CASE STUDY: ENHANCING SYSTEMS TO IMPROVE HEALTH OUTCOMES
CASE STUDY:: Enhancing Systems to Improve Health Outcomes
RHODE ISLAND: Refining a Centralized Referral
System to integrate primary care practice and
community wellness resources
The Association of State and Territorial Health
Officials (ASTHO), in partnership with the United
Health Foundation (UHF) convened a nationwide learning collaborative with five states. The
learning collaborative focused on five states
working to improve health outcomes around
diabetes, obesity, infant mortality, and/or smoking
through systems-level changes in an effort to
improve their America’s Health Ranking®. All
states participating in this learning collaborative
utilized the Plan, Do, Study, Act (PDSA) quality
improvement model to identify areas of focus,
set goals, identify measures, and analyze health
outcomes. ASTHO used a comprehensive, multilevel framework to ascertain how conditions
affecting policy and systems change move from
© ASSOCIATION OF STATE AND TERRITORIAL HEALTH OFFICIALS
the state policy level to the community practice
level while understanding the conditions necessary to implement change, key actions needed to
support change, and the components of accountability to measure change.
This case study highlights the health systems
transformation currently taking place in Rhode
Island. The Rhode Island Department of Health
(RIDH) worked with medical practitioners across
the state to assess the feasibility and acceptability
of using the Rhode Island Community Health
Network (CHN) Centralized Referral System (CRS),
and refined its processes using their feedback,
in an effort to create a system that effectively
connects Rhode Islanders to needed services.
2231 CRYSTAL DRIVE, STE 450, ARLINGTON, VA
CASE STUDY: ENHANCING SYSTEMS TO IMPROVE HEALTH OUTCOMES
Rhode Island’s Story
Like many states, Rhode Island has seen an
increase in the percentage of adults with chronic
conditions. The percentage of Rhode Islanders
with diabetes has more than doubled since 1996,
to an estimated 9.8 percent in 2013, or 62,000
with diagnosed diabetes, and an estimated 31,000
with undiagnosed diabetes.1 Roughly 26 percent
of adults older than 18 are obese and 23 percent
of adults—more than 200,000 adults—report
being physically inactive.2 The prevalence of
smoking in Rhode Island has decreased recently,
from 20 percent to 17.4 percent of adults;
however, more than 150,000 Rhode Island adults
still smoke.3
To help RIDH address the state’s challenges
related to diabetes, obesity, and smoking, RIDH
launched the Community Health Network (CHN)
in 2012 to link patients with community-based
resources. Recognizing the need for a comprehensive clinical and community response, the CHN is
an innovative “one-stop shop” that links patients
to multiple evidence-based chronic disease
management programs within and outside of
the state health department. Examples of these
evidence-based programs include those focused
on smoking cessation, weight management,
healthy eating, or self-care.
Physicians can refer patients to any of the
programs by sending a Community Health
Network Program Referral to RIDH via electronic
health record, a secure fax line, phone, or email.
A patient navigator, employed or contracted
by RIDH, contacts the patient to assess their
needs, directs them to the appropriate program,
and helps them to overcome any barriers to
completing the referral.
Since the initiation of the CRS, RIDH has worked
to optimize the number of referrals and patients
that follow up on referrals. Over time, it became
apparent that providers were inconsistently using
the CRS to refer patients to community-based
programs, and patients weren’t always following
up on those referrals. Through the learning collaborative process, RIDH worked intensively with
three “micro-practices”—medical practices with
one or two physicians and few, if any, additional
staff—to better understand the process of using
the CRS and helping patients connect to important
community resources that are unavailable or
unknown to single practitioners.
Specifically, RIDH sought to test:
• CUSTOMER SATISFACTION of micro-practice providers with CRS cuing materials (e.g.,
posters, brochures, and prescription pads for a
safe and healthy life) developed by RIDH;
• SYSTEM EFFECTIVENESS in connecting
patients with evidence-based community
smoking cessation and weight management
resources; and
• BEHAVIOR CHANGE IMPACT in influencing
patient confidence to change their behavior and
participate in smoking cessation and/or weight
management services, in sustaining change.
RIDH worked with micro-practices to allow
more flexible, real-time testing of approaches
and changes. Also, working with these practices
allowed RIDH to see how referrals might be facilitated using both paper and electronic medical
records since the practices used a combination of
these methods. Together, RIDH and the practices
examined workflow practices to help promote
referrals, as well as identified possible tools and
resources to support physicians in making the
referrals, such as visual prompts. Additionally,
the micro-practices provided important feedback
to RIDH on assessing patient’s readiness to and
confidence about making behavioral changes,
such as quitting smoking, improving diet, or
increasing exercise.
CASE STUDY: ENHANCING SYSTEMS TO IMPROVE HEALTH OUTCOMES
Leadership and Vision
Leadership and vision is defined as the extent to
which the health department’s senior leadership,
including the State Health Official (SHO), provided
strategic direction, aspirational goals, and leadership of efforts towards the achievement of
measureable and sustainable outcomes.
• The SHO, Michael Fine, MD, has initiated a
statewide effort to achieve a ranking of one in
America’s Health Rankings®, “making Rhode
Island the healthiest state in the nation.” A
cross-state agency health rankings workgroup
convenes every two weeks to evaluate measurable outcomes and determine actions for
reaching Rhode Island’s goals.
• RIDH initiated the CRS and CHN in 2012 with
the leadership and support of the SHO.
• The SHO was instrumental in targeting this
project to micro-practices, which resulted in
immediate responses and changes to RIDH’s
approaches. Micro-practices are also a strategy
for improving quality of care and driving down
overhead costs. With this project, the physicians have been able to leverage and connect
to community resources and help develop a
“care team” approach to best meet the varied
needs of their patients.
• RIDH recently began to convene senior leadership from across the health department as a
way to regularly discuss shared challenges and
opportunities for collaboration. As a result of
the learning collaborative process, the SHO and
RIDH staff have learned valuable lessons about
sharing resources towards desired goals.
Engaged Partners and
Meaningful Partnerships
Public health professionals recognize that they
cannot maximally accomplish their goals without
engaged and invested partners, collaborating
meaningfully on work towards a shared vision
and mission.4
• The structure of the CHN necessarily
promoted partnerships between a variety of
state entities and programs, particularly the
YMCAs, LiveWell Rhode Island, QuitWorks,
and others. The group promoted a joint
problem solving and strategic planning
approach that increased partner engagement
and commitment to the initiative.
• The partnerships between the micro-practices
and RIDH were also instrumental in making
this a successful initiative. RIDH served as the
point of contact for all of the community-based
programs, which not only was easier for practitioners, but also increased the positive relationships between public health and primary care.
• As a result of the strong partnerships
between the planning group representatives,
RIDH was able to address process concerns
about referrals to the programs and reduce
confusion for patients.
• Funding through the ASTHO/UHF learning
collaborative was essential in convening these
partners and promoting their efforts.
Spread and Sustainability
Spread and sustainability help illustrate the return
on investment in leveraging leadership and vision
to engage meaningful partnerships within primary
care and public health integration work. Learning
collaboratives are intentional to increase capacity
within the health system at all levels. The end goal
is to foster strong partnerships within states to
allow for a more efficient delivery of resources and
healthcare services.
• RIDH plans to scale up the CHN CRS in clinical
practices and other services venues in communities identified with disparities in health
outcomes and in risk-reduction resources by
CASE STUDY: ENHANCING SYSTEMS TO IMPROVE HEALTH OUTCOMES
leveraging various funding sources including
CDC. RIDH plans to increase outreach with
the state’s patient-centered medical home
network, representing 25 percent of Rhode
Island’s population (almost 262,877 people).
RIDH also plans to scale up the CHN CRS in
“Health Equity Zones,” which will target highrisk geographic areas across the state.
• Rhode Island will pursue a sustainable funding
mechanism through the funding made
available through the Patient Protection and
Affordable Care Act for increasing workforce
capacity by developing core competencies and
training. They are also currently developing
relationships with third party insurers, Medicare,
and Medicaid to identify long-term funding
strategies.
• As the program is scaled up and communities
increase their capacity to provide prevention services, RIDH is anticipating a dramatic
increase in utilization of the CRS. Going
forward, RIDH will monitor patient success
in completing prevention services, changing
behavior, and sustaining behavior change.
Results/Outcomes
The RIDH’s efforts throughout the learning collaborative process led to a variety of systems-level
improvements, including:
• The relationships between RIDH, the three
micro-practices, and the community programs
improved significantly. Through these relationships, RIDH refined and improved the referral
process and thus maximized the contacts
between providers and patients and ensured
that patients were referred to appropriate and
meaningful services.
• In conversations with clinical and service/
program providers, RIDH found that some
evidence-based program providers were
not providing feedback on patients to their
primary care provider so RIDH created a
more streamlined communication process.
Additionally, they found that some geographic
areas lacked coordinating programs and
decided to include more place-based programs
in the CHN CRS.
• RIDH and the practices developed a “confidence scale” to assess how ready and able
patients were to make sustainable behavior
change. The practices refined this tool to help
them understand how patients approached
this process and the likelihood that they would
follow through with modifying their lifestyles.
RIDH learned that making referrals without this
understanding led to frustrating interactions
between patients and providers and increasing
awareness about patient readiness opened up
new avenues for discussion.
• The three primary care practices referred 83
patients to smoking cessation and obesity
prevention/treatment services. Of these, 6
percent of those referred received Quitline
services and 7 percent participated in the
Living Well RI program. This is higher than the
numbers referred and receiving services in
other practices.
Lessons Learned and
Recommendations
RIDH and its partners shared valuable lessons
learned and recommendations for other state
health departments and primary care providers
to consider when implementing and refining a
similar system.
• RIDH learned important lessons about provider
workflow, including how referrals are made
in these clinical settings, the need for referral
methods applicable to both paper and electronic recordkeeping systems, and the utility
of specific tools. Because RIDH and its clinical
partners were in constant communication and
RIDH understood their workflow, RIDH could
quickly adjust throughout the process.
CASE STUDY: ENHANCING SYSTEMS TO IMPROVE HEALTH OUTCOMES
ww For example, paper prescription pads
referring patients to the CRS were not
found to be an effective tool, as the
majority of providers and patients now
use electronic prescription referrals.
ww Additionally, collecting data from
providers is challenging given their work
load and the lack of electronic records
at some practices. It is recommended
that state health departments and their
partners understand this challenge
and work together to determine a data
collection and feedback system that
works for all.
For more information, contact:
Lynn Shaull
Senior Analyst, Health Promotion &
Disease Prevention
Association of State and Territorial Health
Officials
(202) 371-9090
[email protected]
• Providers stated that asking and expecting
patients to change behaviors can be frustrating,
as behavior change is notoriously difficult.
However, providers found that understanding
readiness to change allowed them to maximize
their limited time with patients, only referring
those who were most ready to make changes.
• RIDH and community groups streamlined
their referral protocols, eliminating duplicative outreach to patients, as well as creating
the inherent value in providing information to
patients to allow them to initiate contact. For
example, the Quitline referral form was previously separate; however, through the learning
collaborative process it was integrated into the
CHN CRS form.
Endnotes
1 Rhode Island Department of Health. (2010). The Burden of Diabetes in Rhode Island 2010. Available at http://
www.health.ri.gov/publications/burdendocuments/2010Diabetes.pdf. Accessed 6-1-2014.
2 United Health Foundation. America’s Health Rankings. Available at http://www.americashealthrankings.com/.
Accessed 10-16-2014.
3 Ibid.
4 Frieden T. “Six components necessary for effective public health program implementation.” Am J Pub Health.
2013. Published Online Ahead of Print, November 14, 2013: e1-e6.