RFP DP Draft 03.10.09

Partnership for Diabetes Improvement (name?)Proposal (8 pages maximum)

Statement of Goals and Specific Heath Needs to be Addressed

(1) Utilizing the input and experience of diabetics, their families, community members and community agencies, and theas partnership of in this proposal, we will develop a plan for care and lifestyle support of adults with diabetes that incorporates elements of the chronic care modelinnovative models of clinical care, and supports factors that influence improved outcomes in this condition. —for example, nutrition, exercise, self-management, and social support.

(2) Diabetics, their families and the community will be involved with the proposal team in developing and validating options for diabetic care, self management support and and lifestyle support that can be combined to best suit the needs of individual patients with diabetes and their families.

(3) During Phases 1 and 2, community members, community agencies, patients and members of this team have identified barriers to access to health care, issues of trust, and need for accessible places that patients can identify as their medical or clinical home. During this time we have developed many ideas that we put forward in this stage 2 Proposal. However, it is clear to us, that during stage 3 we will refine the ideas and continue to ask what the needs and barriers have been for diabetic patients in Durham to have access to health care and what patients and community members perceive would be helpful for our health system to deliver to them in the care of diabetes and how trust and sustainable programs can be built.

(4) During our initial two phases we have identified that we need to Pprovide skills and knowledge to improve the healthcare and lay communitiey’s’ ability to sustain the care and lifestyle support of adults with diabetes and their families by:

(a) Eeducating the community (residents, businesses, government) in the benefits of prevention, nutrition, improved health and fitness for citizens;

(b) involve (educate)Educate health professionals and health profession learners in principles of community engagement, in understanding the chronic disease model and in the planning and working of an this innovative community-based and sustainable approach to chronic disease;

(c) Ddevelop methods to identify and train formal and informal community health advisors, for example, lay health advisors (LHAs) and community supporters to assist with aspects of diabetic care and lifestyle support.

(d) Establish protocols to implement established practice guidelines for diabetes management, decision support, and intervention plans that will allow accurate information and diabetes management support to be given to patients.

4) By utilizing above strategies we expect to reduce diabetes related co-morbidities, hospitalizations, and complications, and reduce health care costs (associated with diabetes hospitalization initially ).

5) An integral part of this models is the need for the Duke Health System and affiliates to implement a clinical Information System that will allow for information to be shared throughout Durham County. (needs better here)

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Specific Health Indicators for Improvement

Specific Health Indicators for ImprovementThis comprehensive initiative, if implemented, will improve the following individual and community health indicators: (a) attendance at clinical care appointments (home, group, medical home) by patients with diabetes participating in the interventions, (b) metabolic control (HgbA1c, lipids, BP, BMI) in patients with diabetes participating in the interventions, (c) patient and family knowledge about diabetes, diabetes self-management and lifestyle behaviors, (d) community infrastructure improvements--especially those in resource poor neighborhoods- that will provide short and long term benefits for individuals with diabetes, (e) progress toward or maintenance of weight goals for diabetics receiving the interventions (f) continuity and coordination of care and resource utilization by patients with diabetes.

Describe the specific health needs that your innovative model will address, and the specific health indicators you intend to improve.

Provide data that supports the importance of the health needs targeted, as well as evidence of disparate burden/impact in Durham County. Utilize at minimum data from the 2007 Durham County Health Department’s Community Health Assessment. The Data and Analysis Core can also facilitate access to other relevant data.

Identify the populations that you will target including location, race/ethnicity, age, socioeconomic status, and gender.

Supporting DataOver a period of 10 years (1994 – 2003), North Carolina, has seen a 76% percent increase in the prevalence of persons diagnosed with diabetes (4.6% vs 8.1%). North Carolina is among the top ten states in the nation with high diabetes prevalencei . In Durham County 8.2% of the population has been diagnosed with diabetes. Ethnic minorities have a 128% higher mortality rate from diabetes as compared with white populationsii . Health problems associated with diabetes include a 2-4 fold increase in risk for cardiovascular disease, increased risk for stroke, blindness, kidney failure, and extremity amputationsiii . Between 1990 and 2002, costs for hospitalizations related to diabetes in Durham County increased by 251%iv . Research has shown that aggressive control of blood glucose, blood pressure, and cholesterol can decrease all of the above complications of diabetesv . The American Diabetes Association (ADA) Clinical Practice Recommendations stress careful attention to glycemic, lipid and blood pressure controlvi . Yet, in Durham County 44% of individuals with diabetes, or their families have never received diabetes education, and 71% of those with diabetes do not meet the recommended goal for physical activityi . The complex nature of diabetes care, which includes attention to diet, physical activity and complicated pharmacological therapy, is difficult to achieve in traditional individualistic, clinic-based care, particularly for those patients and their families who are unable to access services or lack the resources for self-management behaviors.

Target Populations This project will use the planning time to develop a plan for those living with diabetes in Durham County. However, the reality is that many in the county do experience health disparities related to diabetes care, control, and resources. Therefore, we will focus our attention on those most at risk or experiencing a lack of access. For example, in 2008 there were over 24,000 patients seen in the Duke Health System (ER and outpatient) with HbA1c greater than 9%,

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indicating poor metabolic control. Through the use of geomapping, we will identify patients with diabetes seen at Duke practices as well as those followed at community health clinics (DFM, LCHC, Walltown, Lyon Park and DOC) who have HgbA1c >9% and/or have not been attending PCP visits. Neighborhoods or geographic areas noted to be more disease prevalent and resource poor will also be targeted, again using geomapping to overlay income, diabetes prevalence, and health care and lifestyle support resources (i.e. parks, grocery stores vs. fast food, etc). Due to disparities in health and health care access experienced by ethnic minorities such as Blacks and Hispanics, we are anticipating these ethnic groups will also make up a majority of the population with diabetes we will be targeting.

With the goal of bringing diabetes care and support to the community, the proposed plan includes multiple components and resources that involve members of a multidisciplinary team as well as patients, community groups, and community leaders. These will be further developed and utilized by individuals and groups with diabetes in a tailored manner, based on cultural, social, educational, and individual preferences. The model components that will be explored with the team and community and potentially developed further in the planning phase are included below, as well as the research that supports their efficacy and utilization.

INNOVATIVE MODEL OF CARE• Describe the innovative model of care proposed by your team (i.e., what change(s) are proposed in the structure or function of a service, system, or care delivery setting)?• Present the evidence base for your proposed innovative model of care by documenting any similar examples from around the country of this model (i.e., what is the evidence base).• How does your proposed innovative model differ from current models of care delivery, and what evidence suggests it is better? • What evidence exists that the innovative model of care/proven interventions will be accepted and effective? Have there been pilot studies? Does it implement practice guidelines?• What would be the interface to and/or involvement of the Duke University Health System and community partner organizations?

This team proposes to involve the Durham community —in its broadest sense, and diabetics in the development and assessment of all aspects of the proposed improvements in care. The Models of care which will be assessed-as single and /or multiple options are: (1) Medical Home Model; (2) Group Care Model, (3) Current Care Model. Supportive care which will developed and assessed is: (1) Interdisciplinary team home visits, (2) LHA or Community support groups—care site, churc, recreational center, etc. sites, (3) Lifestyle activities and supports—for example:…..We will follow ideas drawn from the Chronic Care Model in establishing Durham specific strategies for improving chronic disease management, specifically diabetes. These strategies have started with the initial partnership with community organizations that have experience in working with individuals with chronic illnesses and in establishing support groups and will continue with meetings with a broader base of patients and community members, focus groups, and meetings with individuals in order to establish a care delivery system that is appropriate, safe and culturally competent.

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Some patients may prefer to meet one on one with lay advisors or health promotoras, others may prefer to have home visits, others would feel more empowered by attending group visits at community sites such as churches, recreation facilities, primary care offices or other sites that community and individual members will identify as safe.

We will use geomapping to identify target areas for disease and existing lifestyle supports and gaps, so that planning can target improvements appropriately. In addition, the project team—which will continue to expand, will be key in advising about improvements that fit with patient, family and community resources and needs. For example, county and city government representation, additional lifestyle resources—food vendors, exercise clubs, and neighborhood associations.

“Medical Clinical homes in the community” Our planned model of care for those with diabetes initially focuses on those affected by lack of health care access and poor glycemic control. The model essentially brings care to the community through home visits and community based group, assisting patients in identifying a “medical home”. The first step is to identify all patients at DFM, LCHC, Walltown, Lyon Park and DOC and other private participating practices with HgA1c> 9 % and offer to visit them in their home initially to reestablish care. We will also advertise at local churches and community organizations for patients that may have diabetes to call a number where if interested they .We would then encourage these patients to transition their diabetes management to a community based group visit within their neighborhood, at the Family Medicine Center, at a local practice, or a community health site that the patient will identify as their medical home.vii This type of comprehensive care model always requires a large investment in (a) professional clinical care; (b) patient and family education and self-management; and (c) excellent access to supportive lifestyle resources such as nutritional education, food purchase and preparation, and feasible exercise innovations. This model incorporates these aspects of diabetes care and includes health professional learners as well as lay health advisors (LHA) in its implementation.

Components of the ModelHome VisitsNeed to enter data from “Just for Us” here, (VIVIANA WILL DO)A multidisciplinary team would be utililzedutilized for both the home and group visits. For the home visits, no more than two to three team members would visit the patient at a given time. The members attending would be based on the patient’s needs (i.e. diabetes education – RN, RD, CDE; medication issues – provider, pharmacist). The entire team is described in the overall goal of the project. The cCase workers and social workers are noted towill be instrumental in making initial patient contact as well as assisting the patient in identifying their diabetes management needs. The patients will then be visited by a case worker, a resident learner and lay health educator to establish diabetes management needs.Planned point of care testing for the home visits will follow established guidelines for diabetic management in terms of tests done and testing intervals1. Point of care testing may include: HbA1c, Cholesterol (LDL), microalbumin/Cr ratio for urine on site, Weight, Blood Pressure, Monofilament test, visual inspection of the feet and glucose. This point of care testing will allow immediate feedback at the time of the visit with face-to-face counseling which in turn can lead to 1 Need reference for guidelines here

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improved diabetes managementviiiix. Mobile laptop connection (via internet) will allow access to the medical record, data entry at the time of the visit, and electronic transmission of all of their medications to a pharmacy (escribing). Glucometers with direct computer interface will be used to allow downloading and analysis of self-monitoring of glucose. These results and the point of care results may be used for intensification of medical treatment based on already developed protocols. Home visits would generally be scheduled for about 30 minutes. The agenda will depend on the patient’s concerns and medical status. However, some proposed aspects of the visit include: discussion of patient concerns, monitoring and physical exam, foot care, medication review and management, self-management education (based on ADA standards), and discussion and planning of follow-up care. In addition to providing in home clinical care, the goal of the home visit would be to assess and understand the home environment and to build trust with the individuals who have not been to, or do not have access to a medical home clinic. Engaging them these patients may improve transition to the community based group visits as well as to their medical home clinic. If a patient is unable to make their community group visit or medical home appointment, a tracking system via EMR would send a reminder to re-visit the patient in their home in appropriate disease management intervals (determined by guidelines stating minimum of every 3 months; more frequently for those with higher risk or poor control). This may help to get these patients to goal and hopefully prevent long-term complications, hospitalizations, ED and urgent care visits.

Group VisitsDuring Phase 3 of this project several group care models will be evaluated together with direct community input to see what model fits the localeach cultural, neighborhood or ethnic group and individual patients community best. We expect to draw from community members’ preference and culturally accepted methods, realizing that more than one approach may be needed for the various groups. The team members with expertise in group visits of varying types will work with the community advisors to determine how they will be implemented. These members include: Kathryn Trotter, CNM, FNP; Sarah McBane, PharmD; Bettina Karpathia,

The Commonwealth Fund (2007) found that adults who have Medical Homes (primary care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective) have an enhanced access, better quality, and rare disparities in health care. Group care is included as one component of medical home carex. Studies have shown that patients in group care and medical home practices develop relationships with their providers and work with them to achieve results of decreased hospitalizations, decreased emergency room visits, increased satisfaction, increased quality of life, and maintain healthy lifestylesxi.xii. Diabetes group visits provide support and empowerment from peers, improve access to care, provide education about disease, improve outcomes, and increase productivityxiii. They have also been shown to improve HbA1C, improve satisfaction with diabetes care and increase confidence in self-management behaviorsxiv; increase preventative procedures among attendees of group visitsxv; improve lipid levels and body mass indexxvi; and increase physician trustxvii. A recent Cochrane Database Systematic Review suggests that lifestyle intervention in type 2 diabetes is especially effective when implemented by interactive group educationxviii.

One of the models being considered is the Centering Model. The Centering Healthcare Institute (CHI) model emphasizes medical assessment, education and support as key components of group care. In this model, a small group of individuals (12-16) (with diabetes) arrive at the

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same time for their group visit. They do not wait in the waiting room, but come in to the group space to begin the visit. Using the CHI model, patients are assisted to obtain and record their own vital signs, weight, and other monitored values. Individual one on one assessment with their provider may be occurring in the first 20 minutes as people arrive. An interactive group session of all patients and two co-facilitators (one of which is usually a provider and the other may be a social worker, nurse, nutritionist, diabetes educator, or lay person skilled in this manner of care) occurs in the next 45-60 minutes. A snack break may occur to allow for informal discussion and socialization, followed by a second brief group session to cover other topics of concern, or perhaps do an interactive meal preparation or exercise activity. Multidisciplinary guests may attend periodically, such as a podiatrist, or spiritual counselor if the group expresses interest. Billing is done as would be normal for a regular follow-up visit. Group visits occur on a regular schedule and ideally involve a cohort of patients with diabetes who return to follow-up visits together. However, patients may join a group for visits, step out, or change “groups” or community group visit locations as individual circumstances or health status change.

Lifestyle improvements:

Geomapping will also be used to look at available resources in the community as a key in planing for targeted improvements in lifestyle supports for those with diabetes and identifying gaps or barriers. The project team and advisors, which will expand, will be vital in advising about improvements that fit with patient, family and community resources and needs for a healthier lifestyle. In this aspect of the proposed model, the HEALTH team will be a strong collaborator. Members of the current team with knowledge and connections to programs or gaps include Michele Easterling, RD; Nicole Weedon, CSW; Jacki Tatum, MSN;. Agencies or organizations that have begun to provide information in addition to the mapping include: churches (i.e. identified on list of members); Project Access; Durham County Health Department; LATCH; el Centro; and DCCR. Clearly, improvements in county-wide lifestyle supports such as nutritional information and improved access to exercise will benefit residents who may not be associated with this proposed diabetes care program as well.The proposed model also includes plans for health educators with patient leaders and lay health advisors (LHAs) who will develop an ongoing support program that incorporates health behaviors for life and reduces individual and community barriers to healthy lifestyle. Some examples are: food and dietary information that is linked to shopping strategies and experiences; recipe development and cooking sessions; food intake tracking; and others. Improving exercise behaviors, for example, requires an individual, family, and community approach, including a self-guided and realistic exercise program. The team as noted above will do extensive planning and investigation of community resources to help achieve lifestyle improvements for Durham county, particularly focusing on those with diabetes.

Training:

A key part of this model will be development of a training plan for the providers, LHAs, community members, and health care professionals involved in any aspect of the model, such as group visits, home visits, and lifestyle improvements planning. Team members with clinical and education expertise will be instrumental in developing and conducting this training. Parts of the training process have been developed as curriculum for diabetes educators; nurses (School of Nursing); residents (CFM); and pharmacy students. Team members with expertise in education

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include Kathy Pereira, FNP; Brian Halstater, MD, Viviana Martinez-Bianchi, MD, Sarah Mc Bane, Pharm D, Nancy weigle, MD

Clinical ManagementPhysicians, Nurse Practitioners, and PA s will be involved assessing the progress of their own patients, but also team members Viviana Martinez-Bianchi, MD, Gloria Trujillo, MD, Nicole E Jelesoff,, M.D., Brian Halstater, MD , Kathy Pereira , Katherine Trotter, (Need clinicians here that will be involved in assessing diabetes ) will be instrumental in looking at outcomes, diabetes intensification protocoloes being done, respond to other team members and team manager clicnical questions… etc, etc (WE HAVE NOT DEFINED THE ACTIVITIES OF THE DUKE PH YSICIANS IN THIS, AND NEED TO DO SO) PARTNERSHIPS

1. Ability of Community members, agencies and Duke members to effectively address the needs identified in your proposal.

The partnership submitting this proposal brings collected strengths and experience in the clinical, community , and individual aspects of diabetes and interventions to improve this problem—for example, nutrition, exercise, self-management, social support and others.

Geomapping will include assessment of existing resources, such as community centers, parks, grocery stores, and schools with a focus on also identifying gaps in available resources. These resources speak to the support infrastructure that exists within neighborhoods as well as provides insight into physical and social resources that may assist in the planning and implementation of this project as well as be existing pieces of the social network of patients with diabetes.

The Durham County Health Department addresses diabetes prevention and management with the following services/programs.

• Nutrition Division—Provides individualized medical nutrition therapy (MNT) on referral from treating diabetes management providers. MNT is an integral component of diabetes prevention, management, and self-management education. Health Department nutritionists are Registered Dietitians and are licensed by the State of North Carolina as Licensed Dietitians/Nutritionists and are recognized as the qualified provider for medical nutrition therapy. Nutritionists also conduct presentations and group events on eating for health and disease prevention at worksites, faith-based and other community groups.

• Neighborhood Nursing Program—Registered Nurses provide educational and support services in nine low income residential communities in Durham County.

• Health Education Division—Conducts diabetes education, smoking cessation, and disease self management at worksites and faith-based and other community groups. Services may be able to be expanded if additional funding becomes available.

The Durham County Department of Social Services (DSS) goal is to meet basic economic needs, provide access to health care and nutrition to improve health status, help people find jobs then to develop strong work habits and create career paths.  The agency strives to help people become self-sufficient.  DSS staff have the ability to solicit assistance in locating people that could benefit from the plans of the proposal.  Nicole Weedon, MSW is a community leader on the team representing this department. Nicole anything else??

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Durham Community Health Network (DCHN) is a community-based managed care program for Durham Carolina Access II enrollees funded by the State of North Carolina. DCHN is governed by a network of agencies and providers, who serve the Medicaid population, including: primary care clinics, local hospitals, and the Durham Departments of Social Services and Health. The program is administered by the Duke Division of Community Health. DCHN helps primary care practices improve the quality of care that Carolina Access patients receive by removing barriers to healthcare access, helping patients better understand their healthcare conditions and responsibilities, sharing best practices. The case management team includes clinical personnel, social workers and community/lay health workers. health workers.

Duke services-Susan, Gloria ??? DUHS will provide many members of the multidisciplinary team including RNs, NPs, nursing students, physicians (CFM), physicians assistants, residents, pharmacists. At this time we have commitments for planning support from care delivery sties at Lincoln Community Health Center and affiliated practices: Lyon Park and Walltown.

Lincoln Community Health Center operates a diabetes specialty clinic and has staffing for education and support groups. Needs additional info—Kelly O’Daniel

Existing faith based groups ? Need info that we will gather from next few meetings—faith based info form possible participants of proposed programs (e.g., person with diabetes).

Other organizations – i.e. el Centro, Holton Center?

Lay health advisors (LHA) – The proposed model will utilize the LHA model of health care assistance and community support. LHAs will extend the support and services of the group care model to the patients’ family and to the community. LHAs will be instrumental in assisting with the group visits and activities such as shopping and cooking demonstrations; and facilitate patient attendance or follow-up.Health professional students – Participation in both home and group visits and lifestyle improvement planning will be a learning opportunity for a selected number of nursing, pharmacy, physician residents, and health students. This comprehensive, innovative approach to care will be of great value to future health professionals.

Info from LP, Walltown models here2. Describe the community and Duke strengths of your team, particularly as they are relevant to the proposed health need and populations being targeted.Community Strengths:

A major strength in the community is the already existing history of collaborations among Duke Health Care, Lincoln Community Health Center, Durham County of Social Services, and the Durham County Health Department. There is also the Partnership for a Healthy Durham, a coalition of agencies, organizations, community members, and leaders. The Partnership is a certified Healthy Carolinians program. Healthy Carolinians is North Carolina's statewide network of partnerships that address health and safety issues at the community level. They created a set of health promotion objectives for 2010 that form the agenda for all local programs.

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One activity that the Partnership completed recently and will be useful for this project is the mapping of parks, recreational centers, greenways, schools, etc in Durham County.

Duke Team Members Strengths:K. Trotter, FNP: Project-Co-PI Nationally recognized group care model expert with 8 years clinical practice using and consulting about this model.G. Trujillo, MD: Project-Co-PI F. Medical Director DFM teaches chronic disease management to students and residents, helps with IT development via feedback of chronic disease management working group for electronic disease registry development and leads the Diabetes Collaborative at DFM.F Mauney, MSN: Project-Duke Administrator. Extensive, varied background developing and implementing health care programs. V. Martinez-Bianchi, MD: Project-Duke MD. Associate Residency Director DFM-teaches and implements resident training chronic disease management and is physician representative for Group Visit RFP proposal. Community trained faculty for community sites in Durham County. Provider and preceptor at Lyon Park; bilingual.J. Strand: Duke PA program. Health student learners support.K. Pereira, FNP: Project-Duke Nurse. Six years experience with diabetes management as NP in Duke Endocrinology, board certified in Advanced Diabetes Management.S. Denman, FNP: Community and Duke student contact for project. Twelve years experience with Durham community health initiatives and evaluation; bilingual.Brian Halstater MD Residency Director DFM-teaches students and residents and implements resident training in chronic disease management and works closely with the medical director for IT development surrounding chronic disease management.Sarah Mc Bane Pharm D Campbell University/ DFM faculty- Teaches pharm D, family medicine residents, physician assistant students, and medical students chronic disease pharmacy management and sits on Diabetes Collaborative Duke Family Medicine. Major impetus in initial development of in-office group care. Nancy Weigle MD Assistant Predoc director DFM-teaches chronic disease management, in collaboration with Dr Joyce Copeland, for student clerkships at Duke Family Medicine.Neil Willams Pharm D CPP Medication Management. Vice President Clinical Services-currently contracted with Carolina Care Network/BCBS to setup escribing specifically targeted to Chronic Disease Management.David Lobach, MD Endocrinologist and ebrowser development for Chronic Disease ManagementKimberly Yarnall, MD Medical Director Community Health ClinicsFred Johnson, MBA: Business plan development.

Senior PharmAssist program—describe more. Others????Project Access??

3. List Community members and agencies that live in or serve this population and have been involved in the assessment and proposed development.

Michelle Easterling, RD Clinical Team Program Manager Health Department Durham County-currently works with high risks group needing nutritional counseling and chronic disease management at county health department.Nicole Weedon MSW Durham County Social Services-community social worker currently targeting high risk Diabetics in the community and works with the Diabetic Collaborative at Duke Family Medicine.

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Have names of persons with diabetes—what are their thoughts, suggestions?

Agencies—Durham Community Health Network—experience in home visiting, chronic disease management classes. Health Department—experience in home visiting, management of DM through medical nutrition therapy; Neighborhood nursing program. Need input from Health Educators—what are they hearing in their group work, PEACE project?

Lincoln Community Health Center (and affiliated sites – Walltown and Lyon Park) has committed to supporting planning efforts on this project. —success with walking club; other input?

E. Brothers: MD, Community Health Coalition. Community support of health services and wellness initiatives. G. Albergo, R-PA,: Durham VA, formerly Lincoln diabetes specialty clinician, bilingual. Co-founder and current supporter of Latino diabetic support group at Lincoln.Azucena Santana, RN. Community nurse. Co-founder and current supporter of Latino diabetic support group at Lincoln.B. Karpathian: LATCH RN, Lincoln Latino diabetic support group co-founder and current supporter; bilingual. E. Schmidt, MD, CEO-Lincoln.. Supportive of project goals . K. O’Daniel: Health educator, Lincoln. Works extensively with existing diabetic support goups and diabetic referrals. L. Perla, L. Estrella, C. Harrington, J. Clayton. Current diabetic patients in Lincoln support group, committed to assist with project. E. Brothers: MD, Community Health Coalition. Community support of health services and wellness initiatives. S. Gauger & L. Jee: MSN, NPs inpatient diabetes care at DRH, volunteers in community initiatives. L. Perla, L. Estrella, C. Harrington, J. Clayton. Current diabetic patients in Lincoln support group, committed to assist with project. H E Tatum, Jr: Durham resident with diabetes. Rev Brooks: St James Family Life Center. Committed to assist with project. Rev Irwin: St John’s Missionary Baptist . Committed to assist with project. Rev Herbert Davis: M. Div. Nehemiah Christian Center church, Durham CAN, Project Access. S. Wilson: Director of Project Access. Extensive community knowledge and relationships. J. Tatum: MSN, Durham VA, chronic illness care. African American with extensive Durham community relationships. Rosa M Gattas: Director, El Centro Hispano. Site of Latino community projects for training of LHAs, and HTN, obesity, and exercise support group. Pilar. Rocha, RD: nutritionist and leader of Duke and ECH Latino HTN and obesity support groups; bilingual.

4. Identify how your innovative model might impact on other community programs and projects.

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Hypertension, obesity, diabetes, cardiovascular disease, and renal disease all have a healthy lifestyle (nutrition, physical activity, stress management) as an integral component of disease prevention and management and have all been identified as targets for other proposed projects as well as existing community initiatives. Our goal in working with other Durham Innovations groups as well as current community groups is to enhance or promote these initiatives; not to alter what is in place if effective. The targeted intervention messages and strategies for each project may have similar general messages (although there still may be the need for some individualization with easy, affordable access to these services). Other disease states and health conditions beyond diabetes may be addressed through the same or similar models so interventions sites, staffing, record keeping could be merged and costs shared. Our model could be duplicated by others or merged for better efficiency and service coordination. Additionally, the Internatal Care; a Life Course Model project will focus on women’s health across the life course (e.g. preconception and post partum prevention and treatment) and has diabetes care as one of the focuses of interventions. Medical management issues will be the same or similar; intervention models could be similar—e.g., centering type group. The diabetes project could serve as a referral source for this project. Planning Process• Describe the planning process that your team will use (meetings, focus groups, community town halls, etc.).• Describe the plan for maintaining communication and receiving input from all members of your proposed team.• Describe how you intend to maintain communication with the community or population served and receive input and feedback from community members during the planning process.NEED

EvaluationThe more clearly you can specify aims and objectives the more easily you can align the evaluation approach

Project Evaluation

1. Delineate how you will evaluate the success of your team Success of the team needs to be evaluated on several levels: implementation of the

program/intervention; achievement of patient outcomes; acceptance and participation in the program by community organizations; satisfaction with the program by all stakeholders – participants, providers and community organizations; and sustainability of the program beyond the research phase. Each of these levels needs an evaluation plan with articulated interim goals and feedback loops.

Our first short term goal is to achieve consensus among the stakeholders, clearly articulate the intervention/program, as well as desired outcomes on patient, provider and community levels.

Buy in, participation and support of Durham community members

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Patient participation in program Acceptance of model by Duke Health System administrators Dissemination and applicability of model to patients with other chronic disease The success of the team will be evaluated by its ability to maintain a collaborative

relationship with all the different organizations that are part of the project. We will have meeting deadlines, goals and objectives to be met …..

2. Describe how you will ensure that your innovative model will be endorsed by the communities you propose to serve.

Endorsement is more likely if the program development is an iterative approach with all team participants listening to and understanding community needs and perspectives. How does the community frame the problem? How would the community define success? etc

During the planning phase (Stage 3), we will be conduct focus groups, neighborhood meetings, and interviews with individuals to gather information from community members and patients on locations for meetings to be included in this project, what kind of model for group visits will be best to fit their needs and how to make it feasible, attractive and relevant for the diverse population of Durham county. We will incorporate their feedback into the plan

The several community members who are currently part of our planning team are helping

us begin this process as we write the Stage 2 proposal. Additional community members have been added to ensure adequate input from Durham residents.

Lay health advisors (LHAs) from the community will be part of the development and advisory process. The ultimate plan it to have LHAs involved in service with patients, for example--group care, home visits, nutritional and activity initiatives.

3. Identify any specific metrics that can be used to track intermediate and outcome endpoints associated with your identified health needs.

Intermediate outcomes can process measures such as participation, keeping appointments, etc. outcome endpoints need to be articulated on individual and community levels – e.g., mean HgbA1C for participants, and overall county rates for ED visits related to complications of diabetes. Also consider patient satisfaction, self-perceived health status and self-efficacy. This can be included in the design of the group visits with pre and post measures of these outcomes.

Point of care testing will be performed during home and group visits, measuring HgbA1C, blood pressure, urine micro-albumin, cholesterol, and weight using EMR integration with laptop computers. Can also track other DM standards of care such as ACE inhibitor use, annual foot exam, eye exam, immunizations.

Using the DEDUCE tracking system, hospitalization rates as related diagnosis and complications of diabetes, emergency department visits.

We can also track the relationship of residence change within Durham to change in Medical Home; specifically whether the patient chooses new Medical Home or has hiatus from care

Patient participation in program based on health care appt attendance either in group or home visits.

Through EMR and E-prescribing, will track refills on prescribed medications and diabetes testing supplies as marker of adherence.

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Also exercise targets, weight reduction (if needed), improvement in nutritional habits will be evaluated through the use of diaries, exercise tolerance testing—pre and post, and focus group sessions.

Improvement in community resources related to exercise options, good nutritional resources will be tracked and reevaluated from baseline geomapping data.

4. How will your innovative model result in improved health status for the population served and how will you measure this?

Think about sustainability and how that can improve the health of diabetics in durham county over time –

Our innovative model will result in participants’ improved health as measured by decreased HgA1c, decrease in admission to the hospital and decrease in visits to the Emergency Room for illnesses related to diabetes.

Press Ganey or other similar surveys related to patient satisfaction with the care being received will be administered before starting the program, during and after. We expect improved scores in this area. – consider CAHPS rather than Press Ganey – CAHPS focuses on patient experience with care rather than ‘happiness’

Measurements of levels of “Patient Activation” will also be obtained at set intervals to assess progress.

5. What is the period of time over which you expect to achieve results in improved health status for each set of metrics above?

This gets into fleshing out the discussion of short versus long term measures – you can measure participation quickly, but sustainability, adoption, population health takes longer to measure – Would this be evidence to support “sticking it out” with this project for a period of time? We expect to see some metrics improving rather quickly: such as keeping scheduled

appointments, involvement of community supporters and diabetics, others may start improving in 6 months:HgBA1c, Lipids levels. Improvements in patient Satisfaction and Activation level may take one year, we expect to see a reduction in admission to the ED and Hospital to start decreasing in 2 years. It will take longer to show a reduction in rates of conditions secondary to diabetes such as renal disease, cardiac, foot ulcers . We believe this will be sfficient evidence to show that on the long run this project will be not only improve outcomes in health status of all participants but will also decrease health care costs.

6. How does your model aim to Reduce health disparities?

By bringing health care to the home of the patients and to the places in the community where they now feel safe we will be creating a Patient Centered Medical Home for all participants. The Medical Home has shown to improve health outcomes, and decrease health disparities.

Improve quality? Point of care testing would allow for immediate and patient centered

decision making on changes in medical therapy (I need to include Commonwealth Fund’s data and Starfield’s and others data on improving quality by creating medical homes VMB)

Reduce cost and/or increase efficiency? Our plan would reduce co morbidities and long term complications of renal disease (dialysis cost), blindness/ulcers and diabetes related

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amputations(disability handicap), cardiovascular events including heart attack, stroke, and long term care. There is data already in Durham county to support that the utilization of similar models is cost neutral to the health system, and improves outcomes

7. What evidence will you need to demonstrate that your innovative model can be successfully implemented and sustainably operated?

Will need more specifics on the business model for this section

8. What are the financial and operational impacts of your innovative model on projects in Durham County and Duke University Health System?

Decreased hospitalizations and costs related to medical care for diabetes Improved worker productivity and decreased worker absenteeism as related to diabetes Will need more info from business model

9. Is your plan scalable beyond Durham County? Explain. This plan should be applicable to the care of any patients in any community with chronic

illness and logistical challenges to receiving health care in the traditional clinic setting

Dissemination• How do you intend to engage and inform members of the community or population served of your findings and future steps?• How do you plan to disseminate your findings through academic journals and other publications? To which academic journals or other publications will you be submitting your findings?

The results of our planning efforts will be distributed to the Durham County community at many levels. Clearly this iterative planning process will involve sharing and collaboration with input from the providers of care in the county in order to be translated into care for patients with diabetes in the future. We will present the findings to multidisciplinary providers (physicians, nurses, PA’s, NP’s, social workers, psychologists, pharmacists, and students) in many clinical settings such as the local hospitals and clinics. It is also vital that the information be shared throughout the process of planning and upon completion with the community at large, particularly key community leaders, members, and most of all, patients with diabetes. This will be done by working with community and church leaders to reach publications, gatherings, and speaking opportunities within community organizations – religious, support organizations, and community centers. Information will also be disseminated to the larger community of Durham County by coordinating efforts with the Public Affairs department at the School of Nursing.

Dissemination to professionals beyond Durham County, nationally and internationally will take place via publication of manuscripts. Relevant peer-reviewed journals that we will submit to include: JAMA; Diabetes Care; American Family Physician; and Progress in Community Health Partnerships: Research, Education, and Action. In addition, information will be shared at relevant professional conferences including the American Diabetes Association Annual Scientific Sessions; .

Appendices

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• Schedule and Milestones – Prepare a timeline that describes activities you propose to accomplish during the planning period. Include target dates as well as team members responsible for the proposed activities, where appropriate.

• Letters of support – Include letters of support from all participating agencies and organizations. Letters from additional organizations are optional.

• Budget and Justification – Include a proposed Line-Item Budget and Budget Narrative for the Stage 3 implementation plan development process that are linked to the goals and outcomes of the proposed plan. The Budget Narrative must include an explanation for each line-item you include in your proposed budget. Please note that the budget is for the Stage 3 implementation plan development process, not for implementation itself or for pilot projects. Clarification of acceptable budget expenses will be provided during the technical assistance workshops. Please see the attached sample budget template.

SAMPLE BUDGET TEMPLATE

Duke Personnel Role Percent effort Salary Fringe Total

Total

Sub-Contracts Description Total

i North Carolina Behavioral Risk Factor Surveillance System NC, at: http://www.schs.state.nc.us/SCHS/brfss/index.html ii N.C. State Center for Health Statistics, Vital Statistics, Volume 2; 1996-2002iii American Diabetes Association. National Diabetes Fact Sheet. Available at: http://www.diabetes.org/diabetes-statistics/national-diabetes-fact-sheet.jspiv N.C. State Center for Health Statistics, 1990-2002v UK Prospective Diabetes Study Group, Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33), Lancet 352 (1998), pp. 837–853 vi American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2008, 31: S5-S54.vii Please see grant proposal titled IMPROVING DIABETES OUTCOMES AMONG DURHAM ADULTS USING A GROUP CARE MODEL AND A COMPREHENSIVE APPROACHviii Immediate feedback of HbA1c levels Improves Glycemic Control in Type 1 and Insulin –Treated type 2 Diabetic Patients, Gagliero, Levina, Nathan. Diabetes Care 22:1785-1789, 1999

ix Point-of-Care Testing in Diabetes Management: What Role Does It Play? Judith Belle Brown, PhD, Stewart B. Harris, MD, MPH, FCFP, FACPM, Susan Webster-Bogaert, MA and Sheila Porter, RN Diabetes Spectrum 17:244-248, 2004

x Group visits for Diabetes and Other Chronic Diseases, E. Shahady, http://www.transformed.com/Perspectives/GroupVisits-E.Shahady.cfmxi Closing the Divide: How Medical homes Promote Equality in Health care. http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=506814xii Effectiveness of a Group Outpatient Visit Model for Chronically Ill Older Health Maintenance Organization Members: A 2-Year Randomized Trial of the Cooperative Health Care Clinic, Scott et al. Journal of the American Geriatrics Society, Vol 52 Issue 9 1463-1470 16 Aug 2004xiii (Trento et al. Lifestyle intervention by group care prevents deterioration of type 2 diabetes: a 4-year Randomized control trial. Diabetologia 2002; 45:1231-1239).xiv Sadur, et al Diabetes Management in a Health Management organization: efficacy of care management using cluster visits. Diabetes Care 22:2011-2017, 1999xv Wagner, Grothaus et al: Chronic Care clinics for diabetes in primary care: a system-wide randomized trailxvi Trento et al, Group visits improve metabolic control in type 2 diabetics: a 2-year follow-up. Diabetes Care 24:995-1000, 2001xvii Clancy, DE; Brown, SB; Magruder, KM; Huang, P. Group visits in medically and economically disadvantaged patients with type 2 diabetes and their relationships to clinical outcomes. Topics in Health Information Management. 2003;24(1):8–14.xviii Vermeire E, Wens J, Van Royen P, Biot Y, Hearnshaw H, Lindenmeyer A: Interventions for improving adherence to treatment recommendations in people with type 2 diabetes mellitus. Cochrane Database Sys Rev no. CD003638, 2005

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Total

Meeting expenses Description Total

Total

Materials and suppliesDescription Total

Total Total funds requested ___________

SUBMISSION FORMAT

Please compend all required elements into a single PDF document and submit via email to DukeDurhamTeams@mc.duke.edu.

Applications must be received by 5:00 pm on March 2, 2009. A complete application must include all of the elements above, be typed, single-spaced using 12 point Times New Roman font on 8.5 X 11 paper, 1” margins, and pages numbered at the right lower corner.

INQUIRIES

We welcome the opportunity to answer questions from Stage 2 applicants. Please feel free to direct inquiries related to this funding announcement to:

Sue SchneiderzDuke Center for Community ResearchTel: (919) 681-8598E-mail: Suzanne.schneider2@duke.edu or DukeDurhamTeams@mc.duke.edu

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