The Pennsylvania Department of Health (DOH) will implement a comprehensive prevention and management program to address the burden of diabetes and cardiovascular disease (CVD).
Throughout the project period, the DOH will address the access to, participation in, and coverage for Diabetes Self-Management and Support (DSMES) and Diabetes Prevention Program (DPP) ; the tracking and use of clinical data for the identification, management, and treatment of patients with hypertension and high cholesterol; the increased use of team-based care and a multidisciplinary approach to blood pressure control; and increased community-clinical links to support self-management and systematic referrals to lifestyle change programs. These outcomes will be accomplished by improving access to and participation in DSMES; assisting health care organizations with the referral of patients with prediabetes to lifestyle change programs; expanding DPP as a covered benefit; increasing the use of Electronic Health Records (EHRs) in hypertension and high cholesterol prevention and management; and increasing the use of pharmacists in the provision of DSMES and hypertension and cholesterol management. All activities and progress towards outcomes will be measured, tracked, and analyzed through data collection led by The Evaluation Institute at the University of Pittsburgh. All data analyses will provide feedback as to successes and to identify and address any gaps discovered in the initiatives.
The goal of these coordinated efforts and the development of a comprehensive diabetes and CVD program will be to achieve long-term reductions in the proportion of people with diabetes with an A1C > 9 and the proportion of adults with hypertension and high cholesterol that have achieved control, as well as an increase in the number of people with prediabetes enrolled in lifestyle change programs and that have achieved a 5-7% weight loss.