Background: The burden of diabetes is much higher for racial/ethnic minorities than for whites and often results in higher rates of diabetes-related complications and death. We can improve those outcomes by using a web portal to transform diabetes care from silos of exam-room centered medical practice and public health education to the three-component, integrated model of transformed practices supporting engaged patients in a community context with rapid-cycle outcome-improvement feedback loops.
Program background: The National Center for Primary Care at Morehouse School of Medicine (NCPC) was funded by Bristol Myers Squibb Foundation for a project to maximize the national impact of Together on Diabetes by achieving replicability, sustainability, and scalability. This will be accomplished by creating rapid cycle feedback and quality improvement loops; and linking the implementation of Together on Diabetes lessons, tools and evidenced based care models to specific revenue enhancements, financial incentives, and/or concrete ROI models that reward impact on practice-level and community-level diabetes outcomes, i.e. patient centered medical home certification, hospital community benefit IRS requirements, NCQA diabetes certification, accountable care organization gain sharing.
Evaluation Methods and Results:
- At least five of these new communities will achieve at least a 70% moderate glycemic control rate as measured by A1c < 7.9% across an entire neighborhood or community .
- At least three of these communities will achieve a measurable closing of the gap in diabetes health outcomes (glycemic control rates) between racial and ethnic minorities and whites/Anglos or the local general population.
Conclusions: The Learning Collaborative, which will use the learn-share-connect (virtual community) model is currently underway. Already, we have seen 700+ diabetes professionals benefit from web-based material that can enhance their quality of care. By using this web portal we can see the needle move in integrated diabetes care. By the end of September 2016, 12 - 15 communities from across the nation will have engaged in practice changes that will totally integrate their care for underserved populations suffering from diabetes.
Implications for research and/or practice: At the end of this project evidence will be available suggesting health equity can be achieved and replicated by engaging in virtual, learning collaborative style lessons. This model can be replicated and will create best practice models to be used by health professionals.