Crown Point's Diabetes Education & Prevention: Objectives, Partners, and Timeline, Study notes of Community Health

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Community Health Implementation Plan—

Crown Point

Franciscan St. Anthony Health‐Crown Point

Community Health Improvement Plan

• Community Health Improvement Plan CONTENTS
  • Executive Summary of CHNA
  • Franciscan St. Anthony Health‐Crown Point
• Top Health Needs and FSAH‐Crown Point Selections
• Approach and Methodology
  • Principles and Methodology
  • Intervention Design
  • Evidence Base
  • Evaluation
  • Documentation
• Implementation Plans
  • 2013‐2016 Results
  • 2016‐2018 Implementation Plan

FSAH‐Crown Point is a member of the Mishawaka, Ind.‐based Franciscan Alliance, one of the largest Catholic health

care systems in the Midwest with 14 growing hospitals, approximately 20,000 employees and a number of nationally

recognized Centers of Health Care Excellence.

FSAH‐Crown Point is located in Lake County, 1201 South Main Street, Crown Point, IN 46307. The CEO of FSAH‐

Crown Point is Barbara Anderson.

The FSAH‐ Crown Point statistics include:

FSAH Services

Annual Outpatient Visits 183,

Annual Emergency Department Visits 30,

Annual Surgical Procedures 6,

Births 1,

Employees 1,

Volunteers XX

Total Physicians (includes Franciscan Physician Network and affiliated doctors) 375

Average length of patient stay 4.

FSAH‐ Crown Point‐ Services include:

Anticoagulation Clinics Gastrointestinal Services OBGYN Surgical Services

Audiology Gynecologic Surgery Occupational Health Urgent Care

Behavioral Health Heart & Vascular Orthopedics Women’s Health/OBGYN

Breast Health Home Health Care Outpatient Services WorkingWell

Cancer Care Hospitalists Palliative Medicine Wound Care

Colon and Rectal Surgery Imaging Pediatrics

Da Vinci Robotic Surgery Incontinence Care Primary Care Physicians

Diabetes Care Infusion Services Pulmonary Medicine

Dietitians Intensive Care Unit Registered Dietitians

Ear, Nose, and Throat Interventional Radiology Rehabilitation Services

Electrophysiology Lab Joint & Spine Care Respiratory Care

Emergency Medicine Laboratory Services Robotic Surgery

Employee Assistance Program Lymphedema Services Senior Services

Family Doctor Mammography Sleep Disorders

Franciscan ExpressCare Massage Therapy Sports Medicine

Franciscan Point Nuclear Medicine Stroke Care

The FSAH‐Crown Point mission is To Continue Christ’s Ministry in our Franciscan Tradition. Values include:

Respect for Life

The gift of life is so valued that each person is cared for with such joy, respect, dignity, fairness and compassion that

he or she is consciously aware of being loved.

Fidelity to Our Mission

Loyalty to and pride in the health care facility are exemplified by members of the health care family through their joy

and respect in empathetically ministering to patients, visitors and co‐workers.

Compassionate Concern

In openness and concern for the welfare of the patients, especially the aged, the poor and the disabled, the staff works

with select associations and organizations to provide a continuum of care commensurate with the individual's needs.

Joyful Service

The witness of Franciscan presence throughout the institution encompasses, but is not limited to, joyful availability,

compassionate, respectful care and dynamic stewardship in the service of the Church.

Christian Stewardship

Christian stewardship is evidenced by just and fair allocation of human, spiritual, physical and financial resources in a

manner respectful of the individual, responsive to the needs of society, and consistent with Church teachings.

Top Health Needs and FSAH‐Crown Point

Selections

Based on the CHNA, several priority health needs, including social determinants of health, were identified. Per IRS

guidelines, the table below provides a list of the priority needs, which needs FSAH‐Crown Point will commit to

working on, and justification of why the other needs were not selected. Selection of priority health needs were based

on the magnitude, impact, feasibility, cost, and partnerships.

Health Need Description FSAH‐

Crown

Point

Priority?

Justification/Explanation

Physical Activity

and Nutrition

Obesity, diabetes management,

arthritis, and cardiovascular

conditions all score highly in incident

rates and perception of need. A

common theme amongst all of these

clinical issues is the lack of physical

activity and proper nutrition.

Yes Physical activity and nutrition education

will be integrated into the Diabetes

Prevention Program.

Behavioral

Health

Suicide, poor mental health days,

depression, and substance abuse all

rank highly in the community.

Some‐

what

Stress, depression, and poor mental health

rates also contribute to poor chronic

disease management, obesity, and self‐

satisfaction. This will be addressed in

educational programming.

Access to Health

Care

The county does have a portion

designated as health professions

shortage area due to low income

populations. In addition, there is a

shortage of providers, or long waits to

see a primary care provider.

Yes The St. Clare Clinic will be expanded to

offer additional services.

Intervention Design

Interventions implemented by FSAH‐Crown Point are person‐centered and designed to create lasting change.

Malcolm Knowles’ Principles of Andragogy provides the frame work (image courtesy of eLearning Industry):

Social Determinants of Health Socio‐Ecological^ Model

While this model is based on educational programming, it applies to all types of interventions. For example, in the

provision of clinical care or medication assistance, participants not only receive the care or medication, they also learn

to better manage their own health or access components of the health system or assistance program. Reflection,

teach‐back, and communication techniques are utilized to empower the participant to move beyond a one‐time

interaction or assistance.

Evidence Base

FSAH‐Crown Point uses evidence‐based practices in planning interventions whenever possible, as these programs

have been thoroughly tested and proven efficacy. When evidence‐based programs are not available, best practices

and documented research guides the development and implementation of the intervention.

Evaluation

Implementation activities presented in this document will be evaluated to the fullest extent. Using Kirkpatrick’s

model as a guide, evaluation of not only the program, but its impact and results will be reviewed. This process allows

for changes to be made to improve the program on an ongoing basis. While it can be difficult to determine the exact

Education programs offered through St.

Clare Health Clinic.

Diabetes through the CDC’s Diabetes

Prevention Program. The clinic will

be expanding services and

anticipates an increase in

educational opportunity.

Cardiovascular

Health

The goal in this area also included an

increase in screening, implementation of

best clinical practices, weight loss, and

diabetes prevention.

Indirectly

through

programs

While cardiovascular health

specifically is not included in the

implementation plan, a

comprehensive physical activity and

nutrition program will address the

root cause of many cardiovascular

conditions including but not limited

to diabetes, tobacco use and obesity.

2016‐2018 Implementation Plan

Three priority areas have been identified for the 2016‐2018 timeframe—diabetes prevention and management, fall

prevention, and access to healthcare.

The following plans document the anticipated activities and outcomes.

Date Created: 5/16/2016 Date Updated:

Goal HP 2020 Alignment: Other Alignment: Comments:

Frequency Short Term: Quarterly

Intermediate Term: Annually

Long Term: Reduction of incident rates of diabetes 3 ‐ 5 years Reduction of complications from diabetes in ED and Inpatient

Indiana Hospital Association

PERFORMANCE MEASURES

How will we know that we're making a difference?

To decrease incident rates of diabetes and complications from diabetes D‐1, D‐5, D‐ 14 Cardiovascular and Diabetes Initiative, Indiana Healthy Weight Initiative, American Diabetes Association; CDC

Indicator Source Biometric data DPP evaluation/data

Participant data

Improvement in management/behavioral strategies by participants

Pre/Post Test; biometric data

Objective #1: Evidence Base:

Action Target Date

Resources Needed Team

Anticipated Product/Result

External Partners

Implement one DPP program with a target of 10 participants 8/31/

Facility; instructors; marketing

Julie Maller, Chris Mallers, Amy Pleasant, Amy Delaney

Improvement in participant biometric data YMCA

Objective #2: Evidence Base:

Action Target Date

Resources Needed Team

Anticipated Product/Result

External Partners

Provide four classes for St. Clare patients focused on pre‐ diabetes, diabetes management, nutrition, and/or physical activity 12/31/

education for RN

Julie Mallers, Debbie Jordan, Quinessa Bell, Cyndi Maiko

Clinical outcomes trending toward goals as set by ADA and JNC 8

FSAH‐CP,

FPN,

YMCA,

ISBH,

Wise Woman

Develop evaluation protocol 8/31/2016 Evaluation

Julie Mallers, Debbie Jordan, Quinessa Bell, Cyndi Maiko Evaluation

FPN,

YMCA,

ISBH,

Wise Woman

Market program to patients 12/31/2016 Materials

Julie Mallers, Debbie Jordan, Quinessa Bell, Cyndi Maiko Participants

FSAH‐CP,

FPN,

YMCA,

ISBH,

Wise Woman

ACTION PLAN

Progress Notes

Progress Notes

OBJECTIVES

Implement diabetes education programs for St. Clare patients with low income ADA

ACTION PLAN

OBJECTIVES

Implement the CDC DPP program in the Crown Point Service Area CDC; ISDH

Date Created: 5/18/2016 Date Updated:

Goal: HP 2020 Alignment: Other Alignment: Comments:

Frequency Short Term: quarterly

Intermediate Term: Annually

Long Term: 3 ‐ 5 years

Indicator Source Reduction in hospital readmissions through the Transitions Clinic at St. Clare Health Clinic

EPIC

Increase the number of insured individuals that have routine preventive services with an established Primary Care Provider.

EPIC

BRFSS

County Health Rankings

PERFORMANCE MEASURES

How will we know that we're making a difference?

To increase the number of those who are uninsured able to access primary care AHS‐3; AHS‐ 5

Improvement of individuals with good physical health days Improvement of chronic disease management scores

BRFSS

County Health Rankings

Objective #1: Evidence Base:

Action Target Date

Resources Needed Team

Anticipated Product/Result

External Partners Develop and implement Transitions Clinic 10/31/2016 Epic traing, credentialing of NP's, collaborative physician agreement

Julie Mallers, MaryJo Spearson, Dr. Foriet, Barb Anderson, Dr. MCMorrmick

Transitions clinic will see patients discharged from the hospital unable to get in with their physician within 48 hours.

FPN,

physician s, ACO

Promote Clinic and services 10/31/2016 Marketing materials

Julie Mallers, MaryJo Spearson, Dr. Foriet, Barb Anderson, Dr. MCMorrmick

Transitions clinic will see patients discharged from the hospital unable to get in with their physician within 48 hours.

FPN,

physician s, ACO

Develop evaluation system for patients using the clinic 10/31/2016 N/A Julie Mallers, MaryJo Spearson, Dr. Foriet, Barb Anderson, Dr. MCMorrmick

Evaluation data FPN, physician s, ACO

OBJECTIVES

To establish a Transitions Clinic at St. Clare Health Clinic Patient centered medical home model with medical and social services; Joint Commission; AHRQ

ACTION PLAN

Progress Notes In Early phase of credentaling

Objective #2: Evidence Base:

Action Target Date

Resources Needed Team

Anticipated Product/Result

External Partners Accept HIP 2.0 patients at St. Clare Health Clinic with NP's as Primary Panel Providers

7/1/2016 EPIC, FPN,

credentialing

St. Clare Health Clinic/ FPN

Increase the number of individuals receiving primary care through HIP

HIP 2.

Marketing and advertising of expansion 6/1/2016 PR St. Clare Health Clinic/ FPN Develop evaluation strategies 7/1/2016 N/A St. Clare Health Clinic/ FPN

Evaluation Data

Objective #3: Evidence Base:

Action Target Date

Resources Needed Team

Anticipated Product/Result

External Partners Train a Navigator to provide education and resources to patients regarding preventive services, screening, lifestyle modifications, access to healthcare, and social resources.

7/1/2016 ISDH grant for Navigator

St. Clare Case Manager, BCCP, HIP Navigator

Increased utilization of preventive healthcare services

Develop resources for patients, including worksheets, brochures, and other materials

7/1/2016 ISDH grant for Navigator

St. Clare Case Manager, BCCP, HIP Navigator

Patient materials

Develop an evaluation strategy, establish number of potential patients

7/1/2016 ISDH grant for Navigator

St. Clare Case Manager, BCCP, HIP Navigator

Evaluation report

Develop a navigation program to assist patients through preventive healthcare

Progress Notes Fully in progress

Expand services of St. Clare Health Clinic to the underinsured and HIP 2.0 patients Indiana State Department of Health; CHC‐Look Alike Guidance

ACTION PLAN

OBJECTIVES

CMS, AHRQ, Indiana State Department of Health

ACTION PLAN

Progress Notes

Objective #1: Evidence Base:

Action Target Date

Resources Needed Team

Anticipated Product/Result

External Partners Contue to serve patients that are unable to follow up with their physician with in 48 ‐ 72 hours of discharge; increase usage by 10%

12/31/2017 Additional staffing for St. Clare Health Clinic, NP, MA, hospitalist

St. Clare / Case Management/ Nursing / Hospitalist

Reduce readmissions and assist patients with Chronic disease management

Physician s

ACTION PLAN

Progress Notes

OBJECTIVES

To establish a Transitions Clinic at St. Clare Health Clinic Patient centered medical home model with medical and social services; Joint Commission; AHRQ

Objective #3: Evidence Base:

Action Target Date

Resources Needed Team

Anticipated Product/Result

External Partners Continue to Navigate patients through access to healthcare and primary care, social services, and other resources; increase usage by 10%

12/31/2018 ISDH grant for Navigator

St. Clare Case Manager, BCCP, HIP Navigator

Increased utilization of preventive healthcare services

CMS, AHRQ, Indiana State Department of Health

ACTION PLAN

Progress Notes

OBJECTIVES

Develop a navigation program to assist patients through preventive healthcare

Date Created: 5/17/2016 Date Updated:

Goal: HP 2020 Alignment: Other Alignment: Comments:

Frequency Short Term: Post‐program

Intermediate Term: Annually

Long Term: 3 ‐ 5 Years

Objective #1: Evidence Base:

Action Target Date

Resources Needed Team

Anticipated Product/Result

External Partners

Develop marketing materials for participant recruitment 8/31/

Marketing materials

Stepping On team Materials

YMCA, FPN,

pharmacies, University of St. Francis, allied health professionals, EMS

Provide training for program staff 8/31/

Training Materials

Stepping On team Trained Staff

YMCA, FPN,

pharmacies, University of St. Francis, allied health professionals, EMS

Determine evaluation strategies 8/31/2016 N/A

Stepping On team Evaluation data

YMCA, FPN,

pharmacies, University of St. Francis, allied health professionals, EMS

Recruit and provide program to participants into program 12/31/

Training Materials

Stepping On team Participants

YMCA, FPN,

pharmacies, University of St. Francis, allied health professionals, EMS

Indicator Source Number of participants in Stepping On program; transfer of learning in program

Program facilitators Pre‐post evaluation program Reduce number of falls in targeted population EPIC Program participant tracking

PERFORMANCE MEASURES

How will we know that we're making a difference?

To reduce falls and related injuries in older adults IVP‐1.2; IVP 1. CDC

Reduction of unintentional injury in service area Reduction of deaths due to unintential injury in service area Reduction of hospitalizations due to unintentional injury in service area

Indiana Hospital Association data EPIC

OBJECTIVES

Implement the Stepping On program for 420 individuals annually Stepping On, CDC

ACTION PLAN

Progress Notes