Transcript Frequently-Asked Questions

Frequently-Asked Questions
Additional Resources: FAQ
Program Background
– What is Cities for Life?
– Why implement this
program in my local
community?
– Why is it important to
involve the community in
diabetes management?
– How is Cities for Life
different from other chronic
disease management
programs?
– Who were the target
audiences for Cities for Life?
– How were patients identified
for the Cities for Life
program?
In Primary Care Practices
– How will this model
improve my practice?
– What benefits did Cities
for Life bring patients?
– How did Cities for Life
recruit physicians?
– How did Cities for Life
engage physicians?
– What were the benefits
for Cities for Life
physicians?
Funding
– Who funded this program?
– How do I find funding?
– How much does a
program like Cities for Life
cost?
Patient Navigation
– What was the role of the
patient navigator?
– What skills were important
for patient navigators?
– How do I find patient
navigators?
In the Community
– How did Cities for Life
engage community
members?
– What resources are
beneficial in helping those
living with diabetes?
What is Cities for Life?
• Cities for Life was a community-based diabetes management program in
Birmingham, Alabama, led by the American Academy of Family
Physicians Foundation with support from Sanofi US.
• The program helped Birmingham’s community groups and primary care
providers create an environment that facilitated and encouraged healthy
lifestyles and diabetes prevention and self-management.
– Cities for Life had both clinical and community components.
• The clinical component included local family medicine practices that refer
patients living with or at risk for type 2 diabetes to patient navigators. Patient
navigators work with the patient to identify the best programs in their local area,
encourages program participation and serve as a resource.
• The community component of Cities for Life was driven by a Community Action
Team (CAT) of more than 80 local organizations. Led by a Steering Committee, the
CAT helped supplement resources to inform the website,
www.mydiabetesconnect.com, a free searchable database that alerts people to
the availability of local programs and services. Patient navigators used this
database to help patients find programs and services to help them manage their
diabetes.
Why implement this program in my
local community?
• Nearly 26 million people in the U.S. have diabetes, including seven million
who are undiagnosed.1 An additional 79 million people in the U.S. have
elevated blood glucose levels and are at increased risk of developing type
2 diabetes.2 If current trends continue, the Centers for Disease Control
and Prevention (CDC) estimates one in three people in the U.S. will have
diabetes in 2050.3
• Better models of diabetes management are needed.
• The Cities for Life model helped primary care providers and community
organizations develop stronger linkages to provide support for patients
living with or at risk for diabetes, allowing them to better self-manage
their condition outside of their doctors’ offices.
References:
1 Centers for Disease Control and Prevention. National Diabetes Fact Sheet, 2011. Atlanta, GA: U.S. Department of Health and Human Services; 2011.
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. Accessed June 17, 2011. P.1, l.2,7.
2 Centers for Disease Control and Prevention. National Diabetes Fact Sheet, 2011. Atlanta, GA: U.S. Department of Health and Human Services; 2011.
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. Accessed June 17, 2011. P.1, l.16-18.
3 Centers for Disease Control and Prevention. Diabetes Success and Opportunities for Population-based Prevention and Control, At A Glance; 2011. Atlanta, GA: U.S. Department of Health and
Human Services; 2011. http://www.cdc.gov/chronicdisease/resources/publications/aag/pdf/2011/Diabetes-AAG-2011-508.pdf. Accessed August 30, 2011. P.2,l.B7-B8
Why is it important to involve
the community in diabetes
management?
• One of the challenging aspects of managing diabetes is that it is a 24/7
disease. People living with diabetes likely only see their primary care
physician three to four times a year for a total of six hours annually,
leaving patients with 8,760 hours each year where they are largely “on
your own” to manage their disease.
• During this time, individuals could turn to family members, colleagues
and other sources of community “peer support” to help them better
manage their diabetes. The individual’s ability to live a healthy life with
diabetes–and confidence in that ability–is enhanced by the support
provided by the surrounding community.
• The Cities for Life model helped primary care providers and community
organizations develop stronger linkages to provide support for patients
living with or at risk for diabetes, allowing them to better self-manage
their condition outside of their doctors’ offices.
How is Cities for Life different
from other chronic disease
management programs?
• Cities for Life incorporated the use of both patient navigators and peer
support. Patient navigators worked directly with family medicine
practices and helped create sustainable linkages between existing
community resources and patients living with or at risk for diabetes.
• Cities for Life worked closely with key community partners to help
develop the patient navigation system and guide patients towards
appropriate, accessible resources that facilitate a healthy lifestyle and
diabetes management outside the exam room.
Who were the target audiences for
Cities for Life?
• Target audiences include:
– Those living with diabetes
– Those at risk for diabetes
– Community health and business organizations
– Local primary care practices
– The community at large
How were patients identified for the
Cities for Life program?
• Physicians from the Cities for Life primary care practices referred patients
living with or at risk for type 2 diabetes to a patient navigator. Patients
were referred to navigators based on:
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Age over 19 years,
Diagnosed with type 2 diabetes,
Have prediabetes or abnormal glucose, or
At risk for type 2 diabetes (two or more of the following):
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Overweight or obese
Not exercising regularly
Have a parent or sibling with diabetes
Age 45 or over
Have high blood pressure
Non-white race
low HDL cholesterol, high LDL cholesterol, or high triglycerides
Women who had gestational diabetes or a baby that weighed 9 pounds or more at birth
How will this model improve my
practice?
• Cities for Life provided an opportunity to enhance patient care without
increasing physician workload. The program helped physicians provide
diabetes patients with the resources they needed to take care of their
diabetes 24/7.
• The program helped link people from primary care to community support
by creating partnerships with community organizations which could
benefit people living with and at risk for diabetes.
What benefits did Cities for Life bring
patients?
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Cities for Life patient navigators helped patients find services in their local
community to help reduce their risk of diabetes or better manage their
condition.
Cities for Life developed mydiabetesconnect.com, a free, searchable database of
local programs and services. The goal of the site was to help promote healthy
lifestyles, reduce the risk of diabetes and encourage diabetes management in the
greater Birmingham area. The website lists a variety of local programs and
services for categories, including:
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Healthy Eating
Physical Activity
Healthy Families
Support and Education
Healthcare
Research Opportunities
How did Cities for Life recruit
physicians?
• A local coordinating center, housed in the medical school of a local
university, recruited physicians
• The coordinating center operated a practice-based research network, so
they already had a relationship with physicians in their community.
• Physicians who were recruited were willing to:
– Engage in a collaborative process with community agencies and other primary care
providers to identify ways to enhance the links between clinical care and
community/education resources.
– Dedicate staff time to participate in necessary calls and planning sessions to implement
plans with colleagues, etc.
– Complete necessary paperwork, as needed.
– Use a registry from which data could be abstracted for later study (e.g., clinical status,
dates of care, characteristics of visits (scheduled vs. unscheduled), etc.).
How did Cities for Life engage
physicians?
• Cities for Life physicians were engaged through on-going communication,
including:
– Local events
– E-mail communications
– E-newsletter distribution
What were the benefits for Cities for
Life physicians?
• Cities for Life provided an opportunity to enhance patient care without
increasing physician workload. The program helped physicians provide
diabetes patients with the resources they need to take care of their
diabetes 24/7.
Who funded this program?
• Cities for Life was led by the American Academy of Family Physicians
Foundation with support from Sanofi US.
How do I find funding?
•
Funding options are available from a variety of sources
– At the national level, potential funding sources include:
• Opportunities listed on Grants.gov
• Federal agencies, such as:
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Centers for Medicare and Medicaid Services (e.g. Innovation Center)
Centers for Disease Control and Prevention
US Department of Health and Human Services (e.g. HHS Forecasts)
– At the state level, potential sources of funding include:
• State agencies, such as health departments
• National Registry of Recognized Diabetes Prevention Programs
• The Grantsmanship Center
– At the local level, potential sources of funding include:
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Universities, especially medical schools
Hospitals
Prominent local businesses
County health departments
Local community health grants (e.g. Walgreens and CVS)
How much does a program like Cities
for Life cost?
• The cost of a program like Cities for Life depends on your own program
model and your community’s needs. Funding options are available from a
variety of sources at the local, state and federal levels.
• Examples of areas that may require funding include:
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Patient navigator salaries if they aren’t already employed in your community,
Data collection for evaluating the project,
Printing promotional literature,
Developing and maintaining websites, and
Salary and office space for personnel to coordinate the effort.
What was the role of the patient
navigator?
• Patient navigators were a critical link between the primary care practice,
the patient and community-based organizations. They had special training
and extensive knowledge of existing programs and services within the
local community, so they could work with patients to identify the best
programs in their local areas to help them manage their diabetes.
• The patient navigators checked in on patients, encouraged program
participation and served as a resource for patients in addition to their
physicians.
What skills were important for patient
navigators?
• Patient navigators had special training and extensive knowledge of the
existing programs and services within the Birmingham community that
could help patients manage their diabetes.
• Key attributes of a patient navigator include:
– Extensive knowledge of existing programs within patient’s community, as listed above.
– Understanding of what is best for the patient as it pertains to individuals needs, budget
and desires.
– Ability to understand the inner workings of primary care practices and successfully
coordinate between practices and patients.
How do I find patient navigators?
• Patient navigators may already be working in your community, employed
by groups such as public health organizations, the health department,
clinics, hospitals, and organizations such as the American Cancer Society
or the American Diabetes Association.
• Patient navigators may have different titles such as patient advocate,
patient coordinator, community health worker, community outreach
worker, patient advocate, or screening outreach worker.
• If you need to hire new personnel as patient navigators, you may find
willing people through the community organizations you are working with.
How did Cities for Life engage
community members?
• The community component of Cities for Life was driven by a Community
Action Team (CAT) of more than 80 organizations drawn from local primary
care practices, other healthcare organizations, civic organizations,
businesses, faith-based organizations and media. The CAT members all
have programs, activities or an interest in helping those with diabetes.
• Cities for Life engaged these community members through on-going
communication efforts including:
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Monthly newsletters
E-mail
Phone calls
Events
Social media
What resources are beneficial in
helping those living with
diabetes?
• Beneficial resources may include:
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Healthy eating and grocery shopping options
Walking trails, gyms and fitness classes
Diabetes education events and classes
Weight-loss programs
Diabetes support groups