Increasing Referrals to Diabetes Prevention and Management Programs

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Thank you for joining us today for the
webinar "Strategies to Increase Health
System Referrals to Type 2 Diabetes
Prevention and Diabetes Management
Programs". Our presenter is Krista Proia,
who is a Health Scientist with the
Centers for Disease Control and
Prevention. I am Michelle Knight with ICF
Next and I will be your moderator today.
the recording and transcripts as well as
the PowerPoint slide deck for this
webinar will be available on the CDC
website. Our learning objectives for this
webinar are shown here.
Moving forward we will refer to chronic
disease prevention programs and chronic
disease management programs collectively
as chronic disease programs. The content
of this webinar is drawn from the CDC
brief "Increasing Health System Referrals
to Diabetes Prevention and Diabetes
Management Programs". Now Krista will
begin by describing the need for chronic
disease programs. Thank you Michelle. As
many of you know chronic diseases are
the leading cause of death and
disability in the United States and the
leading cause of health care costs.
Prevention and management of chronic
diseases are critical to improving
health and reducing cost. One way to
improve prevention and management is
increased Health System referrals to
evidence based chronic disease programs
such as the National Diabetes Prevention
Program lifestyle change program and
diabetes self-management education and
support.
The types of chronic disease programs
we are going to talk about today are
chronic disease prevention programs and
chronic disease management programs.
Chronic disease prevention programs are
designed to provide lifestyle change
support and education to reduce chronic
disease risk.
Examples of chronic disease prevention
programs include the National Diabetes
Prevention Program,
also known as National DPP, other
lifestyle change programs, and smoking
cessation programs. Chronic disease
management programs promote self
efficacy, self monitoring and adherence
to better manage disease and prevent
complications in people who already have
a chronic disease. Examples of chronic
disease management programs include
diabetes self-management education and
support or DSMES for those diagnosed
with diabetes and cardiac rehabilitation
programs for people who recently had a
heart attack. Referrals from a health care provider
can be important in helping make sure
individuals participate in effective
chronic disease programs. However, often
people eligible for these programs are
not aware of and do not participate in
them. This is particularly true for
people with prediabetes who are
eligible to participate in a National
DPP lifestyle change program. Often
people only hear about their risk from a
health care provider and thus health
care providers are an important champion
to raise awareness of the availability
of effective chronic disease programs.
Health care providers are often viewed
as credible sources of health advice and
thus are likely to influence behavior
change and continued participation in
chronic disease programs. Health care
provider referral can also predict
enrollment for some types of programs and
thus program planners will have a better
idea of how many participants to expect
based on health care provider referral.
For the purposes of this webinar we define a
Health System referral as a process by
which an individual in the clinical
setting is recommended to receive a
specific service or attend a specific
program delivered by another entity. A
health system referral can serve as a
community-clinical linkage, connecting the clinical
sector to the community sector. An
example of this is the physician
referring one of her patients to a
community-based National DPP lifestyle
change program. Referrals can also
connect one clinical setting such as a
physician's office to another clinical
setting like a hospital. Referrals to
chronic disease programs may be made by
a variety of healthcare providers
including physicians, nurse practitioners,
physician assistants, registered nurses
midwives, diabetes educators, pharmacists,
dietitians, nutritionists, dentists or
community health workers. However in some
instances for reimbursement purposes
only certain healthcare providers can
refer an individual to certain programs
or services. For example only physicians
and qualified non-physician healthcare
providers can make referrals to DSMES.
Let's talk more about barriers to
referral. We will use referral of
patients with prediabetes to National DPP
lifestyle change programs as our example.
Barriers to referral may occur because health
care providers lack specific information
about the lifestyle change program, such
as where and when the program occurs.
Health care providers are not aware of why the
program is important or the impact
the program has on preventing type 2
diabetes. Or, health care providers may
not understand the referral process
within their network, program eligibility
requirements, or cost and coverage/
payment options. Barriers occur among
potential participants. Too many eligible
persons aren't aware of the program and
their need for it and don't participate
because of this. People may not ask their
health care provider for more
information about the National DPP or a
referral to one.
In 2019 scientists in the Division of
Diabetes Translation at CDC conducted a
systematic review to identify strategies
that may help address the barriers
mentioned on the previous slide and
improve referral rates for chronic
disease prevention and management
programs. The strategies we present
today are those we identified from that
systematic review. Because type 2
diabetes prevention and diabetes
management programs can learn from
multiple strategies used for other types
of chronic disease programs this review
included studies of referrals to other
programs such as smoking cessation
counseling, cardiac rehabilitation and
nutrition and weight loss services. The
work also included studies of referrals
to preventive services recommended by
the US Clinical Preventive Services Task
Force such as mammograms and HIV testing.
From that systematic review we
identified four types of health system
referral strategies. Provider education
strategies have a primary focus on
health care staff education and training.
Examples include distribution of
referral guidelines or providing
feedback from current provider referral
practices. System change strategies
involve large-scale activities such as
the movement of health staff, expanding
roles for existing staff, and inclusion of
non-traditional staff into the care
team to increase referral. System
changes may even involve relocation of
clinics or changes to financial
arrangements to support referral process.
Change strategies involve smaller
changes that impact the individual
referral process such as the use of
electronic referral system or automatic
referrals for patients who meet certain
criteria. And multiple strategy types can
also be used. Multiple strategies involve
combinations of at least two of the
strategy types I've already mentioned.
During this webinar
I will provide information for each
strategy type. This information will
include an overview of the studies
included with details about referral
settings, and the common types of referring
providers. Identification and definitions
for individual strategies that fall
within each strategy type and an
implementation example for each
individual strategy. Highlights of
individual strategies that have been
shown to increase referrals, based on
available information in the systematic
review and methods developed by the
Guide to Community Preventive Services. And
finally a description of implementation
considerations. The first referral
strategy type I will talk about are
provider education strategies. As I
mentioned previously provider education
strategies include a primary focus on
healthcare staff education or training.
We found that most studies that evaluated
provider education strategies involved
referrals to chronic disease programs
that are shown on this slide. Some
studies involved referrals to preventive
services including mammograms, genetic
testing, and other cancer screenings. We
also found that most referrals in these
studies are made in a primary care
setting and physicians are most often
the referring providers. So let's dive in...
this slide shows a list of all
individual provider education strategies
we identified in the systematic review.
Strategies that have enough evidence to
conclude that they increase referrals
are indicated with the green dot. In
determining whether a strategy received
a green dot we looked at four criteria:
the number of studies evaluating the
strategy, the more the better,
the consistency of the effect across these
studies or were most of these studies
showing that referral rates improved;
the strength of the study designs used
to evaluate the strategy, for example
randomized controlled trials held more
weight than a study design that did
not include a comparison group, and the
quality of the study, were there concerns
about how the study was conducted that
caused us to question the accuracy of the
findings. We found that formal training
and professional development, the
provision of educational materials and
providing audit and feedback
were strategies that had enough evidence to conclude they
increased referrals. Strategies without a
green dot did not meet the criteria to
show evidence for increasing referral,
not because they decrease referral, but
because we did not have enough studies
that evaluated these specific strategies
or they were evaluated using weaker
study designs,or the overall quality
of the studies were too limited to make a
conclusion. From the studies that assessed
formal training or professional
development we learn of these strategies
included trainings and workshops that
provided information for providers about
when and how to make referrals, build their
overall knowledge base and skill set, or
learn how to incorporate a formal
referral protocol into their clinical practice.
These trainings and workshops varied in
frequency and delivery and included
webinars, workshops or lecture sessions,
discussion-based sessions, phone
education, group meetings, demonstration
or roleplay, simulation, symposium and by
mail courses. Now I will present an
example of formal training and professional
development involving a smoking
cessation program. The study aimed to
educate providers about tobacco quit
lines, referral methods and tobacco
interventions. Researchers developed an
online continuing medical education
program that included quit line
education and intervention and referral
skills training tailored specific
providers such as physicians, nurses,
dentists, pharmacists and others. Specific
patient settings such as outpatient and
inpatient settings are also addressed.
The program included a module about
strategies to enhance patient motivation.
Now let's turn our attention to
educational materials. Referring health care
providers received marketing materials
describing the chronic disease program
or service available to refer
individuals to, guidance documents or
formal steps that provided detailed
information on how and when to refer
individuals to chronic disease
prevention or management programs, and
resources, tools, and templates to help
facilitate referral. Educational
materials may include materials from
training or education session, pocket
cards, examples of screening materials,
information about billing codes,
information about where to refer
individuals, educational websites,
newsletters, direct mailings, promotional
materials and FAQ sheets.Using
educational materials to increase referrals
can work well. For example, a diabetes
management study aims to inform
general practitioners about the
existence of community-based dietitian
led diabetes clinic and the type of
patient who would benefit most from care at
the clinic.
Researchers developed posters of
information about the clinics and mailed
them to individual general practitioners.
The posters outlines how to provide a
referral to the clinic dietician, the
types of patients with diabetes who
would benefit most from the clinic, and
the location and schedules of the clinic.
The next strategy we evaluated was audit
and feedback. An audit and feedback
strategy involves a third-party review
of current provider referral behaviors
and delivering feedback to the referring
provider on their referral progress and
whether they are referring appropriately.
An audit may include referral rates of
other referring providers so that
providers can compare their referral
progress with that of their colleagues. I
want to share with you an example of the
use of an of an audit and feedback
strategy for increasing referrals. This
example comes from a smoking cessation
program. The study involves a group
randomized clinical trials to assess the
impact of comparative feedback versus
general reminders on health system
referrals to a tobacco cessation quit line.
Every quarter for six quarters
clinicians received a mailed comparative
feedback report or a general postcard
reminder about quit line services. The
feedback report was a single page with
one graph showing quarter bench marks
for referrals for the individual
clinician,, his or her practice group and
the performance of the study group. The
second graph showed the actual number of
referrals made by the individual
clinician per quarter. An example
feedback report used in the study is
shown on this slide.
The next provider education strategy
I will discuss is academic detailing. This
means that referring health care
providers receive University or non
commercial based educational outreach.
Academic detailing involves brief
face-to-face education with referring
providers by trained healthcare
professionals, typically pharmacists
physicians or nurses, that is repeated at
periodic intervals. Detailers sometimes
share tailored materials and approaches
to address a health care providers
barriers to referral. Academic detailing
has shown to be a helpful strategy. In one
example an academic detailing
intervention aimed to increase referral to
breast cancer screening by physicians
working in medically underserved urban
areas. Intervention physicians received
four academic detailing visits from two
masters level health educators. These
averaged about nine minutes in length
and physicians received self-learning
packets that included professionally
designed print materials, scientific
articles, and a sample verbal
transcript. The visits and materials
highlighted the American Cancer
Society's breast cancer screening
recommendations. With physician consent the
materials were shared with other staff.
The intervention supplemented office
visits with dinner seminars and
dissemination of a newsletter to
decrease attrition. The next provider
education strategy was individual
consultation. Referring health care
providers received one-on-one
consultation to go over strategies, tools,
guidelines or suggestions that can help
them increase referrals to programs or
preventive services. This may include
meetings or consultations with other
providers, one-on-one supervision,
individual skills demonstration, or
simulation, and individual workshops. In
an implementation example, researchers
examined how an education program
affected the quality of care for
patients with chronic obstructive
pulmonary disease or COPD. The education
program included individual consultation
for general practitioners and their
staff and examines the impact on
referral to pulmonary rehabilitation.
Specifically, an individual meeting with
a consultant focused on international
guidelines for COPD care. In addition to
the individual consultation a regional
meeting with about 30 general
practitioners and their staff focused on
a discussion of international guidelines
with experts, and a symposium was
offered for all participating general
practitioners and their staff with
plenary sessions and workshops
addressing practical issues. Several
considerations could inform your
implementation of provider education
strategies to increase referrals to
diabetes management and type 2 diabetes
prevention programs. We learned that
studies using formal training or
professional development, educational
materials, or audit and feedback provide
enough evidence to show that they
increase referrals. Both individual
consultation strategies and academic
detailing strategies can be used but
because less is known about whether they
increase referrals program evaluation is
especially important. Most provider
education strategies were implemented in
the primary care setting. Other settings
may work as well but less is known about
them. It is important to understand
referral practices in your specific
implementation setting and tailor your
strategy to the referring providers. Most
of provider education strategies
involved physicians as the referring
providers. Other healthcare team members
or staff may be able to serve as
referring providers, but less is known
about these situations. Many studies
included multiple provider education
strategies. For example, formal training
and professional development strategies
were often accompanied by individual
consultation or educational materials.
Implementing multiple strategies may be
an effective approach. Because most studies
do not report on patient characteristics
the effectiveness of provider education
strategies to increase referrals for
specific populations is not known. Those
programs should be evaluated for
evidence of increasing referrals in
specific populations.
The next strategy type we will discuss
is system change strategies. System
change strategies include large-scale
changes that involve the movement of
health staff, expansion of roles for
existing staff, integration of
non-traditional staff into the health
care team, relocation of clinics,
or changes to financial arrangements for
referrals such as incentives. When we
looked at system change strategies we
found that most studies involved
referrals to the chronic disease
programs shown on this slide. Some
studies involved referrals to preventive
services including cancer screening and
HIV testing. We also found that most
referrals are made in a primary care
clinic setting. Other settings included
specialty clinics and hospitals. Referrals
are most often made by multiple
healthcare team members including
physicians, health advocates, nurses and
clinical social workers. This slide shows
the two system change strategies we
identified in a systematic review - team-based
care and the addition of clinics. The
strategy that was shown to increase
referrals - team-based care - is indicated
with a green dot. As mentioned previously
in determining whether a strategy
received a green dot we looked at four
criteria shown on this slide. The
addition of clinics did not meet the
criteria to show evidence for increasing
referrals because only two studies
assess the strategy. With team-based care
a new team member is added to the
healthcare team to focus on facilitating
referrals within their health system or a
current team members role shifted to
focus on facilitating referrals to
chronic disease prevention or management
programs. Team-based care can also include
adding trained staff to implement new
patient-focused initiatives. Team members
in the studies we reviewed
included physicians, nurses, patient
health advocates, and medical support
staff. In an example of team-based care
to facilitate referrals, a study assigned
practice nurses as case managers of
patients with depression and diabetes, or
depression and heart disease. The case
managers identified depression and
reviewed pathology results, lifestyle risk
factors, and patient goals and priorities.
Practice nurses received training in a
two-day workshop to prepare them for
enhanced roles in nurse-led
collaborative care. Training included use
of tools to screen for depression,
behavioral techniques, and protocols for
peer management based on patient
depression scores. The intervention was
designed to fit into normal clinic
operation. The addition of clinics
involves implementing a collaborative
care approach by adding a specialty
clinic in a primary-care setting to
facilitate referrals to chronic disease
prevention or management programs. I'd
like to share an example of how this
works. To help improve care for patients
with cognitive impairments, a family
medicine practice in Canada implemented
an interdisciplinary memory clinic. One
aim was to allow for access to
comprehensive assessment and care. Another
aim was to improve referring physicians
knowledge of dementia management as well
as their confidence in managing
cognitive difficulties. Clinic staff
included a family physician lead, two
registered nurses, a social worker, a
pharmacist, and a receptionist. A geriatrician
was available to support the lead
physician in more complex cases. The
clinic operated one to two days per
month with four new assessments and two
follow-up appointments scheduled on each
clinic day. Referring family physicians
are encouraged to inform patients about the
memory clinic assessment. They were also
provided with handouts for patients
outlining what to expect. Referring
physicians are informed when patients
decline to schedule an assessment and
clinic staff were available to assist
physicians with strategies to increase
the likelihood of referral acceptance.
Several considerations could inform your
implementation of system change
strategies. We learned that studies using
team-based care provide enough evidence to
show that they increase referrals.
Addition of clinic strategies can be used,
but, because less is known about whether
they will increase referrals, program
evaluation is especially important. Most
system change strategies were
implemented in the primary care setting.
Other settings may work as well but less
is known about them. Most of system change
strategies focus on changing how
healthcare team members work together to
increase referrals. Thus, focusing these
strategies on the entire team may be an
effective approach. System change
strategies, which tend to focus on a
collaborative approach, should account
for the level of collaboration between
staff members. Implementing these types
of strategies in a way that is mutually
agreeable for all provider types
involved may be most effective. Because
most studies did not report on patient
characteristics the effectiveness of
system change strategies to increase
referrals for specific populations is
not known. Thus, programs should be evaluated for
evidence of increasing referrals in
specific patient populations. The next
strategy type we evaluated were process
change strategies. These types of
strategies include small scale changes
to some aspects of the individual
referral process such as introducing
electron referral systems, bi-directional
referrals, and automatic referrals with
opt-out provisions. When we looked at
process change strategies we found that
most studies involved referrals to the
chronic disease programs shown on this
slide. Some studies involved referrals to
preventive services including genetic
testing, bone density screening, and
mammogram. We also found that most
referrals are made in primary care
clinic settings. Other settings included
specialty clinics and hospitals.
Referrals are most often made by
multiple healthcare team members
including physicians, health advocates,
nurses, and clinical social workers.
We looked at several process change
strategies. The strategy that was shown
to increase referrals - decision support -
is indicated with a green dot based on
the four criteria listed on this slide.
Strategies without a green dot did not
meet the criteria to show evidence for
increasing referral because only a small
number of studies assessed these strategies.
Prompts, alerts, reminders for screening,
and treatment algorithms are decision
support strategies that assist health
care providers in making referrals. Here is
an example of how decision support was
implemented. The quality improvement team
of an academic family medicine clinic
created a tobacco registry, which
included a decision support tool for
referring patients to a tobacco quit
line or nicotine dependence program.
Smokers who expressed a readiness to
quit could choose one, both, or neither
option. Medical assistants used the
decision support tools assess patients'
level of tobacco use and ask about
quiting. The tool included prompts for
fax referral to the quit line, referral to
the nicotine dependence program, offering
medication, providing self-management
support, offering a pneumococcal vaccine
and administrating depression and aortic
aneurysm screening. Providers use the
information obtained by the medical
assistants and a list of prompts
recommended services to guide their
advice to patients, and to develop an
appropriate treatment plan. The next
strategy is
automatic referral which involves putting a
process in place that triggers a
referral based on specific patient
criteria without the healthcare provider
making the decision to refer. Electronic
or paper-based format can be used with
automatic referrals.
I'll review an example with you. In one
study, hospital electronic patient
records were used to prompt referrals to
a cardiovascular rehabilitation program
for all eligible patients with cardiac
diseases. The referral was automatically
initiated in the inpatient unit as a
discharge order, printed on a hospital
network printer, and screened for
eligibility. After being discharged from
the hospital cardiovascular
rehabilitation center each patient was
automatically mailed an information
package. This package included a
personalized letter stating the name of
the referring physician, a program
brochure of scheduled classes, and a
request that the patient call to book
an appointment. Patients who lived
outside of the geographic area were sent a
similar package and were provided the
contact information of the site closest
to their home. With an electronic or
ereferral, referrals go from paper-based
referrals to referrals that are
electronically transmitted. Referrals are
often emails or sent through an
electronic health record system. The
messages may include supplemental
attachments such as medical history or
or test results. In one example, a regional
health system, an EHR vendor, a tobacco
cessation quit line vendor, and a
university research center work, together
to create an e-Referral system within the
health system EHR. The modifications
included adjustments in clinic workflow
and EHR prompts.
The next process change strategy is
bi-directional referral. With
bi-directional referral the healthcare
provider sends information to the
program or service and the program or
service sends feedback on the patient's
progress to the healthcare provider. Here
is an example of bi-directional referral.
In Massachusetts a referral program
called QuitWorks was used to link health
care organizations, providers, and patients
to the state's tobacco cessation quitline
and provided feedback reporting. The
state launched a fully electronic
version of QuitWorks in 2010 in
partnership with a large health system.
The program accepted referrals from any
EHR with patient medical record
identification. The program also had the
capability to transmit feedback reports
electronically to the referring provider
organization. The last process change
strategy we evaluated were referral
letters. With referral letters, patients
receive a mailed letter from their
healthcare provider referring them to a
program or service. For example, a
two-year study aims to increase breast
cancer screening. Physicians who agreed
to participate obtained a list of all
female patients in their practices and
identified appropriate candidates.
Personalized letters on physician
letterhead were signed and mailed to
eligible participants along with fact
sheets and maps. The letters explained the
purpose of screening and asked women to
book screening appointments during a
two-week period. For women who did not book
an appointments, follow-up letters signed by
their physician were mailed two weeks
after the initial letter. Here
are some considerations that could inform your implementation of
process change strategies. Currently,
studies using decision support provide
enough evidence to show that they
increase referrals. Automatic referral,
e-referral, bi-directional referral or
referral letter strategies can still be
used, but because less is known about whether
they will increase referrals program
evaluation is especially important. Many
process change strategies use health IT,
such as EHR systems. In these cases you
will need to connect with staff
with working knowledge of the relevant
technologies and how to implement
changes. You may need to involve other
stakeholders such as EHR vendors. Most
strategies involving process change
strategies were implemented in the
primary care setting. Other settings may
work as well, but less was known about
them. It's important to understand
referral practices in your specific
implementation setting and tailor your
strategy to the referring providers. Most
strategies involved physicians and
nurses as the referring providers. Other
healthcare team members and staff
including non-clinical staff may be
able to serve as referring providers but
less is known about these situations.
Some studies included multiple process
change strategies. For example, one study
used both decision support and automatic
referral. Implementing multiple process
change strategies may be an effective
approach. Because most studies did not
report on patient characteristics the
effectiveness of process change
strategies to increase referrals for
specific patient populations is not
known. The program should be evaluated
for effectiveness in specific patient
populations. The final strategy type we
will discuss today are those that use
multiple strategies. Multiple strategy
types are interventions using strategies
from at least two of the referral
strategy types already described in this
webinar.
Provider education strategies, system
change strategies, and process change
strategies. When we looked at multiple
strategy types we found that most
studies involved referrals to the
chronic disease programs shown on this
slide. Some studies involved referrals to
preventive services including cancer
screening, and
genetic testing. Most studies involved
referrals made in a primary care clinic
setting. Other settings include hospitals,
specialty clinics, nursing homes, community
based organizations, county government and
medical schools. Physicians and nurses
were most often the referring providers.
Other referring providers included nurse
practitioners, nutritionist or dietitians,
medical assistants, clinic managers,
occupational therapists, physiotherapists,
and physician trainees. In some cases
front office staff also made referrals.
You can see the specific combinations of
strategy types to be evaluated on this
slide. Provider education strategies
combined with process change strategies
were the only combination that showed
sufficient evidence for increased
referrals based on the four criteria
we've mentioned previously and thus is
indicated with a green dot. Strategy
combinations without a green dot did
not meet the criteria to show evidence
for increasing referral not because they
decreased referrals but because we do
not have enough studies that evaluated
these combinations, or they were
evaluated using weaker study designs,
or the overall quality of the studies
were too limited for us to make a conclusion.
Studies that assessed provider education
and process change strategies in
combination includes some of the
provider education and process change
strategies we described earlier. It also
includes one new process change strategy,
FAX referral programs. With a fax referral program,
the referring health care providers fills out
a fax referral form with the patient
and then faxed the form to the program. A
Fax referral was mostly used to refer
patients to tobacco cessation quitlines.
I will share
an example of this combination. The Bronx
Collective Action to Transform Community
Health partnership, or CATCH, implemented
a formal training strategy and
an e-referral strategy to increase
referrals in federally qualified health
centers to the YMCA-based Diabetes
Prevention Program or YDPP which is
part of the National DPP. For the e-Referral
strategy, a referral template
was added to the EHR system to make
patient referrals to the YDPP easier.
Health care providers received formal
training to use the EHR to increase
and sustain clinic based YDPP
referrals over time. The next combination
includes some of the provider education
and some of the system change strategies
we described earlier. It also includes
one new system change strategy. Regional
Outreach Specialists. With this strategy,
outreach specialists are assigned to
specific geographic regions to assist
health systems in establishing referral
programs. This strategy was mostly used of
tobacco cessation programs. In a 2016
study, a formal training strategy and
a team-based care strategy were used to
increase referrals to help coaches
assist patients with chronic disease
management. Two health coaches joined the existing
health care providers. The health coaches
received 40 hours of training on chronic
disease care, motivational interviewing,
goal-setting, documentation, identifying
barriers and professional boundaries.
They received 20 hours of in-depth
motivational interviewing instruction.
Primary care physician training included
an introduction to health coaches, an
explanation of criteria for referral to
a health coach, and a specific language
to use. Refresher training at department
meetings reminded primary care physicians
how and when to make referral, and staff
shared stories of patients using the
health coach program.
The next combination was system change
strategies combined with process change
strategies. This multiple strategy type
includes some of the system change and
some of the process change strategies we
described earlier. It also includes the
addition of two new strategies. Pay for
performance is a system change strategy
in which referring health care providers
are offered financial incentives for
meeting certain referral performance
measures. Investment in IT is a process
change strategy in which health systems
invested in new electronic tools or
health information technology to
facilitate referral. Here is an example
of this multiple strategy type. To make
improvements to the post stroke patient
discharge process the neurology stroke
service established a multidisciplinary
team that included a case manager, a
social worker, physical therapist,
occupational therapist, a speech and
language pathologist, charge nurses, and
liaisons from each of the follow-up care
teams. The teams planned for patient
discharge,
identified follow-up care placement
options, identified and attempted to
remove barriers to discharge, and
organized follow-up care resources. Case
managers and social workers received
phones and texting capabilities. Case managers,
social workers and therapists received
tablet computers to support management
of referrals to stroke rehabilitation
and follow-up care, additions to
patient charts, communication about discharge
recommendations, and increased
communication. The final combination
includes all three strategy types.
Studies that evaluated this multiple
strategy type category include some of
the provider education process change
and system change strategies we
discussed earlier. It also includes one
new system change strategy - operating
cost.
With this strategy, health systems are provided
with upfront cost or a portion of
operating costs to cover the referral
systems they establish.
Here's one example of a study that
evaluated multiple strategy types. To
improve the quality of care for dementia
by primary care physicians, physicians
at two community-based clinics
participated in an intervention that
included results of audits of medical
records of five patients with dementia
per physician; decision support, with,
prompts to address the condition with
appropriate data collection, diagnostics,
and follow-up care; a physician fax referral
form to local Alzheimer's
Association chapters, and an Alzheimer's
Association fax response form to support
bi-directional referral; training to
support physicians in incorporating
recommended processes into patient
visits; and training for office staff to
support implementation activities.
Several considerations could inform your
implementation of multiple strategy
types. Currently, only studies using a
combination of provider education and
process change strategies provide enough
evidence to show they increase referral.
The most common combination of
specific provider education and process
change strategies was formal training
and professional development
combined with decision support. Other
combinations of strategy types can be
used but because less is known about
whether they will increase referrals
program evaluation is especially
important. As with other strategies we've
looked at most interventions involving
multiple strategy types were implemented
in the primary care settings. Other
settings may work as well but less is
known about them. It's important to
understand what role practices in your
specific implementation setting and
tailor your strategies to refering
providers. Most studies involved
physicians and nurses as the referring
providers. Other healthcare team members
including non-clinical staff may be able
to serve as referring providers but less
is known about these situations.
Implementation of multiple strategy
types should be done with attention to
provider needs to avoid overwhelming
demand from providers and existing
workflows. Because most studies do not
report on patient characteristics the
effectiveness of multiple strategy types
focused on referrals for specific
patient populations is not known. The
program should be evaluated for
effectiveness in specific populations. To
summarize Health System referrals are
important because of their potential to
connect more individuals with effective
chronic disease prevention and
management programs such as the National
DPP and DSMES. Participation in these
programs can lead to lifestyle
improvement, better quality of life and
ultimately reduce morbidity and
mortality and reduce health care costs.
As discussed during this webinar there are
many strategies that can be used to help
increase referrals to effective chronic
disease programs. It's important to note
that this project looked at strategies with
evidence for increasing referrals. However,
this does not automatically mean increased
enrollment or participation in these
programs. Enrollment in chronic disease
prevention and management programs can be
affected by other factors such as
characteristics of the potential
participant or characteristics of the
potential program in which participants
can enroll. But referral by a trusted
healthcare provider is an important
first step in increasing enrollment in
these effective prevention and
management programs. Needs assessments
can help identify specific gaps in
connecting people with chronic disease
prevention and management programs. In
some cases additional strategies to
address other barriers to enrollment may
be implemented alongside strategies to
increase health system referrals. Needs
assessments may also reveal a need for
improved patient education, risk
detection, access to local programs or
retention of those participants who do
enroll in chronic disease prevention or
management programs. Ultimately a
comprehensive and tailored approach to
improving access, referral, enrollment, and
retention is important for improving
access to, and participation in effective
chronic disease prevention and
management programs such as the National
DPP lifestyle change program and DSMES.
Based on what you learned during this
webinar you should be able to define
chronic disease programs and describe
the benefits of increasing Health System
referrals to National DPP and DSMES. This
webinar has helped you to define the
different referral strategies and
multiple strategy combinations including
strategies that increase referrals to
chronic disease programs such as the
National DPP and DSMES and describe the
approach to implement referral. For more
information on strategies to increase
health system referrals please refer to
CDC's referral strategies guidance
document titled "Increasing Health System
Referrals to Type 2 Diabetes Prevention
and Management Programs". Additional
resources from the CDC referral
strategies guidance document include
references of included studies
reviewed, details on the criteria for
determining effective strategies,
referring provider and patient
characteristics, and referral settings. On
behalf of CDC I want to thank you for
participating today in the Strategies to
Increase Health System Referrals to Type
2 Diabetes Prevention and Diabetes
Management Programs webinar. For more
information we invite you to visit the
CDC website at www.cdc.gov.