When I was listening to a webinar on April 11 that discussed innovations from a few Beacon Communities, sponsored by NeHC, I was really impressed with the work the Southeast Michigan Beacon Community Collaborative (SEMBC) had done. Not only was this Beacon Community taking impressive measures to stem the tide of diabetes—which affects one in every 10 Michiganians and more than 16 percent of Detroiters—but it was really doing an amazing job at packaging and marketing its innovations to its citizens.
“Fighting D in the D” is SEMBC’s grass-roots marketing campaign that is micro-targeted to hotspots with large diabetic populations that kicked off on Feb. 22 with a community roundtable of more than 24 healthcare, business, and community leaders, said Terrisca Des Jardins, director of SEMBC. SEMBC has enlisted all six health systems and major laboratories and the large payers in Southeast Michigan to participate in this initiative. Not only did the campaign use social media (launching a new Facebook page), more than 4,000 PSAs on various media outlets, street teams, it partnered with community centers, neighborhood service organizations, and faith-based organizations to get the word out.
Core to the Fighting D in the D program is deploying practice coordinators, patient navigator tools, patient registries, and patient engagement tools to work towards three goals: a 5 percent increase in the proportion of diabetic patients who receive testing and exams; a 5 percent reduction in non-urgent ED utilization; and a 5 percent reduction in the proportion of diabetics having disparity ratios for quality of care and population health measure disparities to gender, insurer, or race.
Among SEMBC interventions are:
Physician data reporting and performance feedback
- Establish a network of physicians who are committed to process change and data exchange
- Deploy practice coordinators to work hand and hand with practices by pulling quarterly data to provide evidence-based care, provide assistance with CDS, i.e. turning on dormant alerts
Ambulatory Care Coordination
- Utilization of seven patient navigators to help patients adhere to treatment plans and navigate the healthcare system by helping patients set goals, and provide point-of-care interventions like health screenings for non-acute patients if they have elevated HB1C levels, and provide referrals to patient health navigators
- Engage federally qualified health centers
Clinical Decision Support
- Targeted alerts, reminders, and decision support information
Care Coordination in Hospital Emergency Departments
- Partnerships with ED that helps identify, treat, and coordinate care of diabetic patients
Patient Engagement and Telehealth
- Partnerships with community and faith-based organizations that extend the reach of SEMBC
- Use mobile and other messaging options like Text4health program to identify diabetes within the SEMBC
Another piece to SEMBC’s diabetes campaign is a robust HIE, BeaconLink2Health, that ties a broad base of stakeholders in the community together. BeaconLink2Health is a two-vendor solution, with Medicity providing the overall HIE framework and Covisint providing the community repository and population-based analytics.
“The future is that once you have all interventions in place connected through this technical infrastructure, we can start talking about taking on additional accountability for care through accountable care organizations, and start talking about payment reform,” said Des Jardins.
Des Jardins said that her Beacon Community plans to participate in its local organized systems of care (OSC), the ACO-like systems that Blue Cross Blue Shield of Michigan is rapidly deploying.
Another linchpin of the SEMBC is its Txt4health program, an interactive, personalized 14-week text-based program that sets goals, tracks weight and activity levels and sends tailored educational and motivational messages. “It’s gotten our stakeholders reenergized and engaged around something that everyone can support, and it’s led to interest in other activities we’re trying to roll out through Beacon.”