Zosia Stanley , JD, MHA, Policy Analyst, WSHA

1. Keeping Patients with Chronic Conditions Out of the Hospital: Perspectives from a Hospital and a Public Health Agency Zosia Stanley, JD, MHA, Policy Analyst, WSHA Eileen Branscome, RN, COO, Mason General Hospital, Shelton Joan Brewster, MPA, Director, Grays Harbor County Public Health and Social Services Department

2. Speakers Impact and cost of chronic disease Zosia Stanley, JD, MHA, Policy Analyst, WSHA Hospital perspective Eileen Branscome, RN, COO, Mason General Hospital, Shelton Public health perspective Joan Brewster, MPA, Director, Grays Harbor County Public Health and Social Services Department

3. The impact and cost of chronic diseases Chronic diseases – such as heart disease, stroke, cancer, and diabetes – are among the most prevalent, costly, and preventable of all health problems About halfof all US adults—125 million people—have one or more chronic health conditions. One in four has two or more chronic health conditions. Seven of the top ten causes of death in 2010 were chronic diseases. Two of these chronic diseases—heart disease and cancer—together accounted for nearly 48% of all deaths. 84% of all health care spending in 2006 was for the 50% of the population who have one or more chronic medical conditions. CDC, Chronic Disease Control and Prevention, May 2014; AHRQ, March 2014.

4. Chronic diseases influence overall health

5. Chronic disease at a county level • One in 8 adults have asthma. • One in 6 adults have diabetes. • One in 12 adults have heart disease • One in 12 adults have asthma. • One in 11 adults have diabetes. • One in 11 adults have heart disease. Washington Department of Health, Chronic Disease Profiles by County, 2014

6. Rising rates of chronic diseases

7. Population Health Perspective Prevention Partnerships Preservation Eileen T. Branscome, COO Mason General Hospital and Family of Clinics June 2014

8. EQUITY Prevention Management Promotion Medical Care

9. Prevention & Promotion Interventions

10. Management & Medical Care

11. Shared Responsibility • Interventions & Outcomes • Public health • Health care delivery • School systems • Social services • Employers • Individual behaviors and choices

13. Break the Vicious Cycle

14. Prevention & Management Diabetes Pre-Diabetes Clinic • Education • Benefits of walking (30” five days/week) • How the body breaks down sugar • Reduces risk: T2DM,stroke, MI, stress • Lowers BP & HDL • Increases circulation, energy • Improves sleep • Monitoring – A1C, health status, lifestyle, nutrition, activity Diabetes Wellness Center • Living well with diabetes • Simple to complex care coordination • Education – Support – Monitoring – Interventions - Advocacy

15. Information Sharing Chronic Disease Management Self care and family health Prevention/ Annual check up with MVWC Prevention/ Annual check up with PCP Employee Wellness High Blood Pressure AIC (labs) high Referred to DWC Active Lifestyle Diabetes Education Class Hypertension Education Stress Management Active Lifestyle Pre-diabetic Assessment Nutrition/Diet Changes Active Lifestyle Spouse - Diabetic Nutrition/Diet Changes Child – Not Diabetic Patient’s Story

16. Outcomes • Improved Health • A1C from 9 4 • BP 168/81 130/78 • Reduced Stress • Improved Well Being • Small significant lifestyle changes • Move more, eat healthier • Environmental change • Room to roam and play • A family affair • Improved nutrition- weight loss [child & parent] • Reduced rice and fast food intake • Increased vegetable intake

17. Complex Diabetic PatientMultiple Chronic Disease Processes • Care Coordination • Internal and external providers and teams • Community resources • Advocacy- needs not covered by health plan • MGHFC intervention-equipment & supplies starting June 16, 2014

19. Stroke Prevention – TIA Clinic • Access to services in our local community • Telemedicine & early interventions • Collaboration with tertiary stroke center • Care Coordination: Primary care and specialists • Personal connection & education • Preliminary Outcomes • Small lifestyle changes – diet, activity, smoking • Positive personal experience-caring & concern • Health Status – No progression to stroke in 12 of 13 individuals

20. Chronic DiseasesCare Coordination & Care Transitions • Risk assessment • Coordination • Follow up medical care and plan • Coaching • Treatment plan, health status, medication management, support • Care Transitions • Warm hand over • Communication • Electronic health record • Community resources • Coverage by health plan • After-hours access to clinics

22. ED Care Coordination Project • ED, clinics, coordinators, providers, community • EDIE – emergency department information exchange • Care guidelines, pain management contracts • Intervention, narcotic and visit history • Behavioral health connection • Connection, communication, primary care follow up • Education, information sharing • Coordination with health plan and MGH coordinators • Re-direct to clinic after triage • Community resource connections

23. Mental Health • Tele-psychiatry pilot – non-urgent patients • Familiar private setting – primary provider team • Timely access • Integrated treatment plan • Combine with other resources [chemical dependency, BHR (limited services), others] • Results so far • 30 patients • 4.1 overall satisfied (five point scale) • Medication management • Spread to other primary care locations

24. MGHFC Approach • Align vision and priorities with Community Needs Assessment • Access to Primary Care and coverage [Apple Health, QHP, Health Plans] • Communication [Electronic Health Record] • Connectivity [personal connection-caring, concern, compassion] • Relationships • Patients First-Always • Caring for our community in our community • Coordination • Specialist referrals • Telemedicine • Expanded hours and services • Community Partners • Mason Matters • Health Department • School System • Sub-Acute settings • Local employers Outcome: Community Health Ranking improved from 39th in 2005 to 35th in 2013

25. Contact Information and References Contact Information: Eileen T Branscome, COO ebranscome@masongeneral.com 360-427-9560 References: Population Health in the Affordable Care Act Era, Michael A. Soto, Ph.D., AcademyHealth, February 2013 IHI Innovations Series 2012 IHI Triple Aim, 2013 Center for Medicare and Medicaid Innovation County Health Rankings Beating Diabetes with Exercise, Catherine McHugh, ARNP

26. Chronic Disease Self-Management Strategies for Building a Community-wide Program Joan Brewster, MPA Director, Grays Harbor County Public Health and Social Services Department jbrewster@co.grays-harbor.wa.us 360-500-4062

27. What is “CDSM”? • Evidenced-based Course • Stanford Patient Education Research Center. Kate Lorig, et. al. • 6 weekly classes, 2.5 hours • Standard Curriculum • “Lay Leaders”, Licensed • General, Diabetes, or Pain “The class was the best one I have been to…” “Helps you to learn how to help yourself do better”

28. Value For Hospitals • Discharge planning • Care coordination • Reduce readmissions • Community Benefit • Reduce extra ER visits • Patient engagement • Provider support Self- managing for Better Health

29. About Our Program Agency on Aging Health Department Hospital Community Action Program Community Health Clinic • A coalition of five community agencies • A commitment to: • Coordinate Efforts • Share the Load • Sustain Over Time • Mutual effort to seek a revenue source and sustain the program

30. Our Motivation If we bring this program to scale, can we change this picture? • Worst health status statewide • Hospitalization and death rates are high • Huge and costly burden of chronic disease

31. Our Aims Create and sustain a community condition in which: • CDSM Programs are commonplace • Access is easy; no cost to the participant • Health providers routinely refer participants

32. Strategy 1: Get Organized Creating a Coalition made this work more powerful than separate, disconnected efforts. • Joint marketing, brochure, media, newsletters • One registration phone line • Coordinated training for Lay Leaders, Master Trainers and special topic courses (diabetes, pain, Tomando.)

33. Strategy 2: Year-Long Calendar • Advance commitment means people can count on us. • Primarily for providers, but worked great for all others. • Each brochure has a long shelf life. Posters and tear off cards also used. (Not prescription pads or stamps.)

34. Strategy 3: Provider Outreach We have used all of the following. CDC materials were very helpful, saved time. • Blast fax • Brochures delivered in person • Request posters be placed in exam, waiting rooms • Letter from Health Officer • Cards in MD boxes at hospital Limited success: Necessary, but not sufficient Best results: • Stand up meetings with MDs before practice opens • Accompanying drug reps, taking lunch • Repeat, repeat, repeat… Grays Harbor Community Hospital Staff are Leaders and Master Trainers

35. Strategy 4: Participants as ‘Marketeers’ Direct Marketing to Providers – with a twist: • Participants inform their providers, take materials, write and deliver letters • Providers listen well to patients, peers • Personal stories carry the most weight “My personal physician…suggested I join the workshop and I will be forever indebted to her for doing so…”

36. Strategy 5: Involve Health Plans Invited Medicaid Health Plans to attend a Coalition Meeting All 4 Plans gave a short summary of their services: Individual support. Disease management and case management, using telephone contact. No group contact. No local contact. Health plan staff were unaware of the availability and efficacy of community based classes.

37. Strategy 5 - Plans: It’s working… May 14, 2014 email: • Agreed with Plans that we could maximize impact by: • Learning how to coordinate individual case management with community offerings • Having Plans influence providers through marketing, reporting requirements, data point feedback • Future? Direct marketing to enrollees by Plans • Funding from Plans? Reduces enrollee health care costs “…to submit a written proposal along with an invoice, to Coordinated Care for sponsorship…”

38. Additional Strategies • Purchased news ads • Free “Senior” columns • Radio shows • Senior meal sites • Civic group talks • Five agency leaders and staff talking about CDSMP-- always have brochures in hand. • Next: Faith communities, behavioral health centers

39. Results

40. Results – Typical Post Class Surveys In general, how effective have you found this program in helping you manage your chronic condition? Excellent 100% I found the approach used to present “Living Well With Chronic Conditions” extremely effective and interesting. Strongly Agree 100% I would recommend this program to others: YES 100%

41. Typical Post Class Comments “I lost weight, have more energy” “Helped me to manage & learn about my Diabetes” “Very informative” “Excellent information” “It is very beneficial and I learned a lot” “Because it tells true feelings of what Diabetes is” “Active, laugh, positive thinking, slow down, ways to be optimistic” “Get more walking and completing more of my projects” “Action plans and goal setting; weight loss” “Better eating, better confidence, worthiness”

42. Thank You For follow up: Joan Brewster jbrewster@co.grays-harbor.wa.us 360-500-4062

43. Questions?

44. Thank you!