“Implementing evidence-based diabetes programs at the community ...

Complications of diabetes for them can be severe,including:AmputationKidney diseaseHeart diseaseBlindness

The Alliance to ReduceDisparities in Diabetes aims tochange the outlook for thosewho experience the worstoutcomes.

The Alliance aims to reduce disparities in diabetesoutcomes by supporting:Evidence-based, community-focusedinterventionsEfforts to ensure that successfulprograms and services are sustained inpolicy and practiceCollaboration with key stakeholders atthe national level through local levels toachieve policy and system change thatreduces inequities in care andoutcomes

Five U.S. cities are the focus of the Alliance’scommunity level efforts:Dallas, TexasThe Baylor Healthcare System’s Office of Health EquityChicago, IllinoisThe University of ChicagoMemphis, TennesseeThe Healthy Memphis Common TableCamden, New JerseyThe Camden Coalition of Healthcare ProvidersWind River Reservation, WyomingThe Eastern Shoshone Tribe in partnership with theNorthern Arapaho Tribe

At the national level theAlliance is collaborating withkey organizations who shareour interest in advancing needed policyand systems change.Centers for Disease Control & Prevention, American DiabetesAssociation, American Association of Diabetes Educators, HHS Officeof Minority Health, National Institutes of Health NIDDK, NationalBusiness Coalition on Health, National Council of Urban IndianHealth, National Association of Community Health Centers, NationalAssociation of Chronic Disease Directors, National Association ofCounty and City Health Officials

The University of Michigan Center for Managing ChronicDisease is serving as the Alliance National Program Office.

Alliance Community Programs* havethree components:123Innovative, evidence-based patienteducationFront-line, proven health provider trainingincluding cultural sensitivitySustainable quality improvements inhealth care access, and coordination*Dallas, Texas | Chicago, Illinois | Memphis, Tennessee | Camden, New Jersey | Wind River Reservation, Wyoming

The Alliance is capitalizing onthe unique strengths of itscommunity partners.

Chicago, IllinoisThe University of Chicago hasstrong community ties with theSouth Side of Chicago, an areaknown for social/political activism.

Memphis, TennesseeHealthy Memphis Common Table isa collaborative partner with over 100churches in the faith-basedcommunity through MemphisHealthy Churches.

Wind River ReservationThe Wind River ReservationAlliance leaders have a history ofcultural bonds that are sharedacross the Shoshone and Arapahoetribes.

Dallas, TexasBaylor Healthcare System’s Officeof Health Equity partners withProject Access Dallas to involvemore than 2,000 physicianvolunteers.

HEALTH PROVIDER EDUCATIONAlliance interventions aim to enableclinicians to be more effective in workingwith diverse patients through training incultural sensitivity and effectivecommunication skills.

SUSTAINABLE ORGANIZATIONAND SYSTEMS CHANGEEach Alliance community is introducingsustainable changes to how healthorganizations and providers manage theirpatients through improvements in:• information exchange• identifying patients at risk of developingdiabetes or of complications• access to care• coordination of services• assessment of outcomes, e.g., clinicalmeasures, patient satisfaction with care andhealth care use and cost

Patient Level Intervention

Memphis Healthy ChurchesDiabetes for LifeThe Community• High level of involvement with the faithbasedcommunity and health ministrymodel• Community members have great trust inchurch-endorsed health care activities• Target group is African American

Memphis Healthy ChurchesDiabetes for LifeApproach to Patient Intervention:• Memphis Healthy Churches:• Coalition of 100+ churches• Recruitment of participants:• Churches• Provider referral• Community health screening events

Memphis Healthy ChurchesDiabetes for Life• Stanford Chronic Disease Self ManagementProject ManagerCertified Diabetes Educator• Augmented with Conversation Mapping

Memphis Healthy ChurchesDiabetes for Life• Patient Level Intervention– Church Health Representatives work closelywith Project Managero Identify of potential participants in churcheso Make referrals to Diabetes for Life Programo Participate in community health screenings

Memphis Healthy ChurchesDiabetes for LifeIntensive Case ManagementoooooConduct participant interviewsIdentify social and environmental barriers to diabetesself managementIdentify resources for patientsRemind patients of appointments for careTrack patient progress and report to physician

Baylor Health Care System:Diabetes Equity ProjectThe Community• Significant Hispanic population• Language and health literacy needs• Citizenship status may impede helpseekingand health care behaviors of somecommunity members

Baylor Health Care SystemDiabetes Equity ProjectApproach to Patient Intervention•Project Access Dallas: Extensive organization ofvolunteer health care providers•5 participating clinics refer patients to DEP• CoDE: Community Diabetes Education• Developed for use with uninsured Mexican-Americans• Adapted for use with more diverse clinic settings

Baylor Health Care SystemDiabetes Equity Project• The role of the community health worker is asignificant aspect of the health care teamDiabetes Health Promoter (DHP)• DHP assigned to each participating clinic• DHP is formal role incorporated in the BHCS

Baylor Health Care SystemDiabetes Equity ProjectNew and Expanding Partnerships:• Collaboration with Genesis Medical Foundation toprovide dilated retinal screening at the 5 clinics• Expanded relationship HTPN to brand 5 clinics as asubset with a special focus on the highest riskpatients• Plans underway to develop health informationsharing with external health care systems

Camden: ‘The Camden Citywide DiabetesCollaborative’The Community• High concentration of patients in relatively smallgeographical area (9sq mi) with limited health careproviders• Residents’ lives are very stressful and marked byhardship, high levels of poverty•Population is primarily African American (49%) andHispanic (39%)

Camden: ‘The Camden Citywide DiabetesCollaborative’Patient Level Intervention• Five community-based clinics participate in standardDSME classes (based on ADA/ AADE guidelines)• DSME program augmented with ConversationMapping• High-utilizer/ high risk patients are targeted throughspecialized Care Management Team

Camden: ‘The Camden Citywide DiabetesCollaborative’Patient Level Intervention:• Care Management Teamo Focus on highest utilizers (ED, hospitalizations)o Led my nurse practitionero Licensed Social Workers

Camden: ‘The Camden Citywide DiabetesCollaborative’New Partnerships• Camden Health Information Exchange:• Data sharing among 3 major health care providers whowere once competitors• Allows physicians to provide timely quality care w/oduplicating care provided by counterparts• Real time ED admissions will be linked by EHRs• Follow up and transition of care is more efficient andtimely• Allows for coordination of care across health settings

Wind River: Improving Diabetes AmongAmerican IndiansThe Community• Two distinct tribes share the Reservation• Community residents and prospectivepatients are disbursed over a very widegeographical range (3500+ square miles)• Community has limited resources/ food desert

Wind River: Improving DiabetesAmong American IndiansPatient Level Intervention:Indian Health Service is primary source of patientreferralsPatient Education:Honoring Your Health: Diabetes Self-ManagementEducation and Community OutreachEducational classes are available on very flexibleschedules to meet the needs of the community

Wind River: Improving DiabetesAmong American IndiansApproach to Patient Level Intervention:Diabetes Navigators:Assist patients in communication and interaction in thehealth care systemDiabetes Outreach Workers:Maintain contact with patients in the communityenvironment (long-term goal to reach 1000+ diabeticson the Reservation)

Wind River: Improving DiabetesAmong American IndiansNew Partnerships• Wind River Diabetes Coalition• Eastern Shoshone & Northern Arapaho Programs, IndianHealth Service, State of Wyoming Diabetes PreventionProgram, County Public Health Nurses,Products of the Collaboration:o Annual Diabetes Awareness Community Conferenceo Lifestyle Balance Program: Pre-diabeteso Enhanced working relationship between 2 tribes

University of Chicago Team‘Improving Diabetes Care and Outcomes on theSouth Side of Chicago’

University of ChicagoImproving Diabetes Care and Outcomes on theSouth Side of Chicago

South Side of Chicago• Challenges:– Poverty– Social challenges– Food deserts– Unsafe recreation– Mistrust of healthcare– Weakened hospital safety net• Strengths– Historical social, political andcultural traditions– Community resources andinstitutions– Healthcare institutions

Health Care Interventions toReduce Diabetes Health Disparities• Patient interventions (e.g. CHWs)• Provider interventions (e.g. practice guidelines)• Support staff interventions (e.g. RN casemanager)• Health systems interventions (e.g. diabetesregistries)– Peek ME, Cargill A, Huang E. Diabetes health disparities: A systematic review ofhealth care interventions. Med Care Res Rev. 2007;64(5):101S-156S.

Health Care Interventions toReduce Diabetes Health Disparities• Relevant take-home points:– Culturally-tailored interventions morepromising than standard QI– Few multi-target interventions with communitypartnerships– No existing literature on interventions thattarget the patient/provider relationship– Peek ME, Cargill A, Huang E. Diabetes health disparities: A systematic review ofhealth care interventions. Med Care Res Rev. 2007;64(5):101S-156S.

Intervention ComponentsSix health centers1) Patient activation training2) Provider communication training3) Community connections4) Systems Change

Intervention ComponentsSix health centers1) Patient activation training2) Provider communication training3) Community connections4) Systems Change

Patient ActivationTraining- Culturally tailored diabetes education- Patient/provider communication training- Shared decision-making- Patients equal partners about healthcare decisions- Improved health outcomes- Improved patient satisfaction- SDM disparities exist, despite similar role preferences

Patient Activation:Culturally tailored diabetes education- BASICS curriculum of the IDC- Evidence-based and theoretically driven- Core:- Basics- Nutrition- Physical Activity- Self-management- Four 2-hr sessions over 9 months

Patient Activation:Culturally tailored diabetes education- Modifications:- health literacy, adult learning theory, cultural tailoring- Reduced session length and increased total number- Reduced time between sessions- Used repetition throughout- Revised slides for literacy/numeracy- Audiovisual aids and interactive role play- Shared stories/narratives and testimony

Lowering Sodium48

LOWERING YOUR SODIUMCHOOSE MORE•FRESH•FROZEN•HOMEMADETRYCHOOSE LESS•CANNED•PACKAGED•PROCESSEDINSTEAD OF

What is Diabetes?Role Play!

Mock Grocery Store• Based on foods locally available• ‘Shopping’ in class– Reading food labels– Counting carbs– Food preparation• Shared recipes

Patient Activation:Shared Decision-Making- Specific skills:- 1) Ask more questions (information-seeking)- 2) Give more detailed information (information-prevision)- 3) Clarify/restate provider information (information verifying)- 4) State preferences for tests/treatment options- Mapped onto 3 SDM Domains- Reflect clinical encounter- 1) Information-Sharing (Discuss)- 2) Deliberation (Debate)- 3) Decision-Making (Decide)- ADA standards of clinical care

Patient Activation:Shared Decision-Making- Curriculum based on our research 1- Interactive sessions- Role-playing and group discussion- ‘Who wants to have a say in their healthcare?’- Educational video- Integrated throughout BASICS- Dedicated focus during last 3 sessions1Peek ME et al. Patient Educ Couns. 2008; 72: 450-458. Peek ME, et al. J Gen Intern Med. 2009; 24:1135-9.Peek ME, et al. Soc Sci Med. 2010;71:13-17. Peek ME, et al. Soc Sci Med. 2010;71:1-9.Peek ME, et al. Medical Decision Making. 2011;31(3):422 – 431.Peek ME, et al. Self-reported racial discrimination in healthcare and diabetes outcomes. Med Care. In press.

Changes in Self-EfficacySurvey Question Number of Patients (n =21)I feel confident in my abilityto manage my diabetesBaselineStrongly Agree / Agree 1 20I feel capable of handlingmy diabetesStrongly Agree/ Agree 2 19I am able to do my ownroutine diabetes care nowStrongly Agree / Agree 1 20I am able to meet thechallenge of controlling mydiabetesPost-InterventionP-value0.020.030.020.22

Changes in Self-Management

Changes in Self-Management

Patient Intervention: Mobile Phone Pilot• 4 week pilot at PCG (n=18)• Text message reminders re:diabetes self-management• Improvements in:– Diabetes self-efficacy– Self-foot examinations– Medication adherence

Results: User ExperienceIt was easy to receive and readthe text messages from theresearch team.It was easy to send textmessages to the research team.I found the text messagereminders to be helpful atdecreasing the number of pills Imissed.I found the text messagereminders to be helpful atincreasing the number of times Ichecked my feet.I found the text messagereminders to be helpful atdecreasing the number of doctorStrongly Agree Moderately orSlightly AgreeDisagree94 6 072 28 089 11 089 11 087 13 0

Changes in Self-Efficacy20.015.0P

Community Connections: Resources

Community Connections• Medical Homes– Urban Health Initiative– Over 4,000 pts connected tomedical homes• Public Education– Television, Radio, Print– Community health venues– Center for Community

Community Connections: Partnerships• KLEO Community FamilyLife Center• Save-A-Lot Grocery Store• Walgreen’s• Chicago Park District• Farmer’s Markets• Chicago Food Depository

Grocery Store Tours• Class graduates• Reinforced skills re:food labels• Save-A-Lot

Free Food Access• Class participants• Cooking demonstrations,tastings and recipes• Health screening andeducation• Chicago Food Depository• KLEO Community Center

Improving Diabetes Care and Outcomes on the South Side of ChicagoRoadmapCommunity LinkagesYear 1: Scope out potential community partners/resourcesYear 2: Participate in events (CANTV, health fairs, screenings, etc)Year 3: Establish partnership with one organization (ex: fresh produce)Year 4: Pilot community health worker (CHW) or extension workerYear 5: Focus on sustainability for successful partnerships/outreach modelsQuality ImprovementYear 1 (2009): Planning & form QI teams at each siteYear 2 (2010): Start with small changes, use QI methodsYear 3 (2011): Scale up successful project, plan & implement project w/larger scopeYear 4 (2012): Implement QI projects in multiple Chronic Care Model areasYear 5 (2013): Focus on sustainability for successful projectsPatient Empowerment and Education ClassesYear 1: Finalize curriculumYear 2: Pilot curriculum (Access Booker site)Year 3: Spread classes to all sitesYear 4: Spread classes to all sitesYear 5: Focus on sustainability for classes at each sitePatient-Centered Communication WorkshopYear 1: Finalize workshop modulesYear 2: Pilot workshop (PCG site)Year 3: Spread workshop to all sitesYear 4: Spread workshop to all sites (booster workshops?)Year 5: Communication training role play

Our Project Team• Marshall Chin• Monica Peek• Abigail Wilkes• Tonya Roberson• Anna Goddu• Kristine Bordenave• Michael Quinn• Doriane Miller• Lisa Vinci• Andrew Davis• Elbert Huang• Jonathan Birnberg• Jonathan Dick• Shantanu Nundy• Seo Young Park• Neha Setha• Emily Lu• Rebecca Lipton• Deborah Burnet• Karen Kim• Dawnavan Davis• Sheila Harmon• Quin Golden• Eric Whitaker• Shelley Scott• Mickey Eder• Peggy Hasenauer• Louis Philipson• Marla Solomon• Hui Tang• Robert Nocon• Katie Raffel• Ndang Azang-Njaah• Gwen Burrows• Braunda Anderson• Marjorie Kerr