You Don’t Have to Get Diabetes

The goal is to streamline the steps required to make referrals to and enroll in the National Diabeties Prevention Program (DPP)

Diabetes Prevention: Your Role as a Healthcare Professional (July 15, 2020)

The Philadelphia Diabetes Prevention Collaborative invites you to learn about the latest in screening, testing and how to easily refer your patients to a National Diabetes Prevention (DPP) lifestyle change program within the greater Philadelphia five-county area. Featuring Health Promotion Council of Southeastern Pennsylvania, the American Medical Association, and the Center for Urban Health and College of Population Health at Jefferso

How CMS Judges Your Quality... And Why You Should Care

Objectives After this session, you will be able to: Define quality for a Medicare population Understand measure development, algorithms, and technical specifications Appreciate how your performance will be measured and reported in your practice Describe how your practice, after graduation, will differ from practice 10 years ag

The Impact Of An Addiction Medicine Consult Service On “Against Medical Advice” Discharges

Patients suffering from addiction and complications of substance use disorder (SUD) increase the cost of health care in multiple ways including longer lengths of stay and higher rates of readmissions (Englander et al, 2020). Additionally, patients with SUD are significantly more likely to leave the hospital against the advice of their care team compared to patients without SUD ((Simon, Snow and Wakeman, 2019; Ti and Ti, 2015). When a patient leaves the hospital against medical advice of their care team, this is termed a discharge against medical advice (AMA). It has been identified that in patients who have SUD and are discharged AMA there is an even higher rate of readmission, multiple readmissions and higher in-hospital mortality (Choi, 2011). At Grant Medical Center (GMC), we began an Addiction Medicine Consult Service in spring of 2019. Recognizing the high risk nature of our patients for AMA discharges, we reviewed data from two 6 month periods of time (one prior to initiation of consult team and one after) to evaluate the impact of our service on the rates of discharges AMA and 30 day readmissions. The results showed that for those patients who received an addiction medicine consult their AMA discharge rate was 17.7%, compared to the group that did not receive an addiction medicine consult at 5.5%. This paper will explore potential differences between groups receiving consults versus not receiving consults including payor mix, zip code of residence and other indicators of social determinants of health (SDoH). This is an opportunity for our team to use this information, among other experiences, to focus the next steps of our addiction medicine work including a focus on our patients’ multiple complex situations (medical and SDoH), expanded education for all hospital staff and engaging providers in prescribing medications for SUD

Exploring the Social Determinants of Health and Hypertension Control in Three Diverse Montana Practices.

The quality outcomes in management of hypertension in three Montana Providence St. Joseph Health (PSJH) primary care clinics (Polson, Grant Creek and Florence) were explored in April 2019. I postulated that determining Social Determinants of Health (SDOH) could help guide interventions to improve hypertension control. This paper is a beginning of the investigation to identify and address the SDOH in our clinics so that disease specific outcomes can be affected. Upon investigation, there was a statistically significant variance in the percentage of patients uncontrolled between one of the clinics, Polson, compared to other two clinics. Further evaluation was undertaken by exploring EMR data and public heath reporting through the lens of SDOH to evaluate for health disparities that could explain the variance between clinical outcomes. It was demonstrated that the average SDOH score was higher in Polson than the other clinics, for both controlled and uncontrolled hypertension. There was a statistically significant difference in in the SDOH scores between the uncontrolled and controlled hypertension groups in two clinics, but not the one with the highest SDOH burden. Considering these findings, we explore further the possible mechanisms of variation, consider different SDOH measurement strategies, as well as strategize interventions for uncontrolled hypertension including telehealth, Community Health Workers (CHWs), and Team Based Care (TBC) models

Creating Community Gadflies in Population Health Promotion: Illuminating the Value of Learning About the Medical Services Payment System

Our health system is in a disordered state. Costs continue to rise without concomitant improvements in outcomes. A population health approach to improving health, rooted in the understanding that health outcomes are the result of a complex interplay of determinants, brings together all community stakeholders whose actions contribute to health outcomes to work in coordination. Getting funding and aligning financial incentives with planning goals is critical. Our current payment system’s complexity and distorted incentives create barriers to successful population health initiatives that are invisible to members of the community outside the health care sector. A “gadfly” is “a person who interferes with the status quo of a society or community by posing novel, potentially upsetting questions, usually directed at authorities.” (Wikipedia, 2020.) Here, “gadflies” represent community representatives to whom the payment system is made visible. With that knowledge, they become empowered to challenge powerful health care sector interests in service of the public interest and increase their ability to deliberate in all stages of population health improvement planning. They stimulate genuine community engagement, increasing the likelihood of a successful improvement plan. This capstone is a two-part educational intervention targeted at health care activists. Part One introduces healthcare activists to how the payment system works, how it creates barriers to innovation, and how it creates incentives that do not align with improving outcomes. Part Two introduces activists to ways they could apply knowledge of the payment system in population health improvement planning on a community level. Participants (8 in Boston; 6 in DC) in two proof of concept sessions of Part One reported that my presentation convinced them they should devote time and energy to understanding the medical services payment system to be competent agents of change and they all agreed to attend a Proof of Concept session for Part Two

Embedded vs Remove Care Management Delivery Models and Their Impact on Achieving the Quadruple Aim

As the health care industry transitions from fee for service to value-based reimbursement, the role of the professional care manager in the delivery of high-quality, low cost care is evolving rapidly (Luo, et al., 2016). Identified as a key strategy to success in value-based payment models, care management programs vary widely in their scope, design and delivery (Kodner, 2015). Health plans that once provided remote care management services as a means to impact quality, cost and utilization are beginning to invest their resources in care management delivery models that are embedded in the Patient Centered Medical Home (PCMH) (Luo, et al., 2016). This represents a significant shift in strategy that positions the care manager alongside the Primary Care Provider (PCP) as a key member of the care team. Through a comparison of published studies and case presentations, this paper aims to understand whether or not the delivery setting for care management is relevant in meeting the goals of the quadruple aim: improved health outcomes, reduced cost of care, and enhanced patient and provider experience. Though there is limited research available that examines the question in totality, evidence exists to support that embedded care management models might be more effective than remote interventions at improving the health outcomes and health care experiences of complex patient populations and reducing provider burnout. Less conclusive evidence was available to support care management as a consistent factor in the reduction of the cost of care per capita. In an effort to standardize and replicate an effective care management program, a set of high-level evidence based best practice recommendations was assembled and organized

Behavioral Health Integration in Primary Care Pediatrics: A Pilot Utilizing a Collaborative Care Model

Many U.S. children suffer from behavioral health disorders such as attention deficit hyperactivity disorder (ADHD), behavior/conduct disorders, anxiety and depression. Nearly 50% of youth do not receive the treatment or counseling from a mental health professional that is indicated for their condition which may lead to significant morbidity. The literature supports the value of integrating behavior health into primary care pediatrics using a collaborative care model. This project was designed to pilot this model in a single primary care pediatric practice location within a multi-specialty, ambulatory medical group. In preparation for the pilot, an analysis of visit data for the pilot site revealed that 17.2% of children had been seen for one or more behavioral health conditions in a 12-month period – findings that very consistent with state and national reports. Pro formas revealed that a behavioral health care manager with a modest patient panel (i.e., 46-53 children) billing monthly for time-based services using Psychiatric Collaborative Care Services CPT codes would provide a financially profitable service. As part of the project, a behavioral health care manager position was also created, and a psychiatric consultant was identified. The EHR was leveraged to develop communication, documentation, and billing tools and to begin the build of a patient registry. The project was interrupted in late February 2020 because the organization’s resources were redirected to the COVID-19 pandemic response. It is anticipated that the project will resume sometime later in 2020 at which point the final preparations will be completed before undertaking the actual pilot. Evaluation will occur over the subsequent six months. The ultimate goal is to roll out this model in 2021 across the remaining ten of the organization’s primary care pediatric practice locations

Philadelphia Makes Diabetes Prevention a Priority: Introducing the Philadelphia Diabetes Prevention Collaborative

With the support of the AMA and CDC, JCPH established the Philadelphia Diabetes Prevention Collaborative (PDPC), a group of local and national stakeholders working to design multi-pronged public health efforts to prevent Type 2 Diabetes in the greater Philadelphia region. Learn more about prediabetes, the National Diabetes Prevention (DPP) program, and our regional efforts