A strategic, Community-based Approach to Diabetes Prevention and Management in Philadelphia - The Health Federation of Philadelphia (HFP), located at 123 S. Broad Street, Philadelphia, PA 19109, is submitting this application for $903,991 in funding under Component B of CDC-RFA-DP-23-0020. The HFP project will focus on Philadelphia County/City, a high-need county that had a population of 1,576,251 in 2021, according to the US Census. Philadelphia is among the poorest cities in the country and it has four times the proportion of Black residents as the state and twice the proportion of Hispanics. The rate of diabetes in the City increased by over 70% in the last twenty years. State Department of Health data for 2021 indicate that the percentage of people in Philadelphia reporting a diagnosis of diabetes is 13%, including 19% of Black residents and 14% of Hispanics. HFP will conduct the proposed project with four partner organizations (Philadelphia Department of Public Health, Delaware Valley Community Health, Esperanza Health Center, and New Kensington Community Development Corporation), all of which are located within and serve Philadelphia. The purpose of the project will be to utilize evidence-based approaches to reduce risk for diabetes in adults and children and improve care for individuals already diagnosed with diabetes. With a combination of health care-system and community-based approaches, HFP will strengthen the clinical and community infrastructure and workforce, strategically utilize technology, and invest in evidence-based prevention programs. All work will focus on priority populations – Black and Hispanic individuals with incomes below 200% of poverty. Within the five-year project period, HFP will utilize lessons learned with the initial collaborating partners to scale and spread the work across the FQHC network in Philadelphia. Along with its partners, HFP has developed a Work Plan for the proposed project that includes objectives and activities under seven of the Component B strategies; #3 Prevent eye and kidney complications of diabetes; #4 Improve diabetes services for priority populations; #5 Increase enrollment and retention in NDPP programming; #8 Increase use of childhood obesity interventions; #10 Improve multi-directional e-referral systems between health care and CBOs; #12 Improve the effectiveness and sustainability of Community Health Workers in diabetes services; and #13 Increase SDOH screening and referral for services. The outcomes the project will seek to achieve are: increases in the proportions of diabetic patients receiving retinopathy services and chronic kidney disease screening; increases in the number of partner organizations with effective programs adapted/tailored for priority populations and evidence-based community behavioral change programs; increases in the numbers of patients participating in evidence-based community behavioral change programs and receiving screenings for social determinants of health needs and referrals for services; increased multi-directional communication among clinical and community resources; and increased effective and sustainable engagement of CHWs in diabetes care. Overall, the project will seek to decrease the proportion of diabetic patients in the partner FQHCs who have uncontrolled HbA1c levels >9. HFP has extensive experience related to the proposed strategies, including longstanding collaborative relationships with project partners, forty years of history addressing health disparities in Philadelphia County, work with the NDPP and with the Community Health Worker workforce, and sophisticated referral system and data management and analysis capability. HFP will lead a robust quality improvement process for the project, allowing improvements in the outcomes over time, sustainability and spread of the improvements, and contributions to the evidence based for the strategies.
