In Connecticut, pre-diabetes, diabetes, hypertension and/or high blood cholesterol tend to disproportionately affect people of lower socio-economic status and blacks. With DP18-1815 (1815) funding Connecticut Department of Public Health (CT DPH) will develop and implement mutually supportive activities to reach underserved patients and address each of these chronic conditions through improved identification, referral options and processes to support self-management and track patient outcomes. The CT DPH will use evidence-based strategies in collaboration with key internal and external partners to coordinate mutually reinforcing diabetes and cardiovascular disease strategies and increase impact within identified, high risk communities. Initiatives begun through, DP13-1305 (1305) will be expanded and will address health equity by focusing efforts on priority populations throughout each of the strategies.
Our approach will be a coordinated effort that supports the current work of the CT DPH chronic disease program to leverage existing partnerships while also establishing new partners. High burden communities will be identified through various chronic disease surveillance data sources. Strategies in both Category A and Category B will be employed in these communities. Through a competitive process, CT DPH will select four health care organizations (HCOs) that each serve a high burden community. These HCOs will collaborate with CT DPH, a selected health care organization technical assistance (HCO-TA) vendor, and subject matter experts (SMEs) to work toward 1815 goals. To determine the HCOs readiness and technical support needs and to provide coordinated oversight of the HCOs activities, one HCO-TA vendor will be selected via a competitive process. SME vendors will also be competitively selected to provide technical assistance in: 1) health information technology (HIT) to advise HCOs in using EHRs to identify and track patient referrals and outcomes; 2) medication therapy management (MTM) to engage pharmacists to help patients with diabetes, hypertension and/or high blood cholesterol to better manage their medication regimen; and 3) self-monitored blood pressure (SMBP) to set up SMBP programs in the selected HCOs. CT DPH will also evaluate approaches to enhance the current community health worker (CHW) infrastructure and work with the CT CHW Association and the State Innovation Model (SIM) CHW Task Force to coordinate certification and curriculum standardization. A Cardiovascular/Diabetes Advisory Board will be convened with cardiovascular, diabetes, and other project related partners to review project progress in meeting objectives, identify barriers and discuss potential solutions. The CT 1815 evaluation activities will be coordinated with UConn Health, the CT DPH 1305 evaluator, under the direction of CT DPH and the CDC.
CT DPH has selected Strategies A1, Optional A1, A3, A4, A6 and A7 for its diabetes efforts and Strategies B1 – B6 for cardiovascular. These strategies were specifically selected for their alignment with successful 1305 strategies and will allow CT to expand the work begun in 1305. These strategies align well with other CT Chronic Disease initiatives including WISEWOMAN and the SIM. The synergy of 1305 successes, WISEWOMAN and SIM with the new 1815 activities puts CT in an excellent position for effective and sustainable outcomes.