Acknowledgements

This project is funded by the REACH Charleston and Georgetown Diabetes Coalition CDC

Grant/Cooperative Agreements U50/CCU422184 and 1U58DP001015 from the Centers for Disease Control

and Prevention.

Additional grant funding to document disparities related to ED and Hospitalizations from

NIH NINR 1 R15 NR009486-01A1

The contents are solely the responsibility of the author and community partners and do not

necessarily reflect the official views of the funding agencies.

REACH Charleston and Georgetown Diabetes

Coalition:Decreasing Disparities in

Diabetes-Related Amputations

REACH Charleston and Georgetown Diabetes

Coalition:Decreasing Disparities in

Diabetes-Related AmputationsCarolyn Jenkins, DrPH, APRN-BC, RD,

FAANAnn Darlington Edwards Chair and

ProfessorMedical University of South Carolina

e-mail: jenkinsc@musc.edu

Carolyn Jenkins, DrPH, APRN-BC, RD, FAAN

Ann Darlington Edwards Chair and Professor

Medical University of South Carolina

e-mail: jenkinsc@musc.edu

““If our nation is committed to the If our nation is committed to the proposition that all people are created proposition that all people are created equal, our most basic indicators of life equal, our most basic indicators of life and death should reflect this principle. and death should reflect this principle. The continuing gap in health indicators The continuing gap in health indicators undermines the vision of one America.” undermines the vision of one America.”

One America, President’s Initiative on Race (1997)One America, President’s Initiative on Race (1997)

Historic ContextHistoric Context

REACH U.S Grantees (CEED and AC Communities)

CEED Communities

Action Communities

City of Chicago, IL

Brooklyn Perinatal Network, Inc, NY

HealthVisions Midwest,

Inc, IN

Eastern Band of Cherokee Indians, NC

Community HealthCouncils, Inc, CA

Choctaw Nation ofOklahoma, OK

Special Service forGroups, CA

Southeast ChicagoDevelopment Commission, IL

Wai’anae DistrictComprehensive Health &

Hospital Board, HI

Los AngelesBiomedical

Research Instituteat

Harbor-UCLA, CA

Children’sHospital

Corps, MA

YMCA of theSanta ClaraValley, CA

YMCA of Greater

Cleveland, OH

ABOR, Universityof Arizona, AZ

Intertribal Councilof

Michigan, Inc, MI, WI, MN, IN

Seattle King CountyDepartment of Public Health,

WA

The Vernon J. HarrisEast End Community

Health Center, VA

To Our Children’s Futurewith Health, Inc., PA

Northern Arapaho Tribe, WY

VirginiaCommonwealthUniversity, VA

West Virginia Dept. of Health andHuman Services, WV

Center for CommunityHealth, Education &

Research, MA

The MountSinai School

of Medicine, NY

Medical University of South CarolinaSC, GA, NC

Khmer HealthAdvocates, Inc,

CT, MA, IL, CA, OR, FL

Public HealthInstitute, CA

The Regents ofthe University of

California, CA

Genesee CountyHealth Department,

MI, WI, IL, MN, IN, OH

University of Alabamaat Birmingham,

AL, AK, KY,LA, MS, TN

Orange County Asianand Pacific Islander

CommunityAlliance, CA

Institutefor

Urban FamilyHealth, NY

HidalgoMedical

Services, NM

Boston Public HealthCommission, MA

Morehouse School of Medicine,GA, NC, SC

The University

ofIllinois

at Chicago,IL

University of Coloradoat Denver and

Health Sciences Center,CO, AZ, NM, SC, WA, AK

Oklahoma StateDepartment of Health, OK

NYUSchool

of Medicine,NY

University of HawaiiHI, American Samoa, North Mariana Islands, Guam

Micronesia, Palau, Marshal Islands

Greater LawrenceFamily Health

Center, MA, Six New England States

REACH CommunitiesREACH Communities

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

REACH Charleston and Georgetown

Diabetes CoalitionTennessee

South Carolina

SC DHECRegion 6

GeorgetownDiabetes

CORE Group

St. James Santee Health

Center

Enterprise HealthCenter

Enterprise Community

Tri County Black

Nurses

MUSC, MUHAVA Medical CenterDiabetes InitiativeCollege of Nursing

Alpha KappaAlpha Sorority

Franklin C. FetterFamily

Health Center

Trident United Way

GeorgetownGeorgetown

North Carolina

Georgia

CharlestonCharleston

County Library

Statewide REACH home-basedin Columbia: Welvista SC DHEC SC DPCP

American Diabetes AssociationCarolina Center for Medical Excellence

TriCounty FamilyMinisteries

SC DHECRegion 7

County Library

East Cooper Community

OutreachS. SanteeSt. James

Senior Center

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

• 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.

Our Coalition Goals• Improve diabetes care and education in 5 health systems

for >12,000 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 >12,000 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.

The Community Chronic Care Conceptual Model REACH Charleston and Georgetown Diabetes Coalition

(Jenkins, Pope, Magwood et al., PCHP 4 (1): 73)

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.

Methods for CollaborationThe 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, 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, and community behavior change, advocacy, and policy change and we evaluate/report our results.

Community Resource Systems

Community Information System

Community & Services System Design

Community Decision Support

Self-Management Support

Clinical Information System

Delivery System Design

Clinical Decision Support

Patient Self-Management Support

Prepared, Proactive HealthSystems

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

Influence Influence

Health Care Provider Systems

REACH South Eastern African American CEEDChronic Care Model for Community Empowerment

External InfluencesExternal Influences

Evaluation Logic Model

CoalitionCoalition

Understanding Context, Causes, & Solutions for Health Disparity

CommunityAction Plan

Planning & Capacity Building

Targeted REACH Action

Existing Activities

Change Agents Change

Widespread Change in Risk/Protective

Behaviors

Reduced HealthDisparity

Community & Systems Change

OtherOtherOutcomesOutcomes

REACH Charleston And

Georgetown Diabetes

Coalition’s Efforts to Decrease

Diabetes-RelatedAmputations

REACH Charleston And

Georgetown Diabetes

Coalition’s Efforts to Decrease

Diabetes-RelatedAmputations

Specific Aims

• Improve foot care for African Americans with diabetes.

• Eliminate disparities in number of amputations for African Americans with diabetes.

• Improve foot care for African Americans with diabetes.

• Eliminate disparities in number of amputations for African Americans with diabetes.

  

 

Interventions• Community skill-building and neighborhood clinicsCommunity skill-building and neighborhood clinics

– 175 lay educators trained175 lay educators trained– Diabetes self management educationDiabetes self management education– Foot care educationFoot care education– Wise Women and Wise Men helping each otherWise Women and Wise Men helping each other

• Community health professional trainingCommunity health professional training– > 90% of health professionals in 5 systems attended update on > 90% of health professionals in 5 systems attended update on

diabetes carediabetes care– 225 RNs completed advanced foot/wound education225 RNs completed advanced foot/wound education– 27 physicians completed foot care education27 physicians completed foot care education

• Outreach by professional and lay educators/navigators Outreach by professional and lay educators/navigators – 30 minute TV program aired 34 times on cable30 minute TV program aired 34 times on cable– Library program/Internet useLibrary program/Internet use– Weekly diabetes management groups in 10 sitesWeekly diabetes management groups in 10 sites– Navigation for diabetes care, supplies and social servicesNavigation for diabetes care, supplies and social services

• Community skill-building and neighborhood clinicsCommunity skill-building and neighborhood clinics– 175 lay educators trained175 lay educators trained– Diabetes self management educationDiabetes self management education– Foot care educationFoot care education– Wise Women and Wise Men helping each otherWise Women and Wise Men helping each other

• Community health professional trainingCommunity health professional training– > 90% of health professionals in 5 systems attended update on > 90% of health professionals in 5 systems attended update on

diabetes carediabetes care– 225 RNs completed advanced foot/wound education225 RNs completed advanced foot/wound education– 27 physicians completed foot care education27 physicians completed foot care education

• Outreach by professional and lay educators/navigators Outreach by professional and lay educators/navigators – 30 minute TV program aired 34 times on cable30 minute TV program aired 34 times on cable– Library program/Internet useLibrary program/Internet use– Weekly diabetes management groups in 10 sitesWeekly diabetes management groups in 10 sites– Navigation for diabetes care, supplies and social servicesNavigation for diabetes care, supplies and social services

  

 

Interventions (cont’d)

• Health systems changeHealth systems change

– Registry and reminder systemRegistry and reminder system– CQI teams to improve care and link to communityCQI teams to improve care and link to community– Chart audit with feedback to providersChart audit with feedback to providers

• Coalition building, fund raising and policy changeCoalition building, fund raising and policy change

– Partners Coalition for Governance Partners Coalition for Governance – Local Coalition formed in each county, each with Local Coalition formed in each county, each with

501(C)3501(C)3– Fundraising for supplies for those unable to payFundraising for supplies for those unable to pay

• Health systems changeHealth systems change

– Registry and reminder systemRegistry and reminder system– CQI teams to improve care and link to communityCQI teams to improve care and link to community– Chart audit with feedback to providersChart audit with feedback to providers

• Coalition building, fund raising and policy changeCoalition building, fund raising and policy change

– Partners Coalition for Governance Partners Coalition for Governance – Local Coalition formed in each county, each with Local Coalition formed in each county, each with

501(C)3501(C)3– Fundraising for supplies for those unable to payFundraising for supplies for those unable to pay

  

 

Methods/Interventions

Community Skill-Building• Training of Health Professionals, Volunteers,

and Lay Health Educators (Community Health Advocates)– 5 AA women and 1 AA male employed as full-time

lay educators in their communities.– 50 faith-based volunteers– 120 broad-based community volunteers– 225 registered nurses (2-3 day foot care course)– 15 registered nurse wound care specialists– More than 150 students participated in various

aspects of projects

• Training of Health Professionals, Volunteers, and Lay Health Educators (Community Health Advocates)– 5 AA women and 1 AA male employed as full-time

lay educators in their communities.– 50 faith-based volunteers– 120 broad-based community volunteers– 225 registered nurses (2-3 day foot care course)– 15 registered nurse wound care specialists– More than 150 students participated in various

aspects of projects

Foot and Nail Care Review Course

Four-part DVD designed to provide basic and intermediate foot and nail care education for RN

• Continuing Education Course offered through Medical University of South Carolina College of Nursing

• REACH (and community partners) paid $225 tuition for nurses from community to take course and 225 completed the course

Four-part DVD designed to provide basic and intermediate foot and nail care education for RN

• Continuing Education Course offered through Medical University of South Carolina College of Nursing

• REACH (and community partners) paid $225 tuition for nurses from community to take course and 225 completed the course

Check Yourself to Protect YourselfCheck Yourself to Protect YourselfTake Care of Our Feet Take Care of Our Feet

A Lesson Plan, Kit of Materials, and A Lesson Plan, Kit of Materials, and Slide Series/Flip Chart for Lay LeadersSlide Series/Flip Chart for Lay Leaders

REACH Charleston & Georgetown Counties Diabetes Coalition

Ezekiel 37:10 “So I prophesied as he commanded me, and the breath came into them, and they lived, and stood up upon their feet, an exceeding great host.”

Lesson ObjectivesAfter the lesson, participants will be able to demonstrate:

• Taking care of feet• Cutting nails to prevent foot problems.• Selecting appropriate footwear.• Checking feet each day to identify early signs of foot

problems.• Using the monofilament to check for loss of feeling in feet.• When and how to notify health provider.• Asking the health care provider for foot exam.• Methods for prevention of foot problems.

After the lesson, participants will be able to demonstrate:

• Taking care of feet• Cutting nails to prevent foot problems.• Selecting appropriate footwear.• Checking feet each day to identify early signs of foot

problems.• Using the monofilament to check for loss of feeling in feet.• When and how to notify health provider.• Asking the health care provider for foot exam.• Methods for prevention of foot problems.

  

 

Testing for Loss of FeelingMethod for testing with Monofilament

Sites for testing with Monofilament

Bottom of FeetCheck eachof these sites 3 times

>6,000 monofilaments were distributed to professionals and people with diabetes.

Community Skill-Building

Outreach by Lay Educators to:• People with diabetes in Congregate Meal Sites,

Senior Centers, Day Care, Worksites, Libraries• People with family or friends with diabetes• Faith-based groups• Ministerial Alliance • Media

– Newspaper information (at least monthly)– 30 minute TV show on Cable Network aired 34 times– Radio talk shows

Outreach by Lay Educators to:• People with diabetes in Congregate Meal Sites,

Senior Centers, Day Care, Worksites, Libraries• People with family or friends with diabetes• Faith-based groups• Ministerial Alliance • Media

– Newspaper information (at least monthly)– 30 minute TV show on Cable Network aired 34 times– Radio talk shows

Community Skill-Building

• Neighborhood Community “Clinics” – Foot care demonstrations– Foot checks with referrals to nurse

specialists and podiatrists

• Expanded marketing of special shoes and medication patient assistance programs

• Ongoing weekly diabetes self-management education at 8 community sites

• Neighborhood Community “Clinics” – Foot care demonstrations– Foot checks with referrals to nurse

specialists and podiatrists

• Expanded marketing of special shoes and medication patient assistance programs

• Ongoing weekly diabetes self-management education at 8 community sites

A Book on Diabetes Care

and Management

&

Patient-Held Mini-Record(available on website

www.musc.edu/reach)

Skill-Building forCHAs and Volunteers

Neighborhood Walk and TalkGroups

Individual and Group

Education Sessions

Community and Media Activities reached >45,000

African Americans

Community Screening and

Education

Photos used with permission of clients and partners

Health Systems Change

• Chart audit with feedback on performance• QI teams with focus on foot care• Registry using DEMS (Diabetes Electronic

Monitoring System)• Inservice on “how to do” foot check, care and

education• Foot exam flow sheets• “Take off Shoes & Socks” signs for waiting and

exam rooms

• Chart audit with feedback on performance• QI teams with focus on foot care• Registry using DEMS (Diabetes Electronic

Monitoring System)• Inservice on “how to do” foot check, care and

education• Foot exam flow sheets• “Take off Shoes & Socks” signs for waiting and

exam rooms

Coalition Activities

• Training for lay volunteers and health care providers (Bubblin’ Brown Sugar)

• Info to communities about extent of problem

• Linkages to diabetes supply and patient assistance programs

• Media information/networking

• Policy and systems change

• Training for lay volunteers and health care providers (Bubblin’ Brown Sugar)

• Info to communities about extent of problem

• Linkages to diabetes supply and patient assistance programs

• Media information/networking

• Policy and systems change

We all work with political systems

  

 Results

Awareness

Foot Inspection

Foot Care

Purchasing Shoes

Patient-Provider Interactions

People with Diabetes

Family/Community

Health Providers

Health Systems#/Timing of Visits

Feet Exams Amputations

% Change in Diabetes Care for African Americans

• A1C Testing 76.8 97.1

• Blood Pressure <130/80 24 38

• Lipid Testing 47.3 87.2

• Eye Exam 34 76

• Feet Exam 64 97.3

• Kidney Tests 13.4 56

• A1C Testing 76.8 97.1

• Blood Pressure <130/80 24 38

• Lipid Testing 47.3 87.2

• Eye Exam 34 76

• Feet Exam 64 97.3

• Kidney Tests 13.4 56

2000 2007

Figure 3: Annual Foot Exam by Race and Gender Charleston and Georgetown Counties

% o

f Pati

ents

Charleston and Georgetown CountiesLEA Rate per 1000 DM Hospitalizations

Data Source: SC Hospital Discharge Data, Office of Research and Statistics

Prepared by SCDHEC Office of Epidemiology and Evaluation

Preliminary Estimated Outcomes for Reduction in Diabetes LEAs in African

Americans in 2 Counties

Preliminary Estimated Outcomes for Reduction in Diabetes LEAs in African

Americans in 2 Counties• Improved QOL for person whose legs were saved.• Cost savings:

– Costs per amputation in Georgetown County = $54,736 in 2008

– Costs per amputation in Charleston County = $42,783 in 2008

– Reduction in amputations compared to 1999 = 44% in African Americans

– Cost savings of >$2 million/year in 2008.

 

Note: release for photo

Limitations

• Denominator– Hospitalizations for diabetes– Population (Census data problematic)

• Measurement Challenges– Contributions of external influences– Number reached by messages – Contribution of each intervention

• Denominator– Hospitalizations for diabetes– Population (Census data problematic)

• Measurement Challenges– Contributions of external influences– Number reached by messages – Contribution of each intervention

Thank you to all community residents with diabetes, community leaders, and our partners who have

worked to eliminate diabetes disparities:

Thank you to all community residents with diabetes, community leaders, and our partners who have

worked to eliminate diabetes disparities:

• Charleston Diabetes Coalition• AKA Sorority (N. Charleston)• Greater St. Peter’s Church• Diabetes Initiative of SC• East Cooper Community Outreach• Franklin C. Fetter Family Health

Centers• MUSC College of Medicine• MUSC College of Nursing• Georgetown Diabetes CORE

Group

• MUSC Library• SC DHEC Diabetes Prevention

and Control Program and Epidemiology

• SC DHEC Region 7 and 8• St James-Santee Family Health

Center• Tri-County Black Nurses

Association• Trident United Way 211 Help Line• Trident Urban League

For additional information

Carolyn Jenkins, DrPH

e-mail: jenkinsc@musc.edu

Phone: 843-792-4625

Carolyn Jenkins, DrPH

e-mail: jenkinsc@musc.edu

Phone: 843-792-4625