2015 – 2016 PDHE Learning Collaborative Teams

Please join us in welcoming the selected teams to the Partnership for Diabetes Health Equity Learning Collaborative!

Please click on the team name below to expand and view their profile.

Texas Health Harris Methodist Hospital Azle – Azle, Texas
BIO

Texas Health Harris Methodist Hospital serves the communities in Northwestern Tarrant, Parker and Wise Counties.  Texas Health Azle is a not for profit hospital committed to improving the health of the community.  As a department of the hospital, Healthy Education and Lifestyles Program (HELP) is a program designed to help decrease barriers and increase access to appropriate care for uninsured patients living with certain chronic diseases.  It also provides coordinated care to increase patients’ self-efficacy to better manage their chronic disease.  HELP provides access to a clinical visit, education, and a support group during each session. Patients also are connected to local resources such as prescription assistance and eye care.

Our goal with this collaborative is to build on the current success and bring HELP to a new level.  One objective is to increase bio-metric scores by decreasing the barriers unfunded patients face.  One way to achieve this is to learn from others.

AIM

Aim:  To improve the health of the unfunded, diabetic patients by improving the self- management skills and the individual bio-metric scores through access to clinical and non-clinical resources thus removing barriers to good health.

Complete Team Charter

Southside/Dodson Avenue Community Health Center – Chattanooga, Tennessee
BIO

Southside/Dodson Avenue Community Health Centers served 13,484 patients, with 1,837 being diabetic patients. Over half of our patient population is African American (44%), with about 5% Hispanic. Our service population includes all of Hamilton County, TN.

The goal is to collaborate and work with individuals and other workgroups who are committed to making a difference in reducing barriers to quality health care for those individuals who need it the most (the most vulnerable populations) which we serve in our communities. Communities of color disproportionately face barriers to high-quality, affordable health care. For all to enjoy the benefits of living in a healthy, productive, and prosperous society, we must work toward eliminating the glaring disparities that exist between those who can get health care and those who lack access to it but need it the most. I believe that this learning collaborative realize this challenge of health iniquity in our society; and would like to bring like minds together to collaborate in efforts to reduce/eliminate gaps in health care that leads to health disparities, in particularly diabetes. Our main aim is to collaborate and partner not only with organizations in our community but in other locations to work toward reducing the high morbidity and mortality rates of disability and premature death in our patients and the community at large.

AIM

Aim:  The Chattanooga Health Equity Partnership will work together to: 1) Assess and identify gaps in community supports for, clinical coordination of, and resources for persons with type 2 diabetes ; 2) Implement enhanced clinical management among persons with diabetes representing selected communities; 3) Identify and mobilize community resources in support of key healthy living conditions including housing, food access, transportation, physical activity, and healthy eating. Enhance the management of diabetes.

Complete Team Charter

Diabetes Health and Wellness Institute- Dallas, TX
BIO

The Baylor Scott & White Health and Wellness Center (BSW HWC) is a collaborative project between the City of Dallas and Baylor Scott & White Health Care System (BSWHCS). BSW HWC serves South Dallas and is in the Frazier community in the Juanita J Craft Recreation Center.

The Diabetes Self-Management Education Training program (DSMET) is a major component in the total experience that BSW HWC offers to clients. However, we have some challenges with the DSMET program; we have challenges with participation/attendance rates and want to be more effective in goal setting, monitoring and documentation of outcomes.

Engagement in a DSMET program is particularly important for our clients with diabetes, as we know that completion of our DSMET program results in better management of one’s diabetes including control of his or her A1c. BSW HWC seeks to better understand the rate in which we experience client retention for the DSMET program. We began the Collaborative with a DSMET participate retention rate of approximately 50%.

AIM

Aim:

  • – Increase attendance and completion rates by 20% for DSME/T over 12 months
  • – Decrease no show/cancellation rates by 25% for DSME/T over 12 months
  • – Establish a lifestyle goal with every DSME/T participant who participates in DSME/T
  • – Collaborate with patients to meet that goal within a month of completing DSME/T

Complete Team Charter

Hunterdon Healthcare System – Flemington, New Jersey
BIO

Hunterdon Health Care System, specifically the Center for Nutrition and Diabetes Management, has two target populations with Type 2 Diabetes and prediabetes. The first is the growing Hispanic community in Hunterdon County. As of 2015, Hispanics make up an estimated 6.3% of the county’s population, up from 5.2% according to the 2010 Census.  Our second target population is older adults over the age of 65. Hunterdon County’s senior population has grown from 12.7% in 2010 to 14.8% in 2013, according to US Census data, which exceeds the national average. The Center for Nutrition and Diabetes Management saw 531 older adults in 2014. In both cases outreach and referrals to diabetes education/treatment resources for these target populations could greatly be increased in Hunterdon County.

The Diabetes Learning Collaborative would help Hunterdon Diabetes CARE improve our process for data collection, evaluation, and rapid feedback between clinical and community partners. We aim to do this in two ways. First, the county-wide coalition focused on diabetes outreach and education, known as Hunterdon Diabetes CARE which focus on measuring improved diabetes health outcomes through data such as the number of emergency room intakes attributed to diabetes complications. Second, collect more data on Hunterdon County’s growing Hispanic population to devise appropriate outreach strategies to increase access and utilization of diabetes-related services.

AIM

Aim:  To improve utilization of resources and data collection. This aim is twofold. First, we aim to increase utilization of community-based programs pertaining to diabetes/pre-diabetes and document whether participants either have diabetes or prediabetes or are caregivers of a person with diabetes, as well as document their knowledge and access to resources. The partners in Hunterdon Diabetes CARE will track cross referrals between programs on a monthly basis. Second, on a clinical level, our aim is twofold: Using EHR at the Center for Nutrition and Diabetes Management to identify available and accessible data, measure increased utilization of DSME by age and ethnicity, and evaluate trends in diabetes outcomes on a monthly basis. Long term aim is to increase our access to Hospital Emergency Room and Readmissions data in order to identify areas of potential change related to diabetes complications and outcomes. Our goal is to demonstrate reduced admissions and readmissions due to diabetes-related complications.

Complete Team Charter

Hope Health – Florence, South Carolina
BIO

HopeHealth currently serves 1,409 African American patients between the ages of 18 – 75 and 32 Hispanic adults in Florence County with DMT2.

Hope Health goals and aim is to learn about best practices of diabetes care in PCMHs to reduce diabetes disparities, to identify opportunities for improvement in clinical care, process or system that can better diabetes health outcomes for African American and Hispanic individuals at HopeHealth, especially focusing on A1C reduction, to test ideas for improvements, and use rapid cycle evaluation tools by working with SC DHEC to collect and analyze data.

AIM

Aim:  HopeHealth Diabetes Center, SC Primary Health Care Association and SC Department of Health and Environmental Control will partner to make fundamental changes to improve diabetes related health outcomes for underserved and inappropriately-served populations. This will be achieved by increasing the number of African American men who complete Diabetes Self-Management Education programs.

Complete Team Charter

Richland Public Health – Mansfield, Ohio
BIO

Richland County serves a population of approximately 121,107, that is multi-ethnic and predominately English speaking.  Demographics of the population served is:  87.4% Caucasian, 9.6% African American, 1.8% Hispanic/Latino, 0.7% Asian, 0.2% American Indian/Alaskan Native, 2.0% two or more races.  There are large pockets of extreme poverty populations within the city of Mansfield which makes up the bulk of Richland County’s population.  The CDC indicates that the rate of diagnosis for diabetes in this region is 11.9 % (2013), diabetes was the 7th leading cause of death in Richland County between 2006-2008.  Approximately 15.1% of the population is at or below poverty level.  The CDC ratio was used to determine a rate of 32.5% at risk of diabetes in Richland County.

The goals would be to improve collaboration between partners in the community, clinical and health system/data sectors by identifying weaknesses in Richland County, such as getting healthcare professionals working efficiently and cohesively to increase access to diabetes care for the targeted population.  We would like to focus on improving data collection, sharing of data, and using the data to evaluate and assess how we can continue to improve care for the high needs, low resource population.  We would aim to work toward policy and system change to decrease diabetes health disparity, while focusing on quality improvement of care, costs and health outcomes through data collection, shared analysis and sustainability of systems and programs for diabetes care.

AIM

Aim:  OhioHealth/RPH will serve as lead organizations to improve the delivery of health care and diabetic self-management in a cost-effective manner by increasing referrals of diabetic and pre-diabetic patients to diabetes education and the Diabetes Prevention Program (DPP).

Complete Team Charter

3 Element Model Learning Collaborative Online Participant Community Check Box

Please click the link below to access the PDHE 3 – Element Model Learning Collaborative Online Participant Community Check Box documentation and evaluation system to enter your monthly narrative data.