Innovation Pilot KELLY VOLKMANN BENTON COUNTY HEALTH SERVICES DST - - PowerPoint PPT Presentation

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Innovation Pilot KELLY VOLKMANN BENTON COUNTY HEALTH SERVICES DST - - PowerPoint PPT Presentation

Dec 14, 2023 465 likes •647 views

School Navigator Innovation Pilot KELLY VOLKMANN BENTON COUNTY HEALTH SERVICES DST PILOT CLOSEOUT PRESENTATION 1 INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION Pilot Summary 2 years: July 1, 2015 June 30, 2017 Budget:

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School Navigator Innovation Pilot

KELLY VOLKMANN BENTON COUNTY HEALTH SERVICES

DST PILOT CLOSEOUT PRESENTATION INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION

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Pilot Summary

  • 2 years: July 1, 2015 – June 30, 2017
  • Budget:
  • Year 1 – $215,000 IHN-CCO (DST pilot)
  • Year 2 - $110,000 IHN-CCO; plus $110,000 each from Benton

County Health Services and Corvallis School District

  • Co-placed 3 bilingual, bicultural Community Health Workers

(School Navigators or SNs) into 2 elementary schools and 1 middle school in Corvallis School District

  • SNs worked with the entire family to connect them to

health care, social services, and community resources

  • utside of the school system

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DST PILOT CLOSEOUT PRESENTATION INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION

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Total Touches and Distinct Members Served: 4/1/2015 – 3/31/2017 Year 1 Year 2 Inc from Y-1 to Y-2 Total Distinct IHN-CCO Members Touched 466 569 103 783 Number of IHN-CCO Member Touches 2356 2546 190 4902

DST PILOT CLOSEOUT PRESENTATION INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION

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WCC and Preventive vision exam rates of visits before and after SN touch - for "N" distinct IHN-CCO members touched: 4/1/2015 - 3/31/2015 Up to 1 year before touch w/in 1 year after touch Follow up percent change Well-Child Check Visit (N = 134 members) 37 (28%) 69 (51%) + 23% Preventive Vision Visit (N = 167 members) 56 (34%) 95 (57%) + 23%

Key Outcomes:

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Key Outcomes

  • Having CHW/SNs co-placed in schools increases the

likelihood that children will be connected to their PCP, will get their well-child checks, and follow up with their vision exams

  • School Navigators increase access to care for students and

families related to transportation, language, knowledge, food, clothing…this allows parents to focus their energy and attention on health

  • Helping these families overcome the social determinants of

health barriers to accessing healthcare will ultimately lead to improved health and lowered health care costs

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Successes – this story repeated

  • ver and over and over…

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DST PILOT CLOSEOUT PRESENTATION INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION

“She [navigator] helped me with the doctor, she [navigator] helped me with the therapies [referring to counseling] that they are giving my daughter” Parent Survey 2016

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Learning Experiences

  • We had NO barriers to success – only challenges that we created

strategies to overcome

  • In expanding the pilot from 2 schools to 3, we learned how to replicate

the process of co-placing a CHW/SN into a school system

  • Having the SNs be county employees and attached to a large CHW team

was beneficial, rather than having them be school employees

  • The few difficulties that arose were usually related to communication

between two different systems (school and government entities) and were resolved immediately with proactive and personal communication

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DST PILOT CLOSEOUT PRESENTATION INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION

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Partnerships & Collaboration

  • We increased the relationship and collaboration between IHN-CCO, the

Corvallis School District and Benton County Health Services. We see each other as partners in the care of “our” students and their families…

  • We also deepened our relationships and connections with all of the

mental health and social service agencies that serve students and families

Our work can not be done without our community partners…it just isn’t possible!

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DST PILOT CLOSEOUT PRESENTATION INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION

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Post Pilot Sustainability

  • Our pilot has been sustained for the 2017-2018 school year, and is going

forward for the 2018-2019 school year with funding from the Corvallis School District and various grant funds from BCHS

  • This reliance on grant funding is stressful and potentially non-

sustainable

  • This has been our only challenge to date…

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DST PILOT CLOSEOUT PRESENTATION INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION

“The Health Navigator program has proven beneficial to our school community. Attendance, participation in the classroom, and readiness to learn have been affected positively as students' and families' basic needs have been better addressed through this program.” School Staff Survey, 2016

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Pre-Diabetes Boot Camp

SAMARITAN NORTH LINCOLN HOSPITAL RUTH MORELAND, RN, CDE SUSAN RICHWINE, RN, OCN

DST PILOT CLOSEOUT PRESENTATION INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION

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Pilot Summary

  • July 1, 2016 to December 31, 2017
  • $15,000
  • Establish a pre-diabetes program in North Lincoln County to help reduce

the transition of IHN-CCO members from pre-diabetes to diabetes.

  • Key pilot activities:
  • Identify IHN-CCO members with pre-diabetes
  • Establish referral workflows
  • Develop class materials
  • Conduct several different types of classes
  • Collect and analyze data

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DST PILOT CLOSEOUT PRESENTATION INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION

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Key Outcomes

  • Specific key outcomes of the pilot, include:
  • Health Equity
  • People with pre-diabetes, estimated to be 1/3 of our adult population, are

starting to receive more focused care

  • Metrics affected
  • Improved access to diabetes prevention services in a rural community
  • Identification and care of people with pre-diabetes is better integrated into

primary care

  • Improved chronic disease prevention
  • Certified three people as CDC-approved diabetes prevention program

Lifestyle Coaches

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DST PILOT CLOSEOUT PRESENTATION INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION

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Successes

  • Pre-Diabetes Boot Camp was designed to attract attention in a noisy

environment and succeeded at doing so

  • 51 participants - average weight loss 7.4 lbs, average A1C decrease 0.32

for the 23 participants with pre and post test results

  • Increased provider and patient awareness of pre-diabetes and

treatment options

  • Samaritan Health Services received CDC recognition as an approved

Diabetes Prevention Program, allowing Medicare billing for classes starting April 2018

  • A rural community project is driving organizational change
  • Project poster presented at 2018 Oregon and SW Washington Health

Literacy Conference

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DST PILOT CLOSEOUT PRESENTATION INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION

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Learning Experiences

  • Relationships are the foundation for change, both personal and

professional

  • The IHN-CCO pilot project structure and support was key in keeping the

pilot on track during difficult periods

  • One significant adjustment during the pilot was to have one class follow

the CDC diabetes prevention program guidelines, resulting in Samaritan Health Services becoming an approved site, allowing Medicare billing

  • Healthcare organizations are conservative
  • Form and function follows the Electronic Medical Record
  • Front line non-management staff can impact organizational change
  • Learnings gave us courage to spawn other improvement projects

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DST PILOT CLOSEOUT PRESENTATION INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION

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Partnerships & Collaboration

  • Lincoln City Community Center
  • Lincoln City Cultural Center
  • Newport Recreation Center and 60+ Activity Center
  • Non-Samaritan local providers
  • OHSU Diabetes Prevention Program
  • Samaritan EPIC Health Information Services
  • Physician Champions
  • Samaritan Health Education Services

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DST PILOT CLOSEOUT PRESENTATION INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION

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Remaining Challenges

  • Moving diabetes prevention program to south Lincoln County and

beyond

  • Coding and billing support for CDC approved diabetes prevention

program

  • Continuing to focus on people with pre-diabetes, which represents 1/3
  • f the adult population, as an important in-road to impact population

health

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DST PILOT CLOSEOUT PRESENTATION INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION

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Post Pilot Sustainability

  • Pilot will be sustained and expanded with 2018 Lincoln County classes in

Lincoln City and Newport. Additional classes being planned in Linn and Benton Counties starting 2019.

  • Reimbursement through Medicare for CDC approved programs starting

April 2018 has been critical to sustainability.

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DST PILOT CLOSEOUT PRESENTATION INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION

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Discussion

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DST PILOT CLOSEOUT PRESENTATION INTERCOMMUNITY HEALTH NETWORK COORDINATED CARE ORGANIZATION

We had a great pilot project. Take me for a walk.