EXpansion, Partnership, Focused TAiloring, and coNnecting SDOH to support DSMES & DPP among Priority Populations [EXPANDD] - Quincy Asian Resources, Inc. (QARI), in close partnership with Joslin Diabetes Center and Dr. Tam Nguyen of Boston College, and in alignment with our organizations’ respective visions, missions, and capacity, seeks funding from Component B of the CDC-RFA-DP-23-0020, "A Strategic Approach to Advancing Health Equity for Priority Populations with or at Risk for Diabetes." Our purpose is to address the risk and consequences of Type 2 Diabetes (T2D) for Asian Americans (particularly Chinese, Asian Indian, and Vietnamese Americans) in four "high need" counties Suffolk, MA pop. 771,245; Kings, NY pop. 2,641,052; Queens, NY pop 2,331,143; and Bronx, NY pop 1,424,948. The project will use an innovative agile implementation model, focused on human-centered design (HCD) and systems thinking to develop comprehensive strategies and work plans to address the challenge. An HCD team with expertise in agile methodologies, will work alongside a community advisory board to co-create, pilot, and evaluate all services tailored to the needs and preferences of the priority populations. Each strategy will initiate a deep-dive needs assessment of stakeholders involved, resource utilization review, current practice scope, and barrier/limitation analysis. In year 1, Strategy 1 will provide hands-on DSMES training and support to four organizations that serve Chinese, Asian Indian, and Vietnamese American populations, targeting older adults given their increased risk for diabetes-related microvascular complications. Strategy 3 will establish diabetic retinopathy and CKD screening services and develop an outreach campaign to emphasize their importance to the target population. Strategy 5 will improve access, appropriateness, and feasibility of the National Diabetes Prevention Program (National DPP) lifestyle intervention and the MDPP by providing subject matter expertise and hands-on training to implement new DPP programs at a minimum of six organizations. Strategy 10 will leverage systems reports from earlier strategies to assess data architecture and interoperability requirements in developing multi-directional e-referral systems that support electronic exchange of information between health care, CBOs, and DPP/DSMES providers. The primary focus of years 2-5 will be on continuous evaluation, submitting necessary revisions, and scaling up the services provided by each of the six organizations to increase enrollment and retention of Chinese, Asian Indian, and Vietnamese Americans into the DPP program, decreasing the proportion of people with diabetes with an A1C > 9%, and increasing the number of program completers served by CDC-recognized National DPP delivery organizations who reduce their risk for type 2 diabetes. The use of an agile delivery model and human-centered design and systems thinking will ensure that the project continually learns from and responds to population and stakeholder needs, tailoring its services to the unique cultural, structural, and human-centered needs of the priority populations. The project aims to address the urgent issue of T2DM in Asian American populations and make a significant contribution to advancing health equity for these communities.
