The REACH Team and Community Partners

1. 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

2. 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

3. “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

4. From Meredith Minkler, DrPH University of California, Berkeley

5. 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)

6. Diabetes Initiative Board Med. Univ. of SC Center of Excellence Council Surveillance Council Outreach 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 Carolinas Center for Medical Excellence REACH And 23 Other Community Coalition

7. 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)

8. Enterprise Health Center 1995 - 2001 Donation of Lot Building Completed Opened November 2001 Now a FQHC site(FCFFHC)

9. 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

10. REACH U.S. Charleston And Georgetown Diabetes Coalition Goal: Decrease Disparities for African Americans with Diabetes1999-2012 Arlene Case-The Lesson

11. REACH U.S Centers of Excellence for Eliminating Disparities (CEED) NYU School of Medicine, NY Genesee County Health Department, MI, WI, IL, MN, IN, OH University of Colorado at Denver and Health Sciences Center, CO, AZ, NM, SC, WA, AK The University of Illinois at Chicago, IL Greater Lawrence Family Health Center, MA, Six New England States The Mount Sinai School of Medicine, NY 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 n = 18 Oklahoma State Department of Health, OK University of Hawaii HI, American Samoa, North Mariana Islands, Guam Micronesia, Palau, Marshal Islands

12. REACH Communities Racial/ethnic groups include: Health Disparities are focused on: • African Americans • American Indians & Alaska natives • Asian Americans • Hispanics/Latinos • Native Hawaiians/Pacific Islanders • CVD • Diabetes • Infant Mortality • Breast & Cervical Cancer • AIDs/HIV • Adult Immunizations

13. REACH: Charleston and Georgetown Diabetes Coalition Tennessee SC DHEC Region 6 NorthCarolina SouthCarolina County Library • Statewide REACH home-based • in Columbia: • Communicare • SC DHEC • SC DPCP • Carolina Center for Medical Excellence Georgetown Georgetown Diabetes CORE Group East Cooper Community Outreach S. Santee St. James Senior Center Enterprise Health Center Enterprise Community TriCounty Black Nurses Georgia St. James Santee Health Center Trident Urban League Trident United Way Alpha Kappa Alpha Sorority SC DHEC Region 7 Franklin C. Fetter Family Health Center Charleston County Library MUSC MUHA Diabetes Initiative College of Nursing Charleston Diabetes Coalition Greater St. Peters

14. Lower 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* Higher levels of: 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 Disparities for African Americans with Diabetes in Charleston and Georgetown *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.

15. Centers for Disease Control and Prevention REACH US CEED MUSC College of Nursing National African American Networks Alpha Kappa Alpha Sorority Black Nurses Association (Professional Organization) Urban League Baptist Association and COOLJC Regional and National 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) Statewide Institutions 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 Diabetes Initiative of South Carolina College of Nursing REACH US Charleston and Georgetown Diabetes Coalition Community Systems and Policy Change Health Systems Change

16. 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 self-management 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.

17. 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.

18. 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.

19. 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………..

20. Approaches • Individual behavior change & lifestyle modification • Environmental restructuring • Social ecological approach

21. Our Community Systems Wheel Faith Based E.T. Anderson and J.M. McFarlane (2006)

22. 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

23. The Community Chronic Care Conceptual Model REACH Charleston and Georgetown Diabetes Coalition (Jenkins, Pope, Magwood et al., PCHP 4 (1): 73)

24. Evaluation Logic Model External Influences Existing Activities Understanding Context, Causes, & Solutions for Health Disparity Community Action Plan Targeted REACH Action Coalition Community & Systems Change Change Agents Change Planning & Capacity Building Widespread Change in Risk/Protective Behaviors Other Outcomes Reduced Health Disparity

25. REACH Charleston And Georgetown Diabetes Coalition’s Efforts to Decrease Diabetes-RelatedAmputations

26. Specific Aims • Improve foot care for African Americans with diabetes. • Eliminate disparities in number of amputations for African Americans with diabetes.

27. 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

28. 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.”

29. 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.

30. 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.

31. A Book on Diabetes Care and Management & Patient-Held Mini-Record (available on website)

32. Working effectively with communities moves the science from Bench to Bedside to Countryside more rapidly.

33. Community and Media Activities reached >125,000 African Americans Neighborhood Walk and Talk Groups Community Screening and Education Skill-Building for CHAs and Volunteers Individual/ Group Education > 3 sessions = 3.2% drop in A1c Photos used with permission of clients and partners

34. Georgetown County Diabetes Core Activities Physical Activity Health Screenings Walk-A-Thon Educational Classes

35. Healthy Cooking Dinner Theater Gardening Class Gardening

36. REACH at the Library Cybermobile Equipped with 6 Internet laptop computers

37. Diabetes at the Library

38. Recognition and Rewards Womanless Wedding Men’s Talk Talk about Diabetes & Foot Care

39. Media

40. Results

41. % 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

42. Charleston and Georgetown CountiesLEA Rate per 1000 DM Hospitalizations Charleston and Georgetown CountiesLEA Rate per 1000 DM Hospitalizations Data Source: SC Hospital Discharge Data, Office of Research and Statistics Data Source: SC Hospital Discharge Data, Office of Research and Statistics Prepared by SCDHEC Office of Epidemiology and Evaluation updated 03/12

43. 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.

44. Note: release for photo

45. 5 Step Community Action Model Hennessey, S. et al. (2005). The Community Action Model: American Journal of Public Health, 95, 611-616.

46. Lessons from the Community #1 “We want to know how much you care before we care how much you know.

47. #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.

48. #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.

49. #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.

50. #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.