The funding opportunity announcement will support evidence-based initiatives and healthcare system partnerships developed to achieve outcomes of CDC-RFA-DP13-1305 and CDC-RFA-DP14-1422. Strategic partnerships formed with pharmacists, providers and hospitals to implement strategies to reduce the burden of diabetes and heart disease in Oklahoma. Linking community resources to clinical outcomes were priorities of the activities selected to support DP14-1422 and DP13-1305. Patients with hypertension, diabetes or pre-diabetes referred to the local health department received education on healthy lifestyles – increasing physical activity, monitoring their blood pressure, choosing healthier options for meals, adhering to their prescribed medications and reducing smoking.
Oklahoma’s Health Ranking of 43, up from a previous ranking of 46, indicates Oklahomans are making strides towards living healthier lifestyles. Decreasing the incidence of chronic diseases through reduction of risk factors will enable Oklahomans to enjoy higher quality lives. Our projects, Heartland OK, DPOk and the brief hospital transition pilot, have shown success in helping patients reduce both their BMI and A1C, achieve the clinician recommended blood pressure reading and increase adherence to their medications. Challenges remain, however, in engaging clinicians in team-based care models. Our approach for this funding opportunity will be engaging statewide associations in promoting community-clinical linkages to clinicians. Through this high-level systems approach we hope to affect system policy change in early identification of pre-diabetic patients as well as those hypertensive patients “hiding in plain sight”. Engagement of community pharmacists through academic detailing provided by both colleges of pharmacy will increase opportunities for patients to receive education on hypertension, diabetes and stroke prevention and management.
High-level health system partnerships will support collection of data for evaluation and response to performance measure outcomes. Clinician reporting of quality measures, whether for reimbursement or attesting and recognition as a patient centered medical home (PCMH) is facilitated through collaboration with statewide associations. Working with systems level associations provides access to aggregated data from the clinicians rather than requiring individual reporting from clinicians. This approach reduces the reporting burden of clinicians and increases the availability of performance measure and outcome data.