Sunday, March 30, 2025
3/30/2025
The Pathways Project: Community Level Innovations for Improving Diabetes Health Outcomes - Project HOPE proposes expansion of a sustainable collaborative network to improve diabetes health outcomes among the underserved 61.3% Hispanic/Latino population of Bexar County, Texas. Poverty, food insecurity, lack of health insurance, and linguistic barriers contribute to stark health disparities by race and ethnicity. Together with The Health Collaborative (THC), Community Information Now (CI:NOW), and C3HIE, the Pathways Project will address two priority social determinants of health (SDOH): 1) Economic Stability and 2) Healthcare Access and Quality, in order to progress toward the Leading Health Indicator (LHI) to reduce the number of adults newly diagnosed with diabetes each year. Bexar County has an estimated 10.2 new cases of diagnosed diabetes per 1,000 adults annually, in stark contrast to the US baseline of 5.5 per 1,000 adults (CDC 2021). For more than 20 years, The Health Collaborative’s (THC) network of community-based organizations has been serving the Bexar County, Texas region, aiming to improve health through a unique “clinical-to-community” continuum of care. The Pathways Project will leverage and expand the network, implementing activities to improve capacity to serve Hispanic/Latino people at-risk for diabetes (PaRD). Experienced community health workers specially trained as bilingual Care Transition Coaches (CTC) will serve as trusted messengers to provide outreach to PaRD, screen for SDOH, and open “Pathways” to address priority SDOH (i.e. employment, education, housing, health insurance, care coordination, etc.). CTCs will provide ongoing support and referrals to an expanded network of Care Coordination Agencies (CCAs) focused on SDOH and diabetes prevention, working together and using the Care Coordination System, a HIPAA certified, shared information platform to track progress. The Pathways Project aims to achieve the following goals: 1) Increase the use of diabetes preventative services, 2) Improve health outcomes and 3) Reduce social determinants of health (SDOH) barriers related to a) Economic Stability and b) Health Care Access and Quality among Hispanic/Latino PaRD in Bexar County, Texas. The project will address the following objectives: (Goal 1) Objective 1: Implement community-level innovations that will link a minimum of 700 people at-risk for diabetes (PaRD) per year to evidence-based diabetes prevention programs (DPP), reaching at least 2800 individuals over the 4-year project. (Goal 2) Objective 2: Increase The Health Collaborative’s Care Transition Coaches (CTCs) from four to eight within the first year of the project by onboarding four bilingual CTCs to serve the focus population. (Goal 3) Objective 3: Maintain and expand a collaborative network of Care Coordination Agencies (CCAs) providing health and social services, aimed at addressing gaps in reducing SDOH and diabetes prevention by 2 new Care Coordination Agencies per year, for a total of 8 new CCAs over the life of the 4-year project. Expected project outcomes include improved access to and utilization of diabetes prevention programs, pre-diabetes health management services, and linkages to health and social services; increased number of bilingual CTCs and formal CCA network partners; percentage of SDOH pathways identified and addressed successfully; and improved health outcomes to progress toward the LHI. Building upon this proven, sustainable collaborative network to focus interventions on prevention of diabetes among underserved Hispanic/Latino community members will transform access to services and achieve the project’s goals and objectives. The expansion, evaluation, and dissemination of this extraordinarily innovative collaborative network model will have far-reaching implications and impact on the field of public health, providing a scalable, replicable, best practice model toward reduction of key SDOH for increased diabetes prevention and improved health outcomes among Hispanic/Latino populations.
HHS’ Tracking Accountability in Government Grants System (TAGGS) website provides access to detailed descriptions of grants, loans, aggregated direct payments and other types of financial assistance awarded by the HHS Operating Divisions (OPDIVs) and the Office of the Secretary Staff Divisions (STAFFDIVs).