It’s no secret that for those in historically underserved populations, daily management of health conditions poses unique challenges. In this webinar, we will look at these challenges through the lens of health equity and social determinants of health with a focus on diabetes, a hugely prevalent disease that is widely known to disproportionately affect underserved populations. Presenter Lisa Packard, who has spent years focused on health inequities and diabetes, will share how diabetes patients can take charge of their health through community-based workshops teaching positive self-management techniques. She will also go over how healthcare professionals can help support these individuals, foster the linkages between communities and clinics/health systems, and find or implement these kinds of trainings – particularly the evidence-backed Diabetes Self-Management Program (DSMP) workshops. Lisa will also review the evidence behind the Diabetes Prevention Program (DPP) and quality improvement opportunities that can be identified using Medicare claims data. This webinar is appropriate for front-line clinicians, patient safety and quality improvement professionals, and anyone involved or interested in making strides in health disparities and/or diabetes work.

1. Reducing Disparities in Diabetes
Care:
From Data to Doing
Lisa Packard, MS
QI Consultant & CDSME Master Trainer
September 21, 2017

2. 2
Qualis Health
• A leading national population health
management organization
• The Medicare Quality Innovation Network - Quality
Improvement Organization (QIN-QIO) for
Idaho and Washington
The QIO Program
• One of the largest federal programs dedicated to
improving health quality at the local level

3. 3
Objectives
• Diabetes prevalence in underserved
populations
• Social determinants of health
• Community-based approach
• Evidence-based programs
• Provider support: QI opportunities
• Clinic to communities linkages

4. 4
Framework for Discussion
• The Data
• The Theory
• The Practice
• The Call to Action

5. 5
The Data

6. 6
The Data: Prevalence
15.7 16.0
18.1
19.0 19.5 19.7 19.9 20.0 20.6 21.3 22.0 22.1 22.7 23.3
25.3
26.9
0.0
5.0
10.0
15.0
20.0
25.0
30.0
State Rate (20.51%)

7. 7
Prevalence among Dual Eligibles

8. 8
No Diabetes
or CKD
Diabetes No
CKD
Diabetes and
CKD
Diabetes and
ESRD
Beneficiaries 604,565 92,152 76,855 4,342
Admits per
1,000
99.8 158.9 616.0 1,497.0
ED Visits per
1,000
285.0 432.7 806.0 1,543.8
Readmits per
1,000
8.8 14.9 117.6 438.7
Mortality 2.7% 3.8% 11.5% 21.2%
Per Capita
Costs
$4,416 $6,977 $18,764 $67,631
Diabetes & Chronic Kidney
Disease – Cost

9. 9
Disparities in Diabetes Care

10. 10
Impact of Disparities on
Diabetes Utilization

11. 11
Impact of Disparities on
Diabetes Utilization

12. 12
Impact of Disparities on
Diabetes Utilization

13. 13
In the News
“The new analysis, which combines data from death
certificates with statistical methods to differentiate
trends from random events, also reveals large swaths in
SeaTac, Kent, Federal Way and Auburn where diabetes
deaths have increased, while dropping almost
everywhere else.”
“How long will you live? It might depend on your King County neighborhood”
Originally published September 5, 2017
http://www.seattletimes.com/seattle-news/health/how-long-will-you-live-it-might-depend-on-your-
neighborhood/

14. 14

15. 15
The Theory

16. 16

17. 17
The Triple Aim Framework

18. 18

19. 19
Reducing Health Disparities

20. 20

21. 21
The Practice

22. 22
Community-Based Approach
• Affordable
Housing
• Senior
Apartments
• Senior Centers
• Area Agencies on
Aging
• District Health
Departments
• First Responders
• Lions Club
• Churches
• Faith-based
Organizations
• Clinics
• Hospitals
• Pharmacies
• Volunteer
Organizations

23. 23
Evidence-Based Programs
• Solid research
• Documented health benefits
• Packaged Programs
• Evidence-based Program Review
Council
• Evidence-based Leadership Council

24. 24
Evidence-Based Programs
• The National Diabetes Prevention
Program
• DPP
• CDC
• The Diabetes Self-Management
Workshop
• DSMP
• Self-Management Resource Center
(formerly Stanford Patient Education Center)

25. 25
National Diabetes Prevention
Program

26. 26
CDC Recognized DPP:
Key Components
• CDC approved curriculum
• A lifestyle coach, specifically trained
to lead the program
• A support group with similar goals
and challenges

27. 27
Basis for Self-Management
Education

28. 28
SMRC’s Diabetes
Self-Management Program

29. 29
SMRC’s Diabetes
Self-Management Program

30. 30
Qualis Health’s
Current EDC Program

31. 31
Implementation Sustainability
• Technical Assistance for Developing:
• Program budget
• Job descriptions
• Project management planning
• Marketing materials
• Lay leader training
• Networking with greater CDSME
community

32. 32
Leader Trainings

33. 33
Leader Trainings

34. 34
Workshop Materials

35. 35
Workshop Materials

36. 36

37. 37
Sample Workshop Flyer

38. 38
Patient Activation Survey

39. 39
Patient Activation Survey

40. 40

41. 41
Local DPP Programs

42. 42
Qualis Health’s Website for DSMP

43. 43
WA DOH Website

44. 44
The Call to Action
• Refer patients who are at-risk for
diabetes to DPP
• Refer patients with diabetes to DSMP
• Implement your own evidence-based
programs
• Develop change packages to support
the Triple Aim, starting with high-risk,
high-cost populations
• Optimize your EHR

45. 45
Thanks and Appreciation

46. 46
Q & A

47. 47
Contact
Lisa Packard, MS
QI Consultant
CDSME Master Trainer
lisap@qualishealth.org
(206) 288-2565
For more information:
http://medicare.qualishealth.org/projects/everyone-with-
diabetes-counts
This material was prepared by Qualis Health, the Medicare Quality Innovation Network - Quality Improvement Organization
(QIN-QIO) for Idaho and Washington, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of
the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. WA-EDC-
QH-3158-09-17