Advancing Health Equity for Priority Populations with or at Risk for Diabetes in High Needs Counties in Nevada and Oregon through Community Integrated Health Networks - Comagine Health is submitting a proposal in response to the Request for Applications for A Strategic Approach to Advancing Health Equity for Priority Populations with or at Risk for Diabetes (CDC-RFA-DP-23-0020). We are applying for Component B. The proposed areas of focus include counties in the following states: Nevada (Clark, population: 2,292,476) and Oregon (Marion, Jackson, Linn, Douglas, Yamhill, Josephine, Lincoln, combined population: 1,060,117). Prediabetes and diabetes are significant and growing health concerns. Diabetes is the 8th leading cause of death and the number one cause of kidney failure, lower limb amputation and adult onset blindness. It is a costly condition, leading to a total of $327 billion annually in medical costs and lost wages. As the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Idaho, Oregon, Nevada, New Mexico, Utah, and Washington and a CDC 1705 Recipient for New Mexico, Oregon, and Utah, Comagine Health has been working to prevent and slow the progression of diabetes by increasing access to recognized lifestyle change programs for over five years and diabetes self-management education for over 20 years. We work with trusted local organizations and state level collaborators to build infrastructure, programs, and participant engagement in lifestyle change, diabetes self-management education and support (DSMES) and community support programs. Our experience, relationships, and established infrastructure from prior work positions us as a leader in this space. The selected counties listed above have significant disparities in diabetes prevalence and incidence, obesity prevalence, and social vulnerability. We have served these counties as a QIN-QIO for many decades and have the established partnerships to meaningfully advance and expand access to programs and social needs services. To achieve the goals of this cooperative agreement, Comagine Health will work with five collaborating partners: • Access to Healthcare Network, Dignity Health, Quality Technical Assistance Center, Southern Nevada Health District (Clark County) • Oregon Wellness Network (All Oregon Counties) • Providence St. Joseph (Jackson, Marion, Yamhill) We will develop capacity to reach the population of 3,352,593 with lifestyle change, DSMES and support programs through effective marketing and engagement campaigns, innovative provider referral models, and investment in local delivery partnerships to strengthen cultural and linguistic adaptations. We will build upon established infrastructures to increase provider referral and CHW centered services to increase engagement and address social needs barriers. We will continue to expand capacity to use and integrate with critical Health Information Technology to scale referral and enrollments. By the end of the five year period, we seek to achieve the following outcomes: 1. Increase the number of organizations implementing evidence-based DSMES, CDC recognized lifestyle change programs, Medicare DPP, and DSMP support programs, supported by a robust backbone infrastructure to advance sustainability. 2. Increased adaptation/tailoring of effective programs, including engagement and outreach models, for priority populations, including African Americans, Hispanic/Latinos, Asian/Pacific Islanders, American Indian/Alaska Natives, Low Socioeconomic Status, rural, older adults, and people with disabilities. 3. Increase in the number of patients screened and referred to community resources through scaling of the Southern Nevada Pathways Community HUB, strengthening SDOH screening and referral standards and partnerships in Oregon, and integration with Community Information Exchanges (CIE) and Health Information Exchanges (HIE) in both states. 4. Increase SDOH screenings in clinical settings and referral into CHW supported services. 5. Increase participation in evidence based DSMES, CDC recognized lifestyle change programs, Medicare DPP, and DSMP support programs.
