Rio Grande Valley Chronic Care Management Coalition Belinda - PowerPoint PPT Presentation

Rio Grande Valley Chronic Care Management Coalition Belinda Reininger, DrPH

Collaborative Project

Implemented Across the RGV

Implemented Across the RGV Upper Valley Project Lower Valley Project

Salud y Vida Serves Participants with Uncontrolled Diabetes each Demonstration Year Individuals Receiving Chronic Care Managment Services 3000 2500 2670 2626 2000 1755 1500 1000 1205 1205 1204 500 0 DY 3 DY 4 DY 5 New Enrollment Total Served

Majority of Salud y Vida participants are improving control of diabetes Comparison of Baseline and Quartery HbA1c Results 1800 73% Success 1600 1665 69% Success 1400 Total Participants 1343 1200 68% Success 1000 69% Success 1072 800 866 600 621 603 62% Success 400 496 381 200 325 200 0 3-MONTHS 6-MONTHS 9-MONTHS 12-MONTHS 15-MONTHS Reduced HbA1c Increased HbA1c Includes data from October 1, 2013 - February 1, 2016

Average HbA1c values improve during the time frame where program services are most concentrated Average HbA1c Results 10.20% 10.12% 9.97% 10.00% 9.80% 9.60% 9.42% 9.28% HbA1c 9.40% 9.22% 9.08% 9.20% 9.00% 8.80% 8.60% 8.40% Baseline 3-Months 6-Months 9-Months 12-Months 15-Months Test Completed 3345 2286 1946 1568 239 525 Tests Missing 0 833 940 933 720 999 Includes data from October 1, 2013 - February 1, 2016

Salud y Vida Program Services Time Line Day 1 for participants  Enroll in program Months 1 – 2 for participants  Receive  Attend DSME classes Months 3 – 12 for participants evaluation  Assigned community  Receive HbA1c test every 3 months  Enroll in Diabetes health worker (CHW)  Receive support via phone & home visits from Self-  If no PCP, connected CHWs Management to a Medical Home by  Attend Participant Advocate Leader Board Education CHW meetings (DSME) course  Receive home visit  For participants with HbA1c results increasing 1.5% and assessments by or greater, receive case review with action plan CHW  Obtain care coordination between program and  Receive motivational medical home text-messages Receive referral to other resources e.g. behavioral health, exercise and cooking classes, Compassion Funds, transportation assistance, social worker services, support groups

Coordinated Care Community Health Worker Across Partner (CHW) home visits Organizations CHWs and Social Services nurses provided by coordinating visits with clinics, CBOs, hospitals medical home at clinics Improved HbA1c Control Behavioral Nurses relaying health screening important and services health provided by information to mental health clinics authority CBOs Providing Diabetes Self- Management Education in clinic and community

Meet a Salud y Vida Participant * Name changed Before Salud y Vida Ms. Cruz* was at high risk • 53-year old with Type 2 diabetes “I always thought that visiting your physician and taking • HbA1c > 10.4% at time of enrollment your medications was all you needed to do. In Salud y Vida I have learned a lot… I was the kind of person that Salud y Vida Team by eleven in the morning, I was sleepy again. No strength, didn’t want to do anything. Now I have lots of • Enrolled the participant in Diabetes Self-Management energy. I believe it’s never too late to start. I’m 53 years Classes (DSME) and completed all classes prior to the 3- old and I feel great, something I could have said in those month time point 12 years I lost.” • Worked together to improve eating habits • Provided glucometer for daily monitoring HbA1c Results • Provided 7 home visits and multiple phone calls 12 10.4 10 Better Health! 8 6.4 • 6 Stabilized glucose levels 7 6.9 6.9 4 • Changed eating and exercise habits 2 • HbA1c decreased after 12 months 0 • Volunteered as peer facilitator with support groups

Projected Final Outcomes Salud y Vida, a program delivered through a coalition model will serve by end of DY 5 at least 4,164 individuals with uncontrolled diabetes in the Rio Grande Valley over 3 years. 77% will attend at least 1 68% of those that receive an 66% will have reduced their Diabetes Self-Management HbA1c test will reduce their HbA1c at 12-months. Education class and 68% will HbA1c within 3-months 41% will reduce their HbA1c complete all classes below 9 at 12-months.