George Rust MD, MPH is a Professor of Family Medicine and is the founding Director of the National Center for Primary Care (NCPC) at Morehouse School of Medicine and currently serves as co-director with Dr. Dominic Mack. The NCPC’s mission is to promote excellence in community oriented care and optimal health outcomes for all Americans. He received his medical degree from Loyola University School of Medicine and completed his residency training in Family Medicine at Cook County Hospital in Chicago. He is board-certified in both family practice and preventive medicine and holds a Masters of Public Health. Dr. Rust was the founding director of the Morehouse School of Medicine Faculty Development Program, which has expanded to conduct executive faculty development for minority faculty across the nation.
Ms. Clancy offers a distinguished background in health care system transformation. Building upon her experience in designing and leading a SAMHSA national technical assistance center, Ms. Clancy has a successful history of working with counties, statewide agencies, provider organizations, advocacy organizations, and health plans to propel large scale quality improvement programs and initiatives. Ms. Clancy has worked in clinical roles as an independent, licensed social worker in New Mexico and in Executive Leadership roles in California. She served as Executive Director of United Advocates for Children of California, the first Executive Director of California’s Mental Health Services Oversight and Accountability Commission, and the Executive Director position at Village Care International, Inc., an organization dedicated to building volunteer driven, children’s systems of care in Kenya and Nigeria. Ms. Clancy also worked at the California Institute for Behavioral Health Solutions where she serves as the Associate Director over statewide ACA Initiatives, including Breakthrough Series Learning Collaboratives on recovery, care coordination, and behavioral health integration. She recently served as a key consultant to the California Department of Health Care Services on behavioral health integration strategies for the 1115 Waiver and was the organizer and facilitator for their statewide Mental Health and Substance Use Disorders Integration Task Force. Most recently Ms. Clancy has started a consulting firm that seeks to support health care transformation and improvement through integration of services, especially behavioral health services, care coordination, promotion of data infrastructure and use in safety net provider organizations, clinic and community partnerships, and focusing on the experience of the patient to drive improved quality, better health outcomes and reduced costs in health care.
Dr. Osagie Ebekozien M.B.B.S, MPH, CPHQ, CPHRM is the Director of Accreditation and Quality Improvement at the Boston Public Health Commission (BPHC), in this role he works with a team of dedicated professionals on numerous large scale improvement initiatives and coordinates all public health accreditation activities.
Prior to joining BPHC, he was the Manager of Quality Assurance and Performance Improvement at a Federally Qualified Health Center in Boston where he directed many community based programs, achieved level 3 NCQA Patient Centered Medical Home recognition and led several quality improvement programs that resulted in significant improvement in clinical outcomes.
His areas of expertise are quality improvement, accreditation, public health service delivery, risk management and program evaluation. He has over 10 years’ experience improving health outcomes of vulnerable populations.
Dr. Ebekozien is a foreign trained primary care physician, received his Masters of Public Health (MPH) degree from Harvard School of Public Health and is a Certified Professional in both Healthcare Quality (CPHQ) and Healthcare Risk Management (CPHRM).
Holly Nannis has over 20 years working in public health. 10 years with the City of Milwaukee Health Department as a Public Health Nurse, Nursing Supervisor and Program Manager; followed by 3 years as a Program Analyst with Health Resources and Services Administration within the Department of Health and Human Services in Washington D.C.
Holly worked as liaison to 10 regional offices setting strategic direction with work plans that had relevant and appropriate performance measures. Upon returning to Milwaukee, continued her career at the Medical College of Wisconsin, coordinating and evaluating research study results. Holly currently is Director of the Chronic Care Health Education Program at Sixteenth Street Community Health Centers. With a team of 8, offers self management education, tools, resources and support that prepares and empowers people with chronic health conditions to make informed decisions about their health. Holly also provides leadership in the area of community partnership development.
Randall Carlyle has over 20 years of healthcare experience. He holds a Bachelors degree in Biology from Pembroke State University, a Medical Technology degree from McLeod Regional Medical Center in Florence, S.C., and a Masters degree in Public Administration from the University of North Carolina at Pembroke. Randall has worked in and with hospital, private practice and community health centers for the past 20 years. He was a participant in the Bureau of Primary Health Care Health Disparity Collaboratives since their inception in 1999. He has served in the capacities as data-entry and team leader in Diabetes, Cardiovascular, and the Cancer Screening HDC Collaboratives. He has served as faculty at numerous Learning Sessions since 1999 and has either attended and/or presented at over 35 Learning Sessions. One of his teams was one of the original 10 beta test sites for the PECSYS electronic patient registry which many of the BPHC teams still use today. He has extensive knowledge of the Chronic Care Model and PDSA development and has presented nationally on all areas of the Chronic Care Model. Currently, Randall is the Director of Health Services CareSouth Carolina; a Community Health Center headquartered in Hartsville, S.C. CareSouth Carolina has 12 centers and serves over 30,000 patients in Pee Dee and Marlboro regions of South Carolina. Randall provides clinical supervision for laboratory, x-ray, and Level 3 Family Support Services departments at CareSouth. He also provides medical administrative support to CareSouth’s Chief Medical Officer.
Sandra Leal, PharmD, MPH, CDE is the Vice President for Innovation at SinfoniaRx in Tucson, Arizona and an adjunct clinical instructor/preceptor for the The University of Arizona College of Pharmacy. Dr. Leal’s last fourteen years of clinical service included serving as the Medical Director of Pharmacy and the Broadway Clinic which serves special populations at El Rio Health Center in Tucson, which included provision of clinical services in the areas of diabetes, hypertension, and dyslipidemia in a largely Hispanic and American Indian population.
She previously served as the National Chair of the Patient Safety and Clinical Pharmacy Services Collaborative and as Chair for the Arizona Diabetes Leadership Council and the Arizona Diabetes Coalition. She currently serves on the Board for the Southern Arizona Diabetes Association. Some of her current work has been published in Diabetes Care, The Journal of Health Care for the Poor and Underserved, Insulin Journal, and Advances in Chronic Kidney Disease.
Dr. Belinda Nelson is a Senior Research Specialist at the University of Michigan, Center for Managing Chronic Disease (CMCD). The CMCD was selected as the National Program Office for the Alliance to Reduce Disparities in Diabetes (funded by the Merck Company Foundation), and Dr. Nelson served as the community liaison. In her role as part of the NPO she provided a wide range of technical assistance and support for the five community-based projects of the Alliance to Reduce Disparities in Diabetes: Camden, New Jersey; Chicago, Illinois; Dallas, Texas; Fort Washakie, Wyoming; and Memphis, Tennessee.
Dr. Belinda Nelson earned a joint doctorate in Social Work and Psychology, and has worked with diverse patients and community groups as a clinician and researcher. Her current research interests include chronic disease, coping, and health behaviors among women, with a special focus on marginalized and disadvantaged communities, as profiled in Jet and Essence magazines.
She has served as the program director for the Detroit Head Start Asthma Project, a community-based clinical trial designed to build capacity for asthma management among parents and Head Start personnel. She also coordinated the Nurse Asthma Care Education Project (NACE), an educational intervention for nurses who provided care for high risk populations with asthma in areas where nursing demand is high. Dr. Nelson recently served as the senior intervention specialist and advisor for the Women of Color with Asthma project (WCA), a program designed by the Center specifically for African American women with asthma. She is currently collaborating with colleagues at the Center for Managing Chronic Disease to translate the strategies utilized in the WCA study for development of culturally specific diabetes intervention among African American women in Detroit Michigan.
Dr. Nelson has presented research findings at several national and state level conferences, and has moderated educational webinars.
William Rhett-Mariscal, PhD, MS, is an Associate Director at the California Institute for Behavioral Health Solutions (CIBHS – formerly California Institute for Mental Health) in Sacramento, CA. Dr. Rhett-Mariscal helps promote, integrate, and infuse cultural competence within publicly funded behavioral health systems in California and seeks the elimination of disparities in mental health for racial and cultural communities. He previously served as the project director of a learning collaborative addressing disparities through integration of community-based primary care, behavioral health, and social services utilizing continuous quality improvement strategies for implementing best practices & incorporating prevention. Dr. Rhett‐Mariscal has a rich background in social anthropology and direct clinical experience in marriage and family therapy as a bilingual/bicultural clinician and brings his experience in both fields to his work addressing disparities.
2015 – 2016 PDHE Learning Collaborative Teams
Click on the team names for Bio/Aim…
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: 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.
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: 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.
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%.
- – 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
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: 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.
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: 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.
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: 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).
*Memorial Hospital – Southbend, Indiana
*Charles Drew University, The Life Center – Los Angeles, California
*(Team did not complete Collaborative Program due to organizational structure.)