Component B applicant, Presbyterian Healthcare Services along with project partners, will address high diabetes levels in five New Mexico counties: Doña Ana, Otero, Quay, Curry, and San Miguel. This service areas has a combined population of 373,850 and includes urban, rural, and frontier counties. The project will use a whole person approach and focus on four populations experiencing health and socioeconomic disparities: Hispanic/Latino, American Indian/Alaska Native, low-income, and pre-natal/peri-natal populations.
The five-year effort will implement CDC strategies 1, 5, 10, and 13. This includes bringing Diabetes ReCHARGE, an ADCES-accredited diabetes self-management program, the National Diabetes Prevention Program, and the Medicare Diabetes Prevention Program to unserved and underserved areas. Partners will increase participation and retention through two complimentary diabetes support programs focused on cooking, nutrition, and healthy food access: Kitchen Creations, by partner New Mexico State University, and a Produce Prescription service by Presbyterian with local food pantries and food security agencies.
Through a network of community health workers, community-based social services agencies, and local health providers, partners will recruit, refer, and support participants using culturally-resonant practices and an electronic referral system to connect individuals with social supports and evidence-based interventions.
Project outcomes are as follows (1) Increase the number of organizations and sites implementing evidence-based diabetes self-management education and support (DSMES), diabetes support programs and services, and diabetes prevention programs (DPP) serving five high-need counties in New Mexico; (2) Increase participation in evidence-based community behavioral change programs, including diabetes self-management education and support (DSMES), diabetes support programs and services, and diabetes prevention programs (DPPs) in five high-need counties in New Mexico; (3) Increase adaptation/tailoring of effective DSMES, National DPP, Medicare DPP and diabetes support programs and services for priority populations of Hispanic/Latino, American Indian/Alaska Native, low-income, and pre-natal/peri-natal populations; (4) Increase the number of individuals (patients, health plan members) in five high-risk New Mexico counties who are screened for social determinants of health (SDOH) and referred to community resources; (5) Increase multi-directional communication between community resource providers, clinical providers, and other health system resources (health plan, community health) within five high-need counties in order to support participation in diabetes management and prevention programs and to help individuals overcome social determinants of health (SDOH) barriers; and (6) Increase diabetes workforce capacity to address social determinants of health and patient/member contact with trained Community Health Workers (CHWs) and Promotoras (Spanish speaking CHWs) to support participation and retention in evidence based chronic disease self-management programs in five high-need counties in New Mexico.
