REACH U.S. SEA-CEED
Charleston and Georgetown
Diabetes Coalition and the
Legacy Projects:
A Community-Academic
Partnership for Decreasing
Diabetes Disparities
The REACH Team and Community Partners
Your Questions related to:
• Impact of social supports on health of
our community
• How supports change our community’s
social determinants of health
• Implications of these changes for
prevention, treatment, and recovery of
people with behavioral health problems
“Everyone has the right to a standard of
living adequate for the health and well
being of himself and his family, including
food, clothing, housing and medical care.”
Universal Declaration of Human Rights 1948
From Meredith Minkler, DrPH
University of California, Berkeley
Diabetes Initiative of South
Carolina
• In 1994, the South Carolina Code of
Laws established the Diabetes Initiative
of South Carolina
(Note: Data supported Policy Change)
Diabetes Initiative
Board
Med. Univ. of SC
Center of Excellence
Council
Outreach Council
Surveillance Council
MUSC Diabetes
Center of Excellence
ADA-SC Outreach
Program
DHEC Diabetes
Prevention and
Control Program
USC School of
Medicine Department
of Family/Preventive
Medicine
REACH
And
23 Other Community
Coalition
Carolinas Center for
Medical Excellence
Other Programs
• Enterprise Neighborhood Health Program
with goal to recruit and train Community
Health Advocates and conduct needs
assessment. (1994–1998)
• Healthy SC- Hypertension and Diabetes
Management and Education—HAD-ME
with goal to improve health. (1997-2001)
Enterprise Health Center
1995 - 2001
Donation of Lot
Building Completed
Opened November 2001
Now a FQHC site(FCFFHC)
Student Involvement and Service Learning
>700 students (MUSC, Clemson, UNC
Howard, SCSU, USC, Rhode Island)
9 Doctoral Candidates/Graduates
10 Certified Diabetes Educators
7 doctoral dissertations
5 masters thesis
32 regional or national
presentations
35+ peer-reviewed
publications
REACH U.S.
Charleston And
Georgetown
Diabetes Coalition
Goal: Decrease
Disparities for
African Americans
with Diabetes
1999-2012
Arlene Case-The Lesson
REACH U.S Centers of Excellence for Eliminating Disparities (CEED)
University of Colorado
at Denver and
Health Sciences Center,
CO, AZ, NM, SC, WA, AK
The
University
of
Illinois
at Chicago,
IL
NYU
School
of Medicine,
NY
Genesee County
Health Department,
MI, WI, IL, MN, IN, OH
The Mount
Sinai School
of Medicine, NY
Greater Lawrence
Family Health
Center, MA, Six
New England States
Institute
for
Urban Family
Health, NY
Boston Public Health
Commission, MA
Khmer Health
Advocates, Inc,
CT, MA, IL, CA, OR, FL
Public Health
Institute, CA
The Regents of
the University of
California, CA
Medical University of South Carolina
SC, GA, NC
Orange County Asian
and Pacific Islander
Community
Alliance, CA
Morehouse School of Medicine,
GA, NC, SC
University of Alabama
at Birmingham,
AL, AK, KY,
LA, MS, TN
Hidalgo
Medical
Services, NM
CEED Communities
Oklahoma State
n = 18
Department of Health, OK
University of Hawaii
HI, American Samoa, North Mariana Islands, Guam
Micronesia, Palau, Marshal Islands
REACH Communities
Racial/ethnic groups
include:
• African Americans
• American Indians &
Alaska natives
• Asian Americans
• Hispanics/Latinos
• Native Hawaiians/Pacific
Islanders
Health Disparities are
focused on:
•
•
•
•
•
•
CVD
Diabetes
Infant Mortality
Breast & Cervical Cancer
AIDs/HIV
Adult Immunizations
REACH: Charleston and Georgetown
Diabetes Coalition
Tennessee
North Carolina
SC DHEC
Region 6
South Carolina
County
Library
Statewide REACH home-based
in Columbia:
 Communicare
 SC DHEC
 SC DPCP
Carolina Center for Medical Excellence
Georgetown
Diabetes
CORE Group
East Cooper
Community
Outreach
Enterprise Health
Center
Enterprise Community
Georgia
Georgetown
S. Santee
St. James
Senior Center
Tri County
Black
Nurses
St. James
Santee Health
Center
Trident Urban
League
Trident United
Way
Alpha Kappa
Alpha Sorority
SC DHEC
Region 7
Charleston
County
Library
Greater
St. Peters
Charleston
Diabetes
Coalition
Franklin C. Fetter
Family
Health Center
MUSC
MUHA
Diabetes Initiative
College of Nursing
Disparities for African Americans with
Diabetes in Charleston and Georgetown
• Lower levels of:
• Higher levels of:
– Per capita income and
education
– Access to health care
– Funding and insurance
– Care and education
– Satisfaction with care*
– Medications and
continuing care
– Treatment
– Trust in health systems*
– Poverty
– Prevalence of diabetes
– Complications including:
• Amputations
• Renal failure (dialysis)
• CVD
–
–
–
–
EMS and ED use
Hospitalizations
Costs of care paid by client*
Deaths, especially CVD
*All disparities were first identified through focus groups and validated
with epidemiological or quantitative data except those with asterisk.
For those with asterisk, quantitative data showed difference in outcome.
Centers for Disease
Control and Prevention
REACH US CEED
MUSC College of Nursing
Regional and National Networks
National African American Networks
Southeastern Region of
American Diabetes Association
Carolinas and Georgia Chapter off
American Society of HTN
National and Regional Network of Libraries of Medicine
Stroke Belt Counties
in Georgia, SC, NC
(Expanded to include all SE States)
Diabetes Initiative of South Carolina
South Carolina DHEC
Diabetes Prevention and Control Program
Medical University of South Carolina
Center for Health Care Disparities
South Carolina State Library
Alpha Kappa Alpha Sorority
Black Nurses Association (Professional Organization)
Urban League
Baptist Association and COOLJC
Statewide Institutions
Diabetes Initiative of South Carolina
College of Nursing
REACH US
Charleston and Georgetown
Diabetes Coalition
Community Systems and Policy Change
Health Systems Change
Our Coalition Goals
• Improve diabetes care and education in 5 health
systems for >13,000 African Americans with
diabetes.
• Improve access to diabetes care and selfmanagement education, diabetes supplies and
social services for people with diagnosed
diabetes.
• Decrease health disparities for African Americans
at risk and with diabetes.
• Increase community ownership and sustainability
of program.
Methods for Collaboration
The health professionals/scientists determine
“science” or “evidence-base” for diabetes care.
Community leaders/members/CHA determine
“what, when, where, and how” to apply
“science” or “evidence” in their community
while generating evidence for community
empowerment.
Together we translate into skills for individual,
organizational, and community behavior
change, advocacy, and policy change and we
evaluate/report our results.
Community Actions

Community-driven activities and creating
healthy learning environments where people
live, worship, work, play, and seek health care.

Evidence-based health systems change using
continuous quality improvement teams (CQI).

Coalition power built through collaboration,
trust, and sound business planning and
focused on systems, community, and policy
change and sustainability.
Bio-Psycho-Social
Management of Diabetes
•
•
•
•
•
•
•
Healthy Eating
Being Active
Monitoring
Taking Medications
Problem Solving
Reducing Risks
Healthy Coping
• Self Management
• Family Management
• Medical Health Care
Management
• Community
Management
• More………..
Approaches
• Individual behavior change &
lifestyle modification
• Environmental restructuring
• Social ecological approach
Our Community Systems Wheel
Faith
Based
E.T. Anderson and J.M. McFarlane (2006)
CDC Social Determinants of Health
•
•
•
•
•
•
•
Socioeconomic status
Education
Employment
Transportation
Housing
Access to services
Discrimination by social grouping
(e.g., race, gender, or class)
• Social or environmental stressors
• Urban-rural environments
http://www.cdc.gov/dhdsp/library/maps/social_determinants.htm
The Community Chronic Care Conceptual Model
REACH Charleston and Georgetown Diabetes Coalition
(Jenkins, Pope, Magwood et al., PCHP 4 (1): 73)
Evaluation Logic Model
External Influences
Existing Activities
Understanding Context,
Causes, & Solutions
for Health Disparity
Coalition
Community
Action Plan
Targeted REACH
Action
Community &
Systems
Change
Change Agents
Change
Planning &
Capacity Building
Widespread Change
in Risk/Protective
Behaviors
Other
Outcomes
Reduced Health
Disparity
REACH Charleston
And Georgetown
Diabetes
Coalition’s Efforts
to Decrease
Diabetes-Related
Amputations
Specific Aims
• Improve foot care for African Americans
with diabetes.
• Eliminate disparities in number of
amputations for African Americans with
diabetes.
Interventions
• Community skill-building & neighborhood clinics
– 175 lay educators trained
– Diabetes Self Management & Foot Care education
– Wise Women & Wise Men helping each other
• Community health professional training
– > 90% of health professionals in 5 systems attended
update on diabetes care
– 225 RNs completed advanced foot/wound education
– 27 physicians completed foot care education
• Outreach by professional & lay educators/navigators (CHAs)
– 30 minute TV program aired 34 times on cable
– Library program/Internet use
– Weekly diabetes management groups in 10 sites
– Navigation for diabetes care, supplies & social services
• Health systems change
– Registry & reminder system
– CQI teams with chart audit & feedback
• Coalition building, sustainability (501c3), & policy change
Check Yourself to Protect Yourself
Take Care of Our Feet
A Lesson Plan, Kit of Materials, and
Slide Series/Flip Chart for Lay Leaders
REACH Charleston & Georgetown Counties Diabetes Coalition
Ezekiel 37:10 “So I prophesied as he commanded me, and the breath came into
them, and they lived, and stood up upon their feet, an exceeding great host.”
Lesson Objectives
After the lesson, participants will be able to demonstrate:
•
•
•
•
•
•
•
•
Taking care of feet
Cutting nails to prevent foot problems.
Selecting appropriate footwear.
Checking feet each day to identify early signs of foot
problems.
Using the monofilament to check for loss of feeling in feet.
When and how to notify health provider.
Asking the health care provider for foot exam.
Methods for prevention of foot problems.
Testing for Loss of Feeling
Method for testing
with Monofilament
Sites for testing with
Monofilament
Bottom
of Feet
Check each
of these sites
3 times
>6,000 monofilaments were distributed to
professionals and people with diabetes.
A Book on
Diabetes
Care and
Management
&
Patient-Held
Mini-Record
(available on website)
Working
effectively with
communities
moves the
science from
Bench to
Bedside to
Countryside
more rapidly.
Community and Media
Activities reached >125,000
African Americans
Neighborhood Walk and Talk
Groups
Skill-Building for
CHAs and Volunteers
Community
Screening and
Education
Individual/
Group
Education
> 3 sessions =
3.2% drop in
A1c
Photos used with permission of clients and partners
Georgetown County Diabetes
Core Activities
Physical Activity
Health
Screenings
Walk-A-Thon
Educational
Classes
Healthy Cooking
Dinner Theater
Gardening Class
Gardening
REACH at the
Library
Cybermobile
Equipped with 6
Internet laptop
computers
Diabetes at the Library
Recognition
and
Rewards
Womanless Wedding
Men’s Talk
Talk about Diabetes & Foot Care
Media
Results
% Change in Diabetes Care
for African Americans
•
•
•
•
•
•
2000 2007 2012
A1C Testing
76.8 97.1
Blood Pressure <130/80 24
38
Lipid Testing
47.3 87.2
Eye Exam
34
76
Feet Exam
64
97.3
Kidney Tests
13.4
56
Charleston and Georgetown Counties
LEA Rate per 1000 DM Hospitalizations
Data Source: SC Hospital Discharge Data, Office of Research and Statistics
Prepared by SCDHEC Office of Epidemiology and Evaluation updated 03/12
Preliminary Estimated Outcomes for
Reduction in Diabetes LEAs in African
Americans in 2 Counties
• Improved QOL for person whose legs were saved.
• Cost savings:
– Costs per amputation in Georgetown County =
$54,736 in 2008
– Costs per amputation in Charleston County =
$42,783 in 2008
– Reduction in amputations compared to 1999 =
44% in African Americans
– Cost savings of >$2 million/year in 2008.
Note: release for photo
5 Step Community Action Model
Hennessey, S. et al. (2005). The
Community Action Model: American
Journal of Public Health, 95, 611-616.
Lessons from the Community
#1 “We want to know how much
you care before we care how
much you know.
#2 Academic-community partnerships are
build on TRUST, RELATIONSHIPS, and community
needs.
•Go to the community.
•Work collaboratively to identify priorities (CHA).
•Listen carefully, communicate clearly.
•Interventions can be creative---but never
underestimate the power of community members.
•Balance the “problem” with strong emphasis on
assets and collaborative problem solving.
#3 Embrace CHANGE
• Start with easily accomplished steps to facilitate
success and provide feedback related to
progress.
• Share community successes from other
communities to illustrate methods.
• Community-wide change often comes slowly, so
provide ongoing encouragement.
• Community members may need to move to other
community priorities.
#4 Community and Academic
“Champions” are needed as facilitators.
•Examine promotion and tenure criteria and
include scholarly community engagement
activities.
•Fund community members and include fringe
benefits!
•Do NOT underestimate the power or
knowledge of person who lacks a formal
education.
#5 Practice Cultural Empowerment!
•Ask the participant about preferred way of
addressing individual, group or health issue.
•Find a trusted community member to guide and
educate the researcher.
•Although cultural competence is important, it is often
used to “stereotype” so appreciate
diversity and
nuances of all.
•Empower participant and community
to celebrate history and culture.
Thank you to all community residents with diabetes,
community leaders, and our partners who have
worked to eliminate diabetes disparities:
•
•
•
•
•
•
Charleston Diabetes Coalition
AKA Sorority (N. Charleston)
Greater St. Peter’s Church
Diabetes Initiative of SC
East Cooper Community Outreach
Franklin C. Fetter Family Health
Centers
• MUSC College of Medicine
• MUSC College of Nursing
• Georgetown Diabetes CORE
Group
• MUSC Library
• SC DHEC Diabetes Prevention
and Control Program and
Epidemiology
• SC DHEC Region 7 and 8
• St James-Santee Family Health
Center
• Tri-County Black Nurses
Association
• Trident United Way 211 Help Line
• Trident Urban League
Acknowledgements
This project is funded by the REACH Charleston and
Georgetown Diabetes Coalition CDC Grant/Cooperative
Agreements U50/CCU422184 and 1U58DP001015 from
the Centers for Disease Control and Prevention.
Additional grant funding to document disparities
related to ED and Hospitalizations from
NIH NINR 1 R15 NR009486-01A1
The contents are solely the responsibility of the author
and community partners and do not necessarily reflect
the official views of the funding agencies.
Thank you to all community residents with diabetes,
community leaders, and our partners who have
worked to eliminate diabetes disparities:
•
•
•
•
•
•
Charleston Diabetes Coalition
AKA Sorority (N. Charleston)
Greater St. Peter’s Church
Diabetes Initiative of SC
East Cooper Community Outreach
Franklin C. Fetter Family Health
Centers
• MUSC College of Medicine
• MUSC College of Nursing
• Georgetown Diabetes CORE
Group
• MUSC Library
• SC DHEC Diabetes Prevention
and Control Program and
Epidemiology
• SC DHEC Region 7 and 8
• St James-Santee Family Health
Center
• Tri-County Black Nurses
Association
• Trident United Way 211 Help Line
• Trident Urban League
Although studies documenting disparities are not in short supply, findings about what works to
reduce disparities are. A 3-year, $6-million program called Finding Answers: Disparities
Research for Change, sponsored by the Robert Wood Johnson Foundation, seeks to identify
effective interventions to eliminate disparities.
Under the direction of Marshall Chin, MD, MPH, an associate professor of medicine at the
University of Chicago Pritzker School of Medicine, the program reviewed more than 200 journal
articles on disparity reduction interventions in cardiovascular disease, depression, diabetes, and
breast cancer. The results appeared in October 2007 in a supplement to Medical Care
Research and Review.
One of the few studies in the review that showed a reduction in racial disparities was part of the
Racial and Ethnic Approaches to Community Health (REACH 2010) program, sponsored by the
US Centers for Disease Control and Prevention in Atlanta, Ga. The demonstration program,
which took place in Charleston and Georgetown counties in South Carolina, brought together
28 community partners, from health professionals to college sororities and local media, that set
goals to improve diabetes care for blacks as well as eliminate health care disparities between
black and white patients with diabetes.
The partners documented disparities in care for 12,000 black patients with diabetes in the 2county community. The intervention included such community activities as health fairs, support
groups, grocery store tours, community clinics, and church-based educational programs. After
24 months, the partners audited medical charts for 158 black patients and 112 patients who
were white or of other racial or ethnic groups. They found that differences between black and
white patients in rates of hemoglobin A1c testing, lipid and kidney testing, eye examinations,
and blood pressure control that had ranged from 11% to 28% at baseline had been eliminated
(Jenkins C et al. Public Health Rep. 2004;119[3]:322-330).
Chin is optimistic that other communities will develop their own, similar
programs in the future. "There are a lot of promising models," he says.
"But you may have to revise as you go along, just like in patient care."
Quote from R. Voelker in JAMA 2008;299(12):1411-1413.
For additional information
Carolyn Jenkins, DrPH
e-mail: jenkinsc@musc.edu
Phone: 843-792-4625