The Alliance to Reduce Disparities in Diabetes I. An Overview Supported by the Merck Foundation www.alliancefordiabetes.org
Presentation for Diabetes Partners in Action Coalition Belinda Wilburn Nelson, PhD. University of Michigan School of Public Health Center for Managing Chronic Disease National Program Office Alliance to Reduce Disparities in Diabetes May 2, 2013 www.alliancefordiabetes.org
The Alliance to Reduce Disparities in Diabetes aims to change the outlook for those who experience the worst outcomes.
People at low income levels, African American, Latino/ Hispanic people, and American Indians often experience the worst health outcomes.
The Alliance targets people who are: economically disadvantaged facing obstacles to receiving quality care at risk for poor outcomes at risk for developing diabetes or complications
Complications of diabetes can be severe, including: Amputation Kidney disease Heart disease Blindness
The Alliance aims to reduce disparities in diabetes outcomes by supporting: Evidence-based, community-focused interventions Efforts to ensure that successful programs and services are sustained in policy and practice Collaboration with key stakeholders at the national level through local levels to achieve policy and system change that reduces inequities in care and outcomes
Five U.S. cities are the focus of the Alliance s community level efforts: Dallas, Texas The Baylor Healthcare System s Office of Health Equity Chicago, Illinois The University of Chicago Memphis, Tennessee The Healthy Memphis Common Table Camden, New Jersey The Camden Coalition of Healthcare Providers Wind River Reservation, Wyoming The Eastern Shoshone Tribe in partnership with the Northern Arapaho Tribe
The University of Michigan is serving as the Alliance National Program Office.
The National Program Office is providing leadership in building the Alliance as a national partnership supporting efforts of the five community partners serving as the hub of communication activities at the national and community level
Camden, New Jersey Camden Coalition of Healthcare Providers has exceptional capacity to work across health care institutions and coordinate city-wide information exchange.
Chicago, Illinois The University of Chicago has a history of community involvement in social and political activism in the Southside of Chicago.
Dallas, Texas Baylor Healthcare System s Office of Health Equity partners with Project Access Dallas to involve more than 2,000 physician volunteers.
Memphis, Tennessee Healthy Memphis Common Table is a collaborative partner with over 100 churches in the faith-based community through Memphis Healthy Churches.
Wind River Reservation The Wind River Reservation Alliance leaders have a history of cultural bonds that are shared across the Shoshone and Arapahoe tribes.
Approach: Three Levels Of Intervention Patient Provider System
PATIENT EDUCATION Project sites are employing evidence-based patient education programs to enable diabetes self-management and empower patients to become: more engaged in their health care decisions better at managing their diabetic condition adopters of behaviors that help prevent complications effective communicators with physicians and other clinicians
HEALTH PROVIDER EDUCATION Alliance interventions aim to enable clinicians to be more effective in working with diverse patients through training in cultural competence, awareness and effective communication skills.
SUSTAINABLE ORGANIZATION AND SYSTEMS CHANGE Each Alliance community is introducing sustainable changes to how health organizations and providers manage their patients through improvements in: information exchange identifying patients at risk of developing diabetes or of complications access to care coordination of services assessment of outcomes, e.g., clinical measures, patient satisfaction with care and health care use and cost
Camden Coalition of Healthcare Providers The Camden Citywide Diabetes Collaborative The Team
Camden Coalition of Healthcare Providers The Community High concentration of patients in relatively small geographical area with limited health care providers Residents lives are very stressful and marked by hardship, however a significant number are highly motivated for change
Camden Citywide Diabetes Collaborative Patient Level: DSME: Diabetes Self Management Education SMART: shared group visit (graduates of DSME) Project Dulce: peer led diabetes education Support groups for graduates (special group for young adults) Care Management Team (outreach to high risk)
Camden Citywide Diabetes Collaborative: Key Accomplishments Provider Level/Practice Transformation: Professional Education Workshops Endocrinology Support Case study sessions with providers Focus on the most complex patients Installation of Electronic Health Records (EHR)
Camden Citywide Diabetes Collaborative System Level: Camden Health Information Exchange (CHIE)
Camden Community Awareness Strategy
University of Chicago Improving Diabetes Care and Outcomes on the South Side of Chicago The Team
Improving Diabetes Care and Outcomes on the South Side of Chicago o South Side disproportionately affected by diabetes compared to the rest of the city and national average o Many challenges: food deserts, safety, mistrust of the health care system o Stressful living environment
Improving Diabetes Care and Outcomes on the South Side of Chicago Patient Level: Intense focus on adapting the BASICS curriculum for the target patients; tailored version consists of ten-week series of classes Inordinately high rate patient retention and completion of education series
Improving Diabetes Care and Outcomes on the South Side of Chicago Provider Level CME series pilot-tested: Three sessions: Cultural Competence Motivational Interviewing Treatment Tailoring Fourth session in process: Shared Decision Making Three-month booster session
Improving Diabetes Care and Outcomes on the South Side of Chicago System Level Clinic Redesign (6 practice sites) Quarterly meetings w/clinic champions from each site PDSA (Plan, Do, Study, Act) Activities led by project manager/quality Improvement Expert
Community Partnerships KLEO Community Family Life Center Chicago Food Depository Save-A-Lot Grocery Store Walgreen s Chicago Park District Farmer s Markets
Integrating Patient Education and CClinommunity Partnerships
Baylor Health Care System Diabetes Equity Project The Team
Diabetes Equity Project The Community Significant Hispanic population (40%) Citizenship status may impede help seeking and health care behaviors of some community members Extensive organization of volunteer health care providers (Project Access Dallas)
Community-Based Kick Off Activities
Dallas: Diabetes Equity Project: Patient Level: DSME education led by community health workers Surpassed patient enrollment of 1000/high demand for participation Mobile retinal eye screening (250 patients) Piloting of VIP Program (complex patients)
Dallas: Diabetes Equity Project: Provider Level: Provider training is CME training program entitled: A Patient-Centered Approach to Cross-Cultural Care Integrated into existing physician forum (Health Texas Provider Network)
Dallas: Diabetes Equity Project: System Level: Community Health Worker role: Diabetes Health Promoter Institutionalized into the Baylor Health Care System Development of secure career path for DHP Role is expanded for use w/other chronic illnesses
Diabetes Health Promoters Community Health Workers Installed in Baylor Health Care System
Healthy Memphis Common Table & Memphis Healthy Churches Diabetes for Life The Team
County Level Estimates of Diagnosed Diabetes, 2008; Estimated Percentage of Adults with Diabetes
Memphis: Diabetes for Life The Community High level of involvement with the faith based community and health ministry model Community members have more trust in church endorsement of health care activities
Memphis: Diabetes for Life Patient Level: Extensive Case Management Model Utilizes Conversation Mapping for educational sessions
Memphis: Diabetes for Life Provider Level: Clinic Redesign (6 practice sites) Quarterly meetings w/clinic champions from each site PDSA (Plan, Do, Study, Act) QI activities led by (PDSA strategy) Endocrinologist (educational sessions) Project manager (coaching)
Memphis: Diabetes for Life: System Level Development of first county wide Quality Improvement Team for Memphis and Shelby County Development of peer education and peer support via Memphis Healthy Churches (CHRs)
Wind River Reservation Reducing Disparities in American Indian Communities
Wind River Reservation Community residents and prospective clients are disbursed over a very wide geographical range Community has limited economic resources Food desert
Reducing Diabetes Disparities Among American Indians Patient Level: DSME Program Classes held in a variety of formats/flexible schedules Extensive outreach Monthly follow-up (includes many in-home visits) and peer support groups available Life Style Balance Program for pre-diabetes
Reducing Diabetes Disparities Among American Indians Provider Level Workshops provided for IHS staff Development of Eastern Shoshone Cultural Guide for Health Providers IHS providers are referring patients, more aware of diabetes program, and more engaged with project diabetes project staff
Reducing Diabetes Disparities Among American Indians System Level Wind River Diabetes Coalition Eastern Shoshone and Northern Arapaho Tribal Health & Tribal Diabetes Programs WR Indian Health Services, State of WY. Diabetes Prevention Program, County Public Health Nurses, University of Wyoming Major Product: Annual Diabetes Conference in 3 rd year and has gained regional prominence. Stronger relationship with Wind River IHS Diabetes Program staff and individual physicians Increased sharing of data Identification of high risk patients Referrals to Tribal Programs for outreach Cultural Awareness training incorporated into orientation for new providers
Major Successes Preliminary results for clinical and behavioral outcomes are encouraging ABCs of diabetes Quality of Life measures Diabetes Self Care Behaviors
Preliminary and Promising Evidence CLINICAL MEASURES Baseline Follow Up Hemoglobin A1c* 8.5 7.9 Blood Pressure 131/80 130/78 Cholesterol 100 99
Preliminary and Promising Outcomes QUALITY OF LIFE MEASURES Physical Functioning 40.3 40.4 Mental Functioning 44.3 46.0 Diabetes Competence 5.2 6.0
Preliminary and Promising Outcomes DIABETES SELF CARE BEHAVIORS General Diet 3.8 4.6 Diabetes Specific Diet 4.1 4.3 Exercise 2.9 3.4 Blood-glucose testing 4.1 5.1 Foot Care 4.2 5.4
Major Successes Focus on pre-diabetes patients (Wind River) Institutionalization of the community health worker role (Dallas) Extensive network of community partners (Chicago) Citywide health information exchange system (Camden) Formation of new county wide diabetes coalitions (Memphis and Wind River)
Challenges Physician engagement is a universal challenge; requires special attention, courting and time Multilevel interventions require precise coordination to offer maximum benefits/outcome Unrealistic expectation regarding the time and commitment needed for behavioral change
Lessons Learned Targeting higher risk patients for intervention can maximize improvement in health outcomes, and reduction of health care costs Identify and address areas of practice/system change as soon as possible Practice/clinic transformation is most successful with a variety of ways to engage with coaching support
Lessons Learned Assess capacity for readiness of organizations and partners to pursue change Committed champions and opinion leaders are essential to success Creation of unlikely alliances have special power to attract broad range support Incorporate the community voice in the very early stages of work
The Alliance seeks to advance policy and systems change informed by local experience and lessons learned on the ground.
How Does the Alliance Contribute? a. It is an opportunity to understand how to implement evidence-based interventions at the local level. b. It allows identification of common features across diverse communities and at the same time affords learning in how to adapt to unique situations and community characteristics c. It can share and inform policy at multiple levels to account for day to day realities of providing quality care to those most in need.
National Messages Alliance sites are generating a range of policy related themes: Data sharing across institutions is necessary to identify the most troublesome diabetes cases [Camden] Cultural guides and training are necessary for providers not of the same ethnicity as clients [Wind River] Community health promoters are needed as official members of the health care team [Baylor]
National Messages Alliance sites are generating a range of policy related themes: Data sharing must extend beyond internal medical systems to independent community practices [Baylor] Formal links are needed between health facilities and community organizations, particularly churches [Memphis] Support is needed in community clinics for diabetes champions to lead disparity reducing interventions [Chicago]
Advancing Policy Changes Invited National Policy Summit convened to discuss achievable actions that can bring about significant reductions in health care disparities among people with diabetes.
Target Policy Considerations Systems Level: Consideration 1= Integrate public health and health care systems Consideration 2= Share and report communitywide health data Consideration 3= Eliminate incentives that encourage underinvestment in low-income highrisk patients
Target Policy Considerations Provider Level: Consideration 4= Make optimum Accountable Care Organization s (ACO) ability to reduce disparities Consideration 5= Support deployment of Community Health Workers (CHWs) Patient Level: Consideration 6= Enhance coverage for selfmanagement supports
At the national level the Alliance is collaborating with key organizations who share our interest in advancing needed policy and systems change. Centers for Disease Control & Prevention, American Diabetes Association, American Association of Diabetes Educators, HHS Office of Minority Health, National Institutes of Health NIDDK, National Business Coalition on Health, National Council of Urban Indian Health.
Visit the Alliance to Reduce Disparities in Diabetes website for additional information about our activities and partners. www.alliancefordiabetes.org
Videos The Camden Citywide Diabetes Collaborative Improving Diabetes Care and Outcomes on the South Side of Chicago The Diabetes Equity Project (Dallas, Texas) Diabetes for Life (Memphis, Tennessee) Reducing Diabetes Disparities in American Indian Communities (Wind River, Wyoming) Learn about the National Program Office for the Alliance