Patty Kelly-Flis, BSN, BA, CPC Consultant with the RI DPCP Quality Systems Coordinator for the Rhode Island Chronic Care Collaborative

Care Model Prepared, Proactive Practice Team Informed, Activated Patient Community Resources and Policies Health System Organization of Health Care Self- Management Support Delivery System Design Decision Support Clinical Information Systems Productive Interactions Functional and Clinical Outcomes

What is Community? Everything outside of your organization

Identifying resources/partners Understand to get something, something needs to be shared Resources are actually partners What is around you? Churches, Community organizations, large meeting areas, parks and recreation, Health Department, Department of Health and Human Services, Schools, YMCA, to name a few

What they want in return To engage a partner, you need to find out what they want/need Examples: YMCA- they want business, they need to have people sign up for their programs to make money and stay in business Church groups- they want their people to be healthy, so education/programs are what they are usually looking for

Continued examples Parks and Recreation Department-what people to use their facilities, so usually they are more of a resource for walking paths, activities that are happening there Large meeting areas: these are good for programs that you may want to run an need spaces-look for rooms at corporations, libraries, schools, to name a few- sometimes they want $$ for the space other times they just offer the space for free.

Department of Health-Especially the Diabetes Prevention and Control program –They want: Data, Data, Data –They each have their own plans for what they need to do in their state-meet with them see how you can fit into their plan –They offer resources-handouts, linkages with other organizations that may be of assistance, $$ (not many), resource links, some have programs that you can access, others only have the ability to get you handouts, data and information

Schools- –They are looking for ways to keep their kids healthy, so offering education, programs and information may be a help –What they have for you: audiences, kids and parents, rooms, outdoor spaces, maybe indoor spaces, resource to disperse information to a large population-(flyers to all kids in the school), school nurse may be helpful in identifying students in need of care

Senior Centers- –They are in need of educational programs, exercise programs, things for the seniors to do –What they have to offer: a population at risk, captive audience that are looking for free things, audience is looking for access to care that is not going to exhaust their resources

Working with a partner Steps: 1.Identify a potential partner/resource 2.Determine what they are in need of 3.Determine what you may be able to do to help their need, but also serve something you need 4.Arrange a meeting with someone who can speak for the organization 5.Pitch the idea to them 6.Do what you said you would do 7.Stay in contact with them

So how does it relate to PDSA Testing in this area may be difficult to quantify, it may be difficult to do small tests of change, it may be difficult to identify the population, but it is possible to track something!

PDSA example PlanYou need to get resource materials for your diabetic patients but you do not know what is available. You have identified that the Diabetes Prevention and Control program in your state may be a resource to you. You go to their website to look at what they are doing right now, what they are working on, what do they have to offer. You determine that you can offer them some data that may help them. You are working on the collaborative and all the DPCPs are aware of the HDC. You contact the person identified on the web site as the contact person. Set up an appointment to speak with them. You come prepared to discuss your population and what you are in need of

PDSA continued You predict that the person at the DPCP will be able to give you materials that you will be able to give to your patients. The meeting will probably last 30 min. and you will come away with resources, they will come away with information you provided (number of diabetic patients, average HbA1c, number of patients with 2 HbA1cs to name a few points)

Do The meeting happens The person can only give you 20 minutes The person indicates that they are very limited in funding and can give you information about what resources are out there but can not actually give you handouts

Study What happened? –It did not go as you planned, it did not result in the outcomes you planned on –But they did offer you other resources, materials, organizations to contact, and other health centers in the state that have participated in the collaborative that could be resources to you

Act The PDSA did not go as planned, but you have places to go Roll the PDSA into the next PDSA- reaching out to one of the resources offered to you from the meeting,

Who is out there? Who do you contact? What do you need to have to meet with them? What are you looking for in return? What resources are you missing out there?? Identify the resources in your community