Increasing Eqity in Diabetes Prevention, Education & Care for Priority Populations in Southeastern Virginia - Component B, Southeastern Virginia Background: The impact of diabetes and prediabetes in Virginia is markedly worse in the state’s southeastern region. In the cities of Hampton (137,746) and Newport News (184,587), about 18% of the population has diabetes and about 15% has prediabetes, while in rural Northampton (12,085) and Accomack (33,246) counties, more than 21% of the population has diabetes and about 15% has prediabetes. In these four localities, the Black population composes from 30% to 45% of the total population, compared to 20% of the Virginia population. The prevalence of diabetes is higher in Virginia’s Black population (17.5%) than in the White and Hispanic populations (both 10%). Purpose: Health Quality Innovators (HQI), with Component B funding, will reduce diabetes-related health disparities for the Black and Hispanic priority populations in Hampton and Newport News, and for the Black, Hispanic and rural priority populations in Accomack and Northampton counties by implementing CDC strategies 1, 4, 5, 8, 9 and 13. Outcomes: Together with our technical assistance partners and community-based organization subgrantees, we will build capacity to deliver local DSMES, National DPP and childhood obesity programs that are tailored to priority populations, have strong referral networks and are able to sustain themselves. This will contribute to an increased number of programs and program completers. We also will increase the ability of local primary care providers to deliver team-based care that enables improved diabetes self-management, and of the entire diabetes workforce to address barriers related to social determinants of health. In the long term, this will result in more people with prediabetes who reduce their risk of diabetes, children with lower BMIs, and fewer people with diabetes who have A1C levels > 9%. Approach: Effective prevention and treatment of diabetes requires a team-based approach, whether that is in the clinic or through CDC-funded efforts like this. Accordingly, we designed this proposal to align with the Virginia Department of Health’s (VDH) Component A application. We do not intend to focus on any of the geographies where VDH plans to perform Component A-funded work and we propose to implement some strategies that VDH does not intend to implement. The geographies we serve can benefit from the spread of strategies that VDH implements, such as the HabitNu Umbrella Hub. The result is extended reach and increased impact that makes smart use of federal funds. In addition to allocating 30.4% of grant funding to CBOs (in Year 1, building to 35.9% in Year 5), we will further engage communities by establishing two regional Patient and Family Advisory Councils (PFACs) that will amplify the voices of people in the priority populations with prediabetes and diabetes. We will consult with the PFACs throughout the grant to gather insights and recommendations for making diabetes care and education more accessible, appropriate and feasible. We also will fund two CBOs to establish a regional diabetes coalition or workgroup. These groups will bring together diabetes stakeholders and CBOs that serve the priority populations for collective action to raise diabetes awareness, reach priority populations more effectively, and remove barriers created by social determinants of health. Capacity: HQI is a current CDC 1815 and 1817 subgrantee to three health departments and a health care quality improvement organization with 39 years of experience. Our project team includes The Virginia Center for Diabetes Prevention and Education and the Virginia Pharmacy Association/Virginia Community Pharmacy Enhanced Services Network.
