1. WELCOME Host: Dr. David Bang Public Health Advisor, CDC Lead: Dr. Carolyn Jenkins Latonya Fisher REACH U.S. SEA-CEED Topic: Diabetes self-management and other related clinical practices and delivery care systems. Host: Dr. David Bang Public Health Advisor, CDC Lead: Dr. Carolyn Jenkins Latonya Fisher REACH U.S. SEA-CEED Topic: Diabetes self-management and other related clinical practices and delivery care systems.

2. Session Plan Welcome and Ground Rules Brief REACH SEA-CEED overview Opportunity to hear from you (efforts, successes and challenges) Welcome and Ground Rules Brief REACH SEA-CEED overview Opportunity to hear from you (efforts, successes and challenges)

3. Do YOU have a STORY? What aspect of your work would be best served through a storytelling format? What audience would react best to the storytelling format? What storytelling formats are successfully being used by REACH awardees? What aspect of your work would be best served through a storytelling format? What audience would react best to the storytelling format? What storytelling formats are successfully being used by REACH awardees?

4. REACH U.S. SEA-CEED Racial/ethnic groups include: African Americans American Indians & Alaska natives Asian Americans Hispanics/Latinos Native Hawaiians/Pacific Islanders Health Disparities are focused on: CVD Diabetes Infant Mortality Breast & Cervical Cancer AIDs/HIV Adult Immunizations

5. Disparities for African Americans with Diabetes in Charleston and Georgetown Lower levels of: –Per capita income –Access to health care –Funding and insurance –Care and education –Satisfaction with care* –Medications and continuing care –Treatment –Trust in health systems* Lower levels of: –Per capita income –Access to health care –Funding and insurance –Care and education –Satisfaction with care* –Medications and continuing care –Treatment –Trust in health systems* Higher levels of: –Prevalence of diabetes –Complications including: Amputations Renal failure (dialysis) CVD –EMS and ED use –Hospitalizations –Costs of care paid by client* –Deaths, especially CVD *All disparities were first identified through focus groups and validated with epidemiological or quantitative data except those with asterisk. For those with asterisk, quantitative data showed difference in outcome.

6. Action Team for Change 4 Coalitions Diabetes Initiative of South Carolina REACH Partners Coalition 2 County Coalitions 85 partner organizations (SC DHEC, Statewide and Community Organizations, Neighborhood Groups, Health Care Systems, Greek Organizations, Faith-Based Groups, Public Libraries, Academic Institutions) 4 Coalitions Diabetes Initiative of South Carolina REACH Partners Coalition 2 County Coalitions 85 partner organizations (SC DHEC, Statewide and Community Organizations, Neighborhood Groups, Health Care Systems, Greek Organizations, Faith-Based Groups, Public Libraries, Academic Institutions)

7. REACH Charleston and Georgetown Diabetes Coalition Tennessee South Carolina SC DHEC Region 6 Georgetown Diabetes CORE Group St. James Santee Health Center Enterprise Health Center Enterprise Community Tri County Black Nurses MUSC, MUHA VA Medical Center Diabetes Initiative College of Nursing Alpha Kappa Alpha Sorority Franklin C. Fetter Family Health Center Trident United Way Georgetown North Carolina Georgia Charleston County Library Statewide REACH home-based in Columbia:  Welvista  SC DHEC  SC DPCP  American Diabetes Association Carolina Center for Medical Excellence TriCounty Family Ministeries SC DHEC Region 7 County Library East Cooper Community Outreach S. Santee St. James Senior Center

8. Our Coalition Goals Improve diabetes care and education in 5 health systems for >13,000 African Americans with diabetes. Improve access to diabetes care and self- management education, diabetes supplies and social services for people with diagnosed diabetes. Decrease health disparities for African Americans at risk and with diabetes. Increase community ownership and sustainability of program. Improve diabetes care and education in 5 health systems for >13,000 African Americans with diabetes. Improve access to diabetes care and self- management education, diabetes supplies and social services for people with diagnosed diabetes. Decrease health disparities for African Americans at risk and with diabetes. Increase community ownership and sustainability of program.

9. Community Actions Community-driven educational activities and healthy learning environments where people live, worship, work, play, and seek health care. Evidence-based health systems change using continuous quality improvement teams (CQI). Coalition power built through collaboration, trust, and sound business planning and focused on systems, community, and policy change. Community-driven educational activities and healthy learning environments where people live, worship, work, play, and seek health care. Evidence-based health systems change using continuous quality improvement teams (CQI). Coalition power built through collaboration, trust, and sound business planning and focused on systems, community, and policy change.

10. Methods for Collaboration The health professionals/scientists determine “science” or “evidence-base” for diabetes care. Community leaders/members determine “what, when, where, and how” to apply “science” or “evidence” in their community while generating evidence for community empowerment. Together we translate into skills for individual, organizational, systems, and community behavior change, advocacy, and policy change and we evaluate/report our results. The health professionals/scientists determine “science” or “evidence-base” for diabetes care. Community leaders/members determine “what, when, where, and how” to apply “science” or “evidence” in their community while generating evidence for community empowerment. Together we translate into skills for individual, organizational, systems, and community behavior change, advocacy, and policy change and we evaluate/report our results.

11. E.T. Anderson and J.M. McFarlane (2006) Faith Based Our Community Systems Wheel

12. External Influences Evaluation Logic Model Coalition Understanding Context, Causes, & Solutions for Health Disparity Community Action Plan Planning & Capacity Building Targeted REACH Action Existing Activities Change Agents Change Widespread Change in Risk/Protective Behaviors Reduced Health Disparity Community & Systems Change OtherOutcomes

13. Changes within Organizations Partners working together developed database to collect health information (in their programs) Wellness programs (exercise/physical activity, cooking classes, screenings for glucose, A1C, BP, lipids, kidney function, foot problems) based in and sustained by the community Community gardens (four community in GT, 2 Chas., master gardener classes, and 4 in LPs) Media Awareness (Television, Radio, Billboards, bus placards, Banners) Partners working together developed database to collect health information (in their programs) Wellness programs (exercise/physical activity, cooking classes, screenings for glucose, A1C, BP, lipids, kidney function, foot problems) based in and sustained by the community Community gardens (four community in GT, 2 Chas., master gardener classes, and 4 in LPs) Media Awareness (Television, Radio, Billboards, bus placards, Banners)

14. Changes within County Organizations have come into the community (FQHC, Public Library, MH, Youth Org., Park & Rec.) Park & Rec. adding several activities sites in GT (workout, court, pool, tennis, daycare) GT county schools removal junk food & sodas from vending machines Local churches have changed foods served Organizations have come into the community (FQHC, Public Library, MH, Youth Org., Park & Rec.) Park & Rec. adding several activities sites in GT (workout, court, pool, tennis, daycare) GT county schools removal junk food & sodas from vending machines Local churches have changed foods served

15. Changes within Health Systems DSME classes and group visits Weight management classes CQI Teams Community Health Workers for community education and linkage to health systems Diabetes “PECS” (now EHRs) Continuous Quality Improvement Teams DSME classes and group visits Weight management classes CQI Teams Community Health Workers for community education and linkage to health systems Diabetes “PECS” (now EHRs) Continuous Quality Improvement Teams

16. Changes within Health Systems 2 AADE certified sites Mandatory attendance at DSME classes Foot, shoe and wound clinics at sites New transportation systems New benefits bank to determine eligible services Influenza vaccines regardless of ability to pay Reduced payment for uninsured (some systems) Expansion of clinic hours Clinic based physical activity intervention 2 AADE certified sites Mandatory attendance at DSME classes Foot, shoe and wound clinics at sites New transportation systems New benefits bank to determine eligible services Influenza vaccines regardless of ability to pay Reduced payment for uninsured (some systems) Expansion of clinic hours Clinic based physical activity intervention

17. Changes in Health Professionals 10 new African American CDEs who trained with REACH (compared to 1 when REACH started)

18. Statewide change Diabetes Advisory Council established the Guidelines for Diabetes Care Adopted in 9/2011 and updated in 3/2012 Presented at the Diabetes Symposium September 2011, by MUSC President Dr. Greenburg “Diabetes Under the Dome” Diabetes Advisory Council established the Guidelines for Diabetes Care Adopted in 9/2011 and updated in 3/2012 Presented at the Diabetes Symposium September 2011, by MUSC President Dr. Greenburg “Diabetes Under the Dome”

19. Policy Change Statewide Guidelines Law requiring DSME coverage (ERISA) PCMH and Care Coordination Foot Care Training for Nurses Statewide Guidelines Law requiring DSME coverage (ERISA) PCMH and Care Coordination Foot Care Training for Nurses

20. Change across States PCMH –Care Coordination training for provider offices integrating SDOH. –Potential National Certification for Care Coordination. PCMH –Care Coordination training for provider offices integrating SDOH. –Potential National Certification for Care Coordination.

23. The Community Chronic Care Conceptual Model REACH Charleston and Georgetown Diabetes Coalition (Jenkins, Pope, Magwood et al., PCHP 4 (1): 73) Community Resource Systems Community Information System Community & Service System Design Community Decision Support Self-Management Support Clinical Information System Delivery System Design Clinical Decision Support Patient Self- Management Support Prepared, Proactive Health Systems Policies & Actions Social, Health, & Economic Informed, Activated Persons External Environment, Resources, and Dissemination influences: Prepared, Proactive Community Systems Improved Community-Wide Health Outcomes and Elimination of Health Disparities Influences Health Care Provider Systems

24. Limitations Challenges –Health System in state of change –Time, funds and personnel changes –Contributions of external influences, community by-in –Legislative support Challenges –Health System in state of change –Time, funds and personnel changes –Contributions of external influences, community by-in –Legislative support

25. For additional information Carolyn Jenkins, DrPH e-mail: jenkinsc@musc.edujenkinsc@musc.edu Phone: 843-792-4625 Carolyn Jenkins, DrPH e-mail: jenkinsc@musc.edujenkinsc@musc.edu Phone: 843-792-4625