Delaware will continue to build around Domains 3 and 4, of the 1305 work implemented during the 5-year funding cycle. During the first year of the 1815 grant, the state will work diligently to address those strategies and measures defined in the application. Delaware has been successful in several areas of healthcare reform and population health, especially with 114 practices we currently have formal Memorandum of Understandings through our collaborative work with Quality Insights (QI). All of the participating practices have Electronic Health Records that supports our work with improving patient health outcomes through the use of Health Information Technology. During this time we will work with developing bi-directional referrals for our DSMEs, DSMPs, CDSMP and DPP in addressing patients with uncontrolled diabetes and hypertension. Using a previously established dashboard for tracking clinical reporting, we will form appropriate measures for tracking cholesterol as well. The dashboard will help identify successes and barriers with the participating practices and utilized to evaluate objectives and outcomes. Workflow modifications will be implemented in health systems that integrate best practices, national standards and protocols for prediabetes, uncontrolled diabetes and elevated blood pressure and cholesterol. Modifications will also include practice redesigns, especially through the use of team based care and the support of self-blood pressure monitoring. Retrospect referral letters will be implemented to effectively increase participation into DSMEs, DSMP, CDSMP and DPP. DSMEs have been long established across the state at each of the hospitals. Mass reach health communication and the promotion of referral methods will be important to increase attendance of those high risk populations who have diabetes. The state will work with the YMCA DPP staff in-order to increase participation into their prevention program. Other work around primary pre
vention will include provider education, referral letters, mass media directed towards high risk populations and those who recently had the DPP provided as a covered benefit. This includes all state employees and the program will work closely with DelaWELL the state employee benefits program in order to increase knowledge among employees that they may attend for free, under the state’s insurance. Work with the YMCA/DPP will also contain the finalizing of the state’s Medicaid program to offer the DPP as a benefit to their members. This is being planned to take place early 2019. Mass reach health communication will play an important role in increasing participation into the program. Delaware pharmacists will work with providers and pharmacy sites in order to provide more intense education and outreach for hypertension, primary prevention and diabetes self-management education referrals. Pharmacists will utilized the CDC diabetes risk test in order for early identification of high risk Delawareans, have them referred to a provider and assure the provider refer them to the DPP. Building on the work of the State Innovation Model Grant, Delaware Center Health Innovation, and our program will work with those identified as Healthy Neighborhood communities, one in each County, who are highest health-risks. The 1815 activities will be implemented in a way that bring synergy towards addressing the targeted health issues in these communities and as well for other high-risk populations in the state. Our goal is to interweave among health conditions, initiatives that provide a comprehensive approach and that provides the least in duplicative services.