The Alameda County Diabetes Disparities Reduction Initiative
At the level of the Health Care team, ACDDRI will provide additional training and technical assistance for paraprofessionals and clinicians to ensure two-way communication and referrals so that all patients with diabetes have access to holistic care that addresses their medical and social needs. Paraprofessionals will be trained using Project Dulce and American Heart Association models, ensuring that they can address diabetes care and hypertension in a culturally responsive way.
Core Care Area:
Program: ACDDRI
Keywords, Themes & Tags:
The Alameda County Diabetes Disparities Reduction Initiative
The Alameda County Diabetes Disparities Reduction Initiative (ACDDRI) is a collaboration of the Alameda County Public Health Department (ACPHD), the Alameda Alliance for Health (the major Medicaid managed care plan in the County), two neighborhood-based clinics (Roots Community Health Center and Tiburcio Vasquez Health Center [TVHC]), and the University of California, Berkeley, and other partners to transform diabetes care and management. With a focus on reducing health disparities in diabetes rates and acuity within the county’s African American and Latino communities, ACDDRI will offer a comprehensive, innovative set of interventions concentrating on two of our most underserved and under-resourced communities: East Oakland and the unincorporated areas of Hayward and Ashland/Cherryland. ACDDRI will transform primary care for diabetes, engage multiple levels of health care, and engage across sectors to address a range of medical and social determinants of health. ACDDRI has the overall aim of improving the quality of care for adults with Type 2 Diabetes and co-morbid hypertension and hyperlipidemia. From decades of research, we know that medical interventions alone are not enough to reduce diabetes rates or prevent diabetes-related complications.
Patients need a range of supports to understand their disease and how diet and exercise influence health; to overcome social and economic barriers to needed behavior changes; and to communicate with their care teams more effectively. As with other health education efforts, short-term diabetes education classes may increase patients’ knowledge, but without additional supports in translating that knowledge into action, many will not be able to realize changes in their behaviors—around healthy eating, exercise, or medication compliance and monitoring, for example–in ways that make a real difference to their health. ACDDRI’s comprehensive model of care aims to offer participants the full range of support they need to address the medical and social determinants of health.
By focusing on two communities in the County with significantly higher rates of diabetes-related health disparities, we hope to reduce or eliminate these disparities and contribute to greater health equity in the County. ACPHD has long been a national leader among local health departments in understanding and addressing health equity and social determinants of health. And ACDDRI’s local evaluation partner, UC Berkeley’s Health Research in Action (HRA) Center, brings together leading researchers in the field. ACDDRI will deploy a linguistically and culturally responsive workforce of paraprofessionals in clinical and community settings to engage and empower people with diabetes in better managing their disease and better advocating for themselves in medical and social service settings.
In order to do so, we will build on and strengthen existing cross-sector partnerships that address medical and social determinants of health. ACDDRI lead agency ACPHD works across sectors and at the program and policy levels to bring together a range of place-based and wraparound services that support individuals and families in living healthier lives, through home visiting programs, work on food security and food access, and financial asset-building, as well as community-based support for local policy change. Roots and TVHC are deeply rooted in the neighborhoods they serve, working directly or in partnership to improve primarily low-income residents’ access to health care, food, exercise, affordable housing, and employment. With our in-house evaluation unit and UC Berkeley evaluators, as well as Merck’s cross-site evaluation team, we will work to disseminate findings to advance population health efforts.
Core Care Area:
Program: ACDDRI
Keywords, Themes & Tags:
ref. ACDDRI Volume I Program Narrative for Merck 4-17-17 FINAL (1) – April 2017, Dan Abrahamson
The Alameda County Diabetes Disparities Reduction Initiative
Each year, ACDDRI will provide up to 200 people with diabetes access to coordinated care:
- Support from paraprofessionals–including staff and volunteer peer educators, promotoras, Community Health Workers (CHWs), and/or Patient Navigators–who are integrated into multidisciplinary care teams.
- American Diabetes Association-recognized Diabetes Self-Management Education (DSME) classes.
- Diabetes/Hypertension Action Plans, developed and monitored in conjunction with the paraprofessionals and clinicians to address both medical and social determinants of health.
- Expanded opportunities for group medical appointments and other types of group sessions that allow for sharing among patients coping with diabetes and related conditions.
- Improved access to diabetes-appropriate food and improved access to opportunities for physical activity.
- Access or referrals to other needed social supports, including identifying and navigating affordable housing, enrolling in health insurance and public benefits for which they are eligible, and preparing for and finding employment, among others.
ACDDRI will transform primary care at two community-based clinics in order to ensure that:
- Paraprofessionals are trained in evidence-based diabetes care management, as well as in case managing for social support needs. We expect to train approximately 15-20 community-based paraprofessionals during the grant period.
- Multidisciplinary teams better integrate paraprofessionals so that both social and medical determinants of health are addressed.
- Clinics become American Diabetes Association (ADA) Recognized programs for DSME, promoting evidence-based practices and offering clinics additional options to bill third-party payers for DSME.
- Clinics expand their capacity for group medical appointments and innovative care options.
- Clinics expand their capacity to access and analyze diabetes and hypertension outcome data and use it to better manage panels of patients and implement Continuous Quality Improvement (CQI) projects.
Core Care Area:
Program: ACDDRI
Keywords, Themes & Tags:
ref. ACDDRI Volume I Program Narrative for Merck 4-17-17 FINAL (1) – April 2017, Dan Abrahamson
The Alameda County Diabetes Disparities Reduction Initiative
For more than 50 years, ACPHD has worked to improve the health and safety of county residents and the neighborhoods in which they live. In Alameda County, low-income communities and communities of color continue to have the worst health outcomes. Among them, African Americans have the greatest health burden and lowest life expectancy. Diabetes is the seventh leading cause of death in California, and determined to be the underlying cause of death in almost 8,000 people each year.1 In Alameda County, 5.7% of adults report having been diagnosed with diabetes.2 Overall, diabetes accounts for more hospitalizations than coronary heart disease, stroke, congestive heart failure, and asthma combined in the County. Inequities in diabetes rates—and especially rates of diabetes mortality and hospitalization—remain stark in the county.
Core Care Area:
Program: ACDDRI
Keywords, Themes & Tags:
ref. ACDDRI Volume I Program Narrative for Merck 4-17-17 FINAL (1) – April 2017, Dan Abrahamson
The Alameda County Diabetes Disparities Reduction Initiative
To address the most pressing disparities in our County, ACDDRI will focus on the African American and Latino populations, with a focus on low-income residents living in neighborhoods of concentrated poverty. We expect to reach up to 200 individuals with diabetes a year with our program model. ACDDRI will prioritize the highest risk patients, as determined by a recent history of diabetes-related emergency department visit or hospitalization, an A1c out of target range, or other new complications. We will work with the Medi-Cal managed care provider, Alameda Alliance for Health, to obtain referral lists of patients with recent diabetes-related hospitalizations, especially those who are already have medical homes at Roots or TVHC. At the same time, ACDDRI will remain open to other people with diabetes who are referred by the clinics, other primary care providers, or even self-referred. These patients are among those most likely to be motivated to make behavior changes that may help them avoid or mitigate diabetes-related complications.
Core Care Area:
Program: ACDDRI
Keywords, Tags & Themes: Population; Medi-Cal
ref. ACDDRI Volume I Program Narrative for Merck 4-17-17 FINAL (1) – April 2017, Dan Abrahamson
The Alameda County Diabetes Disparities Reduction Initiative
In line with the pattern of health inequity in Alameda County, African Americans have a disproportionately high diabetes prevalence (11.0%), more than twice that among Whites (4.3%). Residents with incomes less than 200% of the federal poverty level (FPL) have twice the prevalence of diabetes when compared to those living at or above 200% FPL (10% versus 5.0% respectively). African Americans experience the highest rates of diabetes hospitalizations (2,082.9 per 100,000 women; 1,946.3 per 100,000 men), rates that are three times higher than those of the lowest groups (API males and females and White females). The next highest rates are seen among Latino/Hispanic males and females (1,170.6 and 1,165.1 per 100,000 population respectively).
Core Care Area:
Program: ACDDRI
Keywords, Tags & Themes: Population; Demographics
ref. ACDDRI Volume I Program Narrative for Merck 4-17-17 FINAL (1) – April 2017, Dan Abrahamson
The Alameda County Diabetes Disparities Reduction Initiative
Located on the east side of the San Francisco Bay, Alameda County is home to 1.6 million people and is the most racially and ethnically diverse county in the nine-county Bay Area.4 The county is equally diverse linguistically as 41% of the population speaks a language other than English in the home. The proposed targeted areas for ACDDRI—East Oakland and the unincorporated areas of Hayward and Ashland/Cherryland—have experienced some of the most persistent poverty rates and highest disease burden in the County. Data compiled by ACPHD’s CAPE unit confirms that the targeted neighborhoods are “food deserts” lacking affordable fruits and vegetables and other foods that comprise a healthy diet. In addition, each is home to around three dozen liquor and corner stores and experiences some of the highest rates of overweight, obesity, and weight-related chronic disease in the county. East Oakland and Ashland/Cherryland have high densities of African Americans and Latinos, respectively.
In 2014, 5,236 adults in East Oakland and 6,512 in Ashland/Cherryland reported having diabetes, a prevalence of 7% and 6.7% respectively. This compares to an Oakland prevalence of 6% and an overall county prevalence of 5.7%.5 Strikingly, the annual rates of diabetes hospitalizations for 2012-2014 were even more disproportionate in these neighborhoods, suggesting that residents in East Oakland and Ashland/Cherryland experience more acute diabetes-related health needs. The two areas have a combined 3,000 diabetes hospitalizations a year, accounting for more than 1 out of 5 such hospital visits in the County. East Oakland had an age-adjusted rate of diabetes hospitalizations of 1,605.3 per 100,000 residents, and Ashland/Cherryland had a rate of 1,198.5 per 100,000, substantially higher than the overall County rate of 879.6 per 100,000 residents.
Core Care Area:
Program: ACDDRI
Keywords, Themes & Tags: Population
ref. ACDDRI Volume I Program Narrative for Merck 4-17-17 FINAL (1) – April 2017, Dan Abrahamson
The Alameda County Diabetes Disparities Reduction Initiative
ACDDRI will feature multidisciplinary teams that integrate paraprofessionals with diabetes and hypertension specialization and, where appropriate, offer group medical appointments to supplement individual visits and ADA-recognized DSME and diabetes support groups. ACDDRI will offer care tailored to patients’ risks and responsive to their culture and language through:
- Community Health Workers/Paraprofessionals: On the teams, the paraprofessional will serve to connect patients with diabetes and hypertension to medical and social services and education, supporting the development of individualized Action Plans that address the most will feature multidisciplinary teams that integrate paraprofessionals with diabetes and hypertension specialization and, where appropriate, offer group medical appointments to supplement individual visits and ADA-recognized DSME and diabetes support groups.
ACDDRI will offer care tailored to patients’ risks and responsive to their culture and language through:
- Community Health Workers/Paraprofessionals: On the teams, the paraprofessional will serve to connect patients with diabetes and hypertension to medical and social services and education, supporting the development of individualized Action Plans that address the most
Core Care Area: Care
Program: ACDDRI
Keywords, Themes & Tags: Community Health Workers; Paraprofessionals
ref. ACDDRI Volume I Program Narrative for Merck 4-17-17 FINAL (1) – April 2017, Dan Abrahamson
The Alameda County Diabetes Disparities Reduction Initiative
Group Medical Appointments: As part of ACDDRI, Roots and TVHC will expand and strengthen the practice of offering patients group doctor visits on a regular basis. While both clinics have some experience with such visits, they have not yet implemented them specifically or consistently for diabetes patients. Group medical appointments are a promising practice that seems to be particularly effective in improving care and lowering costs for patients with diabetes, according to recent coverage in the AAFP News of the American Academy of Family Physicians and the New York Times. Such visits allow a small group of patients with diabetes to meet with their primary care provider, other medical staff, a paraprofessional, and family members for an extended appointment. They allow patients to share information about successes and challenges and to encourage each other to improve their disease management, all in the context of a doctor’s visit.
Core Care Area:
Program: ACDDRI
Keywords, Themes & Tags: Group Medical Appointments
ref. ACDDRI Volume I Program Narrative for Merck 4-17-17 FINAL (1) – April 2017, Dan Abrahamson
The Alameda County Diabetes Disparities Reduction Initiative
ACDDRI will address multiple levels of the healthcare ecosystem in order to reduce disparities in diabetes care and health outcomes, as follows:
- Healthcare interventions targeting individual patients (and their families) will include access to coordinated, culturally and linguistically responsive DSME and case management that addresses both medical and social determinants of health. ACDDRI’s leadership understands that, especially for high-risk groups, patient engagement and activation must be built on partnership and trust between the patient and staff, and staff must reach clients where they are and help them to overcome barriers to them accessing and sustaining care. Patients will learn how to talk to and advocate for themselves with their doctors, how to monitor their blood sugar and blood pressure, how to adhere to medication regimens, and how to establish and maintain healthy eating and exercise habits. Through DSME classes, support groups, and group medical appointments, they will have access to both peers and paraprofessionals, two types of support that a growing body of research demonstrates can have lasting impact on promoting and sustaining behavior change. Finally, through ACPHD’s wide array of community partners and referrals, patients will have increased access to diabetes-appropriate food, group exercise classes and workshops, and at-home monitoring equipment, including blood pressure cuffs. Alameda Alliance for Health, which provides managed care to 80% of Medicaid recipients in the County, has agreed to cover blood pressure cuffs as Durable Medical Equipment.
Core Care Area:
Program: ACDDRI
Keywords, Themes & Tags: Interventions
ref. ACDDRI Volume I Program Narrative for Merck 4-17-17 FINAL (1) – April 2017, Dan Abrahamson
The Alameda County Diabetes Disparities Reduction Initiative
At the Health System level, ACDDRI will transform the approach to diabetes care in these clinics, assisting them in gaining recognition from the ADA. This recognition will allow the clinics to bill Medicaid, Medicare, and other payers for DSME, creating a sustainable, cost-effective model of delivering holistic diabetes care. ACDDRI staff will coordinate all project partners in a Diabetes Disparities Reduction Learning Community, facilitating sharing of best practices and lessons learned among the medical professionals, paraprofessionals, and other providers engaged in the project.
Core Care Area:
Program: ACDDRI
Keywords, Themes & Tags: Health Systems; Medicaid; Medicare
ref. ACDDRI Volume I Program Narrative for Merck 4-17-17 FINAL (1) – April 2017, Dan Abrahamson
The Alameda County Diabetes Disparities Reduction Initiative
Finally, at the Health Policy level, project partners, including community leaders and promotoras, as time and interest allow, will also coordinate with ACPHD’s ongoing health policy promotion efforts. ACPHD’s Health Equity Policy and Planning Unit is engaged in advocacy for local and state policies that will improve healthy food access at neighborhood stores and that invest in safer, more walkable neighborhoods. ACPHD’s Healthy Retail Program works to improve the health of our community by engaging and supporting little corner stores to become a full service groceries that offer fresh fruits and vegetables to their shoppers. ACPHD contracts with two community-based organizations to implement the work including: identifying the small stores located in ‘food deserts’ (areas far from full service groceries); supporting store owners in identifying healthy snack distributors; educating store staff how to shelve fresh produce; and hosting community and in-store events to promote the healthy food choices (e.g., “Taste-Test-Tuesdays,” showcasing healthy recipes) to the community. We are currently working with six stores in Oakland and plan to engage a total of ten stores by the end of this fiscal year.
Core Care Area:
Program: ACDDRI
Keywords, Themes & Tags: Health; Health Policy; Food Access
ref. ACDDRI Volume I Program Narrative for Merck 4-17-17 FINAL (1) – April 2017, Dan Abrahamson
The Alameda County Diabetes Disparities Reduction Initiative
Key ACDDRI partners ACPHD, Roots, and TVHC all share a commitment to “addressing the root causes of health care disparities and empowering our community” (in the words of TVHC’s vision statement). Clinicians and paraprofessionals will assist ACDDRI participants in accessing healthier food and physical activity options either through direct services or through “prescriptions” for healthy food, exercise, or other supports. Proposed services include:
- Healthy Food Access: The ACPHD Chronic Disease Program will coordinate with food distribution partners to provide diabetes-friendly food access interventions. Building on and leveraging current and past initiatives, we will develop place-based food access strategies, including tours of farmer’s markets and healthy retail options; low-cost or no-cost community supported agriculture (CSA) bags of fresh, locally-grown produce; cooking and/or gardening demonstrations; and healthy food prescriptions,” coupons, and vouchers.
During the initial six-month planning period, while the paraprofessionals are being trained, we will work will work with staff and patients at each clinic to identify the most appropriate way to structure healthy food access opportunities at the site, based on how best to incentivize consistent participation in DSME classes and other program components; logistics of food storage and distribution; participants’ current familiarity with ways to use fresh, seasonal produce; and the capacity of existing and planned markets. Additional food distribution sites may include Roots, TVHC clinics, farmer’s markets, or affordable housing sites in the Ashland neighborhood where ACPHD provides community health services. We will also seek to leverage existing collaborations, such as the food that Roots already picks up from the Alameda County Community Food Bank for distribution to clinic patients one to two times per week. ACPHD’s Nutrition Services will provide cooking workshops. The clinics will also continue to enroll eligible participants in federal nutrition programs for which they are eligible, particularly the Supplemental Nutrition Assistance Program (SNAP, formerly food stamps) and the Women, Infants, and Children (WIC) Nutrition program.
Core Care Area:
Program: ACDDRI
Keywords, Themes & Tags: Health; Health Policy; Food Access
ref. ACDDRI Volume I Program Narrative for Merck 4-17-17 FINAL (1) – April 2017, Dan Abrahamson
The Alameda County Diabetes Disparities Reduction Initiative
Other Economic and Social Determinants of Health: In addition, ACDDRI partners will also leverage extensive programs and services that support economic and social empowerment of residents of East Oakland and Ashland/Cherryland. HCSA, Roots, and TVHC all provide culturally and linguistically responsive staff to assist residents in enrolling in public health coverage, including Medicaid, and other public benefits such as WIC and SNAP. Roots runs several social enterprises, including a soap-making business, that train and employ residents, with an emphasis on formerly incarcerated individuals. ACPHD also works to support residents in affordable housing and to ensure that residents have “healthy credit” options other than predatory lenders.
Core Care Area:
Program: ACDDRI
Keywords, Themes & Tags: Social Empowerment; Medicaid; SNAP; WIC
ref. ACDDRI Volume I Program Narrative for Merck 4-17-17 FINAL (1) – April 2017, Dan Abrahamson
The Alameda County Diabetes Disparities Reduction Initiative
Other Economic and Social Determinants of Health: In addition, ACDDRI partners will also leverage extensive programs and services that support economic and social empowerment of residents of East Oakland and Ashland/Cherryland. HCSA, Roots, and TVHC all provide culturally and linguistically responsive staff to assist residents in enrolling in public health coverage, including Medicaid, and other public benefits such as WIC and SNAP. Roots runs several social enterprises, including a soap-making business, that train and employ residents, with an emphasis on formerly incarcerated individuals. ACPHD also works to support residents in affordable housing and to ensure that residents have “healthy credit” options other than predatory lenders.
Core Care Area:
Program: ACDDRI
Keywords, Themes & Tags:
ref. ACDDRI Volume I Program Narrative for Merck 4-17-17 FINAL (1) – April 2017, Dan Abrahamson
The Alameda County Diabetes Disparities Reduction Initiative
Key partners in ACDDRI—including ACPHD, Roots, and TVHC—have extensive expertise in deploying paraprofessionals into these communities, supporting underserved patients and families in navigating health insurance and access to care, as well in finding needed nutrition and economic supports. Roots has focused on the needs of African Americans who are homeless and/or re-entering the East Oakland community from incarceration. Roots’ multidisciplinary teams include Patient navigators who assist clients in affordable housing options, employment, benefits and health coverage enrollment, as well as in accessing health care. TVHC has centered its community outreach through its Promotoras de Salud program in the Latino community of Southern Alameda County, including the Ashland/Cherryland area, an area that has one of the County’s largest re-entry populations. TVHC recruits and works with a network of promotoras who serve as health promoters in their neighborhoods and schools, largely serving a monolingual Spanish-speaking population. While paraprofessionals in the targeted clinics and communities have extensive experience with helping families navigate a range of health and social service systems, they have not yet been trained or deployed as full members of diabetes or chronic disease care teams. To fill this unmet need, ACDDRI will expand on these demonstrably successful models to train a cross-agency cohort of paraprofessionals in diabetes self-management. In terms of food access, ACDDRI will build on and adapt a range of innovative programs focused on nutrition and health equity developed by ACPHD in partnership with a range of community-based clinics and partners. ACPHD’s Community Health Services Division includes not only the Chronic Disease Program (including the Diabetes program) but also Nutrition Services and the WIC program. ACPHD has long convened the County Nutrition Action Plan for Alameda County, coordinating nutrition education activities, especially those that prioritize low-income communities such as the targeted neighborhoods, among public agencies and community-based partners.
For example, in 2011-2014, ACPHD’s health equity and nutrition services teams coordinated a large-scale effort called Food to Families (F2F), an innovative partnership project, funded for three years by the Kresge Foundation, with overarching goals to 1) transform the food landscape; 2) provide local economic and employment opportunities for young adult residents; and 3) to reduce the risk of obesity and overweight in West Oakland and Ashland/Cherryland. ACPHD partnered with the County-run social enterprise Dig Deep Farms and Produce and TVHC in Ashland Cherryland and with Mandela Marketplace and another FQHC in Oakland. F2F developed interventions including Produce Rx, a clinic-based program to provide pregnant women with produce “prescriptions” connecting them with local food access points and consumer training developing skills around food purchase, preparation, storage and healthy life skills. Successes included strong partnerships between community-based organizations, the FQHC’s, and ACPHD; enhanced interventions; strong participation by pregnant women and their families; the creation of one model adapted to serve two different communities; integration of young adults into staffing of partner organizations. For ACDDRI, we envision adapting the Produce Rx model to meet the needs of people with diabetes, working with a similar range of community-based food distribution, farm stands/farmers markets, and community-supported agriculture partners.
Core Care Area:
Program: ACDDRI
Keywords, Themes & Tags: WIC, Paraprofessionals, Housing, Employment, Food Access
ref. ACDDRI Volume I Program Narrative for Merck 4-17-17 FINAL (1) – April 2017, Dan Abrahamson
The Alameda County Diabetes Disparities Reduction Initiative
ACPHD has a long history of collaboration with all proposed project partners–including Roots, TVHC, UC Berkeley, and Alameda Alliance for Health–on a range of grant-funded and other projects focused on health disparities, community health, and chronic disease. For example, a longstanding collaboration among the ACPHD Chronic Disease Program, Alameda Alliance and other partners, and the University of California, Berkeley School of Public Health has resulted in an innovative, grant-funded Pay for Success initiative called Asthma Start, focused on improving childhood asthma outcomes by addressing both the medical and social determinants of health. Most recently, the Asthma Start team, under the leadership of Dr. Linda Neuhauser and with the participation of Dr. Leonard Symes, one of the founders of social determinants of disease research, submitted federal research grant proposals to the National Institute of Health and the Environmental Protection Agency. TVHC and Roots are also key clinical partners in a recently funded $17.4 million grant under the leadership of ACPHD’s Office of Dental Health. As part of an initiative to reduce disparities in oral health among low-income children, ACPHD and its clinic partners are initiating an innovative, comprehensive care coordination model. Very similar to the ACDDRI, TVHC, Roots, and a range of other clinic partners will work to integrate paraprofessional staff into their existing health care service system. These paraprofessionals will assist low-income clients in removing barriers to accessing care and maintaining a continuity of care, ensuring, in this case, that more children have recommended preventive services. One aim is that better prevention will help patients avoid costly and painful emergency department visits. Both Roots and TVHC have longstanding and strong partnerships with ACPHD to bolster place-based strategies that improve the health of at-risk residents. Roots, for example, has several focused, coordinated efforts in East Oakland’s Sobrante Park neighborhood. The clinics’ place-based approach to this work includes close partnerships with resident leaders, schools, and relevant city and county departments/offices to: improve the built environment by ensuring safe spaces and food access; implement educational coaching and civic engagement in partnership with local schools and community organizations; and facilitate opportunities for community economic empowerment. In addition, Roots specifically sponsors programs aimed at social enterprises and entrepreneurship for disconnected “opportunity youth” and for those re-entering the community from incarceration. Roots provides fiscal sponsorship, incubation, technical assistance and capacity building for local non-profits and resident groups. This work is serving as a learning laboratory for achieving health equity, focusing simultaneously on upstream approaches and treatment strategies within a defined geographic area that has demonstrated persistent poor health outcomes.
Core Care Area:
Program: ACDDRI
Keywords, Themes & Tags: Partnerships
ref. ACDDRI Volume I Program Narrative for Merck 4-17-17 FINAL (1) – April 2017, Dan Abrahamson
The Alameda County Diabetes Disparities Reduction Initiative
The ACDDRI local evaluation plan will be designed and implemented by a team from UC Berkeley’s Health Research for Action Center and the Alameda County Health Care Services Agency’s Community Assessment, Planning, and Evaluation (CAPE) Unit; it will be overseen by the Chronic Disease Program Director. The ACDDRI local evaluation team will work in partnership with Merck Bridging the Gap cross-site evaluation team, as well as clinic and community. ACDDRI’s local evaluation team will implement a process and outcome evaluation to complement the measures and tools provided through the cross-site evaluation. The local process evaluation will explore: how the program was implemented, including strategies, facilitators, partner roles, barriers and lessons learned; fidelity to the original model, or reasons for any changes; knowledge and confidence gained by paraprofessionals in Project Dulce and American Heart Association training; who and how many clients participated in each component of the program; participant satisfaction with the program; and efforts towards systems change, policy development, and sustainability.
Core Care Area:
Program: ACDDRI
Keywords, Themes & Tags: Evaluation
ref. ACDDRI Volume I Program Narrative for Merck 4-17-17 FINAL (1) – April 2017, Dan Abrahamson
The Alameda County Diabetes Disparities Reduction Initiative
Data collection methods will include: progress reports by partners and lead staff; focus groups with partners, paraprofessionals, and clients; and surveys to determine paraprofessional satisfaction with the training, increase in knowledge of diabetes, and confidence in their ability to influence change. Evaluators will assess the perceived efficacy of each component through client surveys and focus groups with clients. Change in diabetes self-management will be tracked through the American Association of Diabetes Educators’ (AADE) 7-self-care behaviors framework and associated assessment tools.8 Where feasible, data will be collected and analyzed by clinic and ethnicity to explore differences in implementation, as well as any differences in outcomes by geographic location and ethnicity.
Core Care Area:
Program: ACDDRI
Keywords, Themes & Tags: Data; Evaluation
ref. ACDDRI Volume I Program Narrative for Merck 4-17-17 FINAL (1) – April 2017, Dan Abrahamson
The Alameda County Diabetes Disparities Reduction Initiative
Clinics will be able to pull reports from their EHRs to collect data on individual clinical measures. In addition, paraprofessionals will record scores on the Every One with Diabetes Counts or a similar pre- and post-test for participants in DSME classes in a customized spreadsheet or simple database. Once they are ADA recognized, ACDDRI partners will be able to use the ADA’s standards-based DSME documentation system, Chronicle Diabetes, which allows health care professionals caring for patients with diabetes to assess, document, and generate reports regarding their medical care, education, and metabolic management. This web-based system provides tools that DSME providers can use to provide a continuum of care. The clinical methodology of Chronicle is based on published ADA standards as well as NCQA requirements. Chronicle provides electronic medical record features including a complete patient manager, clinical data documentation, and full medications list. Additionally a standards-based behavior change objectives component guides educators through the process of establishing, documenting, and reviewing patient’s behavior change objectives. To supplement data collected from the clinics’ EHRs, Chronicles Diabetes, and the EDC database, ACDDRI will also explore ways to collect data on patients’ Healthcare Effectiveness Data and Information Set (HEDIS) outcomes. By the third year of ACDDRI, we will explore with Alameda Alliance for Health as well as the clinic teams whether and how it will be possible to track HEDIS measures for the cohorts of patients participating in ACDDRI. Such measures included Hemoglobin A1c (HbA1c) testing, HbA1c control, performance of retinal exams, medical attention for nephropathy, and blood pressure control (<140/90 mm Hg).
Core Care Area:
Program: ACDDRI
Keywords, Themes & Tags: Data; Evaluation
ref. ACDDRI Volume I Program Narrative for Merck 4-17-17 FINAL (1) – April 2017, Dan Abrahamson
The Alameda County Diabetes Disparities Reduction Initiative
Since 2001, ACPHD has implemented its Diabetes Program, aimed at mitigating and reducing the documented and persistent diabetes health disparities among certain racial and ethnic groups. In 2004 the program became an ADA Recognized program and is the only Public Health Department in California that is so recognized. The program is also Project Dulce Licensed. In addition, the program received the Frank E. Staggers, MD Community Service Award in October 2008 from the Alta Bates Summit Ethnic Health Institute, recognizing it for community service and outstanding leadership in diabetes education. The program was featured in Diabetes Forecast in August 2014; a copy of the article is included in the appendices. Under the leadership of Chronic Disease Program Director Brenda Rueda- Yamashita, the ACPHD Diabetes program currently includes 3 diabetes educators and registered dieticians, each with two to four decades’ experience, as well as at least 5 trained peer educators.
Core Care Area:
Program: ACDDRI
Keywords, Themes & Tags:
ref. ACDDRI Volume I Program Narrative for Merck 4-17-17 FINAL (1) – April 2017, Dan Abrahamson
The Alameda County Diabetes Disparities Reduction Initiative
Roots offers a variety of case management and care coordination programs and services that use paraprofessionals known as Roots Navigators. The clinic has expanded on early work with reentry men and those with substance abuse and mental health issues, through implementation of the HealthyMeasures Initiative, a strong care/case management model, and OaklandSTOMP, a mobile clinic which targets medically fragile, chronically homeless individuals. Both Healthy Measures and Oakland STOMP utilize Roots Health Navigators who build trust that facilitates their ability to obtain detailed patient information, including family contacts, where they hang out, and what they do when they are under stress. Navigators are assertive in staying connected, via home/encampment visits and active outreach, especially during times of crisis. TVHC’s dedicated Community Health Education Department is committed to empowering its community through the provision of culturally competent and linguistically appropriate information, education and support. By listening with respect to the specific needs of the community we serve as ambassadors to build and sustain community partnership in order to facilitate action that results in increased awareness, healthier lifestyles and social change. Since 1999, TVHC’s Promotoras de Salud program has engaged community health educators to recruit and work with a network of adult community volunteers who serve as health promoters in their neighborhoods and schools. The promotoras are trained in leadership, diseases prevention and outreach including sessions such as planning, conducting a meeting, conducting a presentation and health topics about the importance of immunizations chronic diseases prevention, cancer detection awareness, mental health early prevention and other based on county and community needs. They reach other Latino families through by conducting local community level interventions such as presentations, tablings, attending local health fairs, offering peer and door-to-door counseling, and/or teaching chronic disease self-management.
Core Care Area: Navigation
Program: ACDDRI
Keywords, Themes & Tags: STOMP
ref. ACDDRI Volume I Program Narrative for Merck 4-17-17 FINAL (1) – April 2017, Dan Abrahamson
The Alameda County Diabetes Disparities Reduction Initiative
The in-house CAPE Unit includes a nationally recognized team of epidemiologists and program evaluators who provide data analyses, data reports, and evaluation services to support in-house programs, as well as multi-partner and national initiatives. CAPE collects community-level data on a wide variety of diabetes and chronic disease outcomes and related social determinants of health such neighborhood poverty level, availability of healthy food, and quality of public schools. CAPE staff are experts in GIS mapping software and have been active collaborators in this grant application and in the ACPHD Chronic Disease programs over the years. CAPE Unit epidemiologists and evaluation specialists frequently support program activities by functioning in a technical assistance capacity. Evaluators assist programs in developing logic models and implementation plans; epidemiologists analyze key indicator data to support program applications for funding and periodic health status reports. Recent CAPE publications include: Life and Death from Unnatural Causes: Health and Social Inequity in Alameda County, 2008; Health of Alameda County Cities and Places 2010; and His Health: Alameda County Male Health Status Report, 2010. The Health Research for Action (HRA) Center at UC Berkeley aims to reduce health and health care disparities and to help create healthier, more empowered communities. Center staff includes researchers, practitioners, and communication and policy experts. HRA uses highly participatory methods to investigate the broad determinants of health and to co-design effective interventions and policies with the intended beneficiaries and stakeholders. Examples of their intervention research include: investigation of health disparities and interventions among Asian populations related to cancer/cancer screening, diabetes, and other topics; the use of social impact bonds to support community health efforts for asthma and other health issues; and research on the impacts of Medicaid program transitions for seniors and persons with disabilities. An article on the effectiveness of health coaches in diabetes care, published in Diabetes Spectrum (2012) HRA faculty, including ACDDRI’s lead qualitative evaluator Winston Tseng, is included in the Appendices.
Core Care Area:
Program: ACDDRI
Keywords, Themes & Tags: Data; Evaluation
ref. ACDDRI Volume I Program Narrative for Merck 4-17-17 FINAL (1) – April 2017, Dan Abrahamson
Navigator Initiative
Roots Community Health Center appreciates the invitation to submit a proposal for funding to build our capacity to meet East Oakland’s acute need for whole-person health care by integrating a Roots Health Navigator specializing in diabetes and hypertension to provide direct patient services as well as ongoing training to other Roots frontline community health workers. This new Roots Health Navigator, who will be trained to support patients with diabetes and/or hypertension using Roots’ case management model and health coaching strategies, will also serve as a resource to other Roots care team members on issues specific to diabetes/ hypertension, further increasing our organization’s capacity to provide case and care management. We look forward to partnering with Alameda Alliance for Health (AAH) as we increase access and quality of care for our patient base in East Oakland, where the need for additional panel management and patient self-management support for those with chronic illness is dire.
Core Care Area: Navigation
Program: Navigator Initiative
Keywords, Themes & Tags: Whole health, navigation, diabetes, hypertension
Navigator Initiative
Diabetes and hypertension, which are major risk factors for heart disease and stroke, are especially prevalent in the communities we serve. According to the Alameda County Public Health Department’s 2014 health data profile, heart disease and stroke mortality rates are higher in Oakland than the county average, and Oakland ranks first in the County in stroke hospitalization rates (270.2 per 100,000). In Roots’ East Oakland service area, age-adjusted death rates for diabetes and hypertension are over 50% higher than in the state as a whole. These health outcomes are indicative of poverty levels, which are consistently high, with 49.3% of individuals living below 200% of the Federal poverty level in the neighborhoods of East Oakland served by Roots.
Core Care Area: Navigation
Program: Navigator Initiative
Keywords, Themes & Tags: Hypertension
Navigator Initiative
Roots has a patient base of almost 10,000 individuals, and this base is quickly growing. The RHN will be assigned a caseload of 50 of our highest-risk, highest-utilizing diabetic and hypertensive patients in the course of one year, prioritizing those with both diabetes and hypertension. The RHN with diabetes/hypertension specialization will provide additional training to our five incumbent RHNs, enabling them to enhance the support they deliver to their clients. These RHNs currently serve over 400 patients who are either recently released from incarceration, homeless, or both; approximately 50% of these patients have diabetes and/or hypertension. As such, we anticipate directly benefitting over 250 patients through improved self-management support and health coaching. By stabilizing our patients, we also anticipate indirectly benefitting their families, which—based on average family size—culminates in a positive impact on at least 700 additional community members.
Core Care Area: Navigation
Program: Navigator Initiative
Keywords, Themes & Tags: Population, Demographics, Diabetes, Hypertension