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10 Community Health Centers Recognized with National Award for Innovation in Diabetes Care



BD, Direct Relief, and the National Association of Community Health Centers (NACHC) honored 10 of the nation’s 1,200 community health centers with the Innovations in Care Award at the 2016 Community Health Institute and EXPO in Chicago.

“A strong network of community health centers is critical to improve access to our health system, and this year’s winners represent what’s possible for community health in the U.S.,” said Vincent A. Forlenza, Chairman, CEO and President of BD. “The wellness, prevention and care community health centers provide help avoid unnecessary hospital visits and sometimes represent the only care for some of our country’s most vulnerable populations.”

Part of the BD Helping Build Healthy Communities initiative — a collaboration between BD, Direct Relief, and NACHC — the $100,000 awards acknowledge innovative approaches to the prevention and treatment of diseases that disproportionately affect vulnerable populations. The initiative includes a commitment by BD of approximately $5 million in cash and product for community health centers and clinics nationwide.

“The Innovations in Care Award recognizes the critical role of clinics and community health centers as America’s healthcare safety net,” said Thomas Tighe, President and CEO of Direct Relief. “Direct Relief is delighted to work once again with BD and NACHC to highlight and elevate such deserving health centers for their amazing commitment, insight, and effectiveness in serving their patients and communities.”

The following winners were selected with guidance from a panel of experts in diabetes, its co-morbidities, and clinical and community healthcare:

2016 Award Winners

Community Health and Social Services (CHASS), Detroit: For any provider with 35 percent of its patients diagnosed with uncontrolled diabetes, as have CHASS’s patients, disease management would be daunting. For the patients, it can wreak havoc on their self-esteem, undermining motivation to self-manage their disease. To address this problem, CHASS created the Behavioral Health Intervention for Diabetic Support program. Through this program, the center identifies high-risk patients with diabetes and utilizes the entire health care team – providers, a certified medical assistant, a behavioral health provider, and community health workers – to coordinate wrap-around services for care. This model of care incorporates Population Health tools and techniques to care proactively for both the physical and mental health of patients.

Cornerstone Family Healthcare, Cornwell, N.Y.: The Bridging Gaps: Improving Continuity for Patients with Diabetes program at Cornerstone Family Healthcare enhances access to comprehensive diabetes care for patients in the Hudson Valley Region of New York State. Despite the availability of a full scope of clinical and supportive services, few patients with diabetes have access to all of the services needed to manage their condition. Through this program, patients with diabetes, or with pre-diabetes, are connected to in-house programs and services including primary and specialty care, nutrition services, health and physical education, and diagnostic screening through the work of a registered nurse care manager. The nurse care manager works directly with patients to ensure needed services are utilized and results and care plans are shared among multiple providers for best outcomes.

First Choice Health, East Hartford, Conn.: As the only safety net provider to offer interdisciplinary, integrated care, First Choice Health Centers is expanding a multifaceted diabetes care program through First Choice Focus on Diabetes Initiative 2016. This initiative expands education, nutrition, and exercise classes to the health center’s entire population with diabetes, including the oversight of a diabetes care coordinator who is also a registered nurse. The program addresses the substantial comorbidity between depression and diabetes by integrating a behavioral health specialist into the care team. The value of the model’s focus on tracking, collecting, interpreting, and maintaining information in electronic form, exemplified by the Diabetes Registry and Diabetes Report Card.

The Daily Planet, Richmond, Va.: The Diabetes Impact Program at The Daily Planet integrates shared visits with the primary care provider, pharmacist, oral and behavioral health professionals, and nutritionist for high-risk patients with diabetes and who are also homeless. The pharmacist and nutritionist provide weekly educational sessions for participants through an evidence-based approach to help patients learn methods for medication adherence and better nutritional balance. Outreach workers and case managers are engaged in enrolling patients, resulting in greater access and improvements in the patients’ ability to care for themselves. The Diabetes Impact Program is a comprehensive, interprofessional approach to target the unique needs of patients served by The Daily Planet.

Henry J. Austin Health Center, Trenton, N.J.: Low literacy, difficulty with medication adherence, effective patient-provider communication, and engagement are just a few of the challenges faced by patients with diabetes in Trenton. In response to these difficulties, the Henry J. Austin Health Center developed the successful Improving Outcomes for Diabetics program, a team-based program that combines the work of clinical pharmacists with innovative technology to engage, educate, and treat more patients with diabetes. The Patient Activation Measure and SenseHealth tools increase patient knowledge, create self-management plans, and assist in appointment reminders and follow up.

The Institute for Family Health, Harlem, N.Y.: In response to high demand for nutrition education and counseling services, The Institute for Family Health created the Improve Health Outcomes and Eliminate Disparities diabetes program at their Family Health Center of Harlem (FHCH). The program combines a bilingual certified diabetes educator and health coach with primary and behavioral health care services. Through the creation of a custom registry of patients with diabetes, the FHCH care enhances the ability to provide diet, activity, and behavioral therapy targeted to 1,000 patients.

Lanai Community Health Center (LCHC), Lanai City, Hawaii: Diabetes has long loomed over the rural island community of Lanai City and the Lanai Community Health Center (LCHC). Their work focuses on diabetes treatment and preventative education to those who need it most. Developing from an already successful diabetes program, LCHC is expanding the High Tech and High Touch Diabetes and Prediabetes Management Program, an enhanced office and home-based prevention and treatment program through remote monitoring to include Bluetooth-enabled blood glucose reading along with community-based self-management support. Community health workers take on an expanded role in providing community and home diabetes management while behavioral health and dental care are fully integrated into the program.

Mary’s Center for Maternal and Child Care, Washington, D.C.: Through the nurse-led Empowerment Program, Mary’s Center for Maternal and Child Care (Mary’s Center) aims to reduce and eliminate barriers to diabetes diagnosis through prevention and successful management for its patients throughout Washington. Mary’s Center created a unique and efficient program that combines case management, social engagement, group education, and information technology, which results in documented improvements in patients’ self-management strategies.

Raphael Health Center, Indianapolis, Ind.: The Raphael Health Center took a Population Health approach in treating its newly diagnosed, high-risk patients with diabetes. Lead by a diabetes navigator, the Diabetes Medical Home Partnership program identifies and categorizes patients based on the stage of diagnosis and sets the frequency of education information, including in-person meetings, follow up text messages and phone calls. The diabetes navigator helps determine the barriers to care that a patient may face and works with a care manager and healthcare team to remove the obstacles. A diabetes “checklist” tool tracks and focuses the program’s outcome measures.

Santa Barbara Neighborhood Clinics, Santa Barbara, Calif.: The Diabetes Collaborative brings together three local Santa Barbara organizations to support the multi-dimensional needs of patients with pre-diabetes and diabetes. Santa Barbara Neighborhood Clinics, William Sansum Diabetes Center, and the Foodbank of Santa Barbara County joined to tighten the safety net for patients through the provision of comprehensive diabetes services and resources. Together, these organizations provide screening, medical care, care management, education, and food and nutrition services to support patients who are high-risk. This partnership promotes whole-person care and recognizes the importance of lifestyle changes in the treatment and prevention of diabetes.

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