The Diabetes Prevention and Control Program (DPCP) and Heart Disease and Stroke Prevention Program (HDSPP) will build on their successful 1305 efforts to collaboratively align, implement, and evaluate evidence-based strategies, such as increasing community-clinical linkages and improving quality of care, to prevent and manage cardiovascular disease and diabetes in New Mexico (NM), with a special focus on our high-burden populations. With 1815 funding we estimate that we will reach 200,000 adults, which represents 20% of the total number of adults ages 40 and older. This estimate will be further refined throughout the period of performance as we gather data on NM’s identified high-burden populations. NM’s high-burden populations include those affected disproportionately by high blood pressure (HBP), high blood cholesterol (HBC), diabetes, or prediabetes. They include Blacks/African Americans, American Indians/Alaska Natives, people experiencing poverty, Spanish speakers, residents of rural counties, and overweight/obese adults.
DPCP and HDSPP will leverage resources and partnerships and implement mutually reinforcing strategies to achieve three long-term outcomes: 1) decreased proportion of people with diabetes with an A1C > 9; 2) increased number of people with prediabetes enrolled in a CDC-recognized lifestyle change program who have achieved 5-7% weight loss, and 3) increased control among adults with known HBP and HBC.
A leadership team will manage this project, with its numerous partnerships and collaborations, and will be comprised of those most central to envisioning, implementing, and sustaining the work. This team will include DPCP, HDSPP, Health Insight NM (NM’s quality improvement network), the Wyoming Survey & Analysis Center (the project’s external evaluator), and the NM Primary Care Association. Some of our targeted efforts include the following:
• Improving access and participation in diabetes self-management education and support (DSMES) programs recognized by the American Diabetes Association or accredited by the American Association of Diabetes Educators, especially for programs in rural areas.
• Scaling and sustaining the National Diabetes Prevention Program (NDPP) in NM.
• Engaging non-physician health care providers (e.g., pharmacists, paramedics, community health workers [CHWs] and community health representatives [CHRs]) to provide or enhance team-based care in clinical settings and to form community-clinical links that improve population health by providing TA, training, and access to Paths to Health NM, an online referral website that includes information on programs and resources for people living with chronic illnesses.
• Using electronic health records (EHR) or health information technology and establishing written workflow processes to identify people at risk for diabetes, with diabetes, with hypertension, or with HBC to systematically refer them to NDPP, DSMES services, or other identified community-based programs/resources.
• Strengthening the Office of Community Health Workers to provide long-term sustainability and reimbursement for CHWs/CHRs statewide.
• Loaning automatic blood pressure cuffs to patients in health systems that commit to improving their hypertension control rates by implementing quality improvement checks when analyzing and reporting their data.
• Hosting opportunities, such as webinars, for health systems to share lessons learned and common challenges to improve and implement multi-disciplinary team approaches for blood pressure control and cholesterol and diabetes management.
• Providing technical assistance to healthcare organizations to support screening, testing, and referral of adults at high risk for type 2 diabetes or living with hypertension.