Hennepin County Medical Center Diabetes Prevention Program

Transcription

1 Hennepin County Medical Center Diabetes Prevention Program Mariela Ardemagni-Tollin, CHW Kristen Godfrey Walters, MPH MDH Building Minnesota s Diabetes Prevention System September 13, 2016

2 DPP Program Overview HCMC Diabetes Prevention Program began in 2015 Opportunity for Community Health Worker (CHW) workforce to impact upstream health impacts including quality and cost Opportunity to serve diverse, underserved population in a culturally and linguistically appropriate way Initially grant funded Participation in WCPD Study NDPP through Minneapolis Health Department Sustainability 12 Trained CHWs as Lifestyle Coaches Pursue reimbursement for CHW education services Offer classes across Hennepin county at community clinic locations Pending recognition from CDC/Diabetes Prevention Recognition Program (DPRP)

3 We Can Prevent Diabetes Study Purpose: CMS study to test the effects of incentives on attendance and weight loss among the Medicaid population Overview: 100 Participants from September December 2015 Primarily ages 35-54, African American, non-hispanic, English speaking 4 classes taught by YMCA at YMCA locations and Sabathani Community Center 5 classes taught by HCMC at Sabathani and HCMC clinics Program founded through MDH, HCMC provided recruitment and facilitation Outcomes: Attendance 88% attended 4+ sessions 73% attended 9+ sessions 62% attended 16 core and 1 + maintenance sessions Weight Loss 49% BMI decreased 22% reached 5% weight loss goal 14% reached 7% weight loss goal Clinical Measures 32% A1C decreased (n=69) 45% FPG decreased (n=31) LDL - 29% decreased HDL - 30% increased Trig - 29% decreased

4 Diabetes Prevention Program Purpose: Offer preventive education to underserved patient groups, identifying patients upstream to development of chronic disease Overview: 41 participants, 4 classes (2 Spanish, 2 English) from October 2015 to September 2016 Funded by Minneapolis Health Department grant HCMC provides recruitment and facilitation at 4 HCMC clinic locations Outcomes: One completed class to date with 6 participants (3 classes in progress) 66% A1C or FPG decreased (n=4) 33 referring doctors and 8 CDEs

5 Implementation and Changes Program coordinator and trained Lifestyle Coaches Created pre-registry list and report that identifies patients with prediabetes or high glucose/hgba1c Collaboration with clinics/providers to identify patients and DPP locations Created DPP screening, referral and recruitment workflow Developed schedule templates, documentation, and billing mechanisms Developed data collection and reporting mechanisms for DPRP recognition

6 Barriers Low-income needs Lack of education on diabetes Readiness to change Range of literacy Food tracker Year long commitment Language Mentality change Support tools Highly mobile/homeless Transportation needs Childcare needs

7 Success Program Outcomes Weight loss, reduced BMI, A1C and glucose scores Healthy food choices, more physically active Passing on knowledge to families and friends Recruitment and retention Development of system changes to facilitate scaling/sustainability of program

8 Sustainability/Next Steps Future of DPP at HCMC August Classes (1 English,1 Spanish) at downtown and community clinic locations Continued support of program through both grant funding and reimbursement mechanisms Continued expansion of program across Hennepin County clinic locations, to increase patient participation and to reduce transportation or traveling time for both patients and CHWs Reach out to different patient groups, offer DPP classes in various languages (Spanish, English, Hmong, Somali, etc.) Participation in SAGE database and statewide database

9 Contact Information Kristen Godfrey Walters, Community Care Coordination Manager, HCMC, Mariela Ardemagni-Tollin, Community Health Worker Supervisor, HCMC,