National Kidney Foundation of Michigan Mission: to prevent kidney - PDF document

11/12/2019 Using the Bridge Application to Increase Referrals to the Diabetes Prevention Program National Kidney Foundation of Michigan Mission: to prevent kidney disease and improve the quality of life for those living with it The DPP and Solutions Needed • Educating both Physicians and the Public • Seamless integration with Practice Workflow and Patient expectations • Constant coordination of information 1

11/12/2019 What is prediabetes? • In general, a blood test shows that a patient is nearing the type 2 diabetes range. • Patients are at high risk for developing type 2 diabetes without intervention • Best intervention: Lifestyle Change! • Fairly recent scientific consensus on the prediabetes diagnosis Educating both Physicians and the Public • Huge hurdle in connecting providers to “prescribing” a program like the DPP. • It is a year long. • Results are measured over time. ROI is not conveniently apparent in the near term. • Not necessarily as simple as medication-only interventions. • The NKFM is a community-based organization, not within the typical ACO/care system. • Patients typically don’t fully comprehend, sometimes don’t hear, a prediabetes diagnosis. • “Blood test was ‘bad.’” • “My sugar was off.” • “Why is a ‘kidney non - profit’ calling me?” Seamless Integration with Practice Workflow • NFKM reached out to Practice Managers and Referral Coordinators, identifying the common tool of the Bridge Application. • Hosting Practice Education about Prediabetes, and highlighting direct linkage to NKFM through the Bridge Application. 2

11/12/2019 Seamless Integration with Patient Expectations • NFKM staff connect with potential participants , citing specific provider referral in the Bridge Application . • NKFM provide immediate, direct feedback to Practice Managers about patient registration and health journey. Constant Coordination of Information • Our Program Team records progress of outreach phone calls, emails or home visits to referred patients using the Bridge Application. • Our Referral Team can immediately update providers about patient progress through the registration process and workshop progress. • Our Analytics Team will provide data feedback on outreach, class attendance and health outcomes, using the Bridge Application as cross-reference with our own proprietary database . Resources • ReadySetPrevent.org • NKFM.org 3

11/12/2019 Questions? 4