Type 2 diabetes is a long-term problem which nearly 12% of Durham County adults live with daily. To combat this issue, a Durham partnership was formed to improve health outcomes and quality of life for diagnosed and undiagnosed adults living with the disease.
The Durham Diabetes Coalition is a joint effort between Durham County Public Health, Duke University Medical Center, the University of Michigan School of Natural Resources and Environment, Durham health and community organizations, faith-based groups, local government, and community members.
drives targeted community interventions
Key components of targeted intervention:
- Information Exchange
Geospatial analysis identifies risk and resilience including diabetes-specific resources
Geospatial Mapping identifies Diabetes specific resources
Diabetes Screenings and information dissemination is done in high incidence communities
Targeted screening approach informed by the American Diabetes Association risk assessment.
Diabetes Screenings and information dissemination is done in high incidence communities.
High-risk patients are assigned a clinical care team consisting of :
Supervising Physician Nurse Practitioner,
Licensed Social Worker,
Registered Dietitian and Community Health Worker
Patient Convenient Diabetic Education -
Allows patients to have “visits” where it is convenient for them.
Home Visits for medication reconciliation, safety hazards and diabetic education allow patients comfort, convenience and holistic care.
Telephonic coaching available for moderate to low risk patients and delivered by community health assistants. Self-management modules include different topics such as:
Grocery Store Tours
Provide patients “in the field” training for healthy shopping in their own neighborhoods.
Active Community Advisory Board includes diverse partners: Ebenezer Missionary Baptist Church, CAARE, American Diabetes Association, Cooperative Extension, people living with diabetes, El Centro Hispano, East Durham Children’s Initiative, Lincoln Community Health Center, and others.
Real Time Monitoring and Evaluation drives continuous improvement and a Risk Algorithm assigns high, moderate, and low risk values to patients.