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Chronic Disease Prevention and Management

State: FL Type: Model Practice Year: 2019

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Florida Department of Health in Putnam Coutny
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Chronic Disease Prevention and Management
Putnam County, Florida is a rural county located in the northeastern part of the state with many health disparities, low income, and high incidents of chronic disease. In the 2018 County Health Rankings, Putnam county ranked poorest or close to poorest on many indicators such as poor mental health days, low birth rate, adult smoking, physical inactivity, childhood poverty and unemployment. Putnam County is also the highest in teen birth rates and has a high level of alcohol impairment. Putnam County consistently ranks below Florida overall in adults with hypertension (51.9% versus 34.6%, 2013), coronary heart disease (8.8% versus 4.7%, 2016), obesity and inactivity (43.5% versus 27.4%, 2016) and hypertension age-adjusted death rates (14.9% versus 8.5%, 2017). Putnam County ranks below Florida overall in those who have ever been told they have diabetes (22.1% versus 11.8%, 2016), and age-adjusted death rates from diabetes (39.6% versus 20.7%, 2017). Amputations attributed to diabetes are much higher in the Putnam County Black community (69.4%, 2014) and the Florida Black community (68.5%, 2014) than Florida Whites (23.8%, 2014). There is a higher level of poverty in Putnam County versus Florida overall, (27% versus 16.1%, 2016 respectively), Blacks and Others in Putnam County have a much higher poverty rate than do Whites and Blacks in Florida overall (42.6% Blacks and Others in P.C., 23.6% for Florida overall; 22.8% Whites in P.C., 13.7% Florida Whites). It is very difficult to engage our rural community members to participate in chronic disease prevention and management programs. There is a problem with denial as people with high blood pressure or prediabetes generally do not feel symptoms so they often do not adapt heart healthy lifestyles until they have an event from the disease. Education is one key to managing health and decreasing the occurrence of chronic disease. Our objective is to improve the health of Putnam County residents through education and team care for chronic diseases such as heart health through Blood Pressure Self-Monitoring (BPSM), preventing type 2 diabetes (PT2), and Diabetes Self-Management Education (DSME). Our goal is to increase referrals to chronic health education classes throughout Putnam County to help to decrease the incidence of chronic disease. To reach our goal and objective, DOH-Putnam developed two Quality Improvement Plans (QIP) to first, gain accreditation for our DSME and PT2 programs which will allow us to bill insurance for the sustainability of our chronic disease programs. Our second QIP was developed to increase referrals from county physicians and primary care teams to our Heart Health and PT2 programs. Our QIPs worked wonderfully. We should gain accreditation for our DSME program in early 2019 as our QI action steps addressed all the necessary parameters for accreditation. The QIP for increasing referrals was also very successful. HH had no referrals for FY 2017-2018 and increased to 24 referrals for the first quarter of FY 2018-2019 and PT2 went from 2 classes for FY 2016-2018 to 3 classes for the first quarter of FY 2018-2019; all chronic disease classes now have waiting lists to fill new classes to begin in January, 2019. Our objective was met and the impact of our successful QIPs will help meet the health needs of more county residents through direct contact with their care teams referring patients to our chronic disease education and prevention classes. Our website is http://putnam.floridahealth.gov/
Putnam County Florida ranks among the poorest in the state for health, chronic disease, obesity and lack of physical activity. To improve the health of Putnam County residents, our focus is to engage the underserved, elderly, and other community members who either do not know they have high blood pressure, or do not have their blood pressure in control, who are prediabetic, and those with diabetes. Putnam County has 51.9% of residents with hypertension (38,925 residents), and 43.5% obese and inactive (32,625 residents). Our poverty rate overall is 27% affecting 20,250 residents and 42.6% among our Black and Others” (31,950 community members). Diabetes affects 22.1% or 15,750 community members overall in Putnam County and we have 39% age adjusted death rates from diabetes (29,250 residents). Our chronic disease education programs are just beginning and we are currently implementing processes to monitor the percentage of residents reached by each program. In the past, we had a DSME program for many years until funding was cut; this program was restarted in 2017. To increase our referrals for HH and PT2, we used the Quality Imrovement Plan (QIP) model to identify barriors to success, determine what steps were or were not working and developed an action plan to overcome obstacles blocking success. We also developed a QIP for DSME accreditation by reviewing and implementing required standards. While use of QIPs is not a new practice, it is an efficient way to identify barriors and needs and teases out root causes of problems so that they can be addressed directly. This practice is evidence based in that we can easily track our increased referral rates over time and gaining accreditation for DSME is evidence that the QIP worked.
For our first year in HH, we recruited members of DOH-Putnam to monitor their blood pressures daily, keep a blood pressure log, and attend heart health classes onsite. We had between 11-14 members keeping track of their blood pressure for 2017-2018. All attendees remained in their required blood pressure ranges throughout the study and noted causes for incidences of high blood pressure readings (stress, pain). We then partnered with Putnam County Parks and Recreation (PCPR) to enlist seniors from the Edward Johnson Senior Center in Palatka for the six-week HH class followed by once a month check ins for 6 months. All participants had their blood pressure under control through medications and regular checks with their primary care team. We had 4 core members who attended every class with another 6 clients who checked in with me every month after the class sessions were complete. We had a total of 20 clients in the HH program for year one (FY 2017-2018). HH class participants learned how to accurately measure their own blood pressure, the effects high blood pressure has on arteries and organs, how to eat a heart healthy diet, how to read nutrition labels and the importance of exercise in lowering blood pressure, cholesterol levels and to prevent Type 2 diabetes. All participants met their blood pressure goals and could pinpoint activities or stressors that made their blood pressure rise. Our problem was that we didn't have any further recruits to fill new classes. To increase our responsiveness to other chronic health needs, DOH-Putnam had three health educators trained as lifestyle coaches for the PT2 curriculum developed by the Centers for Disease Control and Prevention (CDC). The program goals are to prevent prediabetes from developing into type 2 diabetes through comprehensive education on healthy eating patterns and slow, measured weight loss. We partner with the University of Florida, Institute of Food and Agriculture Sciences (IFAS) for PT2 by providing education and other support. We began with two class for FY 2016-2018 with few recruits waiting to join new classes. With increased referrals, we are currently coaching 3 classes on revolving schedules with new classes starting in January, 2019. We were able to increase the referral rate for our new HH and PT2 programs by implementing our QIP and directly marketing key stakeholders. We now partner with 1st Coast Cardiology Center for referrals and identified recruits at outreach events by taking names and numbers of interested people and calling them after the event to discuss their needs. We are also partnered with Silver Sneakers at the Pomona Park Fitness Center, ARC of Palatka, and UF (IFAS). PHAB standards for our DSME program have been met since 2017 when the course framework and curriculum education were completed. We examined and implemented each action step for the 10 PHAB standards and expect to gain accreditation by early 2019. Our partners for DSME education include most area physicians as this well-developed program has an urgent need to educate our community members before they reach levels of serious complications from diabetes. These prevention and education programs will help community residents avoid Type 2 diabetes and/or manage their diabetes through self-management education, learn about heart health and how to lower their risk for heart attack and stroke, as well as learning lifestyle changes for a healthier life. With increased prevention and management education, we are hoping to decrease the occurrence of chronic disease and increase heart healthy lifestyles in our community. All our chronic disease programs were built from the ground up. Our DSME program is now well established but not yet accredited. Therefor our goal is to gain accreditation by reviewing and implementing the 10 Public Health Accreditation Board (PHAB) standards. We established a Quality Imrovement Plan (QIP) for accreditation and our action steps were to establish the DSME curriculum and support plan, train staff to lay the foundation for our program, review organizational support structure and program mission, and gain input from external and internal stakeholders and experts. We identified the needs of clients and how to best deliver DSME services, developed outcome measures, and created a document explaining the educational process so that individualized plans could be tailored to specific client needs. All steps in the QIP were completed December 2018 and Accreditation should be complete by early next year, 2019. Our HH and PT2 programs are not well established. There was little to no awareness of these chronic disease classes and we had a very difficult time getting recruits after the first classes were completed. To reach more community members, we created trifold flyers for each program describing the curriculum, class structure, and goals. These flyers were given to doctor's offices, clinics, libraries and fitness clubs. We spoke to receptionists at each site about getting the word out”. This marketing tactic did not produce any new clients or referrals for our HH or PT2 programs. We then developed a QIP for increasing referrals which led us to tease out factors that were not producing the desired result. We reviewed each program and provided systematic changes we thought would increase awareness of our chronic disease programs. Our first action step for HH was not marketing but to tone down the HH presentations as they were too informative and bored our senior clients. We changed our curriculum from information driven to action driven by incorporating interactive games and strategies to fully engage our clients. We then simplified the informational flyers to one page, easy to read information that directly identifies what each program offers. Thirdly, we identified the need to speak directly to critical stakeholders to educate them and increase awareness of our chronic disease programs. Our Nutritionist, Carol Kazounis, met face to face with referral nurses and doctors to describe our programs, the needs of the community, and our request for them to refer patients to our programs to help educate and improve the health of their clients. These action steps identified in our QIPs completely changed our course from a problem of no referrals to enough referrals to fill 2 HH classes and 3 PT2 classes in the first quarter of FY 2018-2019. New community partnerships have also been developed using this direct marketing strategy and we continue to foster those relationships. Our objective of improving the health of Putnam County residents through education and team care for chronic diseases and our goal to increase chronic health education classes throughout Putnam County have been met. Referral rates for HH went from zero in FY 2017-2018 to 24 in the first quarter of FY 2018-2019. Referrals increased for PT2 from 2 classes FY 2016-2018 to 3 classes running concurrently in the first quarter of FY 2018-2019 and a class beginning in January 2019. DSME classes have been on a revolving schedule since FY2017-2018 and continues to have a waiting list. The implementation of our QIP action steps, led to all three chronic health education programs offered at DOH-Putnam increase their referral rates and now have waiting lists. The impact of increased referral rates allows DOH-Putnam to reach many more community members at risk from chronic diseases. We expect further awareness about chronic disease prevention and education will increase our partnerships and lead to more community members to seek out our help. DOH-Putnam keeps in regular contact with our stakeholders whether it is through co-teaching, meetings, or drop in visits. We also let our community partners know how much we appreciate their efforts to support improved health in Putnam County. Our community partners have strong relationships with DOH-Putnam and see us on a regular basis when we hold classes at doctors' offices or other stakeholder offices throughout the county. Funding began with a $10,000 grant in 2015-2016 to built the infrastructure for our DSME program and a $5,000 grant for 2016-2017. For PT2 funding, we received a grant to build the infrastructure and provide training for PT2 lifestyle coaches in 2017-2018. Our HH program began in 2016 with a $30,000 Million Hearts grant. We then received another $30,000, and $25,000 for payroll, supplies, development of curriculum, and implementation of the program.
Our objective of improving the health of Putnam County residents through education and team care for chronic diseases and our goal to increase referrals to chronic health education classes throughout Putnam County have been met. One objective for DOH-Putnam's chronic disease programs is to gain accreditation for our DSME and PT2 programs. The other specific objective is to increase referrals rates to all three chronic health programs including Heart Health. We used Quality Improvement Plans to reach our goals to increase awareness and participation in our chronic disease education programs. To evaluate the effectiveness of our QIPs, we compared data from the first year(s) of each program to this year after we put our QIP into effect. Data were collected directly from referrals to each program. Other data from outreach events were not included in the totals relating to the QIP. Christiana Daley collected and reviewed data from referral sources and compared those data to the previous year's data to determine the initial effectiveness of our QIP. Our outcome measures were the number of referrals for the first quarter of FY 2018-2019 as compared to FY 2017-2018. Our QIPs worked wonderfully. We should gain accreditation for our DSME program in early 2019 as our QI action steps addressed all the necessary parameters for accreditation. The QIP for increasing referrals was also very successful. HH had no referrals for FY 2017-2018 and increased to 24 referrals for the first quarter of FY 2018-2019 and PT2 went from 2 classes for FY 2016-2018 to 3 classes for the first quarter of FY 2018-2019; all chronic disease classes now have waiting lists to fill new classes to begin in January, 2019. The action steps identified in our QIPs completely changed our course from a problem of no referrals to enough referrals to fill 2 HH classes and 3 PT2 classes in the first quarter of FY 2018-2019. New community partnerships have also been developed using this direct marketing strategy and we continue to foster those relationships. The impact of increased referral rates allows DOH-Putnam to reach many more community members at risk from chronic diseases. We expect further awareness about chronic disease prevention and education will increase our partnerships and lead to more community members to seek out our help.
DOH-Putnam learned that recruiting for these new programs had to be direct and involve face to face meetings with community partners and members. We now have our nutritionist maintaining direct contact with decision makers, physicians, and other community partners to make sure they understand what we offer and make personal contact regularly to keep partners engaged. We did not do a cost benefit analyses. DOH-Putnam is working to add chronic disease programs into our Health Management System (HMS) and gain accreditation for DSME and PT2. Once these are accomplished, we will be able to bill insurance providers for sustainable funding. We also have our Coordinator of Chronic Disease undergoing the process to become a Medicare provider to enable billing for services. Classes are also available for those without insurance. DOH-Putnam is also working to incorporate wellness programs at local corporate employers and other organizations as well as developing programs for school health by partnering with our Students Working Against Tobacco (SWAT). We fully expect that our community outreach, physician referrals, corporate involvement and the ability to bill insurance providers will allow us to continue to reach many of our underserved community members as well as those who regularly see their doctor but need help in sustaining lifestyle changes. With sustainable prevention and management education programs, we are hoping to decrease the occurrence of chronic disease and increase heart healthy lifestyles in our community.
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