The Ohio Department of Health (ODH) is applying to the Centers for Disease Control and Prevention for DP18-1815PPHF18: Improving the Health of Americans Through Prevention and Management of Diabetes and Heart Disease and Stroke– financed in part by 2018 Prevention and Public Health Funds. The goal of ODH’s Diabetes and Heart Disease Prevention and Management Program is to prevent and manage diabetes and cardiovascular disease (CVD)in high-burden populations in Ohio through implementation and evaluation of evidence-based strategies that address diabetes management and type 2 diabetes prevention (Category A)and CVD prevention and management(Category B)in a mutually reinforcing way and through a coordinated approach to achieve improved health outcomes. Target populations will include populations with the lowest income and education (e.g., Medicaid patients), blacks, residents of Appalachian counties, those living in underserved areas(such as patients of Federally Qualified Health Centers (FQHCs))and those with limited or no access to health care and Diabetes Self-Management Education Support (DSMES)/National Diabetes Prevention Programs (N-DPP)(e.g.,residents of rural counties). ODH will engage key partners and secure contracts with entities who have the expertise to implement activities and can help address identified gaps to reduce disparities. This program will enhance existing capacity at the state level and build upon current chronic disease and health promotion priorities included in Ohio’s State Health Improvement Plan and 2018 Ohio Diabetes Action Plan. One of the program’s major initiatives is to implement an FQHC Quality Improvement (QI) Project that will focus on implementing six pathways: (1) screening, testing and referring for prediabetes; (2) referring patients with diabetes to DSMES; (3) identifying patients with undiagnosed hypertension (HTN); (4) managing patients with HTN/high blood cholesterol, (5) establishing or expanding medi
cation therapy management (MTM) services for patients with diabetes, HTN and high blood cholesterol, and (6) linking patients with diabetes, HTN and high blood cholesterol to community resources. A Plan, Do, Study, Act cycle will be incorporated into the Key Drivers conceptual framework for the project sites. A Primary Care QI Project, similar to the FQHC QI Project, will also be implemented that will focus on the first four pathways described above with primary care practices that serve high burden populations. ODH will also: work with key partners to improve access to DSMES in underserved areas; establish and coordinate an Ohio Diabetes Collaborative; advocate for N-DPP coverage by employers; develop social marketing initiatives aimed at patients and healthcare teams to increase screening, testing and referrals to prediabetes, diabetes and HTN/high blood cholesterol lifestyle programs; provide initial start-up costs to support establishment of new DPPs or expand N-DPP satellite sites in high burden areas/areas with no N-DPPs; provide resources to existing N-DPPs that support curriculum content and enrollment/retention of participants in the program; continue to provide leadership support and technical assistance to the statewide MTM Collaborative and other MTM activities; educate non-physician team members on their role in HTN/high blood cholesterol management; promote the implementation of Self-Measured Blood Pressure programs with community partners such as libraries and barbershops, and work with key partners to integrate electronic referrals to HTN/high blood cholesterol programs into electronic health records.