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© 2011. National Council on AgingTo improve the lives of millions of older adults, especially those who are vulnerable and disadvantaged.
Webinar Instructions
Thank you for joining today, please wait while others sign in.
Phone Dial in: 1-866-740-1260Access code: 4796665#Due to the large number of participants, all lines will be muted during the call.If you want to ask a question, please type in your question into the box.
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To improve the lives of millions of older adults, especially those who are vulnerable and disadvantaged.
Federally Qualified Health Centers (FQHCs) and CDSMP – Perfect Together
October, 2011
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© 2011. National Council on AgingTo improve the lives of millions of older adults, especially those who are vulnerable and disadvantaged.
Agenda“Federally Qualified Health Centers (FQHCs) and CDSMP –
Perfect Together”
AoA’s National Partnership with the Health Resources and Services Administration and Federally Qualified Health Centers
– Robert Hornyak, U.S. Administration on Aging, Acting Director, Center for Policy, Planning and Evaluation
Missouri – What Works and Lessons Learned– Beth Richards, Program Manager, Missouri Arthritis & Osteoporosis, University of
Missouri
New Jersey – Profile of a Successful Partnership– Gerry Mackenzie, Program Manager, NJ Department of Health and Senior
Services, Community Resources, Education & Wellness– Carol Mallette, Director, Diabetes Outreach and Education System, Southern
Jersey Family Medical Centers
Q&A – All
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MISSOURI CDSMP REFERRALFederally Qualified Health Centers
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Missouri Chronic Disease Collaborative
The Missouri Department of Health and Senior Services (MDHSS) and Missouri Primary Care Association (MPCA) have contractually been partnering since 2000 around chronic disease initiatives – primarily diabetes, cardiovascular disease, and stroke: referred to as the Chronic Disease Collaborative.
This successful clinical effort includes 23 primary care organizations (FQHCs) that primarily serve low-income, uninsured and underinsured persons.
The collaborative utilizes benchmarks and score card measures to identify quality of care improvement opportunities and encourages the FQHCs to implement evidence-based interventions in their clinics to improve access to preventive care and chronic disease management services for those suffering from heart disease and diabetes.
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Community Health Center (FQHC)
Satellite Center
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CDSMP and the Collaborative -Challenges
In 2009, prior to ARRA funding, the FQHC’s rejected contractual language to refer to CDSMP.
In 2009-2010, FQHCs were educated through state-wide meetings on CDSMP.
In 2010-11 contracts, CDSMP referral language was included; MPCA state-wide meeting in-services continue to update/communicate with FQHCs.
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CDSMP and the Collaborative -Successes
FQHCs are actively referring, but are also program delivery partners.
Quarterly meetings with MPCA as MDHSS to review progress on Collaborative – CDSMP at the table.
CDSMP future possibilities:Outcomes data through MPCA EMR systemOutcomes data has intrigued other programs to be involved at MDHSS.
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Swope Health Services – Kansas City Area
Swope Health CentralSwope Health IndependenceSwope Health NorthlandSwope Health SouthSwope Health West
Swope Health Midtown (KS)Swope Health Wyandotte (KS)Swope Mobile
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FQHC support
State-wide communication during quarterly MPCA meetings
Local and regional infrastructure including Area Agencies on Aging(AAAs) and Regional Arthritis Centers (RACs) provide on-going communication with FQHCs
On-site visits to FQHCs to provide brochures for referral, ensure staff have tools they need to make active referralsQuarterly partner and leader meetings (regionally)
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Next Steps
Better tools for active referral
Comparison of in-house self-management education vs. referral to CDSMP
Focusing on Health Centers NOT making active referrals
Focusing on Centers with staff turn-over to educate new staff on CDSMP.
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FEEL BETTER. BE IN CONTROL. DO THE THINGS YOU WANT TO DO.
• Community and Migrant Health Center
• 7 Locations
• 2 Medical Mobile Units
“WHO WE ARE””
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FEEL BETTER. BE IN CONTROL. DO THE THINGS YOU WANT TO DO.
SOUTHERN JERSEY FAMILY MEDICAL CENTERS, INC.
DIABETES OUTREACH & EDUCATION SYSTEMS
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FEEL BETTER. BE IN CONTROL. DO THE THINGS YOU WANT TO DO.
“DOES” The Diabetes Outreach and
Education System is
DESIGNED TO INCREASE PUBLIC AWARENESS AND ACTION THAT WILL HELP COMMUNITIES LEARN
TO PREVENT & CONTROL DIABETES
SOUTHERN JERSEY FAMILY MEDICAL CENTERS, INC.
OUTREACH IS DIRECTED TO 5 SOUTHERN NJ COUNTIES
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WHAT HAVE WE DONE ?
SOUTHERN JERSEY FAMILY MEDICAL CENTERS, INC.
FEEL BETTER. BE IN CONTROL. DO THE THINGS YOU WANT TO DO.
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• Disseminated NDEP and other diabetes educational materials
• Created a Regional Diabetes Advisory Council and a Coalition
• Conducted Diabetes Day Fairs• Hosted Diabetes Educational Workshops for providers
• Participated in the Bureau of Primary Care’s Diabetes Health Disparities Collaborative
• Facilitated Diabetes Self Management sessionsReached potentially more than 1,000,000 people annually
SOUTHERN JERSEY FAMILY MEDICAL CENTERS, INC.
FEEL BETTER. BE IN CONTROL. DO THE THINGS YOU WANT TO DO.
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SOUTHERN JERSEY FAMILY MEDICAL CENTERS, INC.
FEEL BETTER. BE IN CONTROL. DO THE THINGS YOU WANT TO DO.
WHILE WE CONDUCTED SOME DIABETES SELF‐MANAGEMENT PROGRAMS……
WHERE COULD WE FIND A PROGRAM THAT WAS EVIDENCE‐BASED AND WOULD ALLOW OUR PATIENTS TO MANAGE THEIR DIABETES
AND RELATED CHRONIC DISEASE?
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THROUGH THE NJDHSS WE LEARNED ABOUT THE STANFORD UNIVERSITY
EVIDENCE‐BASED CHRONIC DISEASE SELF‐MANAGEMENT PROGRAM (CDSMP) AND THE DIABETES SELF‐MANAGEMENT
PROGRAM (DSMP)
SOUTHERN JERSEY FAMILY MEDICAL CENTERS, INC.
FEEL BETTER. BE IN CONTROL. DO THE THINGS YOU WANT TO DO.
CDSMP/DSMP WORKSHOPS
OFFERING LIFESTYLE SKILLS TO BETTER MANAGE YOUR HEALTH
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FEEL BETTER. BE IN CONTROL. DO THE THINGS YOU WANT TO DO.
SOUTHERN JERSEY FAMILY MEDICAL CENTERS, INC.
DOES STAFFPARTICIPATED IN PEER LEADER & MASTER
TRAININGS ON CDSMP/DSMP
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• Promote the program internally• Secure buy in• Identify sites for sessions• Set calendar• Develop marketing/ outreach tools • Recruit peer presenters• Market program• Order/assemble supplies• Prepare for sessions
ARMED WITH KNOWLEDGE
SOUTHERN JERSEY FAMILY MEDICAL CENTERS, INC.SOUTHERN JERSEY FAMILY MEDICAL CENTERS, INC.
FEEL BETTER. BE IN CONTROL. DO THE THINGS YOU WANT TO DO.
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MARKETING TOOLS
SOUTHERN JERSEY FAMILY MEDICAL CENTERS, INC.
FEEL BETTER. BE IN CONTROL. DO THE THINGS YOU WANT TO DO.
Brochures
Self –Management Prescription Pad
Posters
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SOUTHERN JERSEY FAMILY MEDICAL CENTERS, INC.
FEEL BETTER. BE IN CONTROL. DO THE THINGS YOU WANT TO DO.
RECRUITMENT EFFORTS• Partners
• Word of mouth
• Newspaper advertising
• Notices to patients
• Posters
• Support from provider staff
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SOUTHERN JERSEY FAMILY MEDICAL CENTERS, INC.
FEEL BETTER. BE IN CONTROL. DO THE THINGS YOU WANT TO DO.
TO SUPPORT THE PROPOSED BEHAVIOR CHANGE
CDSMP/DSMP TRAINING FOR SJFMC STAFF
CONDUCTED 2 PEER LEADER TRAININGS‐ 1 CDSMP WITH 14 PARTICIPANTS‐ 1 DSMP FOR 8 PARTICIPANTS
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FEEL BETTER. BE IN CONTROL. DO THE THINGS YOU WANT TO DO.
SOUTHERN JERSEY FAMILY MEDICAL CENTERS, INC.SOUTHERN JERSEY FAMILY MEDICAL CENTERS, INC.
WORKSHOPS FOR COMMUNITY MEMBERS
‐ 4 CDSMP WORKSHOPS‐ 66 PARTICIPANTS
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SOUTHERN JERSEY FAMILY MEDICAL CENTERS, INC.
FEEL BETTER. BE IN CONTROL. DO THE THINGS YOU WANT TO DO.
WORKSHOPS FOR SJFMC PATIENTS
‐ 1 CDSMP WORKSHOP 7 PARTICIPANTS‐ 3 DSMP WORKSHOPS 27 PARTICIPANTS
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FEEL BETTER. BE IN CONTROL. DO THE THINGS YOU WANT TO DO.
OUR APPROACH
• Review program goals• Set the tone• Encourage participation• Stick to curriculum• Topics covered
• Dealing with Frustration• Appropriate exercise• Appropriate use of
medications• Communicating
effectively• Nutrition
SOUTHERN JERSEY FAMILY MEDICAL CENTERS, INC.SOUTHERN JERSEY FAMILY MEDICAL CENTERS, INC.
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EVALUATION
SOUTHERN JERSEY FAMILY MEDICAL CENTERS, INC.
FEEL BETTER. BE IN CONTROL. DO THE THINGS YOU WANT TO DO.
Pre‐Measures
Post ‐Measures
Results
FOR SJFMC PATIENT POPULATIONData collection through PECS
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SOUTHERN JERSEY FAMILY MEDICAL CENTERS, INC.
FEEL BETTER. BE IN CONTROL. DO THE THINGS YOU WANT TO DO.
PRE & POST DSMP MEASURES
130
70
7.42
0
20
40
60
80
100
120
140
Systolic BP Diastolic BP A1c
Systolic BPDiastolic BP
124
72
6.82
0
20
40
60
80
100
120
140
Systolic BP Diastolic BP A1c
Systolic BPDiastolic BP
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SOUTHERN JERSEY FAMILY MEDICAL CENTERS, INC.
FEEL BETTER. BE IN CONTROL. DO THE THINGS YOU WANT TO DO.
158146.8
11.2
0
20
40
60
80
100
120
140
160
180
Pre Measure Post Measure Difference
Pre MeasurePost MeasureDifference
Total Cholesterol
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SOUTHERN JERSEY FAMILY MEDICAL CENTERS, INC.
FEEL BETTER. BE IN CONTROL. DO THE THINGS YOU WANT TO DO.
DSMP OUTCOMES
Results were for a three month period. With continued DSMP interventions, indicators will continue to improve
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FEEL BETTER. BE IN CONTROL. DO THE THINGS YOU WANT TO DO.
Participants give high marks to the program
Feedback on activities offer encouragement, support and improved use of resource tools
Participants report that group support and accountability influence their behavior in positive ways
Participants understand about action planning as a healthy lifestyle skill
Staff enjoy hosting presentations as much as participants
SOUTHERN JERSEY FAMILY MEDICAL CENTERS, INC.
LESSONS LEARNED
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SOUTHERN JERSEY FAMILY MEDICAL CENTERS, INC.
FEEL BETTER. BE IN CONTROL. DO THE THINGS YOU WANT TO DO.
“LOTS OF TIMES I COME TO THESE PROGRAMS BECAUSE I KNOW THEY NEED SOMEONE TO FILL
A SEAT. FOR THE FIRST TIME I CAME TO A PROGRAM THAT I THINK REALLY HAS VALUE FOR
ME ANDI THANK YOU!”