Overview

TLC-MD will build capacity by expanding DPPs and DSMTs, creating new DPPs and DSMTs, and promoting mobile services that go to where clients/patients live and/or work.

Goals:

• Decreased hospitalizations for people with diabetes through education and outreach campaigns and services.
• Increase in diabetes screening rates in Southern Maryland by expanding screening locations and increasing mobile diabetes screening services.
• Decreased health care costs associated with diabetes care.

Grant Details:

Outreach
TLC-MD will use provider education campaigns to raise clinicians’ awareness of diabetes screening guidelines and improve diabetes screening rates; aid providers to engage in bi-directional e-referral; and participate in diabetes care and treatment quality improvement efforts.

TLC-MD will use a social marketing campaign to promote consumer awareness of pre-diabetes and diabetes to prompt residents to seek screening.

Screening
TLC-MD’s participating providers will screen patients according to uniform screening guidelines and make bi-directional referrals of persons testing positive. TLC-MD referral coordinator will review patient clinical and service utilization data that are available through the bi-directional e- referral system to assess the need for care coordination, medication therapy management and/or medical nutritional therapy. Referral coordinator will screen for SDOH and identify patients’ need for health-related social needs support provided by wraparound services.

TLC-MD will educate, engage, and empower residents of southern Maryland. Educate by asking them to “Take the Test” and know their risk of diabetes; Engage by signing up for a free Diabetes Prevention Program to reduce the onset of diabetes or complications of diabetes by attending a Diabetes Self-Management program, Empower each resident to become advocates for their health.

Wraparound Services
TLC-MD will offer patients care coordination, care navigation, medical nutritional therapy and/or CHW services-referral and linkage to resources that mitigate SDOH.

TTA to Providers
TLC-MD Providers-Clinicians will receive TTA to enhance their adherence to diabetes screening guidelines; facilitate use of the bi-directional e-referral system; improve their use of SDOH assessment data; and improve the quality of the diabetes prevention and treatment services they offer.

TLC-MD DPPs and DSMTs will receive TTA so that they become eligible for reimbursement from Medicare, Medicaid and other payers and know how to use CRISP’s bi-directional e-referral system.

Tasks
1: Intervention Support: meetings with Local Health Improvement Coalitions (LHICs), Local Health Departments (LHDs), CRISP, and our Advisory Board to ensure alignment across all stakeholders for the project

2: Expansion of DPPs and DSMTs: TTA to DPPs and DSMT program to support use of bi-directional e-referral systems and expansion to reach enrollment targets.

3: Clinical Provider Outreach: outreach, creating and delivering training materials & programs to providers, including training on the CRISP e-referral tool.

4: Patient Outreach: designing and implementing a comprehensive social marketing campaign using social media and grassroots community outreach strategies.

5: Screening: comprehensive “practice reform” to assist physician practices in collecting and “mining” data to measure pre-diabetes, facilitate bi-directional referrals to DPP/DSMT programs and improve screening rates.

6: Wraparound services CC, MTM, MNT, and CHW services assigned according to patient risk and designed to mitigate SDOH and provide care plan and medication adherence support.

7: Monitoring, Evaluation, Overhead to include periodic meetings with the HSCRC to review progress to goals, designing/tracking measures for success, development of regional data collection and submission protocols, continuous clinical data analysis via a care coordination software platform integrated with CRISP, all supported by back-office resources for billing, contract review, and Administration.

If you would like more information about this program, please contact Margaret Fowler at margaret.fowler@tlc-md.org or visit https://preventionlinkmd.com.

Overview

The HSCRC Regional Catalyst Grant funding program is designed to foster collaboration between hospitals and community partners. It enables the creation of infrastructure to provide emergency integrated behavioral health services to the residents of Prince George’s County. TLC-MD is the conduit to operationalize the grant that allows hospitals to continue working with community resources to implement and manage countywide integrated crisis services to address the behavioral health needs of persons who experience a mental health crisis. TLC-MD administers discrete crisis programs that meet the needs of persons who require ongoing mental health services and co-occurring substance abuse services.

Core Service Elements:

Immediate Triage and Crisis Response

• Mobile Crisis Response
• Urgent Care
• Planned or Emergency Respite
• Emergency Department, Hospital, and/or Detention
• Diversion Programs – assist with treatment instead of jail

Programs:

• Mobile Crisis Teams – 24/7 availability of mobile crisis teams of licensed professional counselors and social workers with the capacity to respond in-person within one hour or less anywhere in the county. Also, connect them to the buddy system to get them the appropriate help.
• Crisis Hotline – 24/7 support hotline
• Develop and successfully implement emergency department and hospital diversion when clinically indicated through a crisis stabilization program
• Provide non-hospital based immediate appointments (within 48 hours)
with extended hours for increased access to care and provide continued stabilization post-release from hospitalization through high-intensity wrap-around services.
• Integrate and coordinate care with key stakeholders.
• Crisis Stabilization Center – A one-stop service for specialized treatment where police or family members can drop off patients. Specialists can also refer them to follow up treatment.
• 988 national mental health response to 911

Overview

The HSCRC Regional Catalyst Grant funding program is designed to foster collaboration between hospitals and community partners. It enables the creation of infrastructure to provide emergency integrated behavioral health services to the residents of Prince George’s County. TLC-MD is the conduit to operationalize the grant that allows hospitals to continue working with community resources to implement and manage countywide integrated crisis services to address the behavioral health needs of persons who experience a mental health crisis. TLC-MD administers discrete crisis programs that meet the needs of persons who require ongoing mental health services and co-occurring substance abuse services.

Core Service Elements:

• Immediate Triage and Crisis Response
• Mobile Crisis Response
• Urgent Care
• Planned or Emergency Respite
• Emergency Department, Hospital, and/or Detention
• Diversion Programs – assist with treatment instead of jail

Programs:

• Mobile Crisis Teams – 24/7 availability of mobile crisis teams of licensed professional counselors and social workers with the capacity to respond in-person within one hour or less anywhere in the county. Also, connect them to the buddy system to get them the appropriate help.
• Crisis Hotline – 24/7 support hotline
• Develop and successfully implement emergency department and hospital diversion when clinically indicated through a crisis stabilization program
• Provide non-hospital based immediate appointments (within 48 hours) with extended hours for increased access to care and provide continued stabilization post-release from hospitalization through high-intensity wrap-around services.
• Integrate and coordinate care with key stakeholders.
• Crisis Stabilization Center – A one-stop service for specialized treatment where police or family members can drop off patients. Specialists can also refer them to follow up treatment.
• 988 national mental health response to 911