie facilitates two community groups (CHWs, and clinic partners). CHWs work all over the county and provide guidance and input based on their work on the ground. They provided input on the mobile market locations, education materials for mobile market, and reasons there have been difficulties enrolling people in evidence-based programs prior to the WRC.

After struggling to train more CHWs as a workshop leader, the CHW group provided feedback that led to scheduling changes to accommodate more evening and weekend classes. Presbyterian provides stipends for CHWs being trained as workshop leaders who work in specific areas of the REACH grant, and will be giving workshops in those areas.

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The Community-clinical linkages group provided feedback on barriers to getting staff to trainings, referring people to these programs, the referral feedback loop, and it also provides a space for internal networking between clinics. The WRC hopes to follow-up and show the experience for the patient if they went to the class/resource, or if not, what were the barriers for not going.

The work that happened before BUILD was from the CTG grant that lost its funding. This project builds on many years of collaboration with the community and relies on feedback from key stakeholders who are engaged with the people they serve and their communities.

What are your top lessons learned from the development process? Key takeaways that have emerged? It is important to involve clinics from the development stage – you can’t impose a system on

them. Providers are very busy and you have to work in their workflow as much as possible. They developed a paper referral form because the providers at those clinics were used to a low-tech method, and that’s working for them.

Institute for Healthcare Improvement SCALE community – learning about idea of PDSA, “failing forward”, and quality improvement. It’s okay to not have it right the first time, but improve the process as you go. This kind of initiative doesn’t happen overnight. It takes time, but it matters that you take the time to engage the right people in the process.

Patients are very eager to get better and are committed to doing things better. That motivates the partners to get more resources for people.

Through this partnership of accountability, everyone has been very flexible. Adelante and WRC have been very flexible with the forms constantly changing. They understand that it’s not a referral center driven process, but it’s a community and clinic driven process. Letting go of ego – when you develop a process for the clinics to use, keep the mentality that you’re developing it together, it’s not one person’s form that others should use. Throughout the many versions of the form, partners have understood that the goal is to make it useful to people and to the program.

What challenges, if any, were presented around data sharing? How did you overcome those challenges?It’s an ongoing challenge, but there are no major issues at this point. Providers don’t feel that it’s HIPPA information they’re sending. WRC doesn’t receive biomedical information or diagnosis information, mostly just demographic info on the patient. Also, the patient signs the form which gives consent (at the clinic). They also have a data-sharing agreement with First Choice and are talking with the other health systems about this though it hasn’t stopped them from moving forward. Confidentiality agreements, training manuals, and other things are in place to address the handling of sensitive information. Participants are asked at every point of the process if they want to participate and if they don’t they are opted out. No major issues at this point.

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How did you get the word out about the WRS?It is not a public referral system, though they will accept self-referrals. The mostly rely on referrals from clinics. They are planning to meet with a communications contractor to talk about developing professionally made posters for waiting rooms and two-pagers that describe the programs to advertise the WRC. Providers suggested setting out color copies in the clinic so people will see them and ask their provider. These ideas were initiated by the providers requesting more communication tools.

Can you provide key insights on the WRS implementation process? What, if any, challenges did you encounter?Looking forward at the things to figure out for the future – scaling and sustainability. Need to find stakeholders who are willing to invest in this. How do you create a seamless process through EHR where you’re referring out and getting information back in about that patient. Probably not a paper process, so how do they do that?

Offering a reward system – can’t incentivize people to attend certain CDSM classes (goes against the evidence-base). However, you can still incentivize people to sign up for the classes. They’re finding issues of getting people to go to the resources they’re trying to sign up for and are currently working through those issues.

Reward system – they are offering $25 gift cards for people who complete classes or walking programs.

2 different reward paths – one for providers to reward (bigger picture for health improvement), and one for Medicaid MCO’s. MCOs have a reward system that has been successful and the WRC is hoping to align with that already existing reward system.

Next Steps: Broaden the referral base to other chronic diseases beyond diabetes (changing referral form, adding more classes, etc.). Build on the established system to scale up what’s working.

Thank you to the Albuquerque team for sharing their tremendous insight!

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