Partnership for Diabetes Health Equity (PDHE)

South Carolina 3-Element Model Learning Collaborative Charter

Problem Statement, Aim, Goals and Objectives, and Guidance

Problem Statement
The burden of diabetes is much higher in some groups (racial/ethnic minorities, age, socioeconomic status, limited literacy) when compared to others in the same populations and often results in higher rates of diabetes-related complications and death.
Prevalence for diabetes in the US is 12.7% and 17.1% in South Carolina. Of those served by HopeHealth in 2014, 15% adult patients had a diagnosis of diabetes. 68% DM patients are African American and 28% DM patients are white. HopeHealth Diabetes Center provided DSME services to 226 patients in 2014 and of those, approximately 13% completed the program. The average reduction of HbA1c of those who completed the program was 1% and were controlled at an average of 7.9%. There is an increasing number of African American patients presenting with diabetes. Uncontrolled people with diabetes are not always identified in a timely manner for appropriate services. There is minimal collaboration with hospitals and community organizations. The rural service areas of Clarendon and Williamsburg Counties have very limited resources for DSME.
Broad Goals
1.  Increase the number of African American diabetic men who complete the DSME program at HopeHealth Diabetes Center by 10%.
2.  Provide DSME services to patients located in rural areas of Clarendon and Williamsburg Counties through telehealth in the Kingstree and Manning sites of HopeHealth.
3.  Collaborate with Managed Care Health Plans to identify people with diabetes who are out of care and/or need gaps in care addressed.
4.  Share improvement cycles with other DSME sites in South Carolina.
Proposed Aim
Over a period of twelve (12) months, HopeHealth Diabetes Center, SC Primary Health Care Association and SC Department of Health and Environmental Control will partner to make fundamental changes to improve diabetes related health outcomes for underserved and inappropriately-served populations. This will be achieved by increasing the number of African American men who complete Diabetes Self-Management Education programs.
Diabetic patients at HopeHealth are comprised of 68% African American and 28% White. The HopeHealth Diabetes Center provided DSME services to 226 patients in 2014 and of those, approximately 13% completed the program. African American men had 25.5% completion of DSME while 38.6% of African American women completed the program.
The Collaborative will work to:
1.  Strengthen relationships between internal and external providers and community organizations for achieving diabetes health equity.
2.  Collect data and share analysis to drive rapid improvements in health outcomes and quality of care.
3.  Implement and share evidence based methodologies and best practices with other state DSME programs.
Target Population
The target population is African American men who have diabetes that live in Florence, SC, a geographic region with historic demonstration of health disparities. The South Carolina 3-EM Partnership Team’s target population is identified through systematic population-identification methods through prevalence rates, referrals to the HopeHealth Diabetes Center, Medicaid / Medicare Managed Care Organizations, and community organizations.
Objectives
1.  Increase by at least 10% the number of patients in target population completing formal diabetes education and close the disparity gap by 15%.(Healthy People 2020)
2.  Increase by at least 10% the number of patients in target population receiving at least one evidenced based neighborhood/community level intervention and close the disparity gap by 15%.
3.  Achieve at least 20% participation DSME telehealth in rural communities from referrals made by primary care providers.
4.  Present collaborative DSME “best practice” care and quality improvement to address disparities at the winter SC Chronic Disease Symposium.
Guidance
Each 3-EM Partnership Team will work together to achieve more optimal and equitable diabetes care for their target population by building a 3-Element integrated clinic-outcomes-community care system.

The 3-EM Partnership Teams will engage in some of the following best practice strategies:
1.  Establish a multiagency partnership:
Partnership consists of representatives from SC Primary Health Care Association, SC Department of Health and Environmental Control, HopeHealth, Inc., and HopeHealth Diabetes Center.
2.  Identify weakest link among the three elements:
Data sharing is the greatest weakness along with program / service duplication.
3.  Increase the depth and strength and effectiveness of whichever element the partnership defines
as their weakest link among the three elements:
SC Department of Health and Environmental Control will gather and share data from DSME programs in the state.
4.  Increase the depth and strength and effectiveness of the connections between the three elements (increase collaboration, coordination, and cohesion):
Scheduled bi-weekly conference calls will bring cohesion. A shared data file will allow partners to view, add, and discuss data / documents, planned activities, and PDSA cycles.
5.  Implement continuous quality improvement methodologies:
HopeHealth will implement continuous quality improvement methodologies and post on shared file. The team will assist in assessing further need, barriers to change, and providing “best practice” strategies for continued improvement of health outcomes.

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