ORGANIZATION:Camden Coalition of Healthcare Providers

LOCATION:Camden, New Jersey

www.ALLIANCefORdIAbeTes.ORG

From 2002 to 2007, 6,295

Camden residents made 48,000 visits to the emergency

departments and hospitals for

conditions related to diabetes.

Total charges for these visits

exceeded $1.2 billion.

THe PROGRAM:The Camden Coalition of Healthcare Providers is an organization that seeks to improve the quality, capacity and accessibility of the health care system for vulnerable, chronically ill residents of Camden, N.J. The Coalition’s activities focus on community outreach, care management of high-needs patients, health care provider education, practice management capacity-building, data collection and evaluation and coalition-building among key stakeholders. The Camden Citywide Diabetes Collaborative will use the Coalition’s existing relationships and project strategies to pursue citywide coordination of services and care for city residents with diabetes. The project seeks to fundamentally change how providers, office staff and community agencies in Camden care for city residents with diabetes by building an accessible, high-quality, coordinated and data-driven health care delivery system with a strong primary care base.

THe GOALs:• Improve the capacity of community-based, primary care

practices to provide comprehensive, proactive care to their patients with diabetes- Facilitate the certification of 10 community-based, primary care

practices in Camden as Patient-Centered Medical Homes by the National Committee for Quality Assurance (NCQA) and as American Diabetes Association (ADA) Education Recognition Program (ERP) sites

- Assist practices in implementing a diabetes registry, electronic health records, group diabetes visits, open-access scheduling, on-site nutrition and diabetes education, patient support programs and other tools for effective diabetes management

• Improve diabetes self-management for the residents of Camden- Tailor culturally oriented diabetes self-management education

programs- Expand bilingual (English/Spanish) community health education

forums with a focus on diabetes self-management education, nutrition, healthy lifestyles and self care

- Implement a monthly series about diabetes self management on the local cable access channel

- Distribute audio and video patient education materials to people with diabetes and their families

Camden Citywide Diabetes Collaborative

THe GOALs: continued...• Increase the capacity of medical day programs to care for

their patients with diabetes- Conduct monthly staff education sessions at medical day

programs in Camden and surrounding areas- Coordinate and standardize diabetes care; create standard

order sets for use by primary care providers who interact with medical day programs

- Implement a diabetes registry at medical day programs

• Improve coordination of care for people living with diabetes across the city of Camden- Develop standard outpatient, emergency department and

hospital order sets for the management of patients with diabetes

- Work with information technology collaborators to develop a citywide diabetes patient registry and chronic disease dashboard

THe APPROACH: • Since 2007, the Coalition has coordinated a citywide project to

provide care management and transitional primary care for city residents who are the highest users of Camden’s emergency departments and hospitals. Guided by an expansive database of patient-level claims data from these facilities, the Coalition has created a program structure that is collaborative, patient-centered and data-driven.

• The Camden Citywide Diabetes Collaborative will be a multi-pronged effort to improve diabetes care at the patient, practice and community level. It will focus on: comprehensive practice transformation in 10 local primary care offices, provider and staff education, improved linkages between endocrinology and primary care providers, community- and practice-based diabetes education, expanded data-sharing, development of citywide care protocols and targeted interventions to key sub-populations.

Diabetes inCamden, New Jersey• There is an extreme

overutilization of Camden emergency departments (ED) and hospitals by city residents; 50 percent of all Camden residents visit an ED or hospital in a one-year period (twice the national rate).

• Thirteen percent of all patients were responsible for 80 percent of the total costs, and 20 percent of all patients were responsible for 90 percent of the total costs at local Camden city hospitals.

• From 2002 to 2007, 6,295 Camden residents made 48,000 visits to the EDs and hospitals for conditions related to diabetes. Total charges for these visits exceeded $1.2 billion; receipts were $163 million (13 percent of charges).

• Health literacy is a critical issue with less than half of residents completing their high school education and 39.6 percent of households reporting that they use a language other than English at home. The most common language is Spanish.

www.alliancefordiabetes.org

organiZation:Healthy Memphis Common Table

location:Memphis, Tennessee

72.6%In the 2007 Memphis Healthy

Churches wellness survey,

72.6 percent of the survey respondents

had Body Mass Indexes

(BMI) above 25 (overweight/

obese) and 41.6 percent had BMIs above 30 (obese).

tHe PrograM:Healthy Memphis Common Table (HMCT) is a regional health improvement collaborative of community organizations, coalitions and individuals dedicated to improving the health of people in the greater Memphis area.

tHe goals:HMCT will address five issues related to health care disparities through its Diabetes for Life (DFL) initiative:

• Implement a proven, evidence-based chronic disease self-management program that can be offered to people with diabetes as part of a comprehensive approach to diabetes management and care

• Increase access to and utilization of programs and resources to promote and maintain patient weight loss, including diet and nutritional counseling, peer support groups and access to various exercise options, based on patient preferences and needs

• Offer case management support for people with diabetes and their families to help them gain access to and better utilize health resources as well as adopt and maintain effective disease self-management and lifestyle changes

• Foster ongoing implementation of standard quality management and clinical improvement procedures to ensure that all patients at participating community health centers receive appropriate screening and treatments for diabetes and related chronic illnesses

• Enhance provider cultural competency and communications training, as well as related patient feedback processes, to measure effectiveness and appropriateness of provider communication

Diabetes for Life

tHe aPProacH: • Memphis Healthy Churches (MHC) will serve as the primary

resource for community outreach to the target population. MHC includes 100 member churches and provides an important venue for addressing health care disparities at the community level. MHC offers training to lay volunteers at participating churches to provide health education and linkages to screening services for congregation members at increased risk of developing diabetes and related chronic illnesses.

Diabetes inMemphis, Tennessee• In 2007, the prevalence of

diabetes in Shelby County was 12 percent, higher than the national average of 8 percent.

• Mortality rates for heart disease, stroke and diabetes among African-Americans in Shelby County are significantly higher than national rates.

• In the 2007 Memphis

Healthy Churches wellness survey, 72.6 percent of the survey respondents had BMIs above 25 (overweight/obese) and 41.6 percent had BMIs above 30 (obese). Yet, only 57.6 percent of the participants considered themselves to be overweight, and only 37.3 percent of participants reported receiving advice about losing weight from a health care professional in the past 12 months.

• Tennessee residents in general, including those in Shelby County, demonstrate high rates of various behavioral risk factors that contribute to diabetes.

• The 2007 Memphis/Shelby County Behavioral Risk Study reported that 28.3 percent of adults in Shelby County were obese, compared with 26.3 percent nationally, and obesity rates in Shelby County have exceeded national averages for many years.

www.alliancefordiabetes.org

organiZation:Baylor Health Care System

location:Dallas, Texas

www.alliancefordiabetes.org

Diabetes affects 1.3 million adult

Texans who have been diagnosed

with the disease, and an additional

half million adults who are believed to be undiagnosed.

tHe PrograM:The Diabetes Equity Project (DEP) will leverage the extensive community partnership among Baylor Health Care System (BHCS), the BHCS Office of Health Equity, the HealthTexas Provider Network Office of Community Health Improvement, Project Access Dallas, Southern Sector Health Initiative and Dallas-area charitable clinics to reduce disparities in diabetes care for underserved people with diabetes in Dallas County, Texas.

tHe goals:As a not-for-profit health care provider in north Texas, Baylor Health Care System has made a system-wide commitment to improving equity in health care access, health care delivery and health outcomes. This commitment is integrated with its overall quality improvement strategy to providing STEEEP care (care that is Safe, Timely, Effective, Equitable, Efficient and Patient-centered).

• The Diabetes Equity Project extends the BHCS commitment to health equity by working to improve both access to and quality of care delivered to low-income, minority, uninsured and underserved people with diabetes who reside in Dallas County, Texas.

tHe aPProacH: • The DEP will utilize a multi-faceted approach that includes

interventions at the physician, patient and system levels to improve diabetes health equity in Dallas County.

• Integral components of the DEP include a community-based disease management program. This component will be led by certified community health workers who are strategically deployed within five Dallas-area charitable clinics, providing patients the opportunity to acquire knowledge, self-care practices and behaviors required for the effective management of their diabetes.

Diabetes Equity Project

tHe aPProacH: continued...• Cross-cultural competency education programs will be delivered

through continuing medical education (CME) events targeted at primary care physicians who volunteer to care for uninsured people with diabetes. These programs will provide physicians the opportunity to attain cultural knowledge and care delivery strategies to promote improved health outcomes for people with diabetes in their practices.

• The implementation of an electronic diabetes registry will foster improved multidisciplinary communication among health care providers in the DEP as well as assist in evaluating the health outcomes of patients enrolled in the program.

Diabetes inDallas, Texas• Diabetes affects 1.3 million

adult Texans who have been diagnosed with the disease, and an additional half million adults who are believed to be undiagnosed.

• There are estimated to be

202,490 diabetes cases in the Dallas metropolitan area.

• In Texas, diabetes is the sixth leading cause of death overall, and the fourth leading cause of death among African-Americans and Hispanics.

• Mortality rates for diabetes among African-Americans and Hispanics are twice as high as for non-Hispanic whites.

• African-Americans and Hispanics experience more diabetes-related complications and poorer long-term outcomes than non-Hispanic whites.

• Between 2003 and 2005, Dallas County reported higher hospitalization rates than the state of Texas overall for short-term complications from diabetes.

• Many Texans with diabetes have limited access to appropriate health care due to disparities in socioeconomic conditions.

www.alliancefordiabetes.org

organiZation:University of Chicago

location:Chicago, Illinois

• African-AmericanneighborhoodsinChicagohavehigherprevalenceratesofdiabetes(12percent)thanpredominantlynon-Hispanicwhite(4percent)andMexican(6percent)neighborhoods,aswellasChicagooverall(7percent).African-Americanneighborhoodshaveamputation rates five times higherthannon-Hispanicwhiteneighborhoods.

• Twenty-ninepercentofSouthSideresidentslivebelowthepovertylevel;grocerystoresarelimited;andconcernsaboutcrimeinmanyneighborhoodscurtailexercise.

• ArichtraditiononChicago’sSouthSideofmobilizingsocialchangeservesasanationalmodelforjusticeandcommunityimprovementwithintheAfrican-Americancommunity.

Diabetes inChicago, Illinois

tHe PrograM:The University of Chicago has developed this program to improve thequalityofcareandoutcomesofpeoplewithdiabetesontheSouthSideofChicago.ManySouthSide residentsareAfrican-Americanandhavesignificant socioeconomic challenges. This program seeks to coordinate community clinics, an academic medical center and community-basedorganizationstoprovidecomprehensivediabetesmanagementandcareinasustainableway.

tHe goals:• Improve processes and outcomes of diabetes care for residents

in the predominantly African-American South Side of Chicago by implementing a collaborative model program in six clinics

• Identify the costs of implementing the interventions from

the business case perspective of the outpatient clinics and determine the major barriers and solutions to successfully implementing this regional program

• Strengthen a coalition comprised of the University of Chicago, safety net health centers and community-based organizations on Chicago’s South Side

• Increase public awareness of diabetes disparities and empower the community to draw upon its new knowledge, assets and resources to combat this problem

tHe aPProacH: • Provideculturallytailorededucationforpatientstoempowerthemto

communicateeffectivelywiththeirhealthcareprovidersandbecomeactiveparticipantsintheirownhealthcare

• Provideculturalcompetencytrainingandbehavioralchangeeducationtohealthcareproviderstoteachthemhowtocommunicateeffectivelywiththeirpatientsandfacilitatelifestyleimprovements

• Redesigndiabetesmanagementattheclinicstoincludepatientadvocates,nursecaremanagementandenhancedcommunitypartnerships

Improving Diabetes Care and Outcomes on the SouthSide of Chicago

12%

ORGANIZATION:The Eastern Shoshone Tribe

LOCATION:Wind River Indian Reservation, Wyoming

www.ALLIANCefORdIAbeTes.ORG

Approximately 12 percent of adults (917 individuals)

on the Wind River Reservation have

been diagnosed with diabetes.

THe PROGRAM:The Eastern Shoshone Tribe of the Wind River Indian Reservation is collaborating with the Northern Arapaho Tribe, the Wind River Indian Health Service, the state of Wyoming Department of Health and Sundance Research Institute to create and support a comprehensive, community-health system partnership to improve outcomes for American Indian people with diabetes and to reduce the substantial health disparities experienced by American Indians. The program approach encompasses individuals, providers and the overall health system to assist individuals in making lifestyle changes to manage their diabetes, increase the effectiveness of communications between health care providers and patients, and extend and increase resources through improved coordination and collaboration among diabetes services at the Tribal, federal and state levels.

THe GOALs:• Increase the proportion of American Indians with diabetes or

pre-diabetes who are successful in managing their condition

• Increase the skills of health care providers to enable them to work effectively to assist patients in managing their diabetes

• Strengthen the health system and community support system to serve people with diabetes

THe APPROACH: The conceptual framework for the program combines elements of the Chronic Disease Management Model and the Tribal Participatory Approach to implement effective programs for reducing health disparities. Major components of the program include:

• Establish the Wind River Indian Reservation Diabetes Working Group comprised of Tribal leaders, Tribal health directors, Tribal diabetes program managers, lay health educator managers and Indian Health Service (IHS) diabetes providers and staff

Reducing Diabetes Disparities in American Indian Communities

THe APPROACH: continued...• Integrate and coordinate program activities with the IHS Quality

Improvement Initiative for Chronic Care Management

• Conduct a community-wide education campaign on diabetes, pre-diabetes and the benefits of lifestyle changes for prevention and management of diabetes

• Provide extensive training on diabetes, diabetes self-management education, nutrition and diabetes, stages of change and motivational interviewing, and exercise and diabetes for Tribal health, diabetes and outreach staff

• Conduct workshops on Tribal culture, traditions, health beliefs and attitudes, patient-provider communication and health literacy issues for IHS and other providers who work with Tribal members with diabetes

• Improve coordination and collaboration among Tribal, IHS, and state diabetes programs and staff, including sharing resources and facilitating access to care

• Recruit Tribal members with diabetes or diagnosed with pre-diabetes to participate in diabetes self-management education classes that will be offered on an ongoing basis. Provide intensive follow-up to program participants and family members for a six-month period after completion of formal classes to provide encouragement, assist with problem solving and goal setting and facilitate lifestyle changes

Diabetes on the Wind River Indian Reservation• Diabetes is the fourth

leading cause of death among American Indians residing on reservations in Montana and Wyoming.

• Approximately 12 percent of adults — 917 individuals — on the Wind River Reservation have been diagnosed with diabetes.

• Among those individuals

with diabetes on the Wind River Reservation, 67 percent have hemoglobin A1C levels above 7.0; 32 percent have hemoglobin A1C levels above 9.0.

• Being overweight or obese is prevalent among this population; 71 percent of individuals on the Wind River Reservation are reported as having a body mass index (BMI) greater than 30.0.