Common Table Health Alliance Take Charge Report #9

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Report #9:Status Report on Efforts toReduce Health DisparitiesAmong African Americanswith Diabetes Type 2in Memphis and Shelby County, TennesseeDecember 2014

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Some games aren’t played for glory.Some are played for more important reasons.

That’s why we created Shape the State, to partner with schools to improve physical education. And teach kids to stay active and healthy. BlueCross BlueShield of Tennessee is proud to have supported Shape the State programs in the following Shelby County Schools:

American Way Middle Bailey Station Elementary Brookmeade Elementary Caldwell Elementary Collierville Elementary Cummings Middle School Macon-Hall Elementary Northaven Elementary Peabody Elementary Southeast Success Academy

Learn more at shapethestate.com A not-for-profit, Tennessee-based company.

Contributors to the Report:

This Take Charge for Better Health® Report is based on the data collected and experiences recorded during the planning and implementation of Diabetes for Life (DFL). Common Table Health Alliance would like to acknowledge the Merck Foundation Alliance to Reduce Disparities in Diabetes for funding DFL and this report. We also would like to acknowledge Baptist Memorial Health Care for their original efforts as the founder and sponsor of Memphis Healthy Churches and the DFL program team. This report is a result of the hard work and dedication of the following:

Diabetes for Life Team Members:

We would also like to thank Church Health Center; Joe Greer, DDS and the Good Health Institute; the many participating church locations and their volunteer educators; the six participating primary care practices; Walgreens; the American Dietetic Association; the Robert Wood Johnson Foundation and the Aligning Forces for Quality partnership; and Philliber Research Associates for their work in carrying out the DFL project evaluation.

©2014 Common Table Health Alliance. All rights reserved.

WritersReneé S. Frazier, MHSA, FACHEJae Henderson, MAPatria Johnson, MSSW

Gail Spake, MA

EditorJanice Ballard, MPH

Reneé S. Frazier, MHSA, FACHECEO, CTHA

Beverly J. Williams-Cleaves, MDCo-Principal Investigator

Patria Johnson, MSSWCo-Principal Investigator/Project Manager

Georgia Oliver, MS, RNDirector, Memphis Healthy Churches

Mae Clayton, RN, CDECertified Diabetes Educator

Wilmetta Neely, RD, LDNRegistered Dietitian

Margaret Thorman Hartig, PhD, APRN-BC, FAANPResearch Advisor

Armika Berkley, BALead Case Manager

Shalonda Tucker, BSCase Manager

Detricia PeeplesProject Analyst

Jeanette Barbee, CHESFitness Instructor

Bobbie TunstallAdministrative Assistant

Sally Brown, PhDProject Evaluator

Julie A. Dodge, MS, RNDeputy Director, The Alliance to Reduce Disparities in DiabetesUniversity of Michigan School of Public Health Center for Managing Chronic Disease

Belinda W. Nelson, PhDResearch InvestigatorUniversity of Michigan School of Public Health Center for Managing Chronic Disease

ABOUT THIS REPORT

This report is designed to reach a broad spectrum of individuals, including those with decision makingcapabilities. Its purpose is to act as a catalyst to bridge the conversation from research to practice.

Copies of this report and additional information are available at www.commontablehealth.org.

3 FOREWORD

4 ABOUT COMMON TABLE HEALTH ALLIANCE

5 EXECUTIVE SUMMARY

6 INTRODUCTION 6 What is Diabetes for Life? 6 Why Diabetes for Life? 7 A Brief History of Diabetes for Life

8 THE CHRONIC CARE MODEL 9 THE FOUR COMPONENTS OF DIABETES FOR LIFE

10 PATIENT COMPONENT 11 Know 12 Do 13 Live

15 PROVIDER COMPONENT 15 Provider Recruitment and Intervention 15 Practice Recruitment and Participation 16 Physician Education 16 Practice Support 18 Evaluation of Practice Quality Improvement 19 Provider Outcomes 19 Going Forward

20 SYSTEM COMPONENT 20 Team Learning Collaboratives 21 DFL Practice Sites Quality Improvement Progress

22 COMMUNITY COMPONENT 22 Linking Faith Community Organizations with Formal Health Care System Providers 22 Engaging Faith Community Members in the Diabetes for Life Program

23 WHAT DOES THIS MEAN TO MEMPHIS

24 REFERENCES 25 ACKNOWLEDGMENTS

27 IN LOVING MEMORY

& SHELBY COUNTY, TN?

TABLE OF CONTENTS

The longtime battle between diabetes and disparities continues to challenge the medical community. Thankfully, there are programs like Diabetes for Life that are working to address those challenges. I commend Common Table Health Alliance and Memphis Healthy Churches for having the desire to engage in this early intervention program to prevent complications by educating patients about the importance of monitoring and managing their diabetes. The faith community has a strong presence in Memphis, and several churches address health conditions through their health-related ministries. I am glad they were willing to join us.

Major approaches in my own practice are prevention and early intervention. DFL spoke to this strong belief and allowed me to impact more lives with the knowledge I have gained in my 40 plus years of practicing medicine. It is this type of special emphasis that will help to create health equity in our community.

I am pleased this intervention had such positive results for the patients and the participating practices. DFL set realistic goals for each individual and provided the resources for participants to achieve them, if they were willing to do the work. DFL also provided resources that allowed health care providers to extend their reach inside and outside their practices. Thanks to the generosity of the Merck Foundation, we were able to offer the diabetes education component at no cost to the participants and practices. The educational classes were hands-on with small group and individual instruction. This personalized care created an atmosphere for open, honest communication that strengthened the patient-provider relationship. The practices also learned additional techniques they can use to better engage with patients to assist them in improving self-management of their disease. It was a win-win situation for all involved.

The data we collected throughout the program helped us to become a national model for other communities that endeavor to improve in this area. Also, the support provided by the Alliance to Reduce Disparities in Diabetes allowed us to utilize information and techniques that had been successfully implemented in other communities faced with the same challenges.

Thank you to Common Table Health Alliance, Memphis Healthy Churches, the Merck Foundation and the Alliance to Reduce Disparities in Diabetes, participating practices and their staff, and the individual participants. This was a joint effort, just as successfully managing diabetes is a joint effort. When the patient, their family and the providers align, great things can happen. The formula is simple: provide education that can prevent complications to improve health and save lives.

Beverly Williams-Cleaves, MDComprehensive Diabetes and Metabolic Center of ExcellenceDFL Co-Principal Investigator

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FOREWORD

Common Table Health Alliance (CTHA) is a non-profit, 501(c)3 regional health improvement collaborative (RHIC) that addresses the health of everyone in the community and the health care delivery system. CTHA’s mission is to achieve health equity through trust, collaboration and education.

There are approximately 50 RHICs in the country, developed as multi-stakeholder organizations committed to improving the health and health care of their entire community. CTHA is Southeast Tennessee’s only RHIC.

CTHA was organized in 2003 as a combined effort of various organizations to align and create a common table. Formerly known as Healthy Memphis Common Table, it was certified by the Department of Health and Human Services as Tennessee’s only Chartered Value Exchange and is seen as a national model of innovation and collaboration. The role of CTHA is three-fold: serve as a multi-stakeholder neutral convener, produce community-level performance reports and execute small scale projects with the potential to expand community-wide.

Currently, CTHA operates six programs focused on four REAL community goals:

REDUCE childhood and family obesityELIMINATE health disparitiesACTIVATE consumers, patients and caregiversLIFT health care quality

Addressing these REAL community goals is very important to the Memphis region, and CTHA is honored to serve in this significant role. The Diabetes for Life program has afforded us the opportunity to address each of our four REAL community goals through our 9th Take Charge for Better Health® Report. By collaborating with consumers, patients and their families, we can simultaneously eliminate, activate and lift. It is with great pleasure we offer you evidence of our success.

Margaret “Peg” Thorman Hartig, PhD, APRN-BC, FAANP

Chair, Board of DirectorsCommon Table Health Alliance

Renee’ S. Frazier, MHSA, FACHEChief Executive OfficerCommon Table Health Alliance

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ABOUT COMMON TABLE

EXECUTIVE SUMMARY

As a Type 2 diabetic, I am pleased Common Table Health Alliance has the opportunity to share our work to address the disparities in diabetes care and outcomes. We hope what we learned these last five years will open the doors to more effective care and improvements in diabetes management. This report provides an approach for engaging patients, providers, health systems and the faith community to improve the care of Type 2 diabetics, especially African Americans. This report provides a summary of DFL, its implementation, its challenges and the overall lessons learned. Here are some of the major points of the report results:

• Patients achieved higher self-efficacy scores as a result of the program.• Providers improved their management of A1c levels.• Patients stabilized their BMIs with fitness coaching.• Providers benefited from training in cultural competency and defined systems of care.

These are positive outcomes, but the most important aspect has been a deeper understanding of how to reduce disparities in African American patients. The focus on provider and patient relationships clearly drove many of the favorable outcomes noted in this report. Early findings revealed some positive changes among intervention participants in:

1. Access to resources and support for disease management.2. Improvement in self-care activities.3. Trust and the ability to communicate with health care providers.4. Overall health-related quality of life.

The initial results of pre- and post-test evaluations in our program show that patients applied the knowledge and skills they learned from the diabetes self-management education classes. DFL participants made behavioral changes that led to improved health outcomes and perceptions of improved quality of life with support and encouragement from their primary care providers, case managers and registered dietitians. We attribute these early positive outcomes to the comprehensive nature of the classes and to the intensive case management support provided by DFL.

This report provides encouragement to our community and a clear framework for comprehensive suggestions for diabetes programs, as well as the need to ensure this comprehensive approach is embraced by third party payors, employers and the government.

Renee’ S. Frazier, MHSA, FACHEChief Executive OfficerCommon Table Health Alliance

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What is Diabetes for Life? Diabetes for Life (DFL) was a chronic disease self-management program aimed at reducing health disparities among African Americans with diabetes Type 2. DFL was designed to mobilize community-based practices, educate patients on self-management, engage policy makers, partner with faith-based ministries and create community awareness of issues associated with disparities in diabetes care.

The goals of the program were to introduce, track and document the chronic disease self-management program activities based on national best practice standards of care by engaging patients, providers, the providers’ staff, faith-based ministries and other key stakeholders. This five-year (2009-2014) initiative investigated factors associated with poor health outcomes in patients with the disease and focused on delivery of interventions to eliminate inconsistencies and disparities in diabetes care.

DFL research and interventions were based on a multi-dimensional framework and the Chronic Care Model. The Chronic Care Model involves community resources, health care organization, self-management support for patients, delivery system design and decision support, and effective use of clinical information systems.1 The Chronic Care Model enabled DFL to address access and resource allocation, and provide training, clinical data benchmarks and case management services for patients.

The project was funded by the Merck Foundation and guided by a leadership team that consisted of Reneé S. Frazier, CEO of Common Table Health Alliance; Dr. Beverly Williams-Cleaves, a highly respected endocrinologist, co-principal investigator and physician champion; and Patria Johnson, co-principal investigator and project manager. Other staff included a certified diabetes educator, a registered dietitian and two case managers. Six primary care practices entered agreements to participate in the program and together formed an alliance to address goals to transform diabetes care in the formal health care system. Memphis Healthy Churches, founded by Baptist Memorial Healthcare, was involved with recruitment and health promotion initiatives associated with the program’s goals.

Why Diabetes for Life? In 2009, African American patients with diabetes Type 2 in Memphis and Shelby County experienced higher levels of death compared to Caucasian patients. In fact, African Americans died at more than twice the rate of Caucasian patients. Death certifications from the Tennessee Department of Health noted death rates of 47 per 1000 for African American patients compared to only 16 per 1000 Caucasian patients.2 More than 112,000 people (or 12 percent of Shelby County’s population) have diabetes. This is a prevalence rate higher than the state average of 11 percent and much higher than the U.S. average rate of 8.3 percent.3

INTRODUCTION

“More than112,000 people (12 percent of Shelby County’s population) have diabetes.”

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In Tennessee, the prevalence of diabetes was highest among African American females (13.2 percent followed by Caucasian males (9.0 percent), Caucasian females (8.8 percent), and African American males (8.4 percent).4 African Americans represent more than half of Shelby County’s population with African American females outnumbering African American males. In Memphis and Shelby County, the burden of diabetes falls disproportionately on African-American residents compared to other races and ethnicities.

Diabetes and pre-diabetes contributed to the majority of premature deaths in Tennessee, according to a study from the University of Tennessee Health Science Center. The same study also reported that diabetes increased medical costs for employers and employees and created a substantial loss of productivity and a decrease in quality of life for persons diagnosed with diabetes Type 2.5

Effective primary care delivered early can prevent emergency department visits later by patients with diabetes. In other words, many diabetes patients’ visits to hospital emergency department are “sensitive” to the availability of, and access to, effective primary care. In 2012, Shelby County primary care sensitive ED visits cost insurance companies and other third-party payers nearly $130 million.6

Primary care providers have become the principal sources of care for an estimated 90 percent of patients with diabetes and are challenged to meet the needs of this large patient base due to inadequate infrastructure, time constraints, and obstacles to providing care and counseling.7 African American patients with diabetes Type 2 are challenged to manage their own care due to limited access to primary care services, and lack of resources and information related to chronic disease self-management.8 Health outcomes of this underserved population can be improved with greater flexibility for health care professionals to deliver care using evidence-based interventions that address specific needs of their communities.9

A Brief History of Diabetes for LifeMemphis Healthy Churches (MHC), funded by Baptist Memorial Health Care, is a network of African American churches that has long been involved in health promotion for their congregants. In 2008, a MHC certified diabetes educator approached a MHC program manager with a funding opportunity announcement from the Merck Company Foundation through its Alliance to Reduce Disparities in Diabetes Initiative. The opportunity announced funding for projects aimed at reducing health disparities, and the announcement described much of MHC’s earlier work done with congregants living with diabetes Type 2 and other chronic diseases. MHC submitted a letter of interest, was invited to submit a grant proposal and later received approval for funding. The approval of the grant request was exciting, but the requirements exceeded MHC’s capacity to manage it adequately. MHC contacted Common Table Health Alliance (CTHA), formerly Healthy Memphis Common Table, for assistance. CTHA, the regional health improvement collaborative dedicated to improving the health of people in the Greater Memphis area, agreed to serve as the grantee and fiduciary agent for the project. In February of 2009, CTHA received five-year grant funding of $1.9 million to launch the program. The leadership team was formed under the direction of CTHA, and one of its first tasks was to name the initiative. The certified diabetes educator found that many saw their diagnosis of diabetes Type 2 as a death sentence. In addition, both the MHC project manager and the certified diabetes educator had family members who died as a result of poor diabetes self-management. As a result, they were both passionate about helping others understand that diabetes is manageable. The team unanimously agreed the program name should elevate the word “Life,” so the name “Diabetes for Life” was adopted.

DFL hoped to show thatemergency department

visits, medical costsand death from diabetescomplications could bereduced by providing

education, coaching andsupport for patients, as well

as training providers andtheir staff on best practices,

improved communicationprocesses and tracking

meaningful quality data.

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“Diabetes for Life assumed a dual focus: conduct research on factors that impact successful outcomes for African American patients with diabetes Type 2, and implement evidence-based, best practice interventions to support better outcomes.”

Specific Objectives of Diabetes for Life1. Implement a proven, evidence-based, chronic disease self-management program that can be offered to people with diabetes as part of a comprehensive approach to diabetes management and care.

2. Increase access to and utilization of programs and resources to promote and maintain patient weight loss, including diet and nutritional counseling, peer support groups, and access to various exercise options based on patient preferences and needs.

3. Offer case management support for diabetic patients and their families to help them gain access and increase utilization of health resources as well as adopt and maintain effective self-management and lifestyle changes.

4. Foster ongoing implementation of standard quality management and clinical improvement procedures to ensure that all patients at participating primary care practices receive appropriate screening and treatments for diabetes and related chronic illnesses.

5. Enhance provider cultural competency and communications training, as well as related patient feedback processes, to measure effectiveness and appropriateness of provider communication.

6. Promote communication, collaboration and information exchange among all DFL stakeholders and extended community.

Conceptually, Diabetes for Life was built on the foundation of a proven patient care improvement strategy called the Chronic Care Model, which was designed and developed originally by Dr. Edward H. Wagner, the founding director of the MacColl Institute for Healthcare Innovation in Seattle, Washington.1 It has been adopted across the United States by many primary care practices and community health initiatives and has proven to be effective in improving physicians’ adherence to the standards of care and clinical outcomes of patients with diabetes, congestive heart failure, asthma and depression.12 The key to the model’s success is its dual emphasis on effective interaction with patients and a prepared practice team that works with patients and their caregivers.13

Using the Chronic Care Model, DFL incorporated a team approach to engage with patients, facilitate improved patient-practice interactions, and support providers and their staffs to enhance and improve delivery of diabetes care. The DFL project leadership team and staff approached these goals by addressing four components of DFL, all of them stakeholders in the diabetes health care system.

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THE CHRONIC CARE MODEL

PatientThe DFL program recruited patients who were diagnosed with diabetes Type 2 as the central focus. The aim was to improve awareness and efficacy of chronic disease self management practices to improve health outcomes and quality of life for participants who were African American patients treated at one of the six participating DFL primary care practices.

ProviderThe DFL project manager and case managers worked with practice providers and their staff to improve patient outcomes through training and improved communication.

SystemAll of the practices participated in DFL Learning Collaboratives that enabled them to share best practices in peer-to-peer interactions and group trainings. The practices then took steps to affect system improvements in support of better outcomes for their diabetic patients.

CommunityThe partnership between Common Table Health Alliance and Memphis Healthy Churches in the DFL program extended the original initiatives of Memphis Healthy Churches and provided training for church volunteers to continue peer education and support of diabetics.

THE FOUR COMPONENTS OF DIABETES FOR LIFE

Dear Diabetes for Life,

This letter is to inform you of the ways that I have benefited since joining the program. I’ve learned to eat three meals daily rather than pigging out on one meal. I’ve gained the knowledge to separate the myths from the truth about diabetes. I’ve also benefited from being able to talk and interact with people who share my disease. Thank you for having this program.

Sincerely,

James Rogers

Letters, such as this one from an early participant, helped to reinforce the effectiveness of the program.9

Throughout the DFL program 600 patients were enrolled with 224 patients participating in the study portion of the program. Participants were primarily older adults (ages 40+), female and married with a high school diploma or some college level education.

The primary goal of the DFL program was to improve the diabetes self-management skills of participants through training and case management support. Educated and empowered patients may become more engaged in their health care, better manage their conditions themselves, adopt preventive health behaviors and communicate more effectively with providers.14 The DFL training sessions were based on the U.S. Diabetes Conversation Maps education program, created by Healthy Interactions in collaboration with the American Diabetes Association15 and sponsored by the Merck Foundation. The Conversation Maps are based on current clinical practice guidelines that represent the best intervention approaches and national standards for diabetes self-management education. The DFL training sessions prompted participants to ask questions and formulate behavior change goals.

Diabetes for Life staff presented information about chronic disease management, meal planning and fitness training. DFL implemented a multi-layered approach titled “Know, Do, Live,” which was derived from the Conversation Maps curriculum and included free education, training and case management support. The Know component included education and training provided by the certified diabetes educator and registered dietitian. The Do component was managed by two DFL case managers, who offered a range of support services to patients and their families. The Live component was integrated in the recruitment process and throughout the duration of the participants’ engagement with DFL. It emphasized improved health outcomes and quality of life benefits experienced when effective diabetes self-management practices are applied.

KnowProper Meal Planning:• How to eat the right

foods and properly prepare them.

• How to monitor your portions.

Regular Exercise: This is important for everyone but especially people with diabetes Type 2.

What You Can Do:• Talk to your provider and

decide together what is a safe exercise plan for you.

• Set realistic fitness goals.• Begin an exercise

regimen and stick to it.

DoOther Skills You Will Learn:• How to test and record

your blood glucose.• How to keep a personal

journal of your health.• The benefits of your medication and how to take it properly.• How to recognize and

treat low/high blood sugar.

• How to monitor and control your diabetes.

LiveDiabetes for Life is a program offered to people ages 18 and older who have been diagnosed with diabetes Type 2 in the last 10 years. In the program, you will learn how to manage your diabetes and LIVE.

What Does the Program Include?• FREE case management.• FREE fitness training.• FREE self-management education.• FREE nutrition education.• Someone to help you

along the journey of life.

Sample Material Provided to Potential Program Participants

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PATIENT COMPONENT

“Knowing is half the battle” is a common but true statement. Patients enrolled in the study experienced many problems associated with poor diabetes management as a result of little or no previous diabetes education. Many did not understand their disease and the associated acute or chronic complications. Many failed to embrace lifestyle changes such as meal planning and exercise. Using the Conversation Maps curriculum, the certified diabetes educator and registered dietitian aimed to raise awareness of the benefits of chronic disease self-management practices with emphasis on causes for acute and chronic complications.

Three Conversation Maps training sessions were held throughout the duration of the program for groups that ranged from five to eight patient participants per class. (View training sessions at http://www.healthyinteractions.com/conversation-map-programs/conversation-map-experience/currentprograms/usdiabetes). The participants were expected to complete three training components: (1) On the Road to Better Managing Your Diabetes; (2) Monitoring Your Blood Glucose; and (3) Continuing Your Journey with Diabetes. Diabetes management, monitoring, tracking, healthy eating and meal planning were taught in an open forum at the end of each session. Participants were instructed how to create action plans to set and reach self-management goals. In 2012, DFL added a fitness component to the program. A fitness expert presented suggestions about setting realistic fitness goals, starting and sticking with an exercise routine, and communicating with the patient’s provider about a safe exercise plan.

The knowledge and skills presented in the Conversation Map classes provided a foundation for participants to engage with their case managers and health care providers to define and achieve success with their own personal self-management goals. Participants’ perceptions for communication with their providers were assessed using the subscale Patient Activation of the Changes in Patient Assessment of Chronic Illness Care20 survey. The subscale of three items asked participants about involvement in their treatment plan. Participants’ assessments of these three items improved after education classes and support from DFL case managers over the course of the DFL program (Table 1).

One hundred and eight (108) group sessions were offered over the five-year duration of the study. Of the 224 patients from participating primary care practices enrolled in the program between December 2009 and November 2012, 50 percent received the expected three or more training sessions. An additional 1 percent attended two sessions, and 4 percent attended one session.

Intervention Participants (113)

Initial Average*

FinalAverage* Change

1.99 3.12 1.13

2.19 3.13 0.94

2.97 3.25 0.28

Asked for your ideas when we made a treatment plan?

Given choices about treatment to think about?

Asked to talk about any problems with medicines or their effects?

Overall Score 2.38 3.17 0.79

Over the past six months, when you received care for your diabetes, were you...

An increase ( ) in score shows improvement in desired perception of engagement with providers for diabetes self-management. *Respondents selected perception on a scale of 0- 4, with 0 being ‘none of the time’ and 4 being ‘always.’

Table 1. Change in Patient Activation Scale at Final Assessment

KNOW

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With the exception of the third question, an increase ( ) in score shows improvement in desired self- care activities; a decrease in score ( ) shows lack of improvement.

In order for the participants to benefit from the Know information provided to them in the DFL classes, it was important for them to apply their knowledge and self-manage their chronic disease. Some components of the Do strategy were introduced as knowledge and skills in the diabetes Conversation Maps education/training sessions. However, intensive support to help participants apply those skills and to encourage behavioral change was provided by the case managers. The case managers helped participants to be successful and effective at implementing self-management activities into their routines.

The case managers helped patients with program enrollment and self-management goals. They also provided individual counseling and maintained regular contact (at least every 90 days) with each participant. They taught them how to document their progress through tracking logs and assisted patients with referrals and access to resources and services such as fitness training, health status logs and clinical status reports from DiaWeb, a specialized diabetes management program. Patients were then trained to use these resources to more effectively discuss their health status with their health care providers.

The DFL participants reported an increased level of confidence for managing their diabetes (self-efficacy).They also had an increase in the perceived competence in diabetes self-care in each of the overall areas measured.

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SPECIFIC OBJECTIVES OF DIABETES FOR LIFE:

1Implement a proven, evidence-based, chronic disease self-management program that can be offered to people with diabetes as part of a comprehensive approach to

diabetes management and care.

2Increase access to and utilization of programs and resources to promote and maintain patient weight loss, including diet and nutritional counseling, peer support groups,

and access to various exercise options based on patient preferences and needs.

3Offer case management support for diabetic patients and their families to help them gain access and increase utilization of health resources as well as adopt and maintain

effective self-management and lifestyle changes.

4Foster ongoing implementation of standard quality management and clinical improvement procedures to ensure that all patients at participating primary care

practices receive appropriate screening and treatments for diabetes and related chronic illnesses.

5Enhance provider cultural competency and communications training, as well as related patient feedback processes, to measure effectiveness and appropriateness of

provider communication.

6Promote communication, collaboration, and information exchange among all DFL stakeholders and extended community.

Participants (118)

Initial Average

FinalAverage Change

3.80 5.45 1.65

4.08 5.44 1.36

2.62 1.70 0.92

Follow a healthy eating plan?

Eat five or more servings of fruits and vegetables?

Eat high fat foods such as red meat or full fat dairy products?

How confident do you feel that you can/will…

Table 2. Change In Self-Care Activities

2.77 3.08 0.31Participate in at least 30 minutes of physical activity.

2.45 2.41 0.04Participate in a specific exercise session (such as swimming) other than what you do around the house or as part of your work?

4.42 6.20 1.78Check your feet?

3.91 5.89 1.98Inspect the inside of your shoes?

3.82 5.51 1.69On average, over the past month, how many days per week have you followed your eating plan?

4.66 5.87 1.21Test your blood sugar?

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DO

At enrollment, participants completed questionnaires to measure behavioral and situational factors related to diabetes self-management, such as health care utilization, trust in health care providers, self-efficacy, perceived competence for diabetes self-management, resources and supports for diabetes self-management, as well as health-related quality of life. The participants’ initial responses to the surveys showed they experienced compromised health, were limited in their perceptions of what they could do to manage their disease symptoms and to prevent complications, were not well-informed about resources, and were lacking in support to successfully work with their physicians for improving their health.

The initial findings in the results of pre- and post-test evaluations showed patients applied the knowledge and skills they learned from the diabetes self-management education classes. With support and encouragement from their case managers, the participants made behavioral changes that led to improved health outcomes and improved perceptions of quality of life. We attribute these early positive outcomes to the comprehensive nature of the disease self-management education and to the intensive case management support provided by DFL.29

All participants’ baseline (‘A, B, C’) clinical measures were also assessed and recorded: ‘A’ for A1c levels; ‘B’ for blood pressure; and ‘C’ for total cholesterol levels. The A1c test results reflect average blood sugar levels for the past two to three months.

LIVE

An increase ( ) in score shows improvement in desired self- care activities; a decrease in score ( ) shows lack of improvement.













Participants (119)

Initial Average

FinalAverage Change

6.44 9.15 2.71

6.30 8.80 2.50

6.19 8.60 2.41

Eat your meals every 4 to 5 hours every day, including breakfast?

Follow your diet when you have to prepare or share food with other people who do not have diabetes?

Choose the appropriate foods to eat when you are hungry? Particularly snacks.

How confident do you feel that you can/will…

Table 3. Change In Diabetes Self-Efficacy Scale

6.21 8.21 2.00Exercise 15 to 30 minutes, 4 or 5 times a week?

6.02 9.38 3.36Do something to prevent your blood sugar level from dropping when you exercise?

6.78 9.64 2.86Judge when the changes in your illness mean you should visit the doctor?

6.63 9.62 2.99Control your diabetes so that it does not interfere with the things you want to do?

6.33 9.12 2.79Overall Score

6.11 9.60 3.49Know what to do when your blood sugar goes higher or lower than it should be?

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Early Findings Revealed Some Positive Changes Among Intervention Participants in:1. Access to resources and support for disease management.

2. Improvement in self-care activities.

3. Trust and ability to communicate with health care providers.

4. Overall health-related quality of life.

Specifically, the A1c test measures what percentage of the patient’s hemoglobin—a protein in red blood cells that carries oxygen—is coated with sugar (glycated). The higher the A1c level, the poorer the blood sugar control and the higher the risk of diabetes complications.16 Among the clinical variables, A1c—the gold standard for clinical management of diabetes—showed a terrific change for a value that is difficult to improve from baseline to follow-up among participants (Table 4).

The participants in the DFL program showed many improvements in their abilities to partner and communicate with their health care providers, to define and implement personal goals for self-management, and to succeed in their efforts. They

were indeed LIVING with diabetes. They increased their knowledge, acquired new skills and received support in applying what they learned. As a result, the measures that impact health and quality of life improved for participants over the course of the program (Table 5).

Participants (192)

Initial Average

FinalAverage

Change

183.0 178.4 4.6Cholesterol Blood Total

Clinical Measure

Table 4. Change In Clinical Measures

80.5 80.6 0.1Diastolic Pressure

35.9 35.9 -BMI

7.9 7.4 0.5A1c

135.3 134.8 0.5Systolic Pressure

A decrease ( ) in score shows improvement in direction toward normal values; an increase ( ) in score shows lack of improvement in desired values.

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Participants (119)

Initial Average

FinalAverage Change

4.86 6.54 1.68

4.63 6.59 1.96

4.62 6.72 2.10

I feel confident in my ability to manage my diabetes.

I am capable of handling my diabetes now.

I am able to do my own routine diabetes care now.

Perceived Competence

Table 5. Change In Perceived Competence For Diabetes At Final Assessment

4.43 6.70 2.27I feel able to meet the challenge of controlling my diabetes.

4.63 6.64 2.01Overall Score

An increase ( ) in score shows improvement in desired self-care activities; a decrease in ( ) in score shows lack of improvement.

Provider Recruitment and InterventionPrimary care providers face challenges with lack of adequate infrastructure and time constraints that limit their ability to provide diabetes counseling, education and care.7 Many small practices do not have the level of staffing that would allow them to adequately support patients’ chronic disease self-management needs. These limitations have significant implications for diabetes care and patients’ self-management. Using the Chronic Care Model, the DFL project aimed to provide resources and support in tandem with the primary care physicians’ plans of care for their patients. Common Table Health Alliance6 previously reported that the Chronic Care Model had been adopted by many primary care practices and had proven to be effective in improving physicians’ adherence to the standards of care and clinical outcomes of patients’ chronic diseases including diabetes.12 The key to the model’s success is its dual emphasis on effective interactions with patients and a prepared practice team that works with patients and their caregivers.13

Practice Recruitment and ParticipationCo-Principal Investigator Dr. Beverly Williams-Cleaves joined the DFL project leadership team in the role of physician champion. The engagement of a well-known and highly respected endocrinologist in the community as the co-principal investigator was important for physician recruitment. Her stature in the medical community provided a trusted voice for the DFL program. Her role as a champion facilitated access to the participating practices, and her relationship with Common Table Health Alliance helped create a stronger connection to the formal health system. This helped to create the one-on-one engagement needed to convince the six community-based primary care practices to enter into a formal agreement to commit time and resources to engage in the DFL program. The project leadership team solicited and received commitments from at least one provider in each of the six practices to serve as the lead contact throughout the duration of the study. These providers agreed to participate in training sessions addressing skills in cultural awareness and communication. Other staff members were encouraged and welcomed to participate as well.

PROVIDER COMPONENT

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The six practices worked to fulfill their commitment to the DFL program by doing the following:

• Referring African American patients with diabetes Type 2 for enrollment in the DFL program.

• Providing clinical data (A1c, LDL, BP and BMI) for enrolled patients. Patients signed a waiver to allow sharing of Protected Health Information.

• Participating in health provider training sessions to enhance cultural awareness and communication.

• Participating in bi-annual Assessment of Primary Care Resources and Supports for Chronic Disease Self-Management assessment.

• Setting goals to improve practice function and organization, patient tracking, patient communication, and patient self-management practices.

• Participating in Quarterly Patient Care Collaborative meetings.

Physician EducationTo engage participating health care providers in the project, DFL offered several opportunities for group learning and team building. The Chronic Care Model component—to promote sharing best practices for making changes—was addressed through quarterly provider training sessions. The sessions covered an array of topics aimed at increasing knowledge of best practices: patient communication, competency in diabetes care, the Chronic Care Model and culturally competent care.

The DFL quarterly provider training sessions were known as “Quarterly Learning Collaboratives.” The first session was the Patient Care and Quality Improvement Collaborative on January 31, 2012. The final session was held on August 22, 2013. A total of seven sessions taught by national and local experts were conducted. Each provider training session was approved for one continuing medical

education credit. DFL trained 15 providers (physicians and nurse practitioners) and 28 other clinical support staff. In total, 43 practice staff members attended the seven training sessions.

Practice SupportTo increase awareness and understanding of all components of the DFL program among targeted medical providers, DFL case managers made weekly visits to the six provider practices. DFL adopted a face-to-face approach, and case managers and program staff committed ample time to understand all phases of the project (patient, provider and system). Offering operational support to offset practice staff time and resources was very important in securing participation from the practices. DFL staff assisted with data collection, review, analysis and feedback produced by and for each of the primary care practices to help them track how they were progressing toward their individual practice goals.

Certified Diabetes Educator Mae Claytontalks with a DFL participant.

Registered Dietitian Wilmetta Neely teaches participants about proper eating.

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During their weekly visits to the primary care practices, DFL case managers:

• Made sure each site had patient referral forms and project brochures.

• Routinely participated in regular practice meetings to provide updates on the project referral process.

• Circulated Patient Satisfaction Surveys to garner feedback from DFL patients about the care they received from their provider and the staff.

• Applied a targeted recruitment strategy that enabled them to enroll patients at the practice sites, provide support and gain access to clinical data (A1c, blood pressure, cholesterol LDL and HDL).

The use of health status logs was instituted within the six primary care practice sites as a best practice for enhancing patient provider communication. They were used as a conduit for discussion and shared decision making. DFL case managers distributed health status logs to DFL participants and trained patients to discuss the information from the reports with providers. Case managers entered the clinical data and the patients’ weekly self-report health status logs into DiaWeb, a specialized disease management program for diabetes practitioners.

To support practice staff, case managers did the following:

• Provided training and support with goal setting to improve practice functioning and organization, and assisted with improving patient tracking and patient communication.

• Conducted monthly downloads from DiaWeb to assess progress made on patients’ self-management goals and to determine when participants were due for quarterly follow-up calls to track patient class attendance logs (provided by the certified diabetes educator and registered dietitian).

• Maintained patient progress notes, contact logs and case management activity logs.

• Sent follow-up letters to patients’ providers with 90-day quarterly updates.

• Set DiaWeb alerts for patient lab work, fitness/education goals, demographic changes and provider/physician follow ups.

• Checked for updates on lab work for patient-physician appointments.

• Made follow up contacts with patients and physicians for missed activities and entered updates in Diaweb.

• Monitored practice recruitment goals for enrolling patients.

Monthly downloads of DiaWeb data were conducted by case managers to assess patient progress on achieving goals. The DFL project manager reviewed and approved the reports after data analysis, and then quarterly reports were generated for patients from each of the six partner practices. A copy of each approved report was forwarded to lead physicians of participating practices (patient specific reports were also available upon request). These reports provided aggregate patient clinical outcomes trend data for hemoglobin A1c, blood pressure, body mass index and total cholesterol. Individual patient reports for clinical outcomes trend data were provided upon physician request.

Potential participant has her A1c checked during a recruitment event.

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Evaluation of Practice Quality ImprovementQuality improvement efforts at the practice sites were assessed using the Primary Care Resources and Support survey for chronic disease self-management.17 The Primary Care Resources and Support survey covers two domains of support: patient and organizational level. Baseline assessments were conducted with 44 providers and practice staff from the six participating practices, with follow up assessments at six and 12 months. Findings from the baseline assessments were used to assist the practice sites to identify areas of change that would be the focus of their quality improvement efforts at each practice. Baseline findings were also used to set goals for improvements using the Plan-Do-Study-Act strategy.18 Some examples of goals included:

1. Incorporate action plans into patient visits.2. Increase patient input into their quality of care by use of a suggestion box and satisfaction surveys.3. Convert all patient medical records to electronic medical records to facilitate alerts for clinical tests.

Health care providers and staff members from five of the six participating practices completed PrimaryCare Resources and Supports surveys for Chronic Disease Self-Management assessments. A majority of surveys showed positive ratings at both the patient support and organizational support level being offered by DFL. Patient Satisfaction Surveys were circulated in the six primary practices to garner feedback from DFL participants about the care they received from their provider and the staff. Participants identified improvements in resources and supports for self-management (Table 6).

Testimonials from Practice StaffPractice physicians and staff reported that Diabetes for Life (DFL) case managers were effective at improving the quality of care with their diabetic patients. They said:• I think they were very effective. Patients seem to be more involved with wanting to do more

for themselves and getting their family more involved.• On a scale of 1 to 10, she is a 10. Very Effective!• Very effective in helping patients to better understand their medical condition.• She has been very effective in improving the quality of care.

Regarding the benefit of having a DFL case manager visit their office on a regular basis, physicians and staff said:• You have no idea HOW EXTREMELY VERY HELPFUL!• Yes, it has been beneficial having her visiting on a regular basis.

Physicians viewed their DFL case managers as a part of their patient care team:• I view her as someone who wants to lead a team effort in ways to better care for our

patients.• Very valuable part of our team!• Essential to treatment and patient education.

Physicians commented about the DFL program:• I think the DFL program is great.• It seems to bring new information and ideas to better help disease management.• Changing and saving lives!

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Provider OutcomesA major tenet of the Chronic Care Model is that the combined effects of an informed and activated patient working with a prepared practice team will result in better functional and clinical outcomes.19 Better outcomes would occur with increased patient trust and an improved patient-provider relationship. Participants identified improved communication with their provider team regarding care of their diabetes and patient support in general.

Improvements in practice processes were reflected in patient responses during an evaluation of patient perceptions of care. Patient perceptions of change were assessed based on the changes in Patient Assessment of Chronic Illness Care survey.20 The Patient Assessment of Chronic Illness Care survey contains 20 questions measured on five different scales. It was administered to DFL participants at baseline and compared over a 12-month period. Participant group patients reported positive improvements were realized for all three items on the Delivery System/Practice Design scale and all four items on the Change in Problem Solving/Contextual scale. There were too few comparison group responses to analyze and reliably measure for significant change.

Going ForwardCommon Table Health Alliance is exploring the possibility of obtaining future grant funding from other foundations and government agencies such as the Center for Medicare and Medicaid Services and the Department of Health Resources and Services Administration to provide similar training models (i.e., cultural competency, Chronic Care Model, etc.) to primary care physicians and allied health professionals.

Assessment of intensive provider training on interaction between patient and provider evaluated change in knowledge for cultural competency and patient-centered communication. Many training participants from the practices were already knowledgeable on the subject of multicultural awareness before the sessions. The survey results showed:

• 94 percent of providers increased knowledge on the Patient Centered Medical Home concept.• 73 percent increased knowledge on the Chronic Care Model.• 59 percent improved understanding of public reporting and the value of data.

Participants (115)

Initial Average

FinalAverage Change

1.61 1.98 0.37

1.50 1.93 0.43

1.73 2.00 0.27

Ask about what’s important to you when helping you manage your diabetes?

Teach you how to deal with stress or feeling sad?

Teach you how to deal with problems that come up?

In the past three months how often did someone on your diabetes care team...

Table 6. Change in Resources and Supports for Self-Management at Final Assessment

An increase ( ) in score shows improvement in desired self- care activities; a decrease in score ( ) shows lack of improvement.

2.03 2.30 0.27Give you the information you needed?

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Use of the Chronic Care Model promotes quality improvement in provider practices. Best care practices that evolve in those primary care settings can be shared with other providers and staff for more effective delivery of care. In peer-to-peer interactions during DFL group training events, the six participating practices took steps to affect system improvements in support of better outcomes for their diabetic patients. By promoting communication, collaboration and information exchange among the practices, DFL staff

trainers and the project leadership team were able to guide the providers and their staffs to identify goals for improvement and implement strategies to achieve those goals.

Team Learning CollaborativesThe Learning Collaborative is based on the Collaborative Learning Approach championed by the Institute for Health Improvement of Cambridge, Massachusetts. It brings together providers and practice staff within a health care organization to “seek improvement in a focused topic area.”21 With the support of the Merck Foundation, DFL leaders visited select Chicago medical sites in 2011 to learn more about the Learning Collaborative strategies implemented within the Chicago practices.

Common Table Health Alliance had previously established quarterly sessions taught by national and local experts for administrative and clinical staff from the five practices engaged in the Project Better Care (PBC) initiatve.6 PBC, funded through the Robert Wood Johnson Foundation Aligning Forces for Quality initiative, proved to be the perfect partnership with which to combine improvement efforts with DFL through Quarterly Learning Collaboratives. Training during the collaborative sessions was conducted by content experts, and each training session was approved for one credit hour of continuing medical education. Between events, participants applied the skills they learned within their practice sites and shared what they learned with other practice staff. As a result, the clinical processes for diabetes care within each practice improved. One such improvement was the frequency of tests, such as A1c and diabetic foot exams, being performed in a standardized way.6 Another legacy of the DFL collaborations with practices was helping the sites identify benchmarks for change in how they managed each individual practice.

Training also involved helping practice personnel become more proficient in their use of electronic medical records (EMR) systems, which is required by 2015 for primary care practices as part of the Affordable Care Act. Additionally, increased proficiency in EMRs will be a step toward practices’ more long-term goal of attaining Patient Centered Medical Home status, a practice model recognized for coordinated care and a long-term relationship between the practice and patient.23

SYSTEM COMPONENT

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Part of the training helped practice personnel learn how to enter information correctly into the appropriate section of the electronic medical records system. DFL case managers trained staff to enter, analyze and use DiaWeb registry information. The practices have all improved their standards of diabetes care.6 DFL did not have as a goal to transition practices toward the standards of certification for Patient Centered Medical Home status, a practice model recognized for coordinated care and a long-term relationship between the practice and patient.23 However, the support and training for practices increasing proficiency in electronic medical records will be a step toward a more long-term goal of attaining for Patient Centered Medical Home status. Proficiency at using electronic medical records is required by 2015 for primary care practices as part of the Affordable Care Act’s requirements. The peer-to-peer interaction among the practices as their providers and staff improved their electronic medical record proficiencies is a partial legacy of their engagement with the DFL program. Another legacy of the DFL collaborations with practices is helping the sites identify benchmarks for change in how they managed each individual practice.

DFL Practice Sites Quality Improvement ProgressParticipating DFL primary care practices had observed that many of their patients made preventable visits to hospital emergency departments related to mismanagement of their diabetes Type 2. The physicians recommended that emergency department discharge summaries advise those patients to see a primary care physician within 72 hours. The practices believed having case managers at the practice sites to provide on-site chronic diabetes education intervention would improve their patients’ disease management. DFL assessed changes by administering Primary Care Resources and Supports evaluations to identify and document benchmarks for change in health care delivery for DFL patients. DFL collected emergency department utilization data from DFL participants and other sources to formally document the impact of the program’s interventions on emergency department utilization. Summarized findings from Primary Care Resources and Supports surveys completed by the six practice groups enabled DFL to map out strategies to implement changes across the practice sites through construction of Plan-Do-Study-Act worksheets. Five of the six primary care providers accomplished their goals as measured by the Plan-Do-Study-Act process for making quality improvements in their practices. Improvement in the health care delivery system enabled DFL to meet its goal to better serve African Americans with diabetes Type 2 in Memphis and Shelby County.20

Dr. Christopher Green and his practice team attend a DFL Learning Collaborative.

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Linking Faith Community Organizations with Formal Health Care System ProvidersThe original idea for providing a diabetes self-management education program evolved from a certified diabetes educator affiliated with a church as a volunteer health care educator. Historically, African American churches have been a source of social and emotional support for parishioners, and increasingly as a source for health care information.24 25 26 The hope was that creating a local alliance of churches to link people with formal systems of care through a grant-funded program would enable the churches to improve care for parishioners with diabetes Type 2.

This type of alliance is not a new method for addressing chronic disease, but traditionally there have been documented barriers27 and challenges. One such challenge is effectively connecting parishioners from church organizations’ health promotion programs with formal health care system resources. DFL was able to alleviate this through the participation of high-profile individuals with influence in the health care community. They were each able to leverage this influence to open doors with both health care providers and churches to engage and build relationships.

Engaging Faith Community Members in the Diabetes for Life ProgramThe DFL certified diabetes educator and project manager provided 24 volunteer parishioners known as church health representatives with formal training in the Stanford Chronic Disease Self-Management program.28 Church health representatives did not play a direct role in delivering the

patient level intervention. However, they were valuable advocates for promoting DFL and encouraging participation of the congregation as well as members of the community. There was overall strong support for DFL in the church community that is believed to have affected participants’ behavior and outcomes. This validation of DFL efforts may have enhanced the participants’ attempts to adhere to diabetes self-management goals. Although the primary goal of DFL interventions was to improve diabetes self-management and health outcomes among African American patients, an overarching aim in the original grant proposal was to address disparities in diabetes care by establishing chronic disease self-management within Memphis Healthy Churches via the church health representatives.

Co-Principal Dr. Beverly Williams-Cleaves talks to a group about how to better manage their diabetes.

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COMMUNITY COMPONENT

Common Table Health Alliance will continue to work with stakeholders in the formal health care community to promote improvement in delivery of care for chronic disease self-management. The Diabetes for Life program demonstrated four key lessons. These findings will impact interventions and policy decisions to improve health and quality of life outcomes for African Americans with diabetes Type 2.

These four lessons can also promote future projects to develop more effective outcomes and improve care in our community:

Additionally, Common Table Health Alliance hopes to use these lessons to engage health insurance plans in a reimbursement model that supports the DFL comprehensive approach to improve quality of care and reduce cost.

Common Table Health Alliance offers this report as a blue print for effective diabetes management which can result in activated patients, engaged providers, system change and community resource alignment. It offers providers, patients and payors a proven model that demonstrates the value of investing in a comprehensive evidence-based approach. Diabetes for Life provides real hope that diabetes Type 2 can be successfully managed and those with the disease can live longer with a higher quality of life.

1. Building patient self-efficacy is key to improving overall diabetes self-management.2. The patient provider relationship must be comprehensive in nature, and the patient must be viewed as the leader in obtaining positive health outcomes.3. Data transparency across patient and provider populations is necessary to achieve health care quality and improvement.4. The DFL case managers often found that before they could address participants’ health concerns they first had to address the social determinants of health and link patients to social resources such as housing, medication, transportation, etc. Therefore, it is imperative that case management is in place to improve health and quality of life.

WHAT THIS MEANS TO MEMPHIS & SHELBY

COUNTY

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1 Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Aff (Millwood). Nov-Dec 2001;20(6):64-78.

2 Tennessee Department of Health. Tennessee Behavioral Risk Factor Surveillance Survey ( (BRFSS), 2010 state and regional weighted data. 2010; http://health.state.tn.us/statistics/PdfFiles/2010_BRFSS_State&Regional/BRFSS_BMI_10.pdf.

3 University of Wisconsin Population Health Institute. County health rankings & roadmaps. n.d.; http://www.countyhealthrankings.org/.

4 Tennessee Department of Health. Behavioral Risk FactorSurveillance System (BRFSS) Fact Sheet: Diabetes. n.d.;http://health.state.tn.us/Downloads/Diabetes.pdf.

5 Bailey JE, Gibson DV, Jain M, Connelly SA, Ryder KM, Dagogo-Jack S. QSource quality initiative. Reversing the diabetes epidemic in Tennessee. Tenn Med. Dec 2003;96(12):559-563.

6 Healthy Memphis Common Table. Report 8. Status report on efforts to improve quality in primary care practices through HMCT’s Project Better Care in Memphis and Shelby County Tennessee. 2013; http://healthymemphis.org/upload/PBC_Report_Final_Web.pdf.

7 Kirkman MS, Williams SR, Caffrey HH, Marrero DG. Impact of aprogram to improve adherence to diabetes guidelines by primarycare physicians. Diabetes Care. Nov 2002;25(11):1946-1951.

8 Centers for Disease Control. Groups especially affected by diabetes: Why do some racial and ethnic groups have higher rates of diabetes? 2014; http://www.cdc.gov/diabetes/consumer/groups.htm.

9 Alliance to Reduce Disparities in Diabetes. Policy considerations that make the link: Connecting community experience and national policy to reduce disparities in diabetes--Executive Summary: November 2012. 2013; http://ardd.sph.umich.edu/158.html.

10 Centers for Disease Control. National Diabetes Fact Sheet, 2011. 2011; http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf.

11 Fisher ES, Goodman DC, Chandra A. Disparities in health andhealth care among Medicare beneficiaries: A brief report of theDartmouth Atlas Project. 2008; http://www.dartmouthatlas.org/downloads/reports/AF4Q_Disparities_Report.pdf.

12 Pearson ML, Wu S, Schaefer J, et al. Assessing the implementation of the chronic care model in quality improvement collaboratives. Health Serv Res. Aug 2005;40(4):978-996.

13 National Coalition on Health Care and Institute for HealthcareImprovement. Curing the system: Stories of change in chronic illness care. Accelerating Change Today (ACT). 2002; http://www.improvingchroniccare.org/downloads/act_report_may_2002_curing_the_system_copy1.pdf.

14 Alliance to Reduce Disparities in Diabetes. Mission and vision.n.d.; http://ardd.sph.umich.edu/mission_vision.html.

15 Healthy Interactions. The U.S. Diabetes Conversation Map® Program. 2013; http://www.healthyinteractions.com/ conversation-map-programs/conversation-map-experience/currentprograms/usdiabetes.

16 Mayo Clinic. A1C test: Definition. 2014; http://www.mayoclinic.org/appointments?wt.adtype=d&wt.mc_id=us&campaign=appt&geo=national&kw=na&ad=banner&network=na&sitetarget=org&account=na.

17 Robert Wood Johnson Foundation. Assessment of primary care resources and supports for chronic disease and self management (PCRS). 2006; http://www.diabetesinitiative.org/support/documents/PCRSwithBackgroundandUserGuide.Rev12.08.FINAL.pdf.

18 Institute for Healthcare Improvement. Science of improvement: Testing changes. Plan-Do-Study-Act (PSDA). 2013; http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx.

19 Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract. Aug-Sep1998;1(1):2-4.

20 Glasgow RE, Wagner EH, Schaefer J, Mahoney LD, Reid RJ, Greene SM. Development and validation of the Patient Assessment of Chronic Illness Care (PACIC). Med Care. May 2005;43(5):436-444.

21 Institute for Healthcare Improvement. The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. 2003; http://www.ihi.org/resources/Pages/IHIWhitePapers/TheBreakthroughSeriesIHIsCollaborativeModelforAchievingBreakthroughImprovement.aspx.

22 Institute for Healthcare Improvement. Plan-Do-Study-Act (PDSA) Worksheet. 2013; http://www.ihi.org/resources/pages/tools/plandostudyactworksheet.aspx.

23 National Committee for Quality Assurance. NCQA Patient-Centered Medical Home 2011: Healthcare that revolves around you. An established model of care coordination. 2011; http://www.ncqa.org/Portals/0/PCMH2011%20withCAHPSInsert.pdf.

24 Chatters LM, Mattis JS, Woodward AT, Taylor RJ, Neighbors HW,Grayman NA. Use of ministers for a serious personal problem amongAfrican Americans: findings from the national survey of Americanlife. Am J Orthopsychiatry. Jan 2011;81(1):118-127.

25 Taylor RJ, Ellison CG, Chatters LM, Levin JS, Lincoln KD. Mentalhealth services in faith communities: the role of clergy in blackchurches. Soc Work. Jan 2000;45(1):73-87.

26 Levin JS. The role of the black church in community medicine. JNatl Med Assoc. May 1984;76(5):477-483.

27 Blank MB, Mahmood M, Fox JC, Guterbock T. Alternative mentalhealth services: the role of the black church in the South. Am J PublicHealth. Oct 2002;92(10):1668-1672.

28 Lorig K, Gonzalez V, Laurent. D. The Chronic Disease Self-Management Workshop: Leader’s Manual. Palo Alto, CA: StanfordUniversity; 2006.

29 Johnson, P., Thorman Hartig, M., Frazier, R., Clayton, M., Oliver,G., Nelson, B. W., William-Cleaves, B. J. Engaging theFaith-based Resources to Initiate and Support Diabetes Self –Management Among African-Americans: A Collaboration of Informaland Formal Systems of Care. Health Promotion Practice. Nov 2014;15(2):71s-82s

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REFERENCES

CTHA BOARD OF DIRECTORSBoard Chair: Peg Thorman Hartig, PhD, APRN-BC, FAANP Assistant Vice Chancellor for Community Engagement and Inter-professional Initiatives Professor, UTHSC

Vice Chair: Reggie Crenshaw Principal, Crenshaw & Associates

Treasurer: Zach Chandler Executive Vice President - Chief Strategy Officer Baptist Memorial Health Care Corporation

Secretary: John Greaud, PE, AAEFacility Maintenance Site Manager for Baptist Memorial Hospitals, Johnson Controls

DIRECTORSLisa Abbay, RDN, LDN Regional Director of Operations Morrison Healthcare Food Services

Donna Abney, MBA Executive VP, Methodist Healthcare

Linda Carter, SPHR Human Resources Executive

Clarence Davis, Jr., MD Medical Director, VSHP Governmental Business BlueCross BlueShield of Tennessee

Thomas “Tad” E. Feeney, MBA, CPA, CGMA

Leigh Fox, RD President and Executive Director Game Day Healthy Kids Foundation

Jim Horsey, MBA Manager, Key Accounts, Pfizer, Inc.

Jennifer Kiesewetter, Esq. Partner, Butler Snow

Casey Lawhead Vice President, Private Banking, IBERIA Bank

Nieika Parks, MHA, PhD Enterprise, Health & Wellness Coordinator FedEx Services Corporation

Sridhar Sunkara, MCRP CEO, eBiz Solutions

Chuck Utterback, MHSA Director of Contracting and Provider Services CIGNA Heath Care

Scottie Walker Sales Director, Coca-Cola Refreshments

ADVISORY COMMITTEE TO THE BOARDCo-Chair: Thomas “Tad” E. Feeney, MBA, CPA, CGMA

Co-Chair: Barry-Lewis Harris II, MD Medical Director, Memphis Health Center

Fayre Crossley Director of the Grant Center Alliance for Non-Profit Excellence

Cynthia Allen System Community Involvement Manager Baptist Memorial Health Care

Charles Griffin Vice President of Operations, Boys & Girls Club

Maria Fuhrmann Special Assistant to Mayor Wharton City of Memphis

Lynn Doyle Executive Director Business Development/Marketing Delta Medical Center of Memphis

Lauren Taylor Program Director for Livable Communities Hyde Family Foundations

Mark Yates President/CEO, Life Enhancement Services

Jacqueline Daughtry President, Memphis Academy of Nutrition and Dietetics

John Zeanah Administrator, Office of Sustainability Memphis and Shelby County Division of Planning and Development

ACKNOWLEDGMENTS

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ADVISORY COMMITTEE TO THE BOARD Cassandra Webster Executive Director, Memphis Challenge

Doug McGowen Director, Memphis Innovation Delivery Team

Amy Israel Director of Cultural Arts & Judaic Enrichment Memphis Jewish Community Center

Pamela Harris Consumer Representative, Memphis Medical News

Blair Taylor President, Memphis Tomorrow

Bobby Baker Director, Faith & Community Partnerships Methodist Le Bonheur Healthcare

Sally Heinz Executive Director, MIFA

Tish Towns Regional One Health Senior Vice President External Relations

Lora Jobe Field Representative Office of Senator Lamar Alexander

Phyllis Fickling Legislative Advisor to Mayor Luttrell Shelby County Government

Michelle Taylor, MD Attending Physician Shelby County Health Department

Yuri Quintana Director, Education and Informatics International Outreach Program, St. Jude Children’s Research Hospital

Marion Hare, MD Associate Professor, UTHSC

Karen Pease Executive Director, Well Child

Connie Binkowitz, MCRP Program Director, YMCA

Tim Goldsmith Chief Clinical Officer, Youth Villages

LEGACY COLLABORATORSDavid Archer President/CEO, Saint Francis Health Care

Stephen Reynolds Past President & CEO Baptist Memorial Health Care Corporation

Gary Shorb President & CEO Methodist Le Bonheur Healthcare

COMMON TABLE HEALTH ALLIANCE TEAMReneé Frazier, MHSA, FACHE Chief Executive Officer

Ayilé Arnett, MBA Data Analyst

Carla Baker, RN Quality Improvement Coordinator

Janice Ballard, MPH Program Coordinator

Kathy Duncan Process Improvement Consultant

Katie Dyer, MPH Data Analyst

Susan Hayne Executive Assistant to the CEO

Crystel Hardin PR and Social Media Coordinator

Patria Johnson, MSSW Care Manager

Monica Morgan, CPA Chief Financial Officer

Susan Nelson, MD, FAAFP Medical Director

Chris Owens, MBA Director of Development and Community Relations

Rene Pickler Project Assistant

Joseph Webb, D.Sc, FACHE Chief Operating Officer

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IN MEMORY

In Loving Memory of Brodie Clayton, Sr.

Brodie Patrick Clayton, Sr. was an avid supporter of Diabetes for Life and an active participant. The son of our Certified Diabetes Educator, Mae Clayton, he was a glowing example of our diabetes management work in action. He applied the lessons he learned and saw improvement in his condition.

Unfortunately, Brodie suffered from other illnesses and succumbed to his battle on March 24, 2014 at the age of 62. His zest for life, winning smile, sense of humor and determination will always be remembered.

We dedicate Report #9 to our dear friend Brodie Clayton, Sr.

Thank you for sharing your light with us.

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COMMON TABLE HEALTH ALLIANCE6027 Walnut Grove Road | Suite 215 | Memphis, TN 38120

P: 901.684.6011 | F: 901.766.1018 | www.commontablehealth.org

Common Table Health Alliance Take Charge Report #9

Documents

Transcript of Common Table Health Alliance Take Charge Report #9