Proposal (8 pages maximum)
Statement of Goal
 Describe the specific health needs that your innovative model will address, and
the specific health indicators you intend to improve.
 Provide data that supports the importance of the health needs targeted, as well as
evidence of disparate burden/impact in Durham County. Utilize at minimum data
from the 2007 Durham County Health Department’s Community Health
Assessment. The Data and Analysis Core can also facilitate access to other
relevant data.
 Identify the populations that you will target including location, race/ethnicity, age,
socioeconomic status, and gender.
In North Carolina, there has been a 76% percent increase in the prevalence of persons
diagnosed with diabetes from 1994 to 2003 (4.6% vs 8.1%). North Carolina is one of the
top ten states in diabetes prevalencei. In Durham County 8.2% of the population has been
diagnosed with diabetes. Ethnic minorities have a 128% higher mortality rate from
diabetes than white populationsii. Health problems associated with diabetes include a 2-4
fold increase in risk for cardiovascular disease, increased risk for stroke, blindness,
kidney failure, and extremity amputationsiii. Costs for hospitalizations related to diabetes
in Durham County have increased by 251% from 1990 to 2002iv. Research has shown
that aggressive control of blood glucose, blood pressure, and cholesterol can decrease all
of the above complications of diabetesv. The American Diabetes Association (ADA)
Clinical Practice Recommendations stress careful attention to glycemic, lipid and blood
pressure controlvi. Yet, in Durham County 44% of individuals have never received
diabetes education, and a majority of individuals with diabetes (71%) do not meet the
recommended goal for physical activityi. The complex nature of diabetes care, which
includes attention to diet, physical activity and complicated pharmacological therapy, is
difficult to achieve in traditional individualistic, clinic-based care, particularly in those
patients who are unable to access that type of care or lack the resources for selfmanagement behaviors.
We have been following diabetic patients at Duke Family Medicine Center and in 2005
we noticed that patients with HgbA1c >9% were less likely to access care, make
medication and behavioral changes to reach goals for control, and follow up. We focused
efforts on our Medicaid patients and then Duke Select patients with HgbA1c > 9%
without much success. We learned that these individuals would be accessible at home by
the Carolina Access social worker or PRIMA case manager but would not come to office
visits or lab testing. We now wish to try to focus on this group in a different way and to
expand the same focus to others with diabetes in Durham County.
We will do this by geomapping patients with diabetes and by identifying patients at
community health clinics (DFM, LCHC, Walltown, Lyon Park) and DOC) who have
diabetes with poor glycemic control (HgbA1c >9%) and have not been attending PCP
visits. Neighborhoods or geographic areas noted to be resource poor and disease
prevalent will be targeted, capturing those most at risk first, followed by others in the
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community with diabetes. Due to the disparities in health and health care access
experienced by ethnic minorities such as Blacks and Hispanics, we are anticipating these
ethnic groups will make up a majority of the population with diabetes we will be
targeting. Also, as those with Medicaid make up a large proportion of those patients not
attending PCP visits, we anticipate a lower socioeconomic status among this group as
well.
The proposed plan of intervention in these communities includes an initial home visit(s)
to establish trust and engagement followed by transitioning patients’ diabetes
management and education to a community based group visit within their neighborhood,
at the Family Medicine Center or at a community health site that the patient will identify
as their medical home. A multidisciplinary team (provider [faculty/midlevel
provider/resident], pharm D student, PA student or medical student, nurse and/or nursing
student, resident and Social Worker) would be a part of the home visits and the group
visits. Point of care testing (hgbA1c, LDL, microalbumin/Cr ratio) utilized both in the
home and at group visits eliminates the access issue for laboratory testing and allows for
immediate feedback and face-to-face counseling at the time of the visit, which in turn can
lead to improved diabetes controlvii,viii. Intensification protocols for medication
management of glucose level and blood pressure have been developed and may be used
in conjunction with testing. Access by mobile laptop connection via internet to
Electronic Medical Records (EMR) and the ability to electronically transmit medication
orders to the pharmacy (escribing) will improve access and continuity of care, as well as
patient safety.
Tracking via the EMR system will be put in place to send reminders to patients and
providers to re-visit the patient at home if a patient is unable to make their community
group visit or medical home appointment at appropriate disease management intervals,
which will help in reaching goals for glycemic control and management of other comorbidities such as hypertension. This would in turn, reduce long term complications
(renal disease, blindness, cardiovascular disease, stroke), hospitalizations, ED and urgent
care visits.
Geomapping will also be used to plan for targeted improvements in lifestyle
supports and gaps or barriers. The project team, which will expand, will be key in
advising about improvements that fit with patient, family and community resources and
needs for a healthier lifestyle. Clearly, improvements in county-wide lifestyle supports
such as nutritional information and improved access to exercise will benefit residents
who may not be associated with this proposed diabetes care program as well.
The goals of this proposal are: (1)Organize and develop a business plan for an
innovative, community based, comprehensive model of care for adults with diabetes that
incorporates patient, family and community as well as associated resources known to lead
to improved outcomes in chronic illness; (2) Improve diabetes care and outcomes
(glycemic control, BP, lipid levels) for patients with diabetes through improved
continuity of care, reduction in barriers to access to care, and use of a multidisciplinary
team; and (3)Community infrastructure improvements, particularly related to lifestyle
modification, that will provide long term benefits for individuals with diabetes and other
chronic illnesses.
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Innovative Model of Care
•
Describe the innovative model of care proposed by your team (i.e., what
change(s) are proposed in the structure or function of a service, system, or care delivery
setting)?
•
Present the evidence base for your proposed innovative model of care by
documenting any similar examples from around the country of this model (i.e., what is
the evidence base).
•
How does your proposed innovative model differ from current models of care
delivery, and what evidence suggests it is better?
•
What evidence exists that the innovative model of care/proven interventions will
be accepted and effective? Have there been pilot studies? Does it implement practice
guidelines?
•
What would be the interface to and/or involvement of the Duke University Health
System and community partner organizations?
Our plan is to identify all patients at DFM, LCHC, Walltown, Lyon Park and DOC and
other private participating practices with HgA1c higher than 9 % and offer to visit them
in their home initially. We would then encourage these patients to transition their diabetic
management to a community based group visit within their neighborhood, at the Family
medicine Center or (at a local practice) or a community health site that the patient will
identify as their medical home.ix
Home Visits
Need to enter data from “Just for Us” here, as it is a proven model that has decreseaed
hospitalizations and become cost neutral (VIVIANA WILL DO)
**The team for the home visit would include a provider (faculty/physician/or? midlevel
/nonphysician/provider/NP/PA/or?resident/trainee=one provider plus one learner), pharm
D student, PA student /NP student or medical student, resident and Social Worker.
NEED TO agree on who is going on home visit:
What about caseworker? Is that same as social worker?
Planned point of care testing for the home visits will follow established guidelines for
diabetic management1. These may include: hgbA1c, LDL, microalbumin/Cr ratio for
urine on site, Weight, Blood Pressure, Monofilament test, and Glucose. This point of
care testing will allow immediate feedback at the time of the visit with face-to-face
counseling which in turn can lead to improve compliancexxi. We also plan mobile laptop
connection (via internet) to access their medical record, enter data obtained at the time of
the visit and to electronically transmit all of their medications to a pharmacy. We will
obtain glucometers with direct computer interface so if students/resident or SW sees
patients (at home?) in intensification visits separate from the provider, medications can
be titrated by (??resident or? nursing staff/pharmacist) per developed protocols.
1
Need reference for guidelines here
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The goal of the home visit would be to build trust with the individuals who have not
been to their medical home clinic or do not have access to a medical home clinic.
Engaging them may improve transition to the community based group visits as well as to
their medical home clinic. If a patient is unable to make their community group visit or
medical home appointment, then we would have a tracking system in place to set a
reminder to re-visit the patient in their home in appropriate disease management
intervals. This may help to get these patients to goal and hopefully prevent long-term
complications, hospitalizations, ED and urgent care visits.
(Meanwhile) the group visits will have a regular schedule and ideally involve a cohort of
diabetic patients who return to follow-up visits together. Other patients may be added or
step out as individual circumstances or health status allow/occur/change.
Description of group care model and supporting statistics:
The Centering Healthcare Institute (CHI) model emphasizes medical assessment,
education and support as key components of Group Care. Additionally, the
Commonwealth Fund (2007) found that adults who have Medical Homes (primary care
that is accessible, continuous, comprehensive, family centered, coordinated,
compassionate, and culturally effective) have an enhanced access, better quality, and rare
disparities in health care. Group care is included as one component of medical home
carexii. Studies have shown that patients in group care and medical home practices
develop relationships with their providers and work with them to achieve results of
decreased hospitalizations, decreased emergency room visits, increased satisfaction,
increased quality of life, and maintain healthy lifestylesxiii.xiv. Diabetes group visits
provide support and empowerment from peers, improve access to care, provide education
about disease, improve outcomes, and increase productivityxv. They have also shown to
improve HbA1C, improve satisfaction with diabetes care and increase confidence in selfmanagement behaviors xvi, they increased preventative procedures among attendees of
group visitsxvii, improvement in lipid levels and body mass indexxviii, and increased
physician trust xix. Lastly a Recent Cochrane Database System Review suggests that
lifestyle intervention in type 2 diabetes is especially effective when implemented by
interactive group educationxx.
How the model works: A small group of individuals (12-16) (with diabetes) arrive at the
same time for their group visit. They do not wait in the waiting room, but come in to the
group space to begin the visit. Using the CHI model, patients are assisted to obtain their
own vital signs, weight, and other monitored values and also record them in their chart.
Individual one on one assessment with their provider may be occurring in the first 20
minutes as people trickle in. An interactive group session of all patients and two cofacilitators (one of which is usually a provider and the other may be a social worker,
nurse, nutritionist, diabetes educator, or lay person skilled in this manner of care) occurs
in the next 45-60 minutes. Then, a snack break may occur to allow for informal
discussion and socialization, followed by second brief group session to cover other topics
of concern, or perhaps do an interactive meal preparation or exercise activity.
Multidisciplinary guests may be part of the group visit periodically, such as a podiatrist,
or spiritual counselor if the group expresses interest. Billing is done as would be normal
for a regular follow-up visit.
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_____________________
Our hope would also be to have EMR integration at least at lab and medication level that
can be accessed from all sites in Durham County, whether patients are seen in the ED,
urgent care of the Duke System or LCHC system or community provider. Our hope is to
have the medications prescribed, and point of care labs accessible from all the systems.
Our ultimate goal for the EMR would be to have a universal electronic system to Durham
residents so that providers in the medical home, the ED or Hospital and patients would
have access to that unique system. Patients would have an EMR card or number that they
would carry identifying them as part of the diabetes project.
Ultimately, this approach in diabetes management would reduce co morbidities and long
term complications of renal disease (dialysis cost), blindness (disability handicap),
Cardiovascular events including heart attack, stroke, or long term care. The universal
Durham county electronic medical record (EMR) and escribing product would allow for
decrease in rework and improved continuity of the uninsured and those without primary
care medical homes. These individuals would have community site medical homes that
may be mobile. The cost reduction in long-term medical care locally would allow for us
to use the resources to continue to support the health of the community.
Partnerships
•
Describe the ability of community members, agencies, and Duke members and
organizations to effectively address the needs identified in your proposal.
•
Describe the community and Duke strengths of your team, particularly as they are
relevant to the proposed health need and populations being targeted.
•
List community members and agencies that live in or serve this population, and
have been involved in the assessment and proposal development.
•
Identify how your innovative model might impact other community programs and
projects.
1. Ability of Community members, agencies and Duke members to effectively
address the needs identified in your proposal.
The Durham County Health Department addresses diabetes prevention and
management with the following services/programs.
• Nutrition Division—Provides individualized medical nutrition therapy (MNT) on
referral from treating diabetes management providers. MNT is an integral
component of diabetes prevention, management, and self-management education.
Health Department nutritionists are Registered Dietitians and are licensed by the
State of North Carolina as Licensed Dietitians/Nutritionists and are recognized as
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•
•
the qualified provider for medical nutrition therapy. Nutritionists also conduct
presentations and group events on eating for health and disease prevention at
worksites, faith-based and other community groups.
Neighborhood Nursing Program—Registered Nurses provide educational and
support services in nine low income residential communities in Durham County.
Health Education Division—Conducts diabetes education, smoking cessation,
and disease self management at worksites and faith-based and other community
groups. Services may be able to be expanded if additional funding becomes
available.
The Durham County Department of Social Services (DSS) goal is to meet basic
economic needs, provide access to health care and nutrition to improve health status, help
people find jobs then to develop strong work habits and create career paths. The agency
strives to help people become self-sufficient. DSS staff have the ability to solicit
assistance in locating people that could benefit from the plans of the proposal. Nicole
anything else??
Durham Community Health Network (DCHN) is a community-based managed care
program for Durham Carolina Access II enrollees funded by the State of North Carolina.
DCHN is governed by a network of agencies and providers, who serve the Medicaid
population, including: primary care clinics, local hospitals, and the Durham Departments
of Social Services and Health. The program is administered by the Duke Division of
Community Health. DCHN helps primary care practices improve the quality of care that
Carolina Access patients receive by removing barriers to healthcare access, helping
patients better understand their healthcare conditions and responsibilities, sharing best
practices. The case management team includes clinical personnel, social workers and
community/lay health workers. health workers.
Duke services---Susan, Gloria ???
Lincoln Community Health Center operates a diabetes specialty clinic and has staffing
for education and support groups. Needs additional info—Kelly O’Daniel
Need info that we will gather from next few meetings—faith based info form possible
participants of proposed programs (e.g., person with diabetes).
Info from LP, Walltown models here
2. Community Strengths:
A major strength in the community is the already existing history of collaborations
among Duke Health Care, Lincoln Community Health Center, Durham County of Social
Services, and the Durham County Health Department. There is also the Partnership for a
Healthy Durham, a coalition of agencies, organizations, community members, and
leaders. The Partnership is a certified Healthy Carolinians program. Healthy Carolinians
is North Carolina's statewide network of partnerships that address health and safety issues
at the community level. They created a set of health promotion objectives for 2010 that
form the agenda for all local programs. One activity that the Partnership completed
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recently and will be useful for this project is the mapping of parks, recreational centers,
greenways, schools, etc in Durham County.
Senior PharmAssist program—describe more.
Others????
Project Access??
3. Community members and agencies that live in or serve this population and have
been involved in the assessment and proposed development.
Have names of persons with diabetes—what are their thoughts, suggestions?
Agencies—Durham Community Health Network—experience in home visiting, chronic
disease management classes. Health Department—experience in home visiting,
management of DM through medical nutrition therapy; Neighborhood nursing program.
Need input from Health Educators—what are they hearing in their group work, PEACE
project?
Lincoln Community Health Center—success with walking club; other input?
Duke Family Medicine, School of Nursing—Susan, Gloria, Kathy T.
Others???
4. Identify how your innovative model might impact on other community programs
and projects.
Hypertension, obesity, diabetes, cardiovascular disease, and renal disease all have a
healthy lifestyle (nutrition, physical activity, stress management) as an integral
component of disease prevention and management and have all been identified as targets
for other proposed projects. The targeted intervention messages and strategies for each
project may have similar general messages (although there still may be the need for some
individualization with easy, affordable access to these services). Other disease states and
health conditions beyond diabetes may be addressed through the same or similar models
so interventions sites, staffing, record keeping could be merged and costs shared. Our
model could be duplicated by others or merged for better efficiency and service
coordination. Additionally, the Internatal Care; a Life Course Model project will focus
on women’s health across the life course (e.g. preconception and post partum prevention
and treatment) and has diabetes care as one of the focuses of interventions. Medical
management issues will be the same or similar; intervention models could be similar—
e.g., centering type group. The diabetes project could serve as a referral source for this
project.
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Planning Process
•
Describe the planning process that your team will use (meetings, focus groups,
community town halls, etc.).
•
Describe the plan for maintaining communication and receiving input from all
members of your proposed team.
•
Describe how you intend to maintain communication with the community or
population served and receive input and feedback from community members during the
planning process.
NEED
Evaluation
•
Delineate how you will evaluate the success of your team.
•
Describe how you will ensure that your innovative model will be endorsed by the
communities you propose to serve.
•
Identify any specific metrics that can be used to track intermediate and outcome
endpoints associated with your identified health needs.
•
How will your innovative model result in improved health status for the
population served and how will you measure this?
•
What is the period of time over which you expect to achieve results in improved
health status for each set of metrics above?
•
How does your innovative model aim to 1) reduce health disparities, 2) improve
quality, 3) reduce cost and/or increase efficiency?
•
What evidence will you need to demonstrate that your innovative model can be
successfully implemented and sustainably operated?
•
What are the financial and operational impacts of your innovative model on
projects in Durham County and Duke University Health System?
•
Is your plan scalable beyond Durham County? Explain.
Project Evaluation
1. Delineate how you will evaluate the success of your team
 Move to Stage 3 of process is our first short term goal
 Buy in, participation and support of Durham community members
 Patient participation in program
 Acceptance of model by Duke Health System administrators
 Dissemination and applicability of model to patients with other chronic disease
 The success of the team will be evaluated by its ability to maintain a collaborative
relationship with all the different organizations that are part of the project.
 We will have meeting deadlines, goals and objectives to be met …..
2. Describe how you will ensure that your innovative model will be endorsed by the
communities you propose to serve.
 During the planning phase (Stage 3), we will be conduct focus groups,
neighborhood meetings, and interviews with individuals to gather information from
community members and patients on locations for meetings to be included in this
project, how to make it feasible, attractive and relevant for the diverse population of
Durham county. We will incorporate their feedback into the plan.
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 The several community members who are currently part of our planning team are
helping us begin this process as we write the Stage 2 proposal. Additional community
members have been added to ensure adequate input from Durham residents.
 Lay health advisors (LHAs) from the community will be part of the development
and advisory process. The ultimate plan it to have LHAs involved in service with
patients, for example--group care, home visits, nutritional and activity initiatives.
3. Identify any specific metrics that can be used to track intermediate and outcome
endpoints associated with your identified health needs.
 Point of care testing will be performed during home and group visits, measuring
HgbA1C, blood pressure, urine micro-albumin, cholesterol, and weight using EMR
integration with laptop computers. Can also track other DM standards of care such as
ACE inhibitor use, annual foot exam, eye exam, immunizations.
 Using the DEDUCE tracking system, hospitalization rates as related diagnosis
and complications of diabetes, emergency department visits.
 We can also track the relationship of residence change within Durham to change
in Medical Home; specifically whether the patient chooses new Medical Home or has
hiatus from care
 Patient participation in program based on health care appt attendance either in
group or home visits.
 Through EMR and E-prescribing, will track refills on prescribed medications and
diabetes testing supplies as marker of adherence.
 Also exercise targets, weight reduction (if needed), improvement in nutritional
habits will be evaluated through the use of diaries, exercise tolerance testing—pre and
post, and focus group sessions.
 Improvement in community resources related to exercise options, good nutritional
resources will be tracked and reevaluated from baseline geomapping data.
4. How will your innovative model result in improved health status for the
population served and how will you measure this?
 Our innovative model will result in participants’ improved health as measured by
decreased HgA1c, decrease in admission to the hospital and decrease in visits to the
Emergency Room for illnesses related to diabetes.
 Press Ganey or other similar surveys related to patient satisfaction with the care
being received will be administered before starting the program, during and after. We
expect improved scores in this area.
 Measurements of levels of “Patient Activation” will also be obtained at set
intervals to assess progress.
5. What is the period of time over which you expect to achieve results in improved
health status for each set of metrics above?
 Would this be evidence to support “sticking it out” with this project for a period
of time?
 We expect to see some metrics improving rather quickly: such as keeping
scheduled appointments, involvement of community supporters and diabetics, others
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may start improving in 6 months:HgBA1c, Lipids levels. Improvements in patient
Satisfaction and Activation level may take one year, we expect to see a reduction in
admission to the ED and Hospital to start decreasing in 2 years. It will take longer to
show a reduction in rates of conditions secondary to diabetes such as renal disease,
cardiac, foot ulcers . We believe this will be sfficient evidence to show that on the long
run this project will be not only improve outcomes in health status of all participants but
will also decrease health care costs.
6. How does your model aim to
 Reduce health disparities?
By bringing health care to the home of the patients and to the places in the community
where they now feel safe we will be creating a Patient Centered Medical Home for all
participants. The Medical Home has shown to improve health outcomes, and decrease
health disparities.

 Improve quality? Point of care testing would allow for immediate and patient
centered decision making on changes in medical therapy (I need to include
Commonwealth Fund’s data and Starfield’s and others data on improving quality by
creating medical homes VMB)
 Reduce cost and/or increase efficiency? Our plan would reduce co morbidities
and long term complications of renal disease (dialysis cost), blindness/ulcers and
diabetes related amputations(disability handicap), cardiovascular events including heart
attack, stroke, and long term care. There is data already in Durham county to support
that the utilization of similar models is cost neutral to the health system, and improves
outcomes ((JUST FOR US DATA HERE)
7. What evidence will you need to demonstrate that your innovative model can be
successfully implemented and sustainably operated?
 Will need more specifics on the business model for this section
8. What are the financial and operational impacts of your innovative model on
projects in Durham County and Duke University Health System?
 Decreased hospitalizations and costs related to medical care for diabetes
 Improved worker productivity and decreased worker absenteeism as related to
diabetes
 Will need more info from business model (JUST FOR US DATA HERE AS
WELL)
9. Is your plan scalable beyond Durham County? Explain.
 This plan should be applicable to the care of any patients in any community with
chronic illness and logistical challenges to receiving health care in the traditional clinic
setting
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Dissemination
•
How do you intend to engage and inform members of the community or
population served of your findings and future steps?
•
How do you plan to disseminate your findings through academic journals and
other publications? To which academic journals or other publications will you be
submitting your findings?
Dissemination
The results of our planning efforts will be distributed to the Durham County
community at many levels. Clearly they must be shared and developed with input from
the providers of care in the county in order to be translated into care for patients with
diabetes in the future. We will present the findings to multidisciplinary providers
(physicians, nurses, PA’s, NP’s, social workers, psychologists, pharmacists, and students)
in many clinical settings such as the local hospitals and clinics. It is also vital that the
information be shared throughout the process of planning and upon completion with the
community at large, particularly key community leaders, members, and most of all,
patients with diabetes. This will be done by working with community and church leaders
to reach publications and speaking opportunities within community organizations –
religious, support organizations, and community centers. Information will also be
disseminated to the larger community of Durham County by coordinating efforts with the
Public Affairs department at the school of nursing.
Dissemination to professionals beyond Durham County, nationally and
internationally will take place via publication of manuscripts. Relevant peer-reviewed
journals that we will submit to include: New England Journal of Medicine; Diabetes
Care; American Family Physician?; and Progress in Community Health Partnerships:
Research, Education, and Action. In addition, information will be shared at relevant
professional conferences including the American Diabetes Association Annual Scientific
Sessions;
.
Appendices
•
Schedule and Milestones – Prepare a timeline that describes activities you
propose to accomplish during the planning period. Include target dates as well as team
members responsible for the proposed activities, where appropriate.
•
Letters of support – Include letters of support from all participating agencies and
organizations. Letters from additional organizations are optional.
•
Budget and Justification – Include a proposed Line-Item Budget and Budget
Narrative for the Stage 3 implementation plan development process that are linked to the
goals and outcomes of the proposed plan. The Budget Narrative must include an
explanation for each line-item you include in your proposed budget. Please note that the
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budget is for the Stage 3 implementation plan development process, not for
implementation itself or for pilot projects. Clarification of acceptable budget expenses
will be provided during the technical assistance workshops. Please see the attached
sample budget template.
SAMPLE BUDGET TEMPLATE
Duke Personnel
Role
Percent effort Salary Fringe Total
Total
Sub-Contracts Description
Total
Total
Meeting expenses
Description
Total
12
Total
Materials and suppliesDescription
Total
Total
Total funds requested ___________
SUBMISSION FORMAT
Please compend all required elements into a single PDF document and submit via email
to DukeDurhamTeams@mc.duke.edu.
Applications must be received by 5:00 pm on March 2, 2009. A complete application
must include all of the elements above, be typed, single-spaced using 12 point Times
New Roman font on 8.5 X 11 paper, 1” margins, and pages numbered at the right lower
corner.
INQUIRIES
We welcome the opportunity to answer questions from Stage 2 applicants. Please feel
free to direct inquiries related to this funding announcement to:
Sue Schneiderz
Duke Center for Community Research
Tel: (919) 681-8598
E-mail: Suzanne.schneider2@duke.edu or DukeDurhamTeams@mc.duke.edu
13
North Carolina Behavioral Risk Factor Surveillance System NC, at: http://www.schs.state.nc.us/SCHS/brfss/index.html
N.C. State Center for Health Statistics, Vital Statistics, Volume 2; 1996-2002
iii American Diabetes Association. National Diabetes Fact Sheet. Available at: http://www.diabetes.org/diabetes-statistics/nationaldiabetes-fact-sheet.jsp
iv N.C. State Center for Health Statistics, 1990-2002
v UK Prospective Diabetes Study Group, Intensive blood glucose control with sulphonylureas or insulin compared with conventional
treatment and risk of complications in patients with type 2 diabetes (UKPDS 33), Lancet 352 (1998), pp. 837–853
vi American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2008, 31: S5-S54.
vii Immediate feedback of HbA1c levels Improves Glycemic Control in Type 1 and Insulin –Treated type 2 Diabetic Patients,
Gagliero, Levina, Nathan. Diabetes Care 22:1785-1789, 1999
viii Point-of-Care Testing in Diabetes Management: What Role Does It Play? Judith Belle Brown, PhD, Stewart B. Harris, MD, MPH,
FCFP, FACPM, Susan Webster-Bogaert, MA and Sheila Porter, RN Diabetes Spectrum 17:244-248, 2004
ix
Please see grant proposal titled IMPROVING DIABETES OUTCOMES AMONG DURHAM ADULTS USING A GROUP CARE
MODEL AND A COMPREHENSIVE APPROACH
x Immediate feedback of HbA1c levels Improves Glycemic Control in Type 1 and Insulin –Treated type 2 Diabetic Patients, Gagliero,
Levina, Nathan. Diabetes Care 22:1785-1789, 1999
xi Point-of-Care Testing in Diabetes Management: What Role Does It Play? Judith Belle Brown, PhD, Stewart B. Harris, MD, MPH,
FCFP, FACPM, Susan Webster-Bogaert, MA and Sheila Porter, RN Diabetes Spectrum 17:244-248, 2004
xii Group visits for Diabetes and Other Chronic Diseases, E. Shahady, http://www.transformed.com/Perspectives/GroupVisitsE.Shahady.cfm
xiii Closing the Divide: How Medical homes Promote Equality in Health care.
http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=506814
xiv Effectiveness of a Group Outpatient Visit Model for Chronically Ill Older Health Maintenance Organization Members: A 2-Year
Randomized Trial of the Cooperative Health Care Clinic, Scott et al. Journal of the American Geriatrics Society, Vol 52 Issue 9
1463-1470 16 Aug 2004
xv (Trento et al. Lifestyle intervention by group care prevents deterioration of type 2 diabetes: a 4-year Randomized control trial.
Diabetologia 2002; 45:1231-1239).
xvi Sadur, et al Diabetes Management in a Health Management organization: efficacy of care management using cluster visits.
Diabetes Care 22:2011-2017, 1999
xvii Wagner, Grothaus et al: Chronic Care clinics for diabetes in primary care: a system-wide randomized trail
xviii Trento et al, Group visits improve metabolic control in type 2 diabetics: a 2-year follow-up. Diabetes Care 24:995-1000, 2001
xix Clancy, DE; Brown, SB; Magruder, KM; Huang, P. Group visits in medically and economically disadvantaged patients with type 2
diabetes and their relationships to clinical outcomes. Topics in Health Information Management. 2003;24(1):8–14.
xx Vermeire E, Wens J, Van Royen P, Biot Y, Hearnshaw H, Lindenmeyer A: Interventions for improving adherence to treatment
recommendations in people with type 2 diabetes mellitus. Cochrane Database Sys Rev no. CD003638, 2005
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