The New Hampshire Department of Health and Human Services (NH DHHS) is applying to implement and evaluate evidence-based strategies to prevent and manage cardiovascular disease (CVD) and diabetes. Target populations for this project include those disproportionately affected by diabetes and cardiovascular disease due to socioeconomic factors, inadequate access to care and/or poor quality of care/poor outcomes compared to the general population in NH such as: adults with mental illness, adults served by federally qualified health centers (FQHC) or rural health clinics (RHC), State of New Hampshire Employees, adults with disabilities (mobility, intellectual, developmental), and priority populations served in health systems outside of FQHCs and RHCs. NH DHHS is well-positioned to reach these target populations through strong, long-standing, relationships with healthcare and community partners (NH’s Health Center Controlled Network, State of NH Risk Management Unit, Granite State Diabetes Educators, for example) and integrating diabetes and cardiovascular strategies into statewide initiatives such as the CMS approved Section 1115(a) Medicaid waiver, known as a Delivery System Reform Incentive Program (DSRIP) and the University of New Hampshire’s Institute on Disability “Disability and Health Project.” The proposed project will expand upon previous outcomes achieved under the 1305 cooperative agreement including improved hypertension and diabetes control in FQHC and RHC, increasing access and enrollment in the National Diabetes Prevention Programs through formation of a Diabetes Prevention Advisory Group, increasing DSMES participation among people with newly diagnosed diabetes, and utilizing the ASTHO Community Health Worker (CHW) Learning Community to build statewide infrastructure for CHWs. Implementation of of A and B strategies in the same high burden populations/health systems in a coordinated fashion will increase NH’s impact and be well-rec
eived by key project partners and ensure that long-term outcomes will be achieved by the project end date in 2023. These include: decreased proportion of people with diabetes with an A1C > 9 % and increased control among adults with known high blood pressure and high blood cholesterol in RHC, FQHC and among select populations such as adults with mental illness, and increased number of people with prediabetes enrolled in a National Diabetes Prevention Program (NDPP) who have achieved 5-7% weight loss by reducing barriers to enrollment among adults at highest risk in NH health systems. Additional detail, including interim targets and data sources are included in the work plan.