Totally Linking Care In Maryland Inc

TO IMPROVE THE HEALTH OF RESIDENTS IN SOUTHERN MARYLAND THROUGH MEANINGFUL PARTNERSHIP-LED EDUCATION, ENGAGEMENT, AND EMPOWERMENT.

SEE SCHEDULE OHSCRC BEHAVIORAL HEALTH CATALYST GRANT: - EXPANDED DATA FIELDS IN BEHAVIORAL HEALTH LINK (BHL) TO CUSTOMIZE DATA FIELD NEEDS OF PRINCE GEORGE'S COUNTY. CONTINUE TO MAXIMIZE PLATFORM UTILIZATION TO DEMONSTRATE EFFECTIVE RESPONSE TIME OF MRT IN REAL TIME. -CONTINUE TO BUILD BEHAVIOR HEALTH CENTRALIZED DATA WAREHOUSE TO DISPLAY "EMERGENCY CRISIS SERVICE DASHBOARD", LONGITUDINALLY TRACK SERVICES THROUGH THE EMERGENCY CRISIS CONTINUUM FROM 911, 988, MRT AND ONCE OPENED DYER CARE CENTER TO STRATEGICALLY PLAN FOR THE BEHAVIORAL HEALTH NEEDS OF PRINCE GEORGE'S COUNTY. -CONTINUE 911-988 DIVERSION PROJECT WITH EXPANDING HOURS FROM 6AM TO 6PM AS WELL AS PERFORMING DATA ANALYSIS OF DATA TRANSFERS TO MEASURE IMPACT AND BUILD DATA FEEDS INTO BEHAVIORAL HEALTH CENTRALIZE DATA WAREHOUSE TO AUTOMATE LONGITUDINAL TRACKING OF EACH CALL FOR QUALITY.-CONTINUE TO SUPPORT FOUR MOBILE RESPONSE TEAM (MRT) IN PRINCE GEORGES COUNTY AND ASSIST WITH EFFECTIVELY UTILIZING THE BHL THROUGH TECHNICAL ASSISTANCE AND SUPPORT MEETINGS WEEKLY . THE MRT TEAM HAD OVER 1,100 DISPATCHES IN CY2022.-THE DYER CARE CENTER IS THE NAME OF THE NEW STABILIZATION CENTER SLATED TO BE COMPLETED BY DECEMBER 2023. THIS WILL BE THE FINAL COMPONENT TO COMPLETE IMPLEMENTATION OF THE CRISIS NOW BEST PRACTICE EMERGENCY CRISIS MODEL IN THE STATE OF MARYLAND.-EXPLORING THE OPPORTUNITY TO UTILIZE EDUCATIONAL HANDOUTS AND TRAINING VIDEO FOR 911-988 DIVERSION PROJECT WITHIN THE PRINCE GEORGE'S COUNTY POLICE, FIRE AND EMS TRAINING ACADEMIES TO CONTINUE TO EDUCATE INCOMING STAFF ABOUT 988, MRT AND DYER CARE SERVICES.-CONTINUE TO ADVOCATE AND WORK WITH STATE AND LOCAL GOVERNMENT, LBHA AND BHA COALITION TO SUPPORT BEHAVIORAL HEALTH LEGISLATIONS, RATES, AND EMERGENCY CRISIS SERVICE REGULATIONS.-EXPLORING OPPORTUNITIES TO BUILD A "PATHWAY TO PROFESSIONALISM" WITH IMIND TO INCREASE THE NUMBER OF MENTAL HEALTH PROFESSIONAL AND HELP TO REDUCE WORKFORCE SHORTAGES AND DEVELOP PIPELINE FOR CLINICIANS, CERTIFIED PEERS, AND MENTAL HEALTH TECHNICIANS.HSCRC DIABETES CATALYST AND PREVENTIONLINK GRANTS:-IDENTIFIED OVER 5,000 PATIENTS ELIGIBLE FOR DPP AND DSMES SERVICES THROUGH EHR OPTIMIZATION PROJECT AND BUILT COLLABORATIVE RELATIONSHIPS WITH 12 PRACTICES AND THEIR PROVIDERS.-PARTNERED WITH GIANT FOOD AS AN EXTENSION TO THE FOOD AS MEDICINE PROGRAM FORMALLY KNOWN AS PRINCE GEORGE'S FRESH TO REDUCE FOOD INSECURITY AND PROVIDE ACCESS TO HEALTH FOODS FOR RESIDENT IN PRINCE GEORGE'S COUNTY WHO ENROLLED IN ONE OF OUR NATIONAL DPP PROGRAMS. -BECAME PENDING ADMINISTRATIVE UMBRELLA HUB WITH SIX STRONG DPP SUPPLIERS. THIS HUB WILL ASSIST WITH DPP CLAIMS SUBMISSION AND PROVIDE AN AVENUE FOR SUSTAINABILITY TO DPP SUPPLIERS.-DEPLOYED WELLNESS KISOK'S TO HOSPITAL MEMBERS AND TLC FOR COMMUNITY OUTREACH AND AWARENESS OF THE RISK OF DIABETES BY MEASURING BODY FAT, WEIGHT AND BLOOD PRESSURE AS WELL AS "TAKE THE TEST" SCREENING. THESE MACHINES WILL BE USED FOR ONGOING EDUCATION AND HEIGHT AWARENESS OF DIABETES PREVENTION AND SELF-MANAGEMENT.-PROVIDED OUTREACH, AWARENESS, AND EDUCATION TO PRIMARY CARE PRACTICES. UTILIZED VARIETY OF OUTREACH METHODS- EMAILS, CALLS, FAXES, DIRECT MARKETING, AND DROP IN AND SCHEDULED ON-SITE VISITS WITH DELIVERY OF PROMOTIONAL MATERIALS; LIVE AND RECORDED WEBINARS; ONLINE SCHEDULING APP. PROMOTED EHR OPTIMIZATION PROJECT AS A BENEFIT TO POTENTIAL NEW PRACTICES AS PART OF RECRUITMENT EFFORTS. PROVIDED 5 PRACTICES WITH A1C POINT OF CARE ANALYZERS AND TESTING SUPPLIES FOR 50 PARTICIPANTS TO HELP PROVIDERS IMPROVE DIABETES PREVENTION AND MANAGEMENT EFFORTS. ASSISTED WITH IDENTIFYING AND ARRANGING OPTIONS FOR TRAINING AND PROVIDED BILLING CODES FOR SUSTAINABILITY.PREVENTIONLINK:-PER REQUEST FROM PGCHD, PROVIDED FUNDING AND RESOURCES TO SUBMIT APPLICATION AND SECURE CMES AND CONTINUING EDUCATION CREDITS FOR PARTICIPANTS FOR PREVENTIONLINK COP MEETING JANUARY 2023.-PROVIDED SUPPORT FOR OUTREACH AT POINT OF CARE THROUGH PRE-VISIT PLANNING REPORT FROM HQI SENIOR IMPROVEMENT SPECIALIST AND CHAS ONSITE. -CONDUCTED OUTREACH VIA MULTIPLE MODALITIES- TEXT MESSAGING PILOT, EMAIL, PHONE CALLS, AND EHR MESSAGING (TEXT AND EMAILS) TO PATIENTS AND PROVIDERS WHERE AVAILABLE. CONTENT FOR TEXT MESSAGES WERE PROVIDED TO PRACTICES FOR REVIEW AND APPROVAL. -PREPARED DPP PROVIDERS FOR POST PHE WITH GUEST PRESENTATION FROM MDH CONSULTANT.CONDUCTED TRAINING NEEDS SURVEY PRE ADVANCED TRAINING. THE SURVEY IDENTIFIED THE TOP 2 TRAINING NEEDS: MARKETING AND OUTREACH; AND SUSTAINABILITY.GUEST SPEAKERS IN MONTHLY MEETINGS.-THE COMMUNITY HEALTH ADVOCATES PROMOTED IDENTIFYING QUALIFYING PATIENTS AND DRIVING PATIENT INDEPENDENCE THROUGH PATIENT EDUCATION/MOTIVATIONAL INTERVIEWING AND HEALTH SCREENINGS IN CONJUNCTION WITH MTM AND RPM PROGRAM REFERRALS AND MANAGEMENT.-COMMUNITY HEALTH ADVOCATES WORKED IN CONJUNCTION WITH PRACTICE TO IMPROVE WORKFLOW EFFICIENCY, INCREASE REFERRALS, AND ADDRESS SOCIAL DETERMINANTS OF HEALTH BARRIERS TO PROGRAM PARTICIPATION AND ADHERENCE. ADDITIONALLY, PATIENTS WHO WERE IDENTIFIED TO MEET THE CRITERIA WERE ENROLLED IN PROGRAMS ON-SITE TO ELIMINATE THE CARE COORDINATION BARRIERS POST-VISIT.ORGANIZATIONS ACCOMPLISHMENT TO SUPPORT ALL GRANTS:-CONTINUE TO EXPAND RESOURCES AVAILABLE AT OUR DIRECT- TO-CONSUMER WEBSITE FOR BOTH HSCRC DIABETES & BEHAVIORAL HEALTH CATALYST GRANT. -BEGAN SOCIAL MEDIA MARKETING THROUGH GOOGLE GRANT AD FOR BOTH DIABETES CATALYST AND BEHAVIORAL HEALTH CATALYST GRANTS TO HEIGHTEN AWARENESS OF PROGRAMS AND SERVICES AND NAVIGATE COMMUNITY TO AVAILABLE SERVICES. -FURTHER DEVELOPED CENTRALIZED DATA WAREHOUSE FOR TLC TO CONTINUE TO MEASURE BOTH DIABETES AND BEHAVIORAL HEALTH GRANT OUTCOMES AS WELL AS BUILD OUT PLATFORM TO SUPPORT UMBRELLA HUB.