Presenters: Sarah Clarke, Sherri Bryant Moore
and Diane Hill Taylor
“On the Road” Diabetes Program:
The Benefits of a Community Partnership Model
PRESENTERS
Sarah Clarke
Sr. Director, Physician Integration
Doctors Community Hospital
Sherri Bryant Moore
Development Officer
Doctors Community Hospital Foundation
Diane Hill Taylor
Associate Director, Health & Wellness Division
Prince George’s County Health Department
For “ On the Road” Program Information: Call 301- 883-3545
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DCH MISSION & VISION
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DCH MISSION & VISION
Mission:
• To provide quality healthcare to all residents of Prince
George’s County, Maryland
• Mission Statement: “Dedicated to Caring for your Health”
• DCH Vision Statement: Continuously strive for excellence in
service and clinical quality to distinguish DCH with our patients
and other customers.
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DCH MISSION & VISION
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Founded in 1975
219 Licensed Beds
1,516 Employees
503 Medical Staff
51,797 Emergency Room Visits
10,857 Total Admissions
11,509 surgical Services
$136,214 Total Inpatient Revenue
$76,993,369 Total Outpatient Revenue
$213,207,813 Total Inpatient and Outpatient Revenue
*Fiscal Year 2013
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DCH OVERVIEW CONTINUED
Comprehensive Services include:
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Joslin Diabetes Center- the only accredited diabetes center in the
county
Bariatric and Weight Loss Center
Center for Comprehensive Breast Care
Sleep Center
Lymphedema Center
Surgical Services
Additional Services Include:
Cardiology Services and Outpatient Vascular Studies
Center for Ear, Nose & Throat
Center for Wound Healing and Hyperbaric Medicine
Comprehensive Orthopedic Services
Doctors Regional Cancer Center
Emergency Services
Imaging Services
Infusion Center
Joint and Spine Center
Magnolia Gardens Nursing Home
Metropolitan Medical Specialists
Outpatient Rehabilitation Services
Spine Team Maryland
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COMMUNITY BENEFITS SERVICE AREAS (CBSA)
Zip Codes
• Lanham, Maryland 20706
• Hyattsville, Maryland 20781
• Cheverly, Maryland 20784
• Landover, Maryland 20785
• Greenbelt, Maryland 20770
• Capitol Heights, Maryland 20743
• Kettering, Maryland 20774
• Bowie, Maryland 20721
• Riverdale, Maryland 20737
• District Heights, Maryland 20747
Demographics:
• Our CBSA has an average household income of $70,114. The population is 63%
African American, 15.2% Latino, 4.3% Asian, 17.5% other nationalities.
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COMMUNITY BENEFITS BASED ON IDENTIFIED NEEDS AND DCH INITIATIVES
Identified Needs
Overweight/ Obesity, Nutrition and Exercise
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DCH’s Bariatric and Weight Loss Center provides free
seminars to educate participants about weight loss
options including nutrition, exercise and surgery.
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Our Joslin Diabetes Center provides free nutrition
seminars at various health fairs and conferences.
Diabetes
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Joslin Diabetes Center in partnership with the Prince
George’s County Health Department have launched its
“On the Road Diabetes Program,” that provides in-depth
education and free diabetes screenings to all county
residents.
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In an effort to increase program participation and expand
reach, plans for an on line component has been added.
Cardiovascular Disease and Related Risk Factors
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DCH provided three to five carotid artery screenings at
various events throughout the county.
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RESULTS
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In FY ‘13 we provided
1,972 screenings for
blood pressure and
cholesterol.
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We had 2,624
encounters through
Educational Outreach .
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The total financial
commitment by DCH
through Community
Benefits was $20,
959,892.
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NEW INITIATIVES WITH PGCHD FOR
FY2015
Mobile Health Clinic
In partnership with the Prince George’s County Health Department and Wal-Mart, DCH will
launch a mobile health clinic in the fall of 2014.
Targeted Health Concerns
A Community Health Assessment survey was distributed among the community members, faith-based
organizations, business leaders as well as current patients and their families. More than 500 surveys
were returned and based on these survey results as well as the DCH admission/re-admission data,
the chart below indicates the types of services the mobile clinic will provide.
Hospital Admission/Re-admission Data
Renal Failure
Chronic Obstructive Pulmonary Disease (COPD)
or Asthma in Older Adults
Congestive Heart Failure (CHF)
Diabetes
Hypertension
Services provided by mobile clinic
Diabetes
Hypertension
Breast Cancer
Obesity
Heart Disease
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PRINCE GEORGE’S COUNTY
MARYLAND HEALTH DEPARTMENT
Public health agency with the overall mission to protect and
improve the health of the community.
PGCHD supports public health efforts to reduce chronic
diseases and promotes healthier lifestyles by improving:
• Health Education
• Health Outreach
• Access to Quality Health Care Systems in
the County
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THE BURDEN OF DIABETES
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Diabetes is one of the five most prevalent chronic
conditions in Prince George's County (University of
Maryland School of Public Health; A Public Health Impact
Study, 2012).
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Eleven percent (11%) of the 863,420 residents of Prince
Georges County is diabetic. An additional 1.5% were told by
a doctor they had pre-diabetes or borderline diabetes (2011
(Maryland BRFSS; URL of Sourcehttp://www.marylandbrfss.org).
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The 2011 Maryland Vital Statistics Report indicates that
Prince George’s County had the highest number of
diabetes deaths in the state of Maryland (192).
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Diabetes was the sixth leading cause of death in 2011 with
an age-adjusted mortality rate of 20.8 per 100,000 people.
This was a 5% increase from 19.8 per 100,000 people in
2010 (Maryland Annual Vital Statistics Report, 2011).
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NEED FOR PREVENTIVE CARE OUTREACH
Preventive Care
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ADDRESSING HEALTH DISPARITIES
Building, Developing and Maintaining
Successful Partnerships
“With diabetes being such a major
issue in Prince George’s County,
the hospital’s Joslin Diabetes
Center, in collaboration with the
Health Department, furthers our
joint commitment to not only treat,
but to also educate the community
about this disease.”
Paul Grenaldo
EVP/COO (DCH)
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ADDRESSING HEALTH DISPARITIES
Building, Developing and Maintaining
Successful Partnerships
“We are thrilled to partner with the
renowned Joslin Diabetes Center at
DCH to serve our residents where
they live, work and play. This
community based approach will
bring diabetes education directly to
the residents that are impacted the
most.”
Pamela B. Creekmur
Health Officer
(PGCHD)
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“ON THE ROAD” PARTNERSHIP
The success of “On the
Road” is contributed to:
• Collaborative partnership with
a hospital
• Evidence based curriculum
adapted for community setting
• Integration of CHW’s who
provide care coordination
• Community partners
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“ON THE ROAD" START UP
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“On the Road” was not grant funded at
its inception.
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Partners had several pre-planning
meetings to identify organizational and
community resources as follows:
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Utilized current CDE, CHW, and Community
Developer staff to implement program
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Hospital assumed A1c lab testing costs, by
negotiating a reduced vendor fee contract
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Met with community partners to secure
commitments for class meeting space at a
minimum of 2 classes per location
(initial/follow-up) at no cost
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Sought and secured program incentives
(grocery store vouchers/cookbooks, etc.)
donated by grocery chains/pharmaceutical
companies
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“ON THE ROAD” OUTREACH
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Travels to diverse communities
throughout the county
Delivers basic diabetes self-care
knowledge in easy-to-understand
discussion format
Targets participants who are
diagnosed diabetics, including
caregivers and pre-diabetics
Classes conducted by certified
diabetes educators from the DCH
Joslin Affiliate
Community Health
Workers/Developers (CHWs/CDs)
from the PGCHD provide follow-up
care coordination
Elements of the class are provided at
health fairs and conferences to
expand reach of program
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“ON THE ROAD” CLASS FORMAT
The two hour initial classes cover a number of topics including:
 What is Diabetes?
 Healthy Eating
 Importance of Physical Activity
 Understanding Your Numbers
*Class also includes a brief exercise demonstration including free
exercise bands and pedometers to promote exercise activities
outside of class.
 Includes A1C test
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LINK TO CARE AND SUPPORT
Take home information packets are distributed to participants at the
initial class including:
 Information on Federally Qualified Health Centers (FQHC’s) in case
a participant does not have a primary care provider
 Services of Joslin Center (free support group meetings, medical and
diabetes education services)
 Related services and resources provided by PGCHD
 A copy of the class power point presentation
 Fact sheets and educational materials about diabetes.
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“ON THE ROAD” FOLLOW-UP CLASS
The two hour follow-up class (2-3
months) consists of the following:
 Participant discussion of skills
learned, changes made and/or
challenges
 Curriculum review using
interactive Diabetes Jeopardy
game
 Incentives such as healthy food
gift cards and cookbooks for
active participation
 Certificate of Completion
 A1C test
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“ON THE ROAD” RESULTS
Status update for April 2013-April 2014
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Conducted eight (8) initial classes with follow-up
sessions
A total of 162 class #1 attendees (~20 per class)
A total of 99 class #2 attendees (~12 per class)
There were 23 participants that attended both the
initial and follow-up class sessions, with both pre
and post A1c tests
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The average A1c of this group was 7.3 at the initial
class and 6.7 at the follow-up class held up to 3
months later
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As of April 2014, 83% of this pre/post group (23) who
initially tested with A1c levels of 9-12 (uncontrolled
diabetes) saw a reduction of one to five points, some
even returning to an A1c of less than 7
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Pre and post education surveys showed a 10%
increase in knowledge (74%84%)
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PROGRAM DEMOGRAPHIC RESULTS
Status update for April 2013-April
2014
• Most participants were African
American women, with a total
of 29 males
• The ages of participants
ranged from 27 to 84 years,
with an average age of 60
years old
• A total 14/162 (9%) of
participants were uninsured
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EARLY LESSONS LEARNED
• “On the Road” welcomed in 5 zip code communities
• Received positive feedback for educators and class
• Attendees did not fully participate in free A1C tests
• More classes needed to reach expanded areas of county
• Plan to rotate class time schedules and pilot Saturday
sessions to learn participant response patterns
• The current model will not allow us to reach a maximum
number of residents in a cost efficient way
• Need to increase utilization of social media to inform and
engage residents about the class
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REPLICABLE TOOLS/TEMPLATES
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Evidence based educational materials and curriculum
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Curriculum (4 hours) adapted for target population
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Trainer of Trainer (TOT) model for program expansion
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Community Health Worker (CHW) training curriculum
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Program designed for transportability to diverse community
settings
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Pre/post education survey tools
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A1c pre/post lab tests
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Collaborative partnerships with clinical practices to
improve diabetic management of A1c
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“ON THE ROAD” NEXT STEPS
Secured Year 2 funding to support the following
goals:
• Expand “On the Road” to include bilingual
program delivery model
• Increase number of classes offered to
residents
• Develop and implement on-line curriculum to
provide alternative or enhancement to
traditional class delivery model and expand
reach
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CAPACITY BUILDING
Key capacity building components for diabetes
outreach include:
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organizational support
staffing
partnerships
funding/resources
outreach and marketing strategy
data collection
evaluation
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“ON THE ROAD” TESTIMONIALS
“With the help of “On the
Road”, I came to understand
my strengths and
weaknesses. It made me stop.
It made me look and deal with
Diabetes! By taking care of
my immediate health needs
my A1c levels have dropped!”
Ronald Frazier
“The Prince George’s County
Health Department Diabetes
class has taught me that no
matter how independent I
thought I was, I need to ask for
and accept help. Diabetes is a
everyday battle and I couldn’t
go through this by myself. The
Joslin educators helped me
become ready for the fight.”
Gloria Bryce
“I couldn’t believe I had
diabetes! My Doctor must
have made a mistake. I had
never been sick, not even a
cold, and had always
considered myself to be a
very healthy person. The
classes helped me to deal
with my diabetes & take
charge of my life.”
Thomas Butler
“Having three adult kids with type 1
Diabetes and a brother who died at 41
due to diabetes related complications
encourages me to do something. “On
the Road” showed me what I need to do
to stay healthy.“
Crystal Hawkins
“When I got diagnosed with
diabetes, I felt so alone. The
“On the Road” program gave
me the support I needed and
knew I didn’t need to face this
alone. The Joslin staff are the
most caring and talented group
of people I have ever had the
privilege of meeting.”
Sabrina Taylor-Turner
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CONTACT US
More Questions?
Call “On the Road! 301-883-3545
Visit Us
www.dchweb.org
www.princegeorgescountymd.gov
MyPGCHealthyRevolution.org
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