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Creating Healthy Connections in Albany County, NY

State: NY Type: Model Practice Year: 2019

Albany County is located in eastern New York State, 136 miles north of New York City. The total County population is 305,279, including 245,557 adults. The County population is predominantly white (78.2%), and the largest minority groups include Black or African American (12.8%), Hispanic/Latino (5.2%) and Asian (5.1%) persons. The percentage of minorities in Albany County is substantially below the estimated percentages for New York State; however, minority populations are concentrated primarily in the urban areas. While the City of Albany is home to approximately 32% of the County population, 77% of the African American population and more than 53% of the Hispanic population reside within the City of Albany.¹ Heart disease is the leading cause of death in Albany County, New York. Among adult residents, 30.8% have physician-diagnosed hypertension, which is higher than the comparable Upstate New York rate of 27.8%. The 2017 National Diabetes Statistics Report indicated that 9.8% (24,065) of Albany County adult residents were diagnosed with diabetes in 2013. It is projected that 33% (81,852) of adult residents have prediabetes with only 4.9% diagnosed.² Obesity is a significant risk factor for diabetes and other chronic diseases. The latest Behavioral Risk Factor Surveillance System (BRFSS) survey conducted in Albany County estimates that 21.7% of adults do not participate in leisure time physical activity, 10% of adults have adequate access to locations for physical activity, and an estimated 62.8% of adults are overweight or obese, a significant increase from the 2003 estimate of 54%. These chronic diseases and associated risk factors are disproportionately occurring in communities with limited access to resources, socio-economic hardship and minority health disparities. With funding from multiple grantors, Albany County Department of Health (ACDOH) collaborates with the local YMCA, a large health system network of primary care and National Diabetes Prevention Program (NDPP) providers, regional supermarket with pharmacist services and other area primary care providers to build capacity for hypertension and prediabetes evidence based self-management programs. Collaboration includes sponsoring the training of the (NDPP) and YMCA Blood Pressure Management Program (Y-BPMP) facilitators, developing a calendar of upcoming programs, increasing referrals to the programs, and utilizing community health workers (CHWs) to maintain participant engagement. Our goal is to annually launch multiple NDPPs serving our priority population (i.e. those residents in neighborhoods experiencing a high prevalence of cardiovascular disease, diabetes and obesity as well as social determinants of health); maintain a rolling enrollment of the Y-BPMP; engage community pharmacists to implement interventions that promote self-management of uncontrolled HTN; and to link patients experiencing adverse social determinants of health (SDH) with CHWs. The objective for each NDPP is to enroll 20-30 individuals of the priority populations and to achieve a 50% completion rate defined as attending 9 of the 16 NDPP core classes. Through these efforts, 60-90 individuals from our priority populations will reduce their risk for diabetes and lose 5-7% of their body weight. The objective of the hypertension initiative is to achieve and maintain controlled hypertension status for at least 100 residents. Objectives include building capacity for delivering Y-BPMP and assisting at least 45 individuals with a history of uncontrolled hypertension maintain their new controlled hypertension status through the Y-BPMP. Other objectives include engaging community pharmacists to support at least 60 patients diagnosed with uncontrolled hypertension achieve control of their hypertension and developing CHW referral workflows for primary care providers, pharmacists, and self-management program facilitators to support patients diagnosed with prediabetes, diabetes and/or hypertension as well as experiencing SDH. In 2018, 32 NDPP and 5 Y-BPMP facilitators were trained to build the capacity for respective programs. Five NDPPs were held and 62 residents primarily experiencing SDH were enrolled with a 69.2% successfully completing the program with CHW support. Thirty-one residents enrolled in the Y-BPMP. Two community pharmacists engaged at one PCP to enroll forty hypertensive patients into the program. Four PCPs utilize prediabetes and hypertension registries to identify patients that will benefit from NDPP, Y-BPMP and/or CHW support. Three CHWs provided support for healthy behavior change to 268 residents diagnosed with prediabetes, diabetes, and/or hypertension. Success is attributed to strategically collaborating with partners who have an aligned vision to improve the health of residents and support evidence-based interventions (EBI) (i.e. NDPP, Y-BPMP, CHWs) while also addressing health equity issues. This approach has a synergistic impact on the community as each agency's resources, expertise, and skills are leveraged to implement EBIs designed to reach those experiencing adverse social determinants of health. Albany County Department of Health http://www.albanycounty.com/Government/Departments/DepartmentofHealth.aspx 1. United States Census Bureau: State & County QuickFacts. Albany City: http://quickfacts.census.gov/qfd/states/36/3601000.html Albany County: http://quickfacts.census.gov/qfd/states/36/36001.html 2. New York State Expanded Behavioral Risk Factor Surveillance System, 2013-2014.
There is a significant disparity in distribution of cardiovascular and obesity related disease within Albany County. In general, hospitalization rates for diabetes and circulatory conditions in the County are higher in urban areas (specifically Albany, Watervliet, Green Island, and Cohoes), than in areas considered suburban and rural. These urban areas also tend to have higher poverty rates than the County as a whole. The percent of persons living below the poverty level in the City of Albany is almost double the percent living below the poverty level in Albany County (25.2% vs. 13% respectively). There is no comparable summary of behavioral risk factors (i.e. nutrition, physical activity, and tobacco use) at these smaller geographic levels; however it is likely that these disparate disease rates are accompanied by a disparity in behavioral risk as well. Chronic diseases and related risk factors are the leading causes of death and disability in the United States. The Albany County priority population, which includes residents in the cities of Albany, Green Island, Watervliet, and Cohoes, has disproportionate risk for chronic conditions. The percentage of residents below the poverty level in the priority neighborhoods of the City of Albany are 28.2% in Arbor Hill, 38.9% in the West End and 31.3% in the South End. In Green Island, 15.9% of residents are below the poverty level; 15.4% of Watervliet residents are below the poverty level; and 14.3% of Cohoes residents are below the poverty level. The poverty rates in these target areas are all above the 13.6% average poverty rate for the County of Albany and 13.5% for the Nation. Prevention Quality Indicator (PQI) data are used to describe the health disparities in certain neighborhoods of the target population. The South End (Zip 12202) and West End (Zip 12206) have Hypertension PQI observed rates approximately three times the Albany County rate of 5.1/10,000: South End - 15.4; West End - 13.9. The West End, South End and West Hill neighborhoods all have observed rates for PQI Diabetes data that were three times as high as the Albany County rate. The anticipated adult population reach for the identified target area is approximately 104,405 adults, or 43%, of Albany County adult residents. Top Tier Neighborhoods are defined as those with residents who are super-utilizers (persons who are emergency room super-utilizers and/or had a 30 day readmission history), as well as those who have multiple chronic physical conditions include Arbor Hill, South End, West End, and West Hill. Neighborhoods like the South End in Albany have high proportions and numbers of these super-utilizers, as well as poverty rates that are almost double the regional average and a more diverse racial mix. Cohoes, Watervliet, and Green Island were also identified as Top Tier Neighborhoods. The Albany County Department of Health's 2016 Community Health Improvement Plan (CHIP) has a focus on reducing obesity to prevent diabetes and related comorbidities. CHIP activities that provide resources to the target population include the creation and subsequent distribution of a diabetes resource guide, promotion of the National Diabetes Prevention Program (NDPP) and the YMCA-Blood Pressure Management Program (Y-BPMP). NDPP is available through the Capital District YMCAs and the St. Peter's Diabetes & Endocrinology Center. The Capital District YMCA also implements the Y-BPMP and programs to increase physical activity. There are a number of primary care providers that are located within the target population communities. Whitney M. Young Health Center is a federally qualified health center located in the Arbor Hill neighborhood in the City of Albany and in Watervliet. Other primary care providers include St. Peter's Family Health Center and Koinonia Primary Care located in the South End and West Hill neighborhoods in Albany. St. Peter's Health Partners also has a family practice, Cohoes Family Care in Cohoes. Healthy Capital District Initiative identifies that neighborhoods such as Arbor Hill, Cohoes, and Watervliet have fewer than the upstate average for primary care physicians. Gaps and barriers to accessing resources and services can have a profound effect on one's overall health and wellbeing. At a clinic-to-community listening forum sponsored by the local YMCA, partner organizations and residents came together to discuss these barriers. It was determined existing barriers include lack of transportation, housing instability, and available hours of current healthcare providers. The current traditional system of care including scheduled appointments at existing clinics is not effective. There are perceived inequalities between service providers and community members. Racial, ethnic, language and cultural barriers exist that limit access to services. The use of community health workers (CHWs) that focus on chronic disease prevention and control helps to reduce or eliminate many identified barriers. ACDOH advances a Health in All Policies” approach and has a 20+ year history of engaging CHWs in maternal-child health. In 2014, ACDOH implemented Local IMPACT (NYSDOH CDC–funded State and Local Public Health Action 1422 Program) an initiative that provided funding to leverage the department's CHW expertise and expand this work to prevent chronic disease i.e. diabetes, hypertension. Over the past four years, additional funding to expand the success of this project and other related initiatives provided opportunities to creatively engage community partners in different ways. Specifically, ACDOH was awarded a Million Hearts grant to promote self-monitoring of blood pressure with clinical-community linkages to reduce cardiovascular disease, Rubin Community Health Fund of the Community Foundation for the Greater Capital Region to prevent chronic kidney disease by delaying the onset of diabetes and hypertension, and Better Health of Northeastern New York Cardiovascular Disease Initiative (New York State Medicaid Reform) to promote clinical community linkages for Medicaid recipients diagnosed with hypertension. ACDOH chronic disease CHWs are trained in prediabetes, diabetes, hypertension, healthy eating, promoting physical activity and motivational interviewing in addition to traditional patient navigation. ACDOH innovatively utilized the Collective Impact (CI) model¹ for its collaborative work with community partners to prevent or delay the onset of diabetes and to achieve and maintain the control of hypertension. ACDOH participated in community workgroups to identify agencies and practices with an aligned vision to improve the health of residents in priority neighborhoods by promoting evidence-based programs that reduce prediabetes and hypertension while simultaneously addressing health equity issues. In this collaboration, the local YMCA conducted focus groups with ACDOH to identify challenges and an effective action plan to provide the evidence-based NDPP and Y-BPMP to priority communities. This plan was implemented by ACDOH with each of its NDPP and Y-BPMP providers. Mutually reinforcing strategies are implemented in the following way: · Lifestyle Change Programs – The ACDOH works with primary care practices (PCP) that serve the priority populations to develop prediabetes and HTN registries. These registries are used to generate a list of patients to refer into the evidence-based NDPP and Y-BPMP as applicable. Simultaneously, the ACDOH sponsored training of NDPP lifestyle coaches and Y-BPMP healthy heart ambassadors to build the capacity of provider agencies to deliver both programs. · Multi-directional Referral – The ACDOH facilitates monthly conference calls between the self-management program providers, PCPs, and pharmacy team to develop a referral and feedback process. This process includes an assessment for CHW support by the NDPP and Y-BPMP facilitators, health care team at the PCP, and the pharmacists. As the relationship between the partners strengthen and the processes work efficiently, the frequency of the calls will decrease over time. · Community-Clinical Linkages – ACDOH CHWs contact eligible patients to facilitate enrollment into the self-management programs. Additionally, they are embedded in the NDPPs, work directly with PCPs and pharmacists; and facilitate participant engagement in the Y-BPMP. Each agency tracks the number of referrals, enrollees, and engagement of patients/participants. During the monthly calls, data results are evaluated to identify successes, challenges and next steps. This extra step facilitates ongoing quality improvement that contributes to the improved health of the participants as measured by weight loss, increased physical activity, improved nutritional intake, and/or blood pressure control as well as improved quality of life as shared through case studies presented by members of the health care team (i.e. PCPs, pharmacists, CHWs, lifestyle coaches). Uniquely applied in this way, the CI approach establishes a common agenda, promotes sharing metrics, facilitates the implementation of mutually reinforcing strategies, maintains open communication, and leverages the resources and skills that each agency contributes to this project's ongoing success and sustainability while improving the health of those most at need. Each partner brings a skill set, perspective and resources that create synergistic impact on the health and lives of those most at risk for diabetes and cardiovascular disease in Albany County. Using the CI framework to increase the engagement of CHWs in clinical and community programs builds on evidence-based practices cited in the CDC's Addressing Chronic Disease through Community Health Workers: A Policy and Systems-Level Approach, 2nd edition published in April 2015. In particular, CHWs cited in this publication have been utilized to perform community outreach, complete home visits to reinforce lifestyle change behaviors and assist with the navigation of health care systems. The Albany County Department of Health has used CHWs not only in these traditional roles but also places them directly within NDPPs, Y-BPMP, and pharmacists. In this capacity, they enhance the work of the lifestyle coaches, the health care team, and pharmacists by providing ongoing support to patients as needed. 1. Kania, John, and Mark Kramer. "Collective Impact." Stanford Social Innovation Review 9, no. 1 (Winter 2011): 36–41.
Albany County Department of Health's (ACDOH) goal is to annually launch multiple National Diabetes Prevention Programs (NDPP) serving our priority population (i.e. those residents in neighborhoods experiencing a high prevalence of cardiovascular disease, diabetes and obesity as well as adverse social determinants of health); maintain a rolling enrollment of the YMCA – Blood Pressure Management Program (Y-BPMP); engage community pharmacists to implement interventions that promote self-management of uncontrolled hypertension (HTN); and to link patients experiencing adverse social determinants of health (SDH) with CHWs. The objective for each NDPP is to enroll 20-30 individuals of the priority populations and to achieve a 50% completion rate defined as attending 9 of the 16 NDPP core classes. Evidence shows that completing 9 of the 16 core NDPP classes reduces the risk for type 2 diabetes by 58% and promotes an average weight loss of 5-7% by promoting healthier eating and at least 150 minutes of physical activity weekly.¹ Through these efforts, 60-90 individuals from our priority populations will reduce their risk for diabetes. The objective of the hypertension initiative is to achieve and maintain controlled hypertension status for at least 100 residents. Objectives include building capacity for delivering Y-BPMP an evidence-based program that has a 74% success rate of helping participants achieve a drop in blood pressure to below 140/90 or at least a 10mmHg drop in systolic blood pressure within 6 months by promoting healthier eating, physical activity and self-monitoring of blood pressure.² At least 45 individuals with a history of uncontrolled hypertension will maintain their new controlled hypertension status through the Y-BPMP. Other objectives include engaging community pharmacists to support at least 60 patients diagnosed with uncontrolled hypertension achieve control of their hypertension and developing CHW referral workflows for primary care providers, pharmacists, and self-management program facilitators to support patients diagnosed with prediabetes, diabetes and/or hypertension as well as experiencing SDH. Steps taken to the implement the program included: identifying the challenges, opportunities and need; leveraging resources and skills; implementing mutually reinforcing strategies; ongoing evaluation and communication about metrics and performance management. 1. Identify the Challenge – ACDOH used the Community Health Needs Assessment to identify priority neighborhoods. Three focus groups were coordinated by the Capital District YMCA with technical assistance from the ACDOH to identify barriers to enrolling in and completing NDPPs in the priority neighborhoods. Findings from the focus group identified competing schedules, untimely life events, transportation, childcare and limited availability to healthy food as barriers or challenges to committing to the program. Programs that were low-cost or had built-in participation incentives, promoted group/peer support, were scheduled to coordinate with other activities (i.e. gym, church group, library, etc.), emphasized weight loss and tools for implementing healthy behaviors attract more participants. Additionally, it was noted that engaging primary care providers to refer participants to the program would positively impact enrollment and participation. These findings were used to structure how participants would be recruited for NDPPs and later for Y-BPMP, where and when programming would be held, as well as how incentives would be used. 2. Leverage Resources and Skills – ACDOH identified community partners based on their alignment with the ACDOHs vision to improve the health of residents in priority neighborhoods by promoting evidence-based programs that reduce prediabetes and hypertension while simultaneously addressing health equity issues; their resources (i.e. staff, facilities, community relationships, services, etc.); their expertise and skills that support the vision and complement the work of ACDOH and other partners. This promotes a sustainable and synergistic relationship that benefits the community. 3. Implementing Mutually Reinforcing Strategies - Build Lifestyle Change Program Capacity Build Demand for Programs: ACDOH worked with community partners to develop a bus shelter campaign (~$8,000 per campaign funded through Local IMPACT (LI) and Rubin Community Health Fund (RCHF)) to raise community awareness about prediabetes and hypertension. ACDOH Chronic Disease CHWs conducted outreach at various community venues to raise awareness about the risk for prediabetes, high blood pressure, self-management programs and CHW support services: worksites, church groups, health clinics, mobile vegetable stops, and other community events within the priority neighborhoods. NDPP and Y-BPMP providers developed fliers about their programs for CHWs to disseminate – each promoted that the programs were free and highlighted program health benefits and weight loss (with NDPP only). Additionally, ACDOH provided technical assistance to five PCPs serving residents in the priority neighborhoods to develop prediabetes, diabetes and hypertension registries; and to implement workflows to refer patients to self-management programs (i.e. NDPP, Y-BPSM, SMBP), pharmacists and CHWs. PCPs participated in the development of the referral and feedback forms to CHWs and self-management programs; and committed staff and time to develop the referral workflows with ACDOH. Build Supply for Programs ACDOH contracted with NDPP providers and sponsored NDPPs ($5,000 per program funded through LI and RCHF). Selected NDPP provider agencies either were in the process of being recognized by the Diabetes Provider Recognition Program (DPRP) or were committed to beginning the process of achieving DPRP status. Contracted agencies included the Capital District YMCA and St. Peters Diabetes & Endocrine Care (part of St. Peter's Heath Partners). Each agency was given a list of priority populations that have a high incidence of health disparity related to their low socio-economic status and /or high percentage of minority demographics. Each agency developed a strategy to recruit in these neighborhoods and to address the challenges identified in the focus groups. In particular, class locations were selected within the priority populations to minimize transportation issues. Classes were offered at varied times to increase the possibility of attendance among different groups i.e. retirees, unemployed, employed with various work schedules. A variety of incentives were offered that included tools for implementing healthy changes including workbooks to track nutritional intake and physical activity, tools for measuring and weighing food, and in some cases produce coupons to purchase fresh fruits and vegetables. ACDOH determined that there were an insufficient number of NDPP lifestyle coaches available to meet the increasing need for NDPPs. In 2018, two NDPP lifestyle coach certification classes were sponsored by ACDOH ($600 instructor charge/class, $140 NDPP workbook/participant, room and light refreshment charges funded though LI and ACDOH) to train 32 lifestyle coaches linked to NDPP provider agencies. Five additional NDPP provider agencies were identified through this effort. 4. Implementing Mutually Reinforcing Strategies – Using Multi-Directional Referral Systems Primary Care Practices Prediabetes and HTN registries (i.e identify both undiagnosed HTN, uncontrolled HTN, and newly controlled HTN) are generated by the PCP and then prioritized based on incidence of co-morbidity, experiencing SDH, severity, and next scheduled visit. The provider assesses the need for enrolling the patient into the NDPP or Y-BPMP as well as for CHW support and submits the referral as applicable. St. Peter's Diabetes and Endocrinology Care (NDPP provider) worked closely with one practice to generate prediabetes registries for NDPPs that they were providing at that PCP location. Community Outreach During outreach and presentation events, CHWs will refer patients that self-disclose or identify as at risk for prediabetes or high blood pressure to PCPs as needed and/or to NDPP or Y-BPMP as applicable. Additionally, the CHWs contact patients identified as potential NDPP and Y-BPMP participants by their PCP to facilitate enrollment. NDPP providers also offer opportunities for self-enrollment into programs and refer participants to CHWs and PCPs as needed. Golub Corporation is a regional supermarket with in-store pharmacies and a pharmacy on-site at a local federally qualified health center, Whitney M. Young Jr. Health Center (WMY). The pharmacy team developed a hypertension protocol with the WMY health care team and ACDOH to engage pharmacists in supporting hypertensive patients. Community pharmacists trained to provide HTN interventions also refer patients to CHWs as needed and provide feedback to PCPs regarding the patient's progress. 5. Implementing Mutually Reinforcing Strategies – Leveraging Community Clinical Linkages i.e. CHWs CHWs increase awareness about the risk of prediabetes and high blood pressure, available PCPs for follow-up and self-management programs. Through these efforts, some residents will enlist the support of the CHW to assist them with navigating resources to better manage their chronic disease. CHWs help promote self-efficacy with clients by providing guidance on health coaching (i.e. nutrition, physical activity), medication adherence; self-management of blood pressure, prediabetes, and diabetes; high blood pressure and prediabetes risk, tobacco cessation, and other healthy behaviors including mental health/social support and patient navigation services (i.e. addressing housing, transportation, etc.). The CHWs utilize motivational interviewing with all their clients to help them adjust and/or maintain action plans that support their healthy behavior changes. In particular, NDPP participants will have a CHW embedded in the class to promote trust. CHWs contact the participants two days before each class to remind them about the upcoming class, address any challenges with attending the class, review progress on their action plan from the previous class, and utilize motivational interviewing to maintain implementation of their action plan. During the NDPP class, the CHWs serve as peer mentors by assisting the lifestyle coach and developing relationships with the participants. They have maintained engagement with PCPs, pharmacists, NDPPs, and Y-BPMP by implementing the following strategies: · Address transportation issues through the provision of bus passes as needed. · Provide accountability through scheduled contacts via phone, home or provider visits. These very individualized contacts give the CHW an additional opportunity to provide nutrition and physical activity information that is relevant to that participant and complements the physician care plan and self-management classwork. · Assist with the navigation of challenges associated with implementing and maintaining healthy behavior changes. This includes addressing access to healthy food, encouraging physical activity by identifying places to walk and participate in no-cost or low-cost recreational activities, and helping them identify physical activity partners. · Help them work through unplanned crisis by linking them to community resources as needed. This has included identifying resources for clothing for their family, mental health services for family members, housing, the provision of basic household goods (i.e. furniture, pots and pans, etc.), and childcare. 5. Ongoing Evaluation and Communication about Metrics and Performance Management Monthly conference calls were initially hosted by the ACDOH to facilitate communication about program challenges and successes, promote development of relationships between community partners, and to implement changes as needed through PDSA cycles (Plan Do Study Act). These calls allowed partners to shift resources and efforts to improve outcomes with identified clients. Overtime, the relationships between partners grew stronger and partners starting reaching out to each other more directly. The success of this project is attributed to the collaboration with community partners in the planning, implementation, and evaluation of the project. RESOURCES: 1. Diabetes Prevention Program Research Group, Knowler WC, Fowler SE, et al. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet. 2009;374(9702):1677-86. 2. Shah BR, Thomas KL, Elliot-Bynum S, et al. Check It, Change It. Circulation: Cardiovascular Quality and Outcomes. 2013;6(6):741-748. doi:10.1161/circoutcomes.113.000148.
The Collective Impact model provides a successful framework for implementing an innovative approach to delivering evidence-based interventions while addressing health equity issues. Albany County Department of Health (ACDOH) attributes success in this multi-strategic initiative to partnering with community agencies that have aligned values and goals; a joint commitment to collecting and evaluating metrics and performance management; applying mutually reinforcing strategies that foster shared use of resources, skills and expertise; and maintaining ongoing communication about challenges, successes and each agency's role in the program. ACDOH's goal is to annually launch multiple National Diabetes Prevention Programs (NDPP) serving our priority population (i.e. those residents in neighborhoods experiencing a high prevalence of cardiovascular disease, diabetes and obesity as well as adverse social determinants of health); maintain a rolling enrollment of the YMCA Blood Pressure Management Program (Y-BPMP); engage community pharmacists to implement interventions that promote self-management of uncontrolled hypertension (HTN); and to link patients experiencing adverse social determinants of health (SDH) with CHWs. 1. NDPP Initiative Objectives and Results: Enroll 20-30 individuals of the priority populations and to achieve a 50% completion rate defined as attending 9 of the 16 NDPP core classes 15 NDPPs launched June 2016 to September 2018 192 residents enrolled predominately of the priority population 106 completers (i.e. completed 9 of 16 core classes, excludes 36 participants currently in core phase); 67.9% completion rate (106 completers/156 enrolled) Data was provided to ACDOH by NDPP providers via reports collected 1 month into NDPP, at the end of the core curriculum phase and then at the end of the maintenance phase. It was noted that completion rates dropped when CHW engagement was less related to staff transition and NDPP lifestyle coach not understanding the role of the CHW. Subsequently, a meeting was held with the NDPP lifestyle coach, CHW, and program administrators to clarify roles and benefits to participants. Since this meeting, CHW and lifestyle coach have been working more effectively to support participants. In 2018, ACDOH recognized capacity limitations with current NDPP provider agencies and shifted the focus from launching additional NDPPs to building up program capacity by sponsoring 2 trainings that trained 32 lifestyle coaches. Four additional NDPP providers have shared their intent to deliver programs in 2019. Work will continue to build the case for NDPP coverage by providers and to support NDPP providers in achieving DPRP and Medicare Diabetes Prevention Program status. 2. Hypertension Initiative Objectives and Results: Build capacity for delivering Y-BPMP 5 new Healthy Heart Ambassadors trained 5 PCPs engaged to use HTN registries to refer patients to Y-BPMP Enroll 45 individuals into Y-BPMP 31 enrollees between September 2017 to November 2018 Engage community pharmacists to implement HTN interventions with 60 patients 2 community pharmacists engaged at FQHC 4 additional community pharmacy sites at local supermarkets engaged 54 patients received HTN interventions provided by community pharmacists (40 FQHC from January 2017 to November 2018; 14 community supermarket from September 2018 to November 2018) Data for the Y-BPMP was provided by the Y-BPMP provider. Enrollment in 2018 was lower than expected related to workflow challenges with PCPs. ACDOH continues to work with PCPs to increase understanding of the program and engaging CHWs to link patients with newly controlled HTN to the program. Data for the community pharmacist intervention is collected by intervention logs completed by the pharmacists and submitted to the pharmacy supervisor. FQHC patient enrollment in 2018 was lower than expected related to staff transition at the FQHC that affected the referral work flow. ACDOH also recognizes the limitation of engaging just one location (i.e. FQHC) and approached Golub Corporation about developing a community-wide intervention to pilot in the last quarter of 2018. Enrollment and intervention results (i.e. medication adherence, achieving controlled HTN) will be tracked. Case studies provided by the pharmacy demonstrated success in helping patients with uncontrolled hypertension obtain control over a period of a few months. 3. CHW Engagement Objectives and Results: Engaging CHWs to support patients diagnosed with prediabetes, diabetes and hypertension and experiencing adverse social determinants of health 2.5 FTE chronic disease CHWs employed by ACDOH (April 2014 to current) In 2018, 772 residents engaged with CHWs: 268 residents received CHW support to manage their prediabetes and/or HTN; 504 residents participated in community presentations provided by ACDOH CHWs ACDOH collects CHW data internally via reporting worksheets completed by the CHW and submitted to the CHW supervisor. In 2019, ACDOH will pilot measuring the qualitative impact of the CHW interventions. The number of contacts does not reflect the time and effort a CHW will spend working with more complex patients i.e. those needing more support during times of crisis and/or transition. CHW clients are identified from PCP referrals, pharmacist referrals, Y-BPMP referrals, and through CHW outreach at NDPPs and community events. The CI approach has a synergistic impact on the community as each agency's resources, expertise, and skills are leveraged to implement EBIs designed to reach those experiencing adverse social determinants of health. Open communication about the evaluation metrics and performance management is essential to making timely changes that directly impact the success of the program i.e. the positive health outcomes of the patients.
The Albany County Department of Health developed this practice around the Four Pillars of National Diabetes Prevention Program (NDPP)” identified by the CDC as being essential for scaling and sustaining the NDPP and applied it to the Y-BPMP. Additionally, it used the collective impact model to successfully engage partners in a shared vision with shared accountability. The four pillars include: Increasing awareness about the chronic disease; Awareness of prediabetes and hypertension was addressed at both the community and clinical level. ACDOH launched community-wide prediabetes and hypertension campaigns targeted to reach the priority populations. CHWs of the health department work directly with the priority populations to increase general community awareness of hypertension, prediabetes and to deliver prediabetes risk assessment tools to individuals. Additionally, ACDOH increases awareness among PCPs and community-based organizations through its participation on chronic disease and equity coalitions in addition to providing technical assistance to select PCPs. Increasing clinical screening, testing, and referral to evidence-based lifestyle change programs; ACDOH has provided technical assistance and guidance to NDPP and Y-BPMP providers as well as to primary care practices that serve the priority population. This has led to an increase diagnosis of prediabetes and utilization of prediabetes and HTN registries to identify patients for self-management programs and CHW support. While the work in developing and implementing health system changes that include referral and feedback workflows is time consuming, the impact is long-lasting as PCPs and lifestyle change programs develop sustainable and effective protocols that efficiently and consistently identify patients that will benefit links to clinical and community resources. Increasing the availability of and enrollment in evidence-based lifestyle change programs; ACDOH has helped foster partnerships between PCPs serving the priority populations and community based organizations providing NDPP and Y-BPMP. This has led to additional self-management programs being strategically placed and scheduled to serve the needs of these residents. Innovative locations include churches, retail sites, and primary care practices located in the neighborhoods of priority populations. This increase availability and referral by clinical providers has positively impacted the enrollment of these programs and has identified the need to train additional program facilitators i.e. NDPP lifestyle coaches, Y-BPMP healthy heart ambassadors. ACDOH trained 32 NDPP lifestyle coaches and 5 healthy heart ambassadors to build the capacity to deliver NDPPs and Y-BPMP. Providing coverage and payment for lifestyle change programs to all eligible populations. Programming during this project has been offered free of charge to participants through ACDOH's funding as a subawardee for the NYSDOH Local IMPACT program and through its award with the Rubin Community Health Fund. ACDOH continues to work with NDPP and Y-BPMP providers to identify creative ways to offset programing costs for priority populations. The NDPP providers currently contracting with ACDOH are each in various stages of achieving DPRP status which will be the first step towards achieving Medicare Diabetes Prevention Program (MDPP) status. MDPP status will allow these agencies to receive Medicare reimbursement. ACDOH has also partnered with a local insurance payor to develop a return on investment (ROI) case for self-insured employers to provide NDPP coverage. Conversations with payors to evaluate the ROI for self-insured employers for Y-BPMP coverage are beginning to take place. The community pharmacist program is evaluating the ROI on this piloted work to determine the feasibility of expanding this program to other locations. By addressing these four pillars through these collaborative and innovative approaches, the Albany County Department of Health is building a foundation to sustain the implementation of the programs. The shared vision, shared accountability, shared resources and open communication of community partners involved in this program strengthens the relationships between partners and thus, generates ongoing support for this practice.
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