Evidence-Based Interventions for Chronic Conditions ... · Evidence Based Self-Management Programs...

Evidence-Based Interventions for Chronic Conditions:

Chronic Disease Self-Management Program Supports

September 25, 2017 2

Introductions• Celeste Harp: NYSDOH Arthritis Program

• Jan Kaelin-Kee: NYSDOH Mohawk Valley CDSME

• Dr. John May: Mohawk Valley PHIP

• Aletha Sprague: Mohawk Valley PHIP

Part of the team and speaking next month:

• Nancy Katagiri: NYSDOH Arthritis Program

September 25, 2017 3

Agenda

• Primary Care Physician Education About CDSMP

• Electronic Health Record (EHR) Success Stories: Experiences From a Closed-loop System

• Ideas to Work with Independent Clinicians

• Questions and Discussion

September 25, 2017 4

Primary Care Physician Education

Communicating what self-management programs can offer:

• Provider Outreach

• Public Outreach

• Non-pharmacological Interventions

September 25, 2017 5

1.2.3 Approach to Provider Outreach

Improved Communication

• Marketing to Providers &

Patients

o CDC 123 Program

o 3 C’s

o Effective Promotion

September 25, 2017 6

Evidence Based Self-Management

Programs & PHIPS• Non-pharmacological Interventions

o Self-Management = Self Efficacy

o Focus on well-care, not sick care

September 25, 2017 7

Primary Care Clinicians

• Inclined to refer these patients to

community resources

– Recognition of shortcomings of the

medical model

– Open to use of inexpensive , community-

based resources

– No insurance prior approval, etc, etc, etc,

September 25, 2017 8

Primary Care Clinicians - Considerations

• Evidence of impact

– Fewer ER visits; fewer hospitalizations

– Also:• Increased management self-efficacy

• Increased energy levels

• Better communication with care-givers

• Improved cognitive symptom management

• Improved aerobic and strength exercise

September 25, 2017 9

Primary Care Clinicians - Motivators

• Ease of referral

• Notification of participation / completion

• Feedback from patients and family care-

givers

September 25, 2017 10

EHR Success Stories & Clinician Education

• Bassett Healthcare Network

– Closed provider system; Bassett Medical Group

– Epic EHR order added

– Clinician education and awareness

– Referral to the Bassett Research Institute

– Follow up with patient and clinician

September 25, 2017 11

EHR Success Stories & Clinician Education

• Nathan Littauer Hospital

– Bi-directional referral capability through

HealthLink Littauer “The Great Connection”

September 25, 2017 12

Working With Independent Clinicians

• Reaching out to

Performing

Provider Systems

(PPS)

• Grand Rounds

September 25, 2017 13

Performing Provider Systems (PPSs)

• Performing

Provider System

(PPS) selection

of Preventing

Chronic

Diseases within

Domain 4

(4.b.ii)

September 25, 2017 14

Performing Provider Systems (PPS) continuedCapital Region ● Albany Medical Center

Finger Lakes ● Finger Lakes PPS

Long Island ● Stony Brook University Hospital

Southern Tier ● United Health Systems and Cortland Regional

North Country ● Adirondack Health Institute

Tug Hill ● Samaritan Medical Center

Mid-Hudson ● Montefiore Medical Center

● Westchester

New York City ● Mount Sinai Hospitals Group

● Advocate

● Staten Island Univ. Hosp. & Richmond Univ. Medical Center

September 25, 2017 15

Grand Rounds• Hospitals offer a regularly scheduled teaching time for

attending physicians as well as residents and students

• CDSMP is a pertinent topic to present providing medical staff with a disease management alternative to pharmacological interventions

September 25, 2017 16

Opportunities for Partnerships

• Local Departments of Health

• Area Offices on Aging

– Referrals

– Promotion

– Other programmatic support

• Quality and Technical Assistance Center of New York – Register workshops as open through Compass

September 25, 2017 17

QUESTIONS AND DISCUSSION

September 25, 2017 18

THANK YOU

September 25, 2017 19

Contact Information

New York State Department of Health

Celeste Roeller Harp, MRP Intervention CoordinatorNYS Arthritis Program518-408-5142 celeste.harp@health.ny.gov

Nancy Katagiri, MPH, CPH NYS Arthritis Program Coordinator518-408-5142 nancy.katagiri@health.ny.gov

Jan Kaelin-Kee, MSW, MS Ed Senior Health Program CoordinatorCDSME in the Mohawk Valley Initiative518-408-5142 janice.kaelin-kee@health.ny.gov

Aletha Sprague Mohawk Valley PHIP Supervisor 607-547-7639 aletha.sprague@bassett.org

John May, MD Mohawk Valley PHIP Program Lead and Primary Investigatorjohn.may@bassett.org