“On the Road” Diabetes Program: The Benefits of a Community Partnership Model

Presenters: Sarah Clarke, Sherri Bryant Moore and Diane Hill Taylor

PRESENTERS

Sarah ClarkeSr. Director, Physician IntegrationDoctors Community Hospital

Sherri Bryant MooreDevelopment OfficerDoctors Community Hospital Foundation

Diane Hill TaylorAssociate Director, Health & Wellness DivisionPrince George’s County Health Department

For “ On the Road” Program Information: Call 301- 883-3545 2

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DCH MISSION & VISION

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DCH MISSION & VISION

Mission: • To provide quality healthcare to all residents of Prince

George’s County, Maryland• Mission Statement: “Dedicated to Caring for your Health”• DCH Vision Statement: Continuously strive for excellence in

service and clinical quality to distinguish DCH with our patients and other customers.

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• Founded in 1975• 219 Licensed Beds• 1,516 Employees• 503 Medical Staff• 51,797 Emergency Room Visits• 10,857 Total Admissions• 11,509 surgical Services• $136,214 Total Inpatient Revenue• $76,993,369 Total Outpatient Revenue• $213,207,813 Total Inpatient and Outpatient Revenue

*Fiscal Year 2013

DCH MISSION & VISION

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Comprehensive Services include:• Joslin Diabetes Center- the only accredited diabetes center in the

county• Bariatric and Weight Loss Center • Center for Comprehensive Breast Care• Sleep Center• Lymphedema Center• Surgical Services• Additional Services Include:• Cardiology Services and Outpatient Vascular Studies• Center for Ear, Nose & Throat• Center for Wound Healing and Hyperbaric Medicine• Comprehensive Orthopedic Services• Doctors Regional Cancer Center• Emergency Services• Imaging Services• Infusion Center• Joint and Spine Center• Magnolia Gardens Nursing Home• Metropolitan Medical Specialists• Outpatient Rehabilitation Services• Spine Team Maryland

DCH OVERVIEW CONTINUED

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Zip Codes• Lanham, Maryland 20706• Hyattsville, Maryland 20781• Cheverly, Maryland 20784• Landover, Maryland 20785• Greenbelt, Maryland 20770• Capitol Heights, Maryland 20743• Kettering, Maryland 20774• Bowie, Maryland 20721• Riverdale, Maryland 20737• District Heights, Maryland 20747

Demographics:• Our CBSA has an average household income of $70,114. The population is 63%

African American, 15.2% Latino, 4.3% Asian, 17.5% other nationalities.

COMMUNITY BENEFITS SERVICE AREAS (CBSA)

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Identified Needs

Overweight/ Obesity, Nutrition and Exercise• DCH’s Bariatric and Weight Loss Center provides free

seminars to educate participants about weight loss options including nutrition, exercise and surgery.

• Our Joslin Diabetes Center provides free nutrition seminars at various health fairs and conferences.

Diabetes• Joslin Diabetes Center in partnership with the Prince George’s

County Health Department have launched its “On the Road Diabetes Program,” that provides in-depth education and free diabetes screenings to all county residents.

• In an effort to increase program participation and expand reach, plans for an on line component has been added.

Cardiovascular Disease and Related Risk Factors• DCH provided three to five carotid artery screenings at various

events throughout the county.

COMMUNITY BENEFITS BASED ON IDENTIFIED NEEDS AND DCH INITIATIVES

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• In FY ‘13 we provided 1,972 screenings for blood pressure and cholesterol.

• We had 2,624 encounters through Educational Outreach .

• The total financial commitment by DCH through Community Benefits was $20, 959,892. 

RESULTS

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Mobile Health ClinicIn partnership with the Prince George’s County Health Department and Wal-Mart, DCH will launch a mobile health clinic in the fall of 2014.

Hospital Admission/Re-admission Data Services provided by mobile clinicRenal Failure DiabetesChronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults HypertensionCongestive Heart Failure (CHF) Breast CancerDiabetes ObesityHypertension Heart Disease

Targeted Health ConcernsA Community Health Assessment survey was distributed among the community members, faith-basedorganizations, business leaders as well as current patients and their families. More than 500 surveys were returned and based on these survey results as well as the DCH admission/re-admission data,the chart below indicates the types of services the mobile clinic will provide.

NEW INITIATIVES WITH PGCHD FOR FY2015

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PRINCE GEORGE’S COUNTY MARYLAND

HEALTH DEPARTMENTPublic health agency with the overall mission to protect and improve the health of the community.

PGCHD supports public health efforts to reduce chronic diseases and promotes healthier lifestyles by improving:• Health Education• Health Outreach• Access to Quality Health Care Systems in the County

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THE BURDEN OF DIABETES• Diabetes is one of the five most prevalent chronic

conditions in Prince George's County (University of Maryland School of Public Health; A Public Health Impact Study, 2012).

• Eleven percent (11%) of the 863,420 residents of Prince Georges County is diabetic. An additional 1.5% were told by a doctor they had pre-diabetes or borderline diabetes (2011 (Maryland BRFSS; URL of Source- http://www.marylandbrfss.org).

• The 2011 Maryland Vital Statistics Report indicates that Prince George’s County had the highest number of diabetes deaths in the state of Maryland (192).

• Diabetes was the sixth leading cause of death in 2011 with an age-adjusted mortality rate of 20.8 per 100,000 people. This was a 5% increase from 19.8 per 100,000 people in 2010 (Maryland Annual Vital Statistics Report, 2011).

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NEED FOR PREVENTIVE CARE OUTREACH

Preventive Care

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ADDRESSING HEALTH DISPARITIES

“With diabetes being such a major issue in Prince George’s County, the

hospital’s Joslin Diabetes Center, in collaboration with the Health Department, furthers our joint

commitment to not only treat, but to also educate the community about this

disease.” Paul Grenaldo

EVP/COO (DCH)

Building, Developing and Maintaining

Successful Partnerships

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ADDRESSING HEALTH DISPARITIES

“We are thrilled to partner with the renowned Joslin Diabetes Center at DCH to serve our residents where

they live, work and play. This community based approach will bring

diabetes education directly to the residents that are impacted the most.”

Pamela B. Creekmur

Health Officer (PGCHD)

Building, Developing and Maintaining

Successful Partnerships

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“ON THE ROAD” PARTNERSHIP

• Collaborative partnership with a hospital

• Evidence based curriculum adapted for community setting

• Integration of CHW’s who provide care coordination

• Community partners

Community partnership models that are

strategic, yet flexible are necessary to

address health disparities and create

sustainable change within our communities.

The success of “On the Road” is contributed to:

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“ON THE ROAD" START UP

• “On the Road” was not grant funded at its inception.

• Partners had several pre-planning meetings to identify organizational and community resources as follows:

– Utilized current CDE, CHW, and Community Developer staff to implement program

– Hospital assumed A1c lab testing costs, by negotiating a reduced vendor fee contract

– Met with community partners to secure commitments for class meeting space at a minimum of 2 classes per location (initial/follow-up) at no cost

– Sought and secured program incentives (grocery store vouchers/cookbooks, etc.) donated by grocery chains/pharmaceutical companies

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“ON THE ROAD” OUTREACH

• Travels to diverse communities throughout the county

• Delivers basic diabetes self-care knowledge in easy-to-understand discussion format

• Targets participants who are diagnosed diabetics, including caregivers and pre-diabetics

• Classes conducted by certified diabetes educators from the DCH Joslin Affiliate

• Community Health Workers/Developers (CHWs/CDs) from the PGCHD provide follow-up care coordination

• Elements of the class are provided at health fairs and conferences to expand reach of program

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“ON THE ROAD” CLASS FORMAT

The two hour initial classes cover a number of topics including: What is Diabetes? Healthy Eating Importance of Physical Activity Understanding Your Numbers*Class also includes a brief exercise demonstration including free exercise bands and pedometers to promote exercise activities outside of class.

Includes A1C test

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LINK TO CARE AND SUPPORT

Take home information packets are distributed to participants at the initial class including:

Information on Federally Qualified Health Centers (FQHC’s) in case a participant does not have a primary care provider

Services of Joslin Center (free support group meetings, medical and diabetes education services)

Related services and resources provided by PGCHD

A copy of the class power point presentation

Fact sheets and educational materials about diabetes.

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“ON THE ROAD” FOLLOW-UP CLASS

The two hour follow-up class (2-3 months) consists of the following:

Participant discussion of skills learned, changes made and/or challenges

Curriculum review using interactive Diabetes Jeopardy game

Incentives such as healthy food gift cards and cookbooks for active participation

Certificate of Completion A1C test

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“ON THE ROAD” RESULTS

• Conducted eight (8) initial classes with follow-up sessions

• A total of 162 class #1 attendees (~20 per class)• A total of 99 class #2 attendees (~12 per class)• There were 23 participants that attended both the initial

and follow-up class sessions, with both pre and post A1c tests

• The average A1c of this group was 7.3 at the initial class and 6.7 at the follow-up class held up to 3 months later

• As of April 2014, 83% of this pre/post group (23) who initially tested with A1c levels of 9-12 (uncontrolled diabetes) saw a reduction of one to five points, some even returning to an A1c of less than 7

• Pre and post education surveys showed a 10% increase in knowledge (74%84%)

Status update for April 2013-April 2014

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PROGRAM DEMOGRAPHIC RESULTS

Status update for April 2013-April 2014

• Most participants were African American women, with a total of 29 males

• The ages of participants ranged from 27 to 84 years, with an average age of 60 years old

• A total 14/162 (9%) of participants were uninsured

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EARLY LESSONS LEARNED

• “On the Road” welcomed in 5 zip code communities • Received positive feedback for educators and class• Attendees did not fully participate in free A1C tests • More classes needed to reach expanded areas of county• Plan to rotate class time schedules and pilot Saturday

sessions to learn participant response patterns • The current model will not allow us to reach a maximum

number of residents in a cost efficient way• Need to increase utilization of social media to inform and

engage residents about the class

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REPLICABLE TOOLS/TEMPLATES

• Evidence based educational materials and curriculum

• Curriculum (4 hours) adapted for target population

• Trainer of Trainer (TOT) model for program expansion

• Community Health Worker (CHW) training curriculum

• Program designed for transportability to diverse community settings

• Pre/post education survey tools

• A1c pre/post lab tests

• Collaborative partnerships with clinical practices to improve diabetic management of A1c

“ON THE ROAD” NEXT STEPS

Secured Year 2 funding to support the following goals:

• Expand “On the Road” to include bilingual program delivery model

• Increase number of classes offered to residents

• Develop and implement on-line curriculum to provide alternative or enhancement to traditional class delivery model and expand reach

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CAPACITY BUILDING

Key capacity building components for diabetes outreach include:• organizational support• staffing• partnerships• funding/resources• outreach and marketing strategy• data collection• evaluation

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“ON THE ROAD” TESTIMONIALS

“With the help of “On the Road”, I came to understand my strengths and weaknesses. It made me stop. It made me look and deal with Diabetes! By taking care of my immediate health needs my A1c levels have dropped!” Ronald Frazier

“I couldn’t believe I had diabetes! My Doctor must have made a mistake. I had never been sick, not even a cold, and had always considered myself to be a very healthy person. The classes helped me to deal with my diabetes & take charge of my life.” Thomas Butler

“Having three adult kids with type 1 Diabetes and a brother who died at 41 due to diabetes related complications encourages me to do something. “On the Road” showed me what I need to do to stay healthy.“ Crystal Hawkins

“When I got diagnosed with diabetes, I felt so alone. The “On the Road” program gave me the support I needed and knew I didn’t need to face this alone. The Joslin staff are the most caring and talented group of people I have ever had the privilege of meeting.” Sabrina Taylor-Turner

“The Prince George’s County Health Department Diabetes class has taught me that no matter how independent I thought I was, I need to ask for and accept help. Diabetes is a everyday battle and I couldn’t go through this by myself. The Joslin educators helped me become ready for the fight.” Gloria Bryce

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CONTACT US

Call “On the Road! 301-883-3545

Visit Us www.dchweb.org www.princegeorgescountymd.gov MyPGCHealthyRevolution.org

More Questions?