1. Update on Partnership and DPH Chronic Disease Activities Lea Susan Ojamaa Director, Division of Prevention and Wellness

2. Progress on State Plan Communities of Practice –meeting regularly –identified strategies –will present this afternoon Finalized strategies due to CDC August 2013 Policy Work Group –M & R surveyed members on policy priorities –results presented today at 3:00 p.m.

3. Division of Prevention and Wellness Revised Structure March 2013 Cheryl Bartlett BCHAP Director and Chronic Disease Director Lea Susan Ojamaa Director, Division of Prevention and Wellness Elizabeth Barry Director of Administration and Finance Thomas Land Director, Office of Statistics and Evaluation Office of Community Health Craig Andrade, Director Focus on creating conditions that enable people to make healthier choices where they live, learn, work and play Office of Tobacco Prevention Patti Henley, Director Focus on creating conditions that prevent young people from beginning to use tobacco, helping smokers quit, and protecting people from exposure to secondhand smoke Office of Clinical Preventive Services Anita Christie, Director Focus on the development and implementation of clinical activities to prevent, identify, control, treat and manage chronic disease and associated risk factors. Office of Integrated Policy, Planning and Management Jean Zotter, Director Will provide leadership in developing an integrative approach to chronic disease prevention and health promotion across the Commonwealth and further enhance linkages between the community and clinical settings Office of Health Communications Gwen Stewart, Director Will provide leadership in development of integrative messages across the division to support chronic disease prevention and health promotion

4. Related Activities at DPH Funding from CDC Combined for Major Diseases/Risk Factors (Heart Disease, Stroke, Diabetes, School Health, Obesity) Wellness Tax Credit Incentive Prevention and Wellness Trust Fund CMS Innovation Grant – e-Referral program

5. e-Referral Program The Triple Aim: Better population health, better experience of care, lower costs What is our goal? Payment Reform How do we do it? Delivery system transformation Cost and quality accountability How does SIM help us get there? Medicaid’s Primary Care Payment Reform Initiative The Group Insurance Commission’s value based purchasing strategy Provider portal on the APCD Adoption of the Health Information Exchange Data infrastructure for LTSS Providers Electronic referrals to community resources Access to pediatric behavioral health consultation Linkages between primary care and LTSS Technical assistance to primary care providers HIE functionality for quality reporting Statewide quality measurement and reporting Payer and provider focused learning collaboratives Rigorous evaluation

6. e-Referral Program: Overview The concept of creating a bi-directional electronic referral is not new: In 2008, Frieden and Mostashari listed twelve key features that would be necessary for a system of electronic health records to function as effectively as possible.* Of the 12 features, only “Linking EMRs to Community Resources” has had no forward movement. In 2010, MA DPH and NH DOH sponsored a project to create electronic referrals to the Tobacco Quitline using a proprietary software, www.health-e-link.netwww.health-e-link.net Currently, the Multi-State Collaborative for Health Systems Change is sponsoring a pilot of this software with 3 sites *Cite: Frieden TR and Mostashari F. Health Care as if Health Mattered. JAMA, February 27, 2008, Vol 299, No. 8, 950-952.

7. e-Referral Program: Grant Activities As part of the MA SIM grant, MDPH submitted a proposal to create an open-source, bi- directional, vendor-neutral, electronic referral program that would enable electronic community-clinical linkages as part of the overall SIM grant The Massachusetts League of Community Health Centers are our primary clinical partners Their CHIA DRVS data system will allow us to evaluate the impact of the e-Referral program both on referrals to community resources as well as health outcomes Funding provides IT support and necessary staff for both clinical and community resources Our initial pilot sites would be 3 CHCs affiliated with the Mass League who are on CHIA DRVS and four community resources such as: Tobacco Quitline, Councils on Aging/Senior Centers (Stanford Chronic Disease Self-Management Programs), VNAs, YMCAs Part of grant includes a roll-out plan to make software available state-wide resulting in more providers using e-Referrals across additional types of community resources

8. e-Referral Program: Example of bi-directional referral CHC Health care provider diagnoses Jane Smith with diabetes. Jane gives consent for referral to Tobacco Quitline and local CDSMP program. Tobacco Quitline & Local Council on Aging Jane is contacted by Quitline and starts counseling program to quit smoking. Jane is also contacted by Senior Center and begins 6 class CDSMP program. Clinical Setting Transmission from EMR Community Resource e-Referrals from Provider to (1) Quitline & (2) Council on Aging Contact Information: Address, Phone Other Health Data: Current smoker and Type 2 Diabetes CHC Automatic updates of smoking and exercise program added to EMR. At next appointment, health care provider is able to see the update of Jane’s progress in Jane’s own electronic health record. Inbound Transaction Progress report from community resources to provider (Standardized HL7 Formatted Transaction) Jane Smith Smoking status at 6 months post referral, CDSMP sessions attended, and improvement in FV intake and exercise Clinical Setting Transmission to EMR Community Resource Tobacco Quitline & Local Council on Aging Quitline calls back 6-months post referral for update. Senior Center prepares final CDSMP report on Jane’s progress. Updates transmitted to provider as requested. Outbound Transaction