Enhancing Care Through Education and Engagement

Transcription

1 Enhancing Care Through Education and Engagement Integrated Programs Summit Strategic Solutions Alex Littlejohn, RD, LDN, CDE

2 Who is Summit Strategic Solutions? A business partner of Summit Medical Group We exist to offer medical groups the support they need to better serve their patients and provide excellent healthcare. Care Coordination assist patients in organizing healthcare activities, navigate the healthcare system and secure needed healthcare resources Integrated Programs Health Education Create active members of the healthcare team by increasing knowledge, self-management skills, and access to needed programs Risk Adjustment Care Coordination Quality Improvement Integrated Programs Risk Adjustment certified coding professionals work together with physicians, showing them how to accurately capture the full risk burden of each patient Quality Reporting and Improvement conduct analyses and develop action plans to address gaps in care and to meet guidelines for primary care

3 About Summit Medical Group 14 Tennessee Counties 56 Practice Locations 346 Primary Care Providers 280,000 Patients 3

4 Integrated Programs and Health Education: Preventing the Development and Progression of Chronic Disease Health Education Classes Individual Diabetes Education Appointments & Shared Medical Appointments Integrated Behavioral Health RetinaVue Program

5 Health Education Classes: Engaging and Empowering Patients Steps to Wellness: a 12-month program that means once monthly to discuss nutrition, exercise, and various lifestyle changes to achieve better health. Living with Diabetes: a comprehensive 2.5 hour class covering carbohydrate counting, diabetes medications, and proper self-monitoring techniques to equip any patient with the tools needed to control their diabetes. Fit to Quit Smoking Cessation: a series meeting 7 times over 6 weeks that offers the information and support needed for a patient to quit smoking successfully.

6 % improvement Outcomes That Make an Impact: 73% 76% 69% Participants with A1c improvement in Living with Diabetes Also saw improvements in weight and triglyceride levels. 48% 59% 2x More successful at helping patients quit smoking than the national average success rate for smoking cessation programs. Steps to Wellness Program

7 Individual Diabetes Education Appointments (IDEA) A patient appointment where the provider and diabetes educator collaborate to facilitate diabetes self-management. Patient Activation Improved Outcomes Quality Measures Patients feel more engaged in their care, and 100% of participants report they would recommend this appointment to others. 79% of participants had improved A1c results. 68% saw weight loss as a result of this appointment. This appointment offers an opportunity to complete retinal eye exams, foot exams, and timely lab results to hit important quality measures.

8 Shared Medical Appointments A minute medical visit with a provider in the company of 8-15 other patients centered around a shared chronic disease state. Shared Medical Appointments allow for better chronic care management and can help prevent the progression of conditions such as diabetes, COPD, and fibromyalgia. 9 out of 10 Diabetes SMA participants saw a decrease in their A1c levels, and 6 out of 10 also saw improvement in triglyceride levels. 4 out of 5 patients indicate they prefer an SMA to a traditional appointment.

9 Praise For Education Programs: Life-changing Outcomes: My A1c went from 7% to 5.7%. Thanks for all your help I know I could have never done this without your intervention. SMG patient Physician satisfaction: Patients who regularly attend classes are motivated to lose weight, stop smoking, or otherwise control their disease state through empowerment.i continue to be amazed at the benefits health education classes provide. -SMG Provider Stand-out Service: As a direct response to [the educator s] help and direction, I have gone from a size 46 to 42 and am working on size 40 I ve been in similar programs before without any changes. [The educator] caught my attention and has made a difference. SMG patient

10 Integrated Behavioral Health: Increasing Access The connection 68% of US adults have a chronic condition, and 26% have a concurrent behavioral condition. The barrier Most behavioral health referrals are made out of the office. Only 10-20% of these are completed. Connection Need Barrier Solution The need Patients with mental health conditions are at higher risk for chronic diseases. There is a serious lack of BH providers. The solution Integrating behavioral health providers into primary care sites increases the referral completion rate to 90%.

11 Successes So Far: 100% Physicians who have referred a patient to a Behavioral Healthcare Provider embedded in the site Current show rate for Behavioral Health appointments 88% Improvement in all 4 areas on the Duke Health Profile for patients using the Behavioral Health Program Duke Health Profile: validated 17-item self report questionnaire measuring functional health status and quality of life. It is scored in four areas including social, physical, emotional, and overall health.

12 RetinaVue Program Collaboration with Welch Allyn to allow for point-of-care retinal exams in order to prevent the leading cause of vision impairment and blindness among workingaged adults. Loss of vision from diabetic retinopathy is preventable if caught early enough. 50% of patients referred to an ophthalmologist for a retina screening never go in to complete it. 11% of screenings so far in 2018 have detected pathology that may have otherwise been missed (673 cases since starting in 2015).

13 If my SMG primary care provider wasn t able to provide me with this test, I don t know where I would be. It can change your entire life, and it has for me. SMG patient on RetinaVue screenings Visit RetinaVue.com to learn more and hear Katie's Story a Summit Medical Group patient.

14 Education Individualization Engagement Access to Care Because we believe there is a better way to do Healthcare.