Montana (MT) Department of Public Health & Human Services is applying for the CDC-RFA-DP18-1815PPHF18 to address the burden of diabetes, heart disease and stroke in Montana.
The Diabetes and Cardiovascular Health Programs (D&CVHPs) will implement activities through a comprehensive and coordinated approach to address standards and policies; increase Montanans’ awareness of chronic disease risk factors, disease self-management activities and resources; work with health care providers to implement quality improvement (QI) strategies and use health information technology (HIT); and link clinical and community resources. These activities will be targeted to the highest burden areas or specific sub-populations at high-risk that may otherwise be missed by these activities.
The D&CVHPs will improve the health of Montanans by achieving the outcomes in the logic model. Surveillance and evaluation activities will continue and be used for monitoring progress, analyzing outcomes and reporting success.
Category A will build upon the existing successful network of Diabetes Self-Management Education and Support (DSMES) services and the Diabetes Prevention Programs (DPPs) in MT. Data will be collected using an existing Chronic Disease data system. Strategies A1 and A6 will use similar approaches to increase access to DSMES services and DPPs in underserved areas for high burden populations, specifically American Indian Reservations and rural areas; ensure high quality services through program recognition/accreditation and training and certification for diabetes educators and lifestyle coaches; and increase participation by implementing referral systems and marketing campaigns. Strategies A2 and A5 will additionally support access, utilization and sustainability of DSMES services and DPPs through insurance coverage and reimbursement. Strategy A4 will emphasize screening and referral of people with prediabetes to DPPs. A team-based care model will be adopted for DSMES services and DPPs and will include pharmacists and community health workers (CHWs). Strategy A3 will engage pharmacists through worksite wellness programs, mentorship to become Certified Diabetes Educators and creation of a learning and action network. Strategy A7 will develop an infrastructure of CHWs from emergency medical services (EMS) for prediabetes or diabetes.
Category B will use six best practice strategies identified by CDC in, “Best Practices for Cardiovascular Disease: A Guide to Effective Health Care System Interventions and Community Programs Linked to Clinical Services.” Strategy B1 on undiagnosed hypertension/blood pressure (BP) management and Strategy B2 on chronic QI will use clinical decision support systems to assist with management of patients who have high BP in Urban Indian Clinics (B1) and larger health systems (B2). Partnering with clinics and pharmacies, strategies B3 and B4 on team-based care and medication therapy management (MTM) will coordinate patient care for those with high BP and/or high cholesterol. Strategy B5 on community health will build the infrastructure to support people who want to self-manage their high BP and high blood cholesterol with assistance from EMS as CHWs. Strategy B6 on self-measured blood pressure monitoring (SMBP) with clinical support plus self-management support and education will establish BP cuff loaner programs in cardiac rehabilitation facilities and large health systems with their associated primary care clinics. Strategy B7 on systematic referrals emphasizes self-management support and education, which involves local health department contractors conducting 8-week sessions of Health Coaches for Hypertension Control for clients with high BP. Patients who have high BP and/or high cholesterol will be referred to evidence-based community programs via the CONNECT bi-directional referral system.