Peer to peer session

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Albuquerque Wellness Referral System Peer to Peer Session
BUILD Health Challenge
February 29, 2016
Moderator:Lisa Curtis,BUILD HealthChallenge
AlbuquerqueBUILDTeamPresenters:
- Jim Bullard,Vice PresidentManagementServices,Adelante DevelopmentCenter
- LeighCaswell,Directorof CommunityHealth,PresbyterianHealthcare Services
- Erin Engelbrecht,SeniorDevelopmentManager,Adelante DevelopmentCenter
- Meta Hirschl,ApplicationDeveloper, Adelante DevelopmentCenter
- Michelle Melendez,DevelopmentDirector, FirstChoiceCommunityHealthcare
- Valerie Quintana,CommunityandClinical LinkagesCoordinator,CommunitiesLeading
HealthyChange,BernalilloCountyCommunityHealthCouncil
For directinquiries regardingthe WellnessReferral System,please contactErinEngelbrechtat
enengelbrecht@goadelante.org.
List of Questions:
From start to finish—how long did it take to get the WRS developed and
launched?.......................................................................................................................... 2
What were some challenges you had to overcome in developing or launching
the WRS? ........................................................................................................................... 3
Can you describe the process of working in partnership on this System? All
sectors come in with separate goals. How do you ensure that all partners have
aligned goals?...................................................................................................................4
What role did the community play in the development of the WRS?...................4
What are your top lessons learned from the development process? Key
takeaways that have emerged? ....................................................................................5
What challenges, if any, were presented around data sharing? How did you
overcome those challenges? ......................................................................................... 5
How did you get the word out about the WRS?......................................................... 6
Can you provide key insights on the WRS implementation process? What, if
any, challenges did you encounter? ............................................................................6
Overview of the Wellness Referral System
The WellnessReferral Center(WRC) developedbyAdelanteDevelopmentCenterinpartnership
withPresbyterianHealthcare Services,BernalilloCountyHealthCouncil’sHealthyHere initiative

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and FirstChoice CommunityHealthcare.The WellnessReferral Centerisabasedon the
Community-Cliniclinkagesmodel whichcreatessustainable,effectivelinkagesbetweenthe
clinical andcommunitysettingsto improve patients'accesstopreventive andchroniccare
servicesbydevelopingpartnershipsbetweenorganizationsthatshare a commongoal of
improvingthe healthof peopleandthe communitiesinwhichtheylive.
Currently,the WRCis linkingPresbyterianHealthcare andFirstChoice CommunityHealthcare
clinics,providers,andpatientslocatedlow- incomeneighborhoodsinthe SoutheastHeightsand
SouthValleyneighborhoodsinAlbuquerque,New Mexicotocommunitybasedactivitieswithin
theirneighborhoods. The goal isforpatientstogainsupportto effectivelymanage theirchronic
disease andtopromote healthandwellbeing.
How itworks:
The providerssendreferral informationaboutthe participantincludingcontactinformation,
demographicinsurance data,andspecificresource activitiestothe WRC.The WRC agent
contacts the participantsanddiscussesthe bestoptionsconsideringlocation,time and
accessibility.The agentregistersthe participantsforthe referredresourcesanddiscusseswith
the participantthe preferredmethodof contactforremindersbeforeactivities(phone,email,
textmessaging).Uponcompletionof the activitythe WRCagentcontactsthe participantfor
feedbackaboutthe experience.Participationinformationissentbacktothe referringprovider
The WRC offersabasic rewardsprogramthat incentivizeshealthybehaviorsandkeeps
participantsengagedthroughevents,email,texts,andanapp.
The communityactionplan(HealthyHere) initiative,inpartnershipwiththe WRC,will increase
capacityover time toinclude more neighborhoodclinics,communitymembers/patientsto
healthyandsupportive community-basedactivities.
From start to finish—how long did it take to get the WRS
developed and launched?
In 2013, PresbyterianHealthcare Servicescompleted itsIRS-requiredCommunityHealthNeeds
Assessmentandthroughthat, identified aneedtoincrease accesstoevidence-basedchronic-
disease self-managementprograms,increase accesstohealthyfoods, andencourage people to
be more physicallyactive. Theyfoundthateventhoughtheywereinvestingincommunity
programs,clinicswere notreferringtothem,andnoreal communityinfrastructureexistedto
supportthe referral process,andclinicswere too busytotake this on.In early2014, theyhad
the opportunitytoapplyfora CDC Reachgrant, and won.That grant supported the buildingof
the referral center.BUILD allowedthemtobringinadditional resourcesandexpandonthe WRC
concept.
Implementationsteps:
 Theyheldan all-dayplanningeventonAugust26, 2015 withall differentpartners(~25
people).Duringthisbrainstormingsessiontheyputtogetheranoperationsteamtodevelop
all the connectionsandreferral system.

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 To get the communityprogramsandresourceson board theymetwitheachorganizationto
understandtheirexistingsignupprogram(didn’twanttooversteportakeover).Afterthey
understoodthe currentsign-upprocess,theywoulddiscusshow the WRCcouldassistthem,
thencome to an agreementonhow the partnershipwouldoperate.
 Theybeganconversationswith referringagency/clinics torecruitproviderstoparticipate in
testingthe referral system.
 In the mannerof IHI’s PDSA model of qualityimprovement,theydecidedtostartsmall by
havingone doctorparticipate totest outthe system,andonlyfocusing onone chronic
disease (diabetes) inthe beginning.
 Developareferral formforthe clinicto capture necessaryinfo.Formwentthroughmany
iterationsastheyidentifiedinformationthatneededtobe capturednotonlyfor provider
purposes,butalsoforthe WRC andfor evaluationpurposes.
 The systemwentlive inJanuary2016 whentheytookthe firstreferral.
Adelante wasinvolvedthroughoutthe planningprocess,butgotmore involvedwiththe BUILD
Healthaward.Adelante wasresponsible fordevelopingthe Referral TrackingSystem(RTS) and
the wellnessrewardsprogramutilizingSalesforce asthe platform, andoperate the Chronic
Disease ManagementReferral System(CDMRS) &Mobile Market.They setupa systemtotrack
whowentto the mobile market.
Theyare still inoperational mode,tweakingandworkingthe process.
What were some challenges you had to overcome in developing
or launching the WRS?
 It was notclear until theystartedthe processthattheyneedaform forpeople whodeclined
participation.Thatinformationwasn’t communicated originally andtheyquicklyrealized
theystill neededtocapture that information.
 Chronic-disease self-management(CDSM) classeswere beingcancelledandnot
communicatedtothe WRC inreal-time. Theyare figuringout how tomake a smallerbridge
incommunicationsotheycouldknow real-timewhatwashappening. Itisimportantto
make sure classesthat are advertisedhappen,evenif there aren’tenoughpeople..
Resolution:exploringwhethertheycan at leastagree to holdthe firstclass,andthenleave
it upto the instructortocancel if necessary (thusmakingitaprogrammaticissue andnot a
referral centerissue).Theyare cancelingclassesbasedon the Stanford universitynumber
requirements,butneedtofigure out how tomake it workfor the WRC system.
 Adoptionissue –everyclinichasin-houseCDSMclassesso referrals were alreadyoccurring
to those in-house resources.Youcan’taska clinictohave a separate formfor in-house and
for WRC. Theydid notanticipate thatissue.

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Can you describe the process of working in partnership on this
System? All sectors come in with separate goals. How do you
ensure that all partners have aligned goals?
Havingcommunityactionplan (HealthyHere) throughthe CDCREACHgrant helped. They
partneredwith alongstandingcommunityhealthcouncil inthe county. Theyregularly report
throughthat networktomake sure they’re aligningwiththe actionplanandare accountable to
stakeholders. There are lotsprojects relatedtoWRCand ithas beenkeytomake sure they’re all
alignedandaccountable toa broadersetof stakeholders. Thisalsohelpsthemfeel like they
were part of a larger effort.
Energyand Champions! Once Dr.Barnesstartedmakingreferralsitbecame real.Thatkickedit
off and theywere excitedaboutmakingithappen. The amountof energybehindthishelped.
Dr. Barneswas a championforthe WRC. He was a keyadopterat that organization – havingthat
championwaskey.
AlignmentwithPCMHModel.Thiswhole processalignedwith the FirstChoice Community
HealthCenterPCMH model,fillinganeedprovidersandhealthcoacheshadtoconnectpatients
withresourcesinthe community.They hadsome internal educationofferings,but neededmore
and the WRC systemreallydovetailswith FirstChoice’s internalneed tomeetitsPCMH
requirements.Itwas an easysell because ithelpsthemachieve PCMHgoalsof connecting
patientswithhealthyresources.
ClinicInvolvementfromthe Beginning.If theyhadn’thadthe clinicsonboardduring the
developmentof the software platform andreferral form itwouldn’thave worked. Michelle
broughtthe PatientCare Facilitators tothe table to share theirideasforwhatthe WRC tool
mightlooklike and askedthe providers –will thisbe helpful?They tookastab at draftingthe
initial firstdraft of a referral form,andthe FirstChoice Staff washelpful byeditingandrevising
it.This waytheyhad some ownership overthe process,butdidn’thave the burdenof
developingaformfromscratch.
What role did the community play in the development of the
WRS?
Valerie facilitatestwo community groups(CHWs,andclinicpartners).CHWsworkall overthe
county and provide guidance andinputbasedon theirwork onthe ground. Theyprovidedinput
on the mobile marketlocations,educationmaterialsformobilemarket,andreasonsthere have
been difficulties enrollingpeople inevidence-basedprogramspriortothe WRC.
Afterstrugglingtotrainmore CHWs as a workshopleader,the CHWgroupprovidedfeedback
that ledto schedulingchangestoaccommodate more eveningandweekendclasses.
PresbyterianprovidesstipendsforCHWsbeingtrainedasworkshopleaderswhoworkinspecific
areas of the REACH grant, and will be givingworkshopsinthose areas.

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The Community-clinical linkages groupprovidedfeedbackon barrierstogettingstaff to
trainings,referringpeople tothese programs, the referral feedbackloop,and italsoprovidesa
space for internal networkingbetweenclinics. The WRChopestofollow-upandshow the
experience forthe patientif theywenttothe class/resource,orif not,whatwere the barriers
for notgoing.
The work that happenedbefore BUILDwasfrom the CTG grant that lostits funding. Thisproject
builds onmanyyearsof collaboration withthe communityandrelies onfeedbackfrom key
stakeholderswhoare engagedwith the peopletheyserve andtheircommunities.
What are your top lessons learned from the development
process? Key takeaways that have emerged?
 It isimportantto involve clinicsfromthe developmentstage –you can’t impose asystemon
them.Providersare verybusyandyouhave to work intheirworkflow asmuchas possible.
Theydevelopedapaperreferral formbecause the providersatthose clinicswere usedtoa
low-techmethod,andthat’sworkingforthem.
 Institute forHealthcare ImprovementSCALEcommunity –learningaboutideaof PDSA,
“failingforward”,andqualityimprovement.It’sokaytonothave it rightthe firsttime,but
improve the processasyougo. Thiskindof initiative doesn’thappenovernight.Ittakes
time,butit mattersthatyou take the time to engage the rightpeople inthe process.
 Patients are veryeagerto getbetterand are committedtodoingthings better.That
motivates the partners togetmore resourcesforpeople.
 Through thispartnershipof accountability,everyone hasbeenveryflexible.Adelanteand
WRC have beenveryflexible withthe formsconstantlychanging.Theyunderstandthatit’s
not a referral centerdrivenprocess,butit’sacommunityandclinicdrivenprocess.Letting
go of ego – whenyoudevelop aprocessforthe clinicsto use, keepthe mentalitythatyou’re
developingittogether,it’snotone person’sformthatothersshoulduse. Throughoutthe
manyversionsof the form,partnershave understoodthatthe goal isto make it useful to
people andtothe program.
What challenges, if any, were presented around data sharing?
How did you overcome those challenges?
It’san ongoingchallenge,butthere are nomajorissuesatthis point.Providers don’tfeel that
it’sHIPPA informationthey’re sending.WRCdoesn’treceivebiomedical informationordiagnosis
information, mostlyjustdemographicinfoonthe patient.Also,the patientsignsthe formwhich
givesconsent(atthe clinic). They alsohave adata-sharingagreementwithFirstChoiceandare
talkingwiththe otherhealthsystemsaboutthis thoughithasn’tstoppedthemfrommoving
forward.Confidentialityagreements,trainingmanuals,andotherthings are inplace to address
the handlingof sensitive information.Participantsare askedateverypointof the processif they
wantto participate andif theydon’ttheyare optedout.No majorissuesatthispoint.

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How did you get the word out about the WRS?
It isnot a publicreferral system,thoughtheywill acceptself-referrals.The mostlyrelyon
referralsfromclinics.
Theyare planningtomeetwith acommunicationscontractorto talkaboutdeveloping
professionallymade posters forwaitingroomsandtwo-pagersthatdescribe the programs to
advertise the WRC.Providerssuggestedsettingoutcolorcopiesinthe clinicsopeople will see
themand asktheirprovider.These ideaswereinitiatedbythe providersrequestingmore
communicationtools.
Can you provide key insights on the WRS implementation
process? What, if any, challenges did you encounter?
Lookingforwardat the thingsto figure outforthe future – scalingandsustainability.Needto
findstakeholderswhoare willingtoinvestinthis.How doyoucreate a seamlessprocess
throughEHR where you’re referringoutandgettinginformationbackinaboutthat patient.
Probablynota paperprocess,so how do theydothat?
Offeringarewardsystem – can’t incentivize people to attendcertainCDSMclasses (goesagainst
the evidence-base).However,youcanstill incentivize peopletosignup for the classes.They’re
findingissuesof gettingpeople togoto the resourcesthey’re tryingtosignupfor andare
currently workingthroughthose issues.
 Rewardsystem– theyare offering$25 giftcards forpeople whocomplete classesor
walkingprograms.
 2 differentrewardpaths – one forproviderstoreward(biggerpicture forhealth
improvement),andone forMedicaidMCO’s.MCOshave a rewardsystemthathas been
successful andthe WRC is hopingto alignwiththatalreadyexistingrewardsystem.
Next Steps: Broadenthe referral base to otherchronicdiseasesbeyonddiabetes(changing
referral form,addingmore classes,etc.). Buildonthe establishedsystemtoscale upwhat’s
working.
Thank youto the Albuquerqueteamforsharingtheirtremendousinsight!